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Sexual risk-taking in the era of HIV/AIDS : case study of adolescents resident in Ketu South, Upper Denkyira,… Sallar, Anthony Mawuli 2001

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SEXUAL RISK-TAKING IN THE ERA OF HIV/AIDS: CASE STUDY OF ADOLESCENTS RESIDENT IN KETU SOUTH, UPPER DENKYIRA, AND OFFINSO SOUTH ELECTORAL CONSTITUENCIES IN GHANA By ANTHONY MAWULI SALLAR B.Sc. (Hons.) University of Ghana, Legon, Accra, Ghana 1981 M.P.H. New York Medical Colege, Valhala, New York, 1995 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE STUDIES DEPARTMENT OF HEALTH CARE AND EPIDEMIOLOGY We accept this dissertation as corforming to the required standard Dr. Martin Schechter (Chair)-Dr. Samuel Sheps (Member)-Dr. Robert Hogg (Member)— Dr. Mark Tyndal (Member) -Dr. Wilam McKelin (Univ. Examiner)-Dr. Richard Mathias (Dept'l Examiner)-UNIVERSITY OF BRITISH COLUMBIA 2001 © Anthony Mawuli Salar, 2001 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. The University of British Columbia Vancouver, Canada DE-6 (2/88) A B S T R A C T Objective Research on HIV/ADDS in sub Saharan adolescents has been limited to students in primary, secondary school, and college. There is a paucity of information on out-of-school adolescents. This research, conducted from July 1998 through June 1999, sought to determine the predictors of HIV knowledge, condom use, and sexual risk taking in the era of HIV/AIDS in a population of in-school and out-of-school adolescents aged 10-19 and resident in Ketu South, Upper Denkyira, and Offinso South electoral constituencies in Ghana. Methods This cross sectional research incorporates in and out of school adolescents and utilizes the AIDS Risk Reduction Model (ARRM) and other supplementary variables to predict AIDS knowledge, condom use and sexual risk taking. Subjects were randomly selected (n = 1415) and assessed via questionnaire on their knowledge of AIDS and other STDs, attitude towards condoms and use, self-efficacy, peer norms, and sexual behaviour. Results While certain aspects of AIDS knowledge were well known by respondents, definite gaps in knowledge and misconceptions about infection through casual contact were common. Three multivariate logistic models for knowledge, condom use, and sexual risk taking, were developed after controlling for potential confounders such as age, gender, location, educational status (being in school or out of school) and constituency. In the HIV/ATDS-related knowledge model, independent associations for higher knowledge scores were being male (p = 0.006), being an older adolescent (p = 0.011), higher educational level (p = 0.005), not believing that one can get AIDS through witchcraft (p = 0.024), believing that AIDS is a problem in Ghana (p = 0.001), having ever had sexual intercourse (p - 0.023), having heard about syphilis (p < 0.001), knowing that nobody can cure AIDS (p = 0.001), having taken steps to avoid HIV (p < 0.001), and having discussed ADDS with friends and acquaintances (p = 0.010). Significant predictors for condom use were being out of school (p = 0.002), having discussed ADDS with regular sexual partner (p < 0.001), having discussed ADDS with friends and acquaintances (p = 0.004), self-efficacy (p < 0.001), reliance on the efficacy of condoms as protection against STDs including HIV (p = 0.019), and negative attitude towards condoms (p = 0.004). In the sexual risk-taking model, independent associations were found for being male (p = 0.040), being a residence of Upper Denkyira (p = 0.001) and Offinso South (p = 0.005), early age of first sexual intercourse (p = 0.001), having a relative or friend or acquaintance who has ADDS (p = 0.025), believing that somebody can cure ADDS (p < 0.001), self perceived risk of contracting HIV in the following year (p = 0.018), and having discussed HIV with family (p = 0.007). ii Conclusion Consistent with the literature, the results of the study demonstrate support that increasing HIV knowledge alone will not stem the spread of HIV among adolescents in Ghana. Rather, it appears that the solution lies in enhancing individual's appreciation of his or her own risk and enhancing self-efficacy for reducing that risk. There should also be policies that mitigate poverty and economic inequality, strict enforcement of sexual assault legislation laws, as well as adoption of an integrated health care delivery system that includes family planning, and the dissemination of correct and relevant materials on AIDS. At the same time the government and other stakeholders should seek to create the enabling environment which increases access to the means of prevention. This approach should form the basis for AIDS risk reduction strategies in Ghana. iii TABLE OF CONTENTS Abstract h Table of Contents iv List of Tables viii List of Figures x Acknowledgements xi CHAPTER 1: INTRODUCTION 1 1.1 Purpose of the study 1 1.2 Thesis Statement 2 1.3 Hypothesis to be tested 10 1.3.1 AIDS knowledge 1.3.2 Condom use 1.3.3 Sexual risk taking 1.4 Thesis Organisation 14 C H A P T E R 2: L I T E R A T U R E REVIEW 17 2.1 HIV Epidemiology 17 2.1.1 Estimates of numbers infected 17 2.1.2 HTV surveillance 21 2.2 Modes of HIV transmission—general and then African specific 23 2.3 Groups most at risk of infection 33 2.4 Biological and Social Determinants of HIV 35 2.5 Economic and Social impact of HIV/AIDS in sub Saharan Africa ...38 2.5.1 Costs of caring and prevention 2.5.2 Per capita/income losses 2.5.3 Education 2.5.4 Labour productivity: agriculture, mining and health sectors 2.5.5 Impact on households 2.5.6 Increasing orphan population 2.6 Demographic Impact of HIV/AIDS in sub Saharan Africa 44 2.6.1 Total population loss iv 2.6.2 Crude death rates 2.6.3 Infant and child mortality 2.6.4 Life expectancy 2.6.5 Rate of population growth 2.6.6 Fertility 2.6.7 Gender ratios 2.6.8 Loss of a spouse 2.7 Current State of Knowledge 50 2.7.1 Review of literature on FfJV and STD studies conducted on adolescents with special emphasis on studies conducted in Africa pertaining to in adolescent knowledge, attitude and sexual risk taking. 2.7.2 Conceptual framework 67 2.7.2.1 The Health Belief Model (HBM) 2.7.2.2 Discussion of the strengths and limitations of H B M 2.7.2.3 The Theory of Reasoned Action (TRA) 2.7.2.4 Discussions and limitations of T R A 2.7.2.5 The AIDS Risk Reduction Model (ARRM) 2.7.2.6 Stage 1 of A R R M (Labelling) 2.7.2.7 Stage 2 of A R R M (Commitment to change) 2.7.2.3 Stage 3 of A R R M (Enactment) C H A P T E R 3: R E S E A R C H SETTING 92 Study Site: 3.1 The Ghanaian Adolescent 92 3.1.1 The adolescent population in Ghana 3.1.2 The sexuality of the Ghanaian adolescent 3.1.3 STDs in Ghana and the Ghanaian adolescent 3.2 AIDS Epidemiology in Ghana 98 3.3 Ethnic and social organization 103 3.4 The three areas of the study .107 3.4.1 Ketu District 108 3.4.1.1 Population characteristics 3.4.1.2 Urban-rural split 3.4.1.3 Economic activities 3.4.1.4 Education 3.4.1.5 Health Delivery Services 3.4.1.6 Cultural and Social Organisation 3.4.1.7 Constraints facing the district v 3.4.2 Upper Denkyira District 115 4.1 4.2 4.3 4.4 4.5 3.4.2.1 Population characteristics 3.4.2.2 Urban-Rural Split 3.4.2.3 Economic activities 3.4.2.4 Education 3.4.2.5 Health Services 3.4.2.6 Constraints facing the district 3.4.3 Offinso District 121 3.4.3.1 Population characteristics 3.4.3.2 Urban-Rural Split 3.4.3.3 Economic activities in Offinso District 3.4.3.4 Education 3.4.3.5 Health Services 3.4.3.6 AIDS in Offinso South Constituency ER 4: METHODOLOGY 131 Part 1: Questionnaire development 4.1.1 Pretesting/Revision 4.1.2 The Questionnaire 4.1.3 Feasibility Issues Sampling 140 4.2.1 Study population: inclusion and exclusion criteria 4.2.2 Rural-Urban classification 4.2.3 Sampling of in-school adolescents 4.2.4 Sampling of out-of-school adolescents 4.2.5 Questionnaire administration Methodological issues that may impact on outcome measure 145 Ethical considerations, confidentiality and informed consent 147 Part 2: Data Analysis 148 4.5.1 Data Base Preparation 4.5.2 Analysis for research questions 4.5.2.1 Research Question 1 149 4.5.2.2 Research Question 2 153 4.5.2.3 Research Question 3 157 CHAPTER 5: RESULTS 162 Descriptions with tables CHAPTER 6: DISCUSSION, INTERPRETATION, CONCLUSIONS RECOMMENDATIONS 218 vi Bibliography 267 Appendix 1 Knowledge of Other STDs 297 Appendix II Questionnaire (Survey Instrument) 305 Appendix III General Data Purpose Sheet used in recording responses 318 Appendix IV The HIV sexual risk taking behaviour scale 320 Appendix V Self Eficacy Scale 322 Appendix VI News Report: New AIDS Cure in Kumasi Appendix VI The Map of Volta Region Administrative Districts Appendix VII The Map of Upper Denkyira District Schools Appendix IX The Map of New Ofinso vii LIST OF TABLES Table 2.1: Major modes of HIV transmission throughout the world 32 Table 3.1 Cumulative AIDS cases in Ghana (1986-1998) 100 Table 3.2 Reported Cumulative AIDS Cases in Ghana by Region (1986-1998) 101 Table 3.3 Expected population growth (comparative table) 102 Table 3.4 Population density: Ketu compared to Volta Region and Ghana 110 Table 3.5 Population distribution and density (Offinso and Ashanti) 123 Table 3.6 A summary of some of the similarities and differences between the 3 districts which constitute the study site 130 Table 5.1: Comparison of socio-demographic variables of the study participants to site and gender 164-165 Table 5.2 Household composition by constituency 166 Table 5.3 Control of Household Finances 166 Table 5.4 Analysis of AIDS transmission knowledge questions 169 Table 5.5 Analysis of questions on general knowledge of AIDS 170 Table 5.6 Analysis of AIDS prevention questions 170 Table 5.7-5.13 Knowledge of other STDs. (in appendix 1) 267-274 Table 5.14 Participants' attitude towards PWAs 172 Table 5.15 Distribution of AIDS Knowledge Score by key demographic Variables 176 Table 5.16 Comparison of key variables between respondents who attained low and high knowledge AIDS score 176-181 Table 5.17 Predictors of high FUV knowledge in among 619 Ghanaian Adolescents 183-184 Table 5.18 Comparison of socio-demographic and AIDS related changed behaviour on condom use 191-193 Table 5.19 Predictors of condom use among 513 adolescents in Ghana 194-195 Table 5.20 Age at first sexual intercourse 198 viii Table 5.21 Reasons for engaging in first sexual intercourse 199 Table 5.22 Demographic characteristics between sexually active males and females 202 Table 5.23 Never had sexual intercourse and age at first sexual intercourse by religious affiliation 203 Table 5.24 Analysis of distribution of age pattern and having sex in the study areas 204 Table 5.25 Lifetime sexual partners by constituency of residence 205 Table 5.26 My regular sexual partner has other partners in past one year 206 Table 5.27 Comparison of socio-demographic and other variables on sexual risk taking 209-211 Table 5.28 Predictors of sexual risk taking among 262 adolescents in Ghana 212-213 Table 5.29 Predictors of FHV knowledge (summary) 216 Table 5.30 Predictors of condom use (summary) 217 Table 5.31 Predictors of sexual risk taking (summary) 217 ix LIST OF FIGURES Figure 2.1 Schematic Diagram of the components of the Health Belief Model 71 Figure 2.2 The Theory of Reasoned Action: Factors determining a person's behaviour... 76 Figure 2.3 Overview of A R R M stages 82 x A C K N O W L E D G M E N T S This manuscript has been completed with the support, encouragement, and contributions from my family, professors, friends, and colleagues. I am very grateful to my family (Stella, Selasie, Kafui, and Elikem) for all their words of encouragement throughout my programme and Kafui's constant question and admonition "Daddy when will you finish, hurry up and finish.". To my mother, Victoria my brothers and sisters, Korku Mensah, Kofi, Agbenyega, Willie, Augustine and my sisters Mawuko, Mansah, Manah, Xoese and cousins, Cyrill, Akpene and Ablavi Acolitse and Dr. Kossi Acolitse I say a big thanks to you all for your diverse contributions toward my success. I am indebted to members of my thesis committee (Dr. Martin Schechter as Chairman, Dr. Samuel Sheps, Dr. Robert Hogg and Dr. Mark Tyndall) for their ideas, guidance, and suggestions throughout the preparation of this manuscript. I will also like to extend in advance my unqualified thanks to the external reviewers of this thesis for taking their time to read this document and making suggestions to be incorporated in the final version. I would also like to extend my thanks to faculty, staff and some students at the University of Cape Coast's (UCC) Department of Geography and Tourism for assisting me in diverse ways during my 18 months stay in Ghana to conduct my field work. Dr. Kofi Awusabo-Asare, Messrs Alexander Kumi and Ekow Wellington Afful, Ms. Doris Nyarko, and Ms. Christine Soku I say a big thank you all for your tremendous assistance and suggestions. Others worthy of mention are Messrs Boadi and Mbiah of U C C Department of Geography and Tourism, Mrs. Delali Badasu, Dr. Abane, Kofi Nyarko xi and Joel Anim and Ralph Avornyo. Other friends who assited me in deverse ways durign my stay in Ghana worth remembering are Wisdom Akpalu (Economicss Department, UCC), Ms. Anatu Mohammed (UCC), Ivy, Irene, Jemila, Anita, my cousin Rita Seddoh, and Mr. Eric Nyankah of Volta River Authority. To Dr. Edward Fekpe of Columbus Ohio, and Margaret Dzakpasu Amuzu and Thomas and Edna Kwadzovia, John Dzah, all of Vancouver and Dr. & Mrs Samuel and Vilma Laryeah of Toronto I say thank you for your encouraging words throughout my programme. I would conclude by expressing my thanks to the Rockefeller Foundation for providing funding for my fieldwork in Ghana under the auspices of its African Dissertation Internship Awards (ADIA) programme. Finally and not the least, my sincere thanks to the UBC Department of Health Care and Epidemiology administrative secretaries, past and present, for all their help and words of encouragement during my stay at UBC. My sincere gratitude goes to Ms. Virginia Anthony, Laurel Slaney, Shirley Naismith, Stephanie Shickerlling and Zeba Lellani. To fellow students, Dr. Chris Bajdik, Mr. Chris Richardson, and Ms. Katherine Heath I say a big thanks to you. To the adolescents who spent their time to share their most intimate personal life and the local authorities who gave me permission to conduct this study, need I say I will be forever grateful? Anthony Mawuli Sallar xii CHAPTER 1 Introduction 1.1 Purpose of the Study Among adolescents in Africa and in the rest of the world, unprotected sexual intercourse is the primary cause of HIV transmission (UNAIDS, 2000). In sub-Saharan Africa the breakdown of traditional cultural controls, resulting from the impact of modernization and education in some communities, has not only led to an increase in adolescent sexuality, but also to the initiation of sexual activity at an earlier age (Gyepi Garbrah, 1987). Accordingly, during adolescence, increased sexual experimentation and sex with multiple sexual partners occur more frequently. While the undesirable consequences of adolescent sexual activities were traditionally limited to unwanted pregnancy, infection with STDs, including HIV/ADDS, has become a major concern. Since HIV has a 10-year median incubation period, it is likely the infection may not manifest itself until early adulthood. The effects become manifest when young people are about to become parents, or have become parents and are ready to enter the labor market and become financially productive citizens. Because of the high rate of infection in adolescents and HJV's long incubation period, HIV/AIDS has had a major impact on the economic, physical and social functioning of infected people and the societies or countries in which they reside. 1 1.2 Thesis Statement The primary objective of this dissertation is to identify the determinants of sexual risk taking in the face of HIV/AIDS in a population of in-school and out-of-school adolescents from three electoral constituencies in Ghana. The population consists of adolescents, age 10 to 19, who reside in the Ketu South (Volta Region), Upper Denkyira (Central Region), and Offinso South (Ashanti Region) constituencies. Although sexual risk-taking behavior is the primary focus of the study, HTV/ATDS knowledge, reproductive health knowledge, health-seeking behavior, and the presence of other sexually transmitted diseases (STDs) are also examined. The secondary objectives of the study are as follows: Firstly, to identify factors that might influence the adoption of safe sexual behavior (that is, condom use and reduction in sexual partners). And secondly, to describe the level of knowledge (e.g. transmission, susceptibility) concerning AIDS and other STDs in this adolescent population and to examine how prevailing beliefs (perceptions and misperceptions), practice systems, and attitudes relate to sexual risk taking in the face of fflV/ATDS. The primary and secondary objectives evolve out of the following pertinent issues: What are the determinants of sexual risk taking in this adolescent population? Do they want to have children, or ensure their economic survival (for example, a 15-year-old girl who gets paid to have sexual relations with a 25-year-2 old man) or simply have sexual intercourse? It is imperative to explore these issues in terms of the present economic malaise in Ghana. More specifically, from an applied perspective, we need to identify what modifications must take place in current health-related and community development programs to maximize the impact of prevention initiatives. In Ghana, it has become common knowledge that some fathers have shirked their parental roles in providing economic sustenance for their children before they either reach majority or become self-sufficient. It is unlikely that children whose fathers fail to provide will be sent to school or receive much in the way of financial support. They may therefore seek comfort and solace in relationships driven by monetary considerations. While Ghanaian cultural and social values frown on early sexual activity, will this time-honored norm stand the test of time in an environment riddled with poverty? What are the implications of all these factors in terms of risk reduction in an adolescent population? Will there be differences in sexual activity arising from sex, religious affiliation or educational levels? Why do some adolescents still refuse to engage in sex at an early age? Furthermore, are there structural constraints such as accessibility (money and availability) affecting whether or not adolescents use condoms? It is important to determine whether the adolescent population is aware that AIDS is incurable and that condoms are the only way to block infection for those who 3 choose to have non-monogamous sexual relationships. Other questions to address include whether a previous infection with a S T D or the existence of multiple partners have an impact on the respondents' knowledge o f A I D S or other STDs and on condom use. In addition, it is crucial to examine what roles other stake holders, such as governments or social, educational, and religious institutions, play in A I D S education to stem the incidence of H I V or in advocacy to mitigate the effects of the disease on those already infected. H o w well do they communicate information on sexual behavior and condom use to adolescents? In Ghana, and for that matter, in most African countries, parents often limit their discussion o f sexuality to exhortations o f "not doing it." H o w are these issues being addressed in the era o f H I V / A I D S ? H I V prevalence in Ghana, like in other parts o f the world, is high in some areas, while low or medium in others. It is equally important to determine how H I V prevalence in a given area affects the sexual behaviour o f the people living there. Ghana is at the early stage of the H I V epidemic, but the country shares borders with some epicentres of H I V in the sub-Saharan region. In these countries, the prevalence o f infection in men and women, age 15 to 49, is 6.0% in Togo, 10.8% in Ivory Coast, 6.4% in Burkina Faso and 3.6% in Ghana (UNATDS, 2000). Thus there is still time to intervene among Ghanaian adolescents before they get infected and in turn infect others. 4 In theory, the best way to avoid HIV through heterosexual transmission is to practice abstinence. However, it is recognized that for many adolescents, abstinence is not a viable option. Thus, using condoms correctly and consistently (i.e. making it part of the sex act) represents the most effective method for making sex safer. This study helps clarify why some adolescents engage in risky sexual behaviour and why some adolescents are sexually active while others are not. It also provides information on knowledge, attitudes, and beliefs about AIDS and condoms, and gives insight into reproductive health knowledge and health seeking-behaviour of the adolescent population in the three areas studied in Ghana. This study does not limit itself to high school or college students but also includes out-of-school adolescents for three reasons: Firstly, in developing countries, there are lower school attendance and higher illiteracy rates than in developed countries. Thus, restricting research to adolescents who are in school may not provide enough evidence regarding the dynamics at play and may provide biased results that cannot be generalized to the adolescent population at large. Secondly, while sexual relationships occur across the whole spectrum of educational levels, they may be more pronounced or occur earlier among out-of-school adolescents than among those adolescents who are in school. Thirdly, survey research regarding AIDS in the young adult population in sub-Saharan Africa has been conducted with those in primary school (Ndeki, Klepp, Seha & 5 Leshabari, 1994), in secondary school (Asuzu, 1994; Patullo, Malonza et al., 1994; Asindi, Ibia, & Young, 1992; Wilson & Lavelle, 1992; Nyachuru-Sihlangu, & Ndlovu 1992; Kapiga, Nachtigal, & Hunter, 1991; Wilson, Greenspan & Wilson, 1989), in college (Wilson, Lavelle, Greenspan & Wilson, 1991; Lule & Gruer, 1991; Pitts, Wilson, Philips, White & Shorrocks, 1989), and with adolescents gathered at truck stops (Nzyuko et al., 1997). Adolescents connect with other adolescents (students or non-students), parents, and others. School is only one of the settings in which they congregate, so restricting studies to adolescents who are in school cannot capture all the issues and problems~we need to know what is happening to the out-of school adolescents also. The need to close this knowledge gap is further magnified by the fact that out-of-school adolescents likely experience greater exposure to risk, as compared to in-school adolescents who spend most of the day in a supervised setting. In addition, it is more likely the out of school adolescents may be confronted with economic problems than in-school adolescents. This study also explores the environments where these adolescents live: What are social and cultural practices? How is AIDS perceived in these cultural and religious environments? It is vitally important to examine HIV/AIDS in a socio-cultural context. For example, it is not sufficient to tell people to use condoms to prevent HIV infection. We need to understand why they do not use condoms, even though they know of their existence. What are the beliefs (some 6 of which may be shared) and practices regarding condom use in the environment where intervention is considered? Such an approach facilitates the development of effective intervention programs, that take into account beliefs and practices about HIV/AIDS, sexuality, and issues relating to safe sex and risk reduction in the population. Failure to consider socio-cultural factors will only delay the development of effective preventive strategies. For example, in the light of this research, appropriate education messages can now be crafted and disseminated to all adolescents in Ghana, in such a way as to increase the impact of prevention programs. Such intervention policies can be all-encompassing~through integrated, aggressive sex education, adult education in community centres, and sex and ADDS education at gathering grounds, such as festivals, market squares, and funerals. Changing sexual behaviour through AIDS education has the added advantage of potentially reducing the transmission of other STDs. These STDs are often associated with significant morbidity and have been shown to be pathways to HIV infection (Laga et al., 1993; Wasserheit et al., 1992; Hook III et al., 1992; Plummer et al., 1991; Quinn et al., 1990; Cameron et al., 1989). Research suggesting that STDs are a contributing factor to HIV transmission led to the World Health Organization's recommendation that improved management of STDs, showing that treatment of bacterial STDs may be one of the most cost-effective AIDS-related interventions available in some developing countries 7 (Over, 1993; World Bank, 1993). Experience in sub-Saharan African countries confirms the importance of these preventive efforts and their success in overall risk reduction. For example Orroth et al. (2000) demonstrate the syndromic treatment of STDs and its reduction of incident HIV infections in rural Tanzania. Other successful interventions include the following: peer education and condom promotion among truck drivers and their sexual partners in Tanzania (Laukamm-Josten et al., 2000); the assessment of the cost effectiveness of arresting HIV infection by improving the management of STDs by primary health workers in the Mwanza region of Tanzania (Gibson et al., 1997); and the cost effectiveness of reduction of sexual transmission of HIV in Kenya and Tanzania through voluntary counseling and testing (Sweat et al., 2000). In addition, the Voluntary fflV-1 Counseling and Testing Group (2000) reported the efficacy of HIV-1 V C T in promoting behavioral change in individuals and couples in Kenya, Tanzania and Trinidad. Studies conducted earlier also show Zaire's and Nairobi's commercial sex workers have experienced a declining incidence of HIV after massive promotion of condom use (Laga, Alary & Nzila et al., 1994; Moses, Plummer, & Ngugi et al., 1991); and Grosskurth et al. (1995) suggest that improved management of STDs in the general population can reduce HIV incidence by 40%. When the benefits of eliminating a case of disease are measured in terms of years of productive life lost, HIV has the highest impact among all diseases 8 (Over, 1992; UNAIDS 1997, Hogg et al., 1997). In North America, Western Europe, and Oceania, antiretroviral drugs stave off the onset of full-blown AIDS resulting from HIV infection, and cause a decline in the mortality associated with HIV. In Africa, avoiding HIV infection is paramount, since there is no cure for HJV/AIDS and treatments to extend life are too costly to be made widely available (Hogg et al., 1997). In April 2001, the government of South Africa and pharmaceutical companies reached an agreement whereby antiretroviral drugs will be made available at very low prices to citizens of South Africa. The government of Kenya and Glaxo Wellcome have also announced similar agreements. In addition, Pfizer announced on June 7 t h that it will offer governments of 50 poor nations unlimited free supply of Diflucan, a drug that is used to treat oesophageal candidiasis (which affects 20-40% of ADDS patients) and cryptococcal meningitis (which affects 1 in 10 AIDS patients and kills more than 20% of those infected). (New York Times, May 24th and June 7th, 2001). Although this is good news, it is doubtful these drugs will be widely available to the majority of those infected. It is therefore necessary to recognize that in the absence of a cure or the availability of a vaccine, prevention is the best option for residents of sub-Saharan Africa. Thus, each case of HtV infection that is prevented may mean a substantial reduction in the total number of AIDS cases, because of the infectious nature of the virus: the original HIV-infected person may spread the infection to others and they, in turn, infect others. Studies have 9 shown adolescents are high-risk takers, not only in maters of sexuality, but also in other areas of human behaviour. This fact underscores the need to have early intervention to cater to adolescents' specifc needs. In addition, adolescents are particularly at risk of HIV infection, because they frequently possess low levels of self-eficacy when it comes to refusing sexual intercourse and/or practising safer sex (Kasen et al 1992). The importance of these issues and their impact on sexual behaviour and risk reduction can only be determined after adequate population-based research. The information this study provides can help to beter understand what puts youth at risk which can in turn suggest improvements in preventive program delivery. 1.3 Hypotheses to Be Tested Based on the reading of the literature, and contextualising issues in the African context, the folowing specifc hypotheses come to mind. 1.3.1 AIDS Knowledge The study hypothesizes that there would be diferences in knowledge scores between the folowing groups: (1) Boys would score higher than girls on the knowledge questions. This is because boys are known to be more sexualy active than girls in Ghana. In addition, more boys atend school than girls. 10 (2) Residents of the Ketu South constituency would score lowest, followed by residents of Upper Denkyira and those in Offinso South. This pattern is expected because people who reside in areas of high HIV prevalence may be more knowledgeable than those who reside in areas were HIV prevalence is low. (3) Young adolescents (10 to 16) would score lower than older adolescents (17 to 19). This is because the older they are the more likely they are to have sexual intercourse. Furthermore, they are more likely to be in senior secondary school and hence more exposed to AIDS education both at the formal and informal levels. (4) Those who have had sexual intercourse are likely to get higher scores than those who have never had sexual intercourse. The rationale here is that in the African context AIDS is basically transmitted via sexual intercourse. Those who are engaged in sexual relations might have knowledge about HIV from peers, from sexual partners or sought information themselves because of self-perceived risk. (5) In-school adolescents are likely to have higher knowledge than out-of-school adolescents. There is limited sex education in the school curriculum in Ghana. It is expected that in-school adolescents may have some AIDS education from the school environment and hence have higher knowledge score than their counterparts who are out-of-school. 11 1.3.2 Condom Use The study hypothesizes that there would be significant differences in condom use between the following groups: (1) In-school adolescents are more likely to use condoms than out-of-school adolescents. The reasoning behind is that those in school may primarily be using condom as a means of preventing pregnancy in addition to HIV prevention. Those in school, whether male or female, may want to avoid pregnancy since that is likely to result in interruption of their education (especially girls) or invite the wrath of parents. This can result in termination of support as it relates to payment of fees and other essentials which the students need to continue their education. (2) Boys are less likely to use condoms with their sexual partners than girls. In the Ghanaian cultural environment females are not supposed to be initiators of sex and a girl who carries a condom is viewed as a commercial sex worker. In this regard girls may not go to the store to purchase a condom or carry them around. (3) Those with multiple partners are more likely to use condoms than those with only one sexual partner, since the latter believe that there is little or no risk in monogamy. 12 1.3.3 Sexual Risk Taking The study hypothesizes that there would be differences in terms of sexual risk taking between the following groups: (1) In-school adolescents would be in the lower spectrum of sexual risk taking compared to out-of-school adolescents. It is likely that since they spend most of their time in school (a controlled environment) they may not have enough time to engage in risk-taking behaviour compared to those not in school. (2) Boys would be more likely to take more sexual risk than girls, because of the cultural environment, which is less judgmental and less harsh on boys' adolescent sexuality than on girls'. (3) Those residents in the Ketu South constituency (area of low prevalence) would be high sexual risk takers; those in Upper Denkyira medium risk takers; and those in Offinso South low risk takers. It is expected that those resident in high HIV prevalence area may take less sexual risk since they are aware of HIV and possibly taking preventive measures. (4) Those who discuss HIV/ADDS with their sexual partners are likely to take less sexual risks than those who don't discuss HIV/AIDS with their sexual partners. 13 1.4 Thesis Organization The thesis is organized into six chapters. Chapter 1 introduces our study. It describes its purpose and includes a review of pertinent facts concerning the topic at hand. It also states the hypotheses that the study seeks to verify. Chapter 2 discusses AIDS epidemiology worldwide and narrows the focus to sub-Saharan Africa and Ghana. It further examines the demographic, social and economic effects of HIV/AIDS in the region. The purpose of the chapter is to review the literature, learn from what other researchers have done, describe the problems encountered and the solutions provided, and use all this information to identify current gaps in knowledge. After examining some theories relating to AIDS prevention, the chapter concludes with a discussion of the theoretical and conceptual frameworks underlining our study. Chapter 3 sets the stage for the setting of the research. It provides an in-depth analysis and discussion on Ghanaian adolescents and their environment. It examines the social organization, cultural beliefs and norms prevalent in the communities where the research was conducted, as well as in Ghana as a whole. The chapter concludes by providing information on the Ketu South, Upper Denkyira and Offinso South Districts with regard to demographical characteristics (population size, rural/urban classification, age and sex distribution) school enrolment, health facilities, prevalent diseases, the top 10 causes of morbidity and mortality, ADDS statistics in the district, problems in health delivery systems, 14 water supply, as well as information on overall expenditure patterns for the health care sector. Chapter 4 discusses the methods used in the study and the justification for using these methods. It consists of brief descriptions of the questionnaire, its administration, sample selection, and classification of what constitutes a rural or an urban area. Issues relating to hypothesis generation, pre testing and sample selections are also described. The chapter concludes with ethical considerations and informed consent. Chapter 5 discusses the findings from the research categorized under demographics, AIDS knowledge and understanding, (descriptives, gaps in knowledge, knowledge of other STDs, attitude towards people with AIDS), reproductive health knowledge and peer norms, and predictors of ADDS knowledge. In addition, it discusses the utility of the ADDS Risk Reduction Model as a framework to examine behaviour change for risk reduction in the adolescent population of Ghana as they relate to determinants of condom use and predictors of sexual risk taking. Chapter 6 revisits the overview and purpose of the study, discusses the major research findings and compares them to the other research conducted in the adolescent population in general, and in sub-Saharan Africa in particular. The variables of the ADDS Risk Reduction Model that were of interest in the study are revisited. The major findings from the three models (ADDS knowledge, condom 15 use as a behavioural change, and sexual risk taking) are explored within the context of other studies conducted in sub-Saharan Africa and elsewhere. Finally, the implications of the findings with respect to ADDS prevention and education as well as a discussion of the limitations of the research are provided. The chapter concludes with what has been learned in this study and suggests future areas of research. 16 CHAPTER 2 Literature review This chapter discusses AIDS epidemiology worldwide and narrows the focus to sub-Saharan Africa and Ghana. It further examines the demographic, social and economic effects of HIV/AIDS in the region. The purpose of the chapter is to provide an in-depth critical review of the literature, learn from what other researchers have done, describe the problems encountered and the solutions proposed, and use this information to determine current gaps in knowledge. After examining some theories relating to ADDS prevention, the chapter concludes with a discussion of the theoretical and conceptual frameworks underlining this study. In particular, an explanation of why the ADDS Risk Reduction Model (ARRM) was used in this study to examine behavioral risk reduction among Ghanaian adolescents with regard to multiple partners and condom use is considered. 2.1 HIV Epidemiology 2.1.1 Estimates of numbers infected It is estimated that, as of December 2000, nearly 36.1 million people worldwide, of which 16.4 million are women and 1.4 million children under age 15, were infected with HIV. This number represents one hundredth of those who are sexually active between the ages of 15 to 49 worldwide (UNADDS/WHO, 2000), although 17 prevalence varies between countries and different regions. The worldwide regional distribution of the HIV infected cases as of December 2000 were as follows: Sub-Saharan Africa, 25.3 million; North Africa and Middle East, 0.4 million; South and South East Asia, 5.8 million; East Asia and Pacific, 0.6 million; Latin America, 1.4 million; Caribbean, 0.4 million; North America, 0.9 million; Western Europe, 0.5 million; Eastern Europe and Central Asia, 0.7 million; and Australia and New Zealand, 0.02 million. (UNAIDS, 2001). In 2000, there were 5.3 million incident cases (4.7 million adults, of which 2.2 million were women and 600,000 children under 15) (UNAIDS 2000). About 90% of children who become infected with HIV acquire the virus from their HIV-positive mothers, usually during pregnancy, delivery, or through breastfeeding. When it comes to HIV infection, women appear to be heading for an unwelcome equality with men. By the end of the year 2000, women accounted for 47% of infected adults. This proportion has been rising over the years. In 1997, women accounted for 41% of infected adults, and in 1998, they constituted 43% of all people over 15 living with HIV/AIDS (UNAIDS/WHO, 1998, 2000). These increases reflect the increasing numbers of women who are getting infected worldwide. Of infected adults, the percentage of women with HIV is highest in Sub-Saharan Africa, 55% compared to the Caribbean, 35%; South and South East Asia, 35%; East Asia and Pacific, 13%; North Africa and the Middle East, 40%; 18 Latin America, 25%; Eastern Europe and Central Asia, 25%; Western Europe, 25%; North America, 25%; and Australia and New Zealand, 10%. According to UNAIDS (2000), sub-Saharan Africa has the distinction of being the only region where more women than men are infected and dying with HIV. In addition, for every 10 male incident cases, there are 12-13 women incident cases. Even though prevalence is 0.2% in the USA, AIDS became the leading cause of death among women aged 25 and 44 (Gregson et al., 1997; Rogers, 1997; Selik & Chu, 1991) before extensive application of antiretroviral therapy. In 1985, women represented 6% of the 10,000 incident cases in the US. However, of the 43,517 new cases of HIV in the United States from July 1999 to June 2,000, 24% were among women. Worldwide, since the inception of the infection in the 1980s, 21.8 million (17.5 million adults, of which 9 million are women and 4.3 million children under 15) have died from the disease (UNAIDSAVHO, 2001). Neither incidence nor prevalence of HIV infections is uniform across Africa. Some regions are affected more than others; some countries in the same region are affected more than others; and some communities and geographic areas in the same country are affected differently. For example with a total of 4.2 million infected people, South Africa has the largest number of people living with HIV/ADDS in the world as well as one of the world's fastest-growing epidemics V 19 (UNAIDS, 2000). Even though West Africa, compared to Southern, Eastern and Central Africa has been relatively less affected (for example Senegal has maintained a prevalence of approximately 2%), there are pockets where the epidemic is comparable to some countries in the worst affected regions: Ivory Coast is among the 15 most affected countries in the world. In addition, it is estimated that the most populous country in sub-Sahara Africa, Nigeria has 2.7 million people infected (UNAIDS, 2000). Different reasons have been suggested as to why West Africa has been relatively less affected by HIV than southern and eastern Africa: the almost universal male circumcision; HIV viral type; the presence of HTV-1 which is not as infective and virulent as HTV-2 which is dominant in eastern and southern Africa; the epidemic started earlier in East Africa; the civil wars in Uganda in the 1980s may have spilled over to Tanzania; and migratory patterns in South Africa, such as working in the mines which requires men to live separate from their wives for extended periods of time. Since the spread of HIV is predicated on individual behaviour, peoples' behaviours may have changed because of occupational requirements, destabilising nature of warfare and other issues raised above hence fueling the epidemic in the eastern and southern African countries. 20 2.1.2 HIV surveillance Despite these statistics, in most African countries, the full extent of HIV infection is unknown, since most countries do not have adequate surveillance systems or voluntary testing. The infection rates cited above are derived by statistical modelling techniques and antenatal screening of all pregnant women. In African societies, most women of childbearing age have children and receive some form of antenatal care. Thus, the antenatal surveillance used as a surrogate measure of HIV infection has yielded dramatic results, exposing the spread of HTV infection in the region. However, it should be noted that sentinel surveys at antenatal clinics might grossly underestimate the prevalence of HIV in the population at large. This is because the factors that expose women of childbearing age are the same that expose them to other STDs, which, in themselves, may prevent them from getting pregnant. It was demonstrated in a study in the Mwanza district of Tanzania that the prevalence in antenatal attenders was below that expected of the general population by a factor of 0.75 (Borgdorff et al, 1993). This could be due to early pregnancy loss, infertility due to other STD infections, or decreased fertility in advanced HIV cases. It has been shown that genital tract infections such as Neisseria gonorrhoea, chlamydia trachomatis, Candida albicans and trichomonas vaginalis infections are more common in women with HIV than non-HIV-positive women (Klugman et al., 1991; Leroy et al., 1995). At any rate, 21 such screening has been useful in giving estimates of HIV prevalence. In African societies, most women of childbearing age do have children and receive some form of antenatal care. Non-uniformity in infection is also observed in antenatal screening throughout sub Saharan Africa. For example Sombre et al. (2000) reported 8.8% prevalence among antenatal women between July July 1995 - July 1998 in Bobo-Dioulasso (Burkina Faso); Wilkinson et al. (2,000) observed 34% prevalence in pregnant women aged 20 and 24 attending a public sector antenatal clinic in Hlabisa health district in rural South Africa; and Glynn, Bure, and Kahindo et al. (2000) reported HIV prevalence among women attending antenatal clinics in Younde (Cameroon) 5.5%, Kisumu (Kenya) 30.6% and Ndola (Zambia) 27.3%. While these differences found in antenatal care can be attributed to differences in prevalence, they also relate to the differences in accessibility of antenatal care to women within countries, regions, districts and differences in sampling. It is imperative to know the variations in prevalence since the distribution of infection has a bearing on how scarce resources should be distributed in preventive, and possibly, treatment efforts. Some moderate successes, however, have been achieved in stemming the epidemic through strong prevention programs. Jackson, Ngugi, Plummer et al. (1999) reported the stabilization of HIV-1 seroprevalence in women who were 22 attending antenatal care clinic in Nairobi even though they called for further observation. The percentage of pregnant girls, age 15 to 19, infected with HIV in the capital of Zambia, Lusaka, has on average dropped by almost 50% in the past six years (from 27% in 1993 to 17% in 1998), and the percentage of women who were sexually active fell from 52% to 35% between 1990 an 1996; Uganda's prevalence now stands at 8% from a peak of 14% in the early 1990s and HIV prevalence among 13- to 19-year-old girls has fallen significantly over an eight-year period, while the prevalence in teenage boys has remained roughly stable. These successes observed in Uganda could be attributed to the use of condoms, while the decrease in infection rates in the urban city of Lusaka, Zambia, was the result of a delay in the onset of sexual activity, the decrease in sexual activity of unmarried men, and the decrease in the number of casual sex partners (UNAIDS, 2000) and probably the epidemic reaching its maximum. The successes in Uganda are also partly attributed to President Yoweri Museveni using his position to emphasize issues of behavioral change intervention. 2.2 Modes of HIV Transmission Worldwide the dominant mode of HIV transmission is sexual intercourse. The other important modes are vertical transmission (mother-to-child), and blood borne. Mother-to-child transmission can occur in pregnancy, during delivery or 23 breastfeeding and accounts for more than 90% of HIV infection in children worldwide (TJNAIDS/WHO, 2001). Risk factors for mother-to-child transmission are high maternal viral load (Shaffer et al 1999, Mofenson et al 1999, Garcia et al 1999), advanced maternal immune deficiency (European Collaborative Study 1992) and prolonged rupture of membranes (Landesman, 1996). With regard to transmission via breastfeeding, Semba et al (1999) reported the association between both viral R N A load and subclinical mastitis as risk factors. However, Coutsoudis et al (1999) reported that exclusive breastfeeding was associated with reduced risk of transmission and carried a significantly lower risk of HTV-1 transmission than mixed feeding even after adjustment for potential confounders such as cd4/cd8 ratio, syphilis screening test results, and preterm delivery. Blood borne transmission includes injection drug use, blood transfusions, use of blood products, and contaminated medical or other skin-piercing equipment. In industrialized countries, transmission through blood products and transfusion has almost been eliminated, as blood is now screened before transfusion. However, in some developing countries this problem still persists. Vertical transmission from mother to child has also been dramatically reduced in industrialized countries with administration of antiretroviral prophylaxis during pregnancy and birth. In the earlier years of the epidemic, between 13% to 40% of the infants born to HIV-infected women were expected to contract HIV 24 (Way and Stanecki, 1994; Gabiano et al., 1992; Ryder, Nsa et al., 1989). Studies have noted that in the absence of breast feeding and antiretroviral prophylaxis, about 30% of mother-to-child transmission of HTV occur in utero and 70% during labour and delivery (Mock et al., 1999; Bertolli et al., 1996; Simonon et al., 1994). In 1994 the efficacy of AZT in decreasing mother-to-child transmission was reported (Connor et al 1994). With this result intensive AZT monotherapy became the standard of care and researchers reported a 2/3 decrease in frequency of mother-to-child transmission compared to no therapy (Cooper et al 1996; Fiscus et al 1996; Mayaux, 1997). It was also found that combination of A Z T and elective cesarean deliveries compared to other modes of deliveries was associated with only 1-2% risk of transmission (The International Perinatal HIV Group 1999; European Mode of Delivery Collaboration, 1999; Mandelbrot et al 1998) and it became the first-line recommendation in Europe (Tovo et al 1999). The industrialized countries have moved from AZT monotherapy to combination therapy, such as lamivudine-zidovudine. Grubert et al. (1999) and Silverman et al (1998) reported the efficacy of lamivudine-zidovudine therapy in pregnancy and Mandelbrot et al (2001) reported overall 1.6% transmission rate in a non-breastfeeding population after lamivudine-zidovudine combination therapy of which 1.10% was following elective cesarean delivery, and 1.75% after other types of delivery. The study group experienced mother-to-child transmission to be 5 25 times lower than what was reported in the control group (zidovudine alone) after adjusting for mode of delivery, maternal disease stage and prior anti retroviral experience. The benefit derived from the combination therapy of lamivudine-zidovudine is said to be partly due to its ability to decrease maternal plasma FflV-1 R N A levels in excess of 1 logio copies/mL compared to zidovudine alone (Sperling et al 1999). In less developed countries, however, the prohibitive cost of these drugs make the treatment unaffordable, resulting in the probability of the transmission of HIV from pregnant mother to child in utero remaining between 21% to 43% (Working Group on Mother-to-Child Transmission of HIV, 1995), with over 50% of the transmission thought to occur late in pregnancy or during labour and delivery (Rouzioux et al., 1995; Bertolli et al., 1996). With an increasing proportion of women being infected especially in sub-Saharan Africa, infant and child mortality rates attributable to perinatal transmission of HIV are increasing. However, recent experiments have been conducted in developing countries and reported in the literature that offer a glimmer of hope. For example shorter zidovudine regimens administered few weeks before and during labour also reduced mother-to-child transmission by 37 to 38% in breastfeeding women in Ivory Coast and Burkina Faso, and 50% in non-breastfeeding populations in Thailand (Wiktor et al 1999, Shafer et al 1999). These trials (Burkina Faso and 26 Ivory Coast versus Thailand) underscore the problem in trying to reduce mother-to-child transmission in areas such as sub-Saharan Africa where there is universal breastfeeding. Nduati et al (2000) report that breastmilk avoidance could potentially decrease overall mother to child transmission by 44% and that early cessation of breastfeeding would prevent some infections but complete avoidance would be necessary to dramatically reduce transmission. Oral nevirapine has also been shown not only for its efficacy over zidovudine (Guay et al., 1999) but also because of its cost effectiveness (Marseille et al 1999) in reducing mother-to-child transmission. Guay et al. (1999) reported the efficacy and safety of a single-dose oral nevirapine over oral zidovudine given to women in Kampala, Uganda, during labour and to neonates during the first week of life. The efficacy of nevirapine compared to zidovudine was 47% better, up to age 14 to 16 weeks. Even though the need for long-term follow up of the babies to find out about possible long-term toxic effects and development of resistant strains in the population is needed, these authors contend that development of a resistance is far less likely in a single dose than in a multi-dose regimen. Apart from antiretroviral prophylaxis in industrialised countries, safe alternatives to breastfeeding have resulted in reduced postnatal mother-to-child transmission. The successful use of antiretroviral agents and replacement feeding in developed countries has led to suggestions that it may be possible to reduce perinatal transmission rates to less 27 than 2% (Bryson, 1996). This optimism, however, is not shared by developing countries, because even if mothers do not infect their babies during pregnancy or delivery, the newborns can still contract the infection through breastfeeding. HIV transmission via breastfeeding was first reported in 1985, when a case report described how a mother infected her baby postpartum after she had blood transfusion (Ziegler, Johnson and Cooper, 1985). In the same year, Thiry et al. (1985), and later others, reported the presence of HIV-1 in breast milk (Oxtoby 1990; Van de Perre et al., 1993; Ruff, 1994; Nduati et al., 1995). Subsequent prospective studies showed that infants born to HIV-positive mothers who breastfeed are more likely to contract the virus than infants from HIV-positive mothers fed on formula, even after accounting for other factors known to be associated with mother-to-child transmission (European Collaborative Study, 1992; Ryder, 1991; Tess et al., 1998; Tovo, 1988). As a result of the report linking breast milk to mother-to-child transmission, the US Center for Disease Control and Prevention issued a guideline that HIV infected women should not breastfeed and this became the standard of care in the industrialized world. (CDC, 1985). However, breastfeeding continued to be responsible for a high proportion of mother-to-child transmission in developing countries, where 1 in 7 children born to HIV-positive mother was 28 expected to be infected through breast milk (UNAIDS, 1997). In addition, breast-feeding is suspected to double the transmission rate between those infants who are breastfed and those not breastfed (European Collaborative Study, 1992; Tess et al. 1998) and may be the major determinant for the difference in transmission rates between developed and developing countries. This is because in industrialised countries few HIV-positive women breastfeed whereas in poor countries alternatives to breastfeeding are not feasible for financial, logistical, health and cultural reasons (Vials, 1997; Nicoll et al. 1995; Kennedy, Visness, & Rogan, 1992). In developing countries, especially sub Saharan Africa, breastfeeding is almost universal. It is suggested that one-third to one-half of perinatal HIV infections in the African environment can be attributed to breastfeeding (Nduati et al 2000; Miotti et al 1999; Wiktor, Ekpini, Nduati 1997; Dunn et al 1992). Nduati et al. (2000) report that substantial transmission occurs early during breastfeeding. In their study, by 6 months, an estimated 75% of all breast milk transmission had occurred despite ongoing exposure for an average of 1 additional year. They concluded that transmission risk is nonlinear during breast milk exposure duration and could be due to variation in breast milk infectivity over time. In an earlier study by the authors, of breast milk samples from birth to older than 9 months, they found the highest prevalence of HIV-1 D N A in breast milk cells in samples collected between 1 week and 3 months (Nduati, John, Richardson 29 et al. 1995) . . The issue of whether HIV-positive mothers in resource-poor countries should knowingly breastfeed has been controversial at best. In 1987 and again in 1992, while acknowledging the association between breastfeeding and mother-to-child transmission of HIV, the World Health Organization's Global Program on AIDS nevertheless issued guidelines which called for the breastfeeding of babies born to both HIV-positive and HIV-negative mothers in developing countries where the primary causes of infant deaths were infections and malnutrition (WHO, 1992). This policy was based on the fact that gastrointestinal, malnutrition, and respiratory infections remain greater killers of children in developing countries than AIDS. The diarrhoel diseases, which killed more than two million children in 1996, could be contracted through use of contaminated water via bottle-feeding. In 1996, a revised statement by the Joint U N Program on HIV/ATDS recommended that that all pregnant women should be offered voluntary counselling and testing, and HIV-infected women should be made aware of the transmission risks of breastfeeding so that they can make informed decisions. Whatever decision the woman makes should be supported (Joint U N Program on HIV/ATDS, 1998). Obviously, there are certain downsides to this policy such as those mentioned above (e.g. malnutrition, deaths from gastrointestinal infections as 30 a result of lack of breast feeding in developing countries) which formed the basis of the 1992 policy. The fact that many women in resource-poor countries have no access to voluntary testing and counselling is a major obstacle to the implementation of this policy. Even when a woman knows her FflV-positive status, she is confronted with unsafe water and cultural norms that dictate infants must be breastfed. It is also difficult to explain to her neighbors why she does not breastfeed without disclosing her HIV status thus reaping unpleasant social consequences. Additional guidelines published by the World Health Organization call for adequate replacement feeding for HIV-positive mothers. Where it is not possible then mothers may choose among three other strategies to reduce the risk of HIV transmission through breast milk: early cessation of breast feeding which reduces the time the infant is exposed to HIV through breast milk (Leroy, Newell, & Dabis, 1998; Epkini et al., 1997; Van de Perre, 1997); heat treatment of breast milk; and finally, wet nursing by a tested HTV-negative women (UNICEF/UNAIDSAVHO, 1998). Thus whatever approach is adopted there is the need for further studies regarding mother-to-child transmission via breastmilk as different schools of thought pervade. Some believe complete avoidance of breastfeeding would be necessary to markedly reduce transmission (Nduati et al 2,000) and some, exclusive breastfeeding with early weaning usually at age 6 months (Coutsoudis et 31 Modes of HIV transmission vary as greatly around the world as do infection levels. Table 2.1 (next page) describes the main mode of transmission for adults and the prevalence (UNAIDS 2000). Table 2.1 Major modes of HIV transmission throughout the world Region Adult prevalence4 % of HTV+ adults who are women Main modes of transmission for adults living with HTV Sub Saharan Africa 8.8 55 Hetero1 N. Afr & MidEast 0.2 40 Hetero, IDU 2 So. & SE Asia 0.56 35 Hetero, IDU East Asia & Pacific 0.07 13 IDU, Hetero, MSM 3 Latin America 0.5 25 MSM. Hetero, IDU Caribbean 2.3 35 Hetero, MSM E. Europe &C. Asia 0.35 25 IDU Western Europe 0.24 25 MSM, IDU North America 0.6 20 MSM, IDU, Hetero Austra & N Zealand 0.13 10 MSM Total 1.1 47 Legends 1 Hetero = Heterosexual transmission 2 IDU = Transmission through injection drug use 3 MSM = Sexual transmission among men who have sex with men 4 The proportion of adults (15-49 years of age) living with HIV/AIDS in 2000 using 2000 population figures 32 2.3 Groups most at risk of infection As can be observed from the table above, HIV transmission in the African continent is primarily heterosexual transmission. Sexual behaviour and existence of other STDs have been linked to facilitate transmission. Infection is highest in the following sub-groups: (1) Commercial sex workers: The prevalence of HIV is very high in this group especially in eastern and southern Africa and Abidjan. In 1994-1995 nearly 70% of them in Abidjan were reported to be HIV positive (UNAIDS, 2000) (2) Displaced populations in armed conflicts such as those in Ethiopia. Rwanda and Liberia: Ethnic conflicts, wars, famines, environmental disasters have displaced millions of Africans in the 1980s and 1990s. When people become displaced, the result is untold hardship that might lead to — or even require ~ sexual-risk taking in order to eke out a living and survive. Furthermore, gathering masses of people in refugee camps results in unsanitary conditions and lawlessness, and exposes individuals to sexual partners they may otherwise never have met. Examples of the displaced include people from Ethiopia, Mozambique, Sudan, Rwanda, Liberia, Sierra Leone and other war-torn countries. Women and girls are at increased risk in these conflicts where rape is rampant. (3) Populations living in urban and trading centers: On the average, HIV prevalence in urban areas is 5 times that in rural areas (World Bank, 1996). Up to 33 30% of urban adults in Malawi, Zambia, Botswana, Rwanda, and Uganda are infected with HIV and according to UNAIDS, more than 1 in 4 adults living in Zambian cities are HIV positive, while about 1 in 7 Zambian adults are infected in the country's rural areas (UNADDS, 2000). The proportion of women to men in urban areas influences HIV transmission. Where there are fewer adult women than men in urban areas, the HIV prevalence is higher in both sexes compared to areas that do not have this inequality in sex ratio (Over & Piot, 1993). (4) Migration within countries/across borders or increased urbanisation This demographic phenomenon may result in communities with a high concentration of males and thus, generate an increased participation in commercial sex (UNAIDS, 1996) or extramarital affairs. Urbanisation, unemployment, and the search for non-existent jobs or lack of skill for existing jobs place migrants at risk. Since HIV has a long incubation period, people in dire need may be more concerned with present survival rather than the consequences of ADDS, which may not manifest themselves for years. Women who find themselves in this situation may engage in commercial sex or barter sex for the basic necessities of life - food, shelter, and clothing (UNDP, 1997). (5) Other professional groups characterized by high mobility: For example groups like military personnel, truck drivers, and traders are at higher risk of HTV infection (UNAIDS, 1996). Of the truck drivers from 8 different countries who 34 travel the Mombassa-Nairobi highway, Bwayo et al. (1992) found an HIV prevalence of 27%. In 1994, a prevalence of 16% was found among truck drivers in Bobo-Dioulasso, Burkina Faso (UNAIDS, 2000). These truck drivers are known to have girlfriends along their routes. (6) Young women especially among 15-24 year olds: Young women (age 15-24) are 2-3 times more likely to be infected by age 24 than young men (UNAIDS, 2000). In Masaka, Uganda, HIV prevalence in 13- to 19-year-old females is 20 times higher than in males of the same age (TJNATDS, 1996). In Ghana, the HIV-infected female to male ratio in the 15 to 19 age group is 10:1 and in the 20 to 24 age group, the ratio is 6:1 (Ghana National AIDS Control Programme, 1996). 2.4 Biological and Social Determinants of HIV There are biological and sociological factors that put women at greater risk than their male counterparts. For example, the rate of transmission from male to female is two to three times higher than from female to male (Royce et al., 1997; Downs & De Vincenzi, 1996). Soto-Ramirez et al. (1996) suggest that the Langerhans' cells of the cervix may provide a portal of entry for HIV and some HIV sero types may have higher affinity for these cells, and therefore, be more efficient in heterosexual transmission. In addition, vulval and vaginal inflammation or ulceration due to inadequately treated or unknown STD infections may act as 35 co-factors for HIV infection (Mayaud 1997; Sewankambo 1997; Irwin & Ellerbrock, 1995; Dallabetta, 1994; Laga, 1993; Hoegsberg, 1990). Moreover, other non-sexually transmitted cervical lesions, such as schistomiasis may facilitate HIV infection (Feldmeier, Krantz, & Poggensee, 1994). In addition to women's increased biological susceptibility to STD infections as compared to men, other reasons account for the disparity between infection in men and women: (1) Girls' first sexual encounter occurring at an earlier age than boys'. In Masaka, Uganda, the median age of first sexual intercourse is 15 for females and 17 for males (UNAIDS, 1996) and in Ghana, the 1988 Demographic Health Survey data shows 16.7 years as the median age of first sexual intercourse for girls. The survey also indicates that among Ghanaian women, age 20 to 24, about 60.5% had their first sexual intercourse by the time they were 18 or 19 (Blanc and Rotenburg, 1992). (2) The nature of sexual relationships. Younger women tend to have sex with older men (age mixing), either through marriage or for money, shelter, or other advantages. (3) The sexual behavior of non-monogamous male partners, who may either have girlfriends or visit commercial sex workers, exposes adult, married women to higher risk. 36 (4) Gender inequities, poor health and lack of communication are also linked to an increasing risk of HIV infection for women. Gender inequity has an impact on a woman's ability to negotiate safe sexual practice. High levels of illiteracy may make women less informed about HIV prevention and access to affordable health care, particularly to treatment of sexually transmitted diseases (UNDP, 1997). In the Ghana Demographic Health Survey of 1993, only 54% of all women interviewed and 34% of women with no education had ever heard of STDs other than AIDS (Ghana STD/ATDS Control Program, 1996). (5) In some societies, traditional practices such as "dry sex" vaginal douching with non-antiseptic compounds, female circumcision and "widow cleansing" may all elevate the risk of HIV infection in women (Taha et al., 1997; Civic & Wilson, 1996; Gresenguet, 1997; Dalabetta, 1995; Sandala et al., 1995; Campbell & Kelly, 1995; Runyanga & Kasule, 1995; Runyanga, Pitts, & McMaster, 1992). Vaginal douching with antiseptic compounds such as Dettol can disrupt vaginal pH and flora, potentially increasing a woman's susceptibility to HIV infection should she get exposed to the virus. (6) Finally, the desire and societal pressure to reproduce make it difficult to practice protected sex. There are no methods for women to use except 37 the female condom (Feldblum et al., 1995; Drew 1990), which most women cannot afford or is not widely available. In conclusion the biological and social determinants of HIV infection include unprotected sex (not wearing condoms) with multiple partners, high levels of promiscuity, high numbers of men who have sex with commercial workers and younger women in some countries, the prevalence and poor management of other STDs, gender inequalities, a disproportionate ratio of men to women in urban areas, social conflicts/upheavals, and extensive migration. It is fairly clear that the HIV epidemic in sub-Saharan Africa would have been less severe had it not been for the pervasiveness of these determinants (World Bank, 1996). 2.5 The Economic and Social Impact of AIDS in Sub-Saharan Africa The ADDS epidemic has spread worldwide and touched every community. AIDS has affected all groups irrespective of age, gender, sexual orientation, and income. The cost of AIDS is very high, and not only in terms of human lives. It also forces communities and countries to divert scarce resources from development programs to providing care to the women and men who are ill and dying in the prime of their lives. HIV infection is also associated with premature death and costs ~ economic, emotional and social ~ not only to caregivers, family, friends, and hospitals, but also to society in general, as those who are afflicted are 38 people of childbearing age, parents who are supposed to provide for their children and for the elderly. HIV/AIDS affects the most productive and socially active segment of society. Thus, premature deaths results in lowered economic productivity. In the African context, this effect is magnified because the continent is already steeped in poverty and general socio-economic malaise: 35 of the 45 countries in the world classified by the U N as "least developed" are in Africa. Moreover, Africa is the only region in the world likely to experience an increase in absolute poverty over the next decade (UNDP, 1997). 2.5.1 Costs of Caring and prevention In Namibia, estimated direct costs of HIV/AIDS to the country for the years 1996 to 2001 is N $384.8 million (US $80.2 million) and indirect costs (lost productivity, absenteeism, additional training costs and others) are estimated in the same period to cost N $8,207.5 million, which is about US $1,709.9 million (UNAIDS, 1997). About $100 million dollars were spent on AIDS prevention programs in 1992 in Africa, only 10% of which came from African governments. In addition, African governments spent $183 million on care for AIDS patients in the same year (World Bank, 1996). According to Ainsworth and Over (1997), the yearly direct cost of treating a single person for AIDS is 2.7 times the per capita income 39 of each patient in some countries. Furthermore, it is estimated that in the developing world, an FflV adult patient has on average 17-ATDS related illnesses prior to death, and a child, 6.5 (UNDP, 1997), which significantly increase expenditures. A study conducted at Mama Yemo hospital in Kinshasa, in former Zaire, states that pediatric in-patient AIDS treatment cost $90 per patient, which is three times the average adult annual income. Moreover, an average of $109 was spent on medical care before admission. Thus, AIDS is clearly straining health systems, especially those in which the yearly expenditure for all health care is less than $16 per capita. Critical decisions will have to be made to redirect scarce resources into HIV treatment. These decisions may have many unintended consequences. 2.5.2 Per Capita and Income Losses Studies suggest that AIDS has a negative impact on the growth of per capita income (Stover, 1993; Over, 1992). This is because, apart from the reduced productivity of the labour force, ADDS diverts public and private savings into medical, burial, and welfare expenses. These costs arise from increased absenteeism, labour turnover, healthcare costs, burial fees, recruitment costs and retraining costs. 40 2.5.3 Education Because of adult premature mortality and infant and child mortality, HIV/AIDS also affects education. Increased illness and death in children will cause school attendance and enrolment to decline. As for adult premature mortality from AIDS, it impacts education for two reasons: First, the death of a parent, especially the father, often deprives the family of income. This ushers in economic hardship: The children may receive no education, because the family resources are woefully inadequate to provide funds for school fees and supplies. Moreover, the children often have to leave school and work to generate income to support the family. The death of a mother denies nurturing and has a more serious impact on education than the death of the father, since children, especially girls, may be taken out of school to assume female roles within the household. Second, teachers and university faculty also suffer from AIDS. This results in a shortage in the labor force and has an impact on the efficiency of the school system. For example, it was projected that of 6,262 teachers, 2,200 (35%) would die from ADDS in Uganda between 1993 and 1996, with a direct replacement cost of $1 million. It is also estimated that 14,460 teachers will die from ADDS by the year 2010 in Tanzania, at a direct replacement cost of $21 million (World Bank, 1996). The HIV infection of personnel is not restricted to the primary and secondary levels, but is also considerable in universities, where faculty and students alike are 41 infected in high numbers. Mburuou (1993) states that 14% of the university faculty in Kenya was infected with HIV. 2.5.4 Labour Productivity (In Such Sectors as Agriculture. Mining and Health) The physically debilitating nature of ADDS saps the energy of those infected. Shifts in agricultural cultivation have been observed in the AIDS-afflicted areas of Uganda's Rakai district, from crops that produce a nutritious diet and crops requiring labor-intensive cultivation, such as coffee and banana, to crops that produce less varied and nutritious diets, consisting mainly of carbohydrates, such as cassava and sweet potato. In the area studied, there was an apparent absence of young people, age 18 to 35 (Stoneburner et al., 1997. 2.5.5 Impact on Households On average, an infected Malawian would lose 15.6 years of productive lifetime, because of disability and death due to AIDS (FHI, 1992). Households feel the debilitating economic effect of AIDS in the adult population when they must pay for medical care and funeral expenses for the deceased. ADDS also results in decreased household savings and disruption in family life. Sometimes an AIDS diagnosis occurs when an infant presents AIDS symptoms. The mother may be blamed as cause of the infection, with untold hardships (such as discrimination, 42 or expulsion from the household) arising as a consequence. 2.5.6 Increasing Orphan Population Since the epidemic began, AIDS has created over 12.1 million orphans out of a global total of 13.2 million. Prior to ADDS, about 2% of all children in .developing countries were orphans (UNAIDS, 2000). In this case, an orphan is denned as HIV-negative children who lost their mother or both parents to AIDS before age 15 (UNAIDSAVHO, 1997). When the effects of AIDS on the number of orphans are tabulated by country, Uganda has 1.2 million cases, and it is estimated that ADDS orphans 50,000 more Ugandan children annually (UNAIDS, 1997). In Kenya, the National ADDS and STD Control Programme (NASCP) estimated that in 1996, about 300,000 Kenyan children under 15 had lost their mothers to ADDS. This number was projected to reach 600,000 by year 2000 and 1 million by year 2005 (USADD/ADDSCAP/FHI, 1996). The burden posed by ADDS has stretched the traditional extended family system beyond coping. The result is that in some households children, are being cared for by other children as young as 10 or 12 years old. In other families, as it has been reported in Kenya, there is a complete collapse of the family structure, leaving orphans homeless in the streets (USADD & FHI/ADDSCAP, 1996). When parents die of ADDS, orphans lose more than parental and emotional 43 support. The loss of a father means the loss of an income and disruption in family life. Children may be sent to live with relatives, end up in orphanages or become the burden of their already aged grandparents. The loss of a mother also means a loss of nurturing. Often, older sisters who are themselves children become "mothers" to younger siblings. Orphans not only suffer the loss of their families, they may also get depressed, suffer from malnutrition, receive no immunization and health care, work to provide an income, lose educational opportunities, lose their inheritance, or be forced into migration, homelessness, vagrancy, starvation, crime, and exposure to HIV infection (Hunter & Williamson, 1994). Hunter and Williamson (1994) observe that prior to HIV, orphaning on large scale has been a sporadic, short-term problem, caused by war, famine or diseases. But HIV has transformed orphaning into long-term, chronic problem in societies having a limited experience dealing with this phenomenon: 2.6 Demographic Impact of HIV/AIDS in Sub-Saharan Africa The demographic impact of HIV/AIDS is examined in terms of population loss, population growth rates, crude death rates, fertility rates, life expectancy, age distribution, infant and child mortality, dependency ratios, gender ratios, loss of a spouse, and household composition. AIDS has a significant impact on demography in sub-Saharan Africa. In Western Europe, North America and Oceania, apart 44 from the advantage of antiretroviral therapy, the population most affected by HIV is men who have sex with men. Thus, the demographic impact in the absence of antiretroviral therapy is seen primarily in the reduction in life expectancy (Hogg et al., 1997). However, in sub Saharan Africa, the predominance of heterosexual transmission and the high infection rates of women (about 40%) of childbearing age, has made the demographic impact of ADDS more devastating. As a result, in developing countries as well as in sub-Saharan Africa, AIDS causes decreased life expectancy, decreased fertility, decreased productivity, increased adult and child morbidity, increased orphan population and adverse effects on labor force participation in agriculture, industry, transport, education, and other sectors. 2.6.1 Total Population Loss In Namibia, AIDS causes nearly twice as many deaths as malaria, which is the next most common killer (UNAIDS/WHO, 1997). A Dar es Salam study identifies AIDS as the number one killer among women of reproductive age (Urassa et al, 1994). In Abidjan, Ivory Coast, AIDS is the number one killer of women of reproductive age and the number fourth highest killer of men, age 20 to 44. In Zimbabwe, more than 2,000 people die of AIDS each week (UNAIDS, 2000). Since HIV weakens the immune system, people infected by tuberculosis, 45 which might otherwise have been dormant, have begun to develop active TB, as has been observed in North America. In sub-Saharan Africa, however, the result is increased mortality due to TB, because of lack of treatment options. Some estimates project that from the year 1995 to the year 2000, annual deaths from TB in the region will double (World Bank, 1996). 2.6.2 Crude Death Rates There are country variations in crude death rates just as there are in population growth rates. Data are not age-adjusted. The intention is not to do cross-country comparisons but to discuss the impact of ADDS on death rates in different countries. Death rates are directly related to the prevalence of HIV in each country. Overall the crude death rates are expected to increase 1.5 times. Specifically, it is projected to increase by half in Ethiopia, three times in Tanzania, Zimbabwe, and Uganda (Gregson et al., 1994) and three to six times in countries like Zambia, Zimbabwe and Malawi (Hunter & Williamson, 1994). 2.6.3 Infant and Child Mortality Improvements in infant and child mortality achieved prior to the arrival of HIV have been compromised. According to the US Bureau of the Census by the year 2010, if HIV propagation is not contained, AIDS will increase infant mortality 46 by as much as 75%, and under age 5 mortality by more than 100% in the worst affected regions (US Bureau of the Census, 1997). ADDS impacts severely on infant and child mortality in sub Saharan Africa because HIV is transmitted to the infant in utero or during delivery or through breastfeeding and most die before their second birthday. 2.6.4 Life expectancy The AIDS epidemic has caused declines in life expectancy in some countries especially those with advanced epidemics. Life expectancy has dropped to 46 years and 46.7 years in Burkina Faso and Ivory Coast respectively and to 56.9 in South Africa and 41.9 in Zimbabwe (Ainsworth and Over, 1997). This dramatic decline has wiped out 2/3 of the advances made in life expectancy from the 1950s to the 1990s. In discussing country-specific effects, Botswana's life expectancy increased to 61 years in 1990 from 43 years in 1955. With estimated 25% - 30% infection of the adult population with HIV, the life expectancy is expected to decline to 44 years (UNAIDS/WHO, 2000). In Zimbabwe it is estimated that life expectancy of children bom today will be 20 years shorter due to AIDS (Ainsworth & Over, 1997). The likelihood of a 15-year-old woman dying before the end of her reproductive years quadrupled from around 11% in the early 1980s to over 40% by 1997 (UNAIDS, 2000). 47 2.6.5 Rate of Population Growth With deaths from AIDS increasing, it is expected that population growth may remain stagnant, low, positive or negative, depending on the HJV prevalence in any given area. Since growth rates are a function of fertility and mortality, in some countries like Botswana and Zimbabwe, the drop in fertility rates may be enough to result in negative population growth by year 2010 (Hunter & Williamson, 1994). In Malawi, the population growth rate may approach zero, while in Central African Republic, Kenya, Lesotho, Rwanda, South Africa, Zambia, and Tanzania it may only be around 1% (Hunter & Williamson, 1994). 2.6.6 Fertility Total fertility may eventually decline as women of childbearing age are infected in higher numbers and die prematurely. Infected women who are aware they will die might also decide not to have more children for fear of leaving them orphaned. Other women may not bear children because other STDS have resulted in sterility. 2.6.7 Gender Ratios Gender ratios are likely to change because HIV afflicts more women than 48 men in some countries. In Masaka, Uganda, HIV prevalence in 13- to 19-year-old females is 20 times higher than in males of the same age (UNAIDS, 1996). In Ghana, the female to male ratio in the 15 to 19 age group is 10:1, and in the 20 to 24 age group the ratio is 6:1 (Ghana National AIDS Control Program, 1996). Thus, there would be more men than women in those countries where infection in women are more prevalent. Gregson, Garnett and Anderson (1994) ascribe these imbalances to two principal factors: the higher risk of transmission through heterosexual intercourse from males to females than conversely; and the tendency for female partners to be younger than their male counterparts (age-mixing), who are likely to have engaged in sexual activity for a longer period and to be at high risk for HIV infection. The result is an increase in the mortality rate of younger adult females as compared to males. Let us note that the death of mothers of childbearing age will adversely affect children's welfare, as childcare is considered the domain of women in sub-Saharan Africa. Moreover, high mortality rates in women exacerbates the already significant association described above, where areas with high male to female ratios tend to have high AIDS rate, especially among women, thus creating a vicious circle. 2.6.8 Loss of a Spouse In countries where more men are infected than women, the number of 49 widows would increase. Since men in sub-Saharan Africa are generally the breadwinners of the family, losing a father may have adverse economic consequences for the family. A study conducted in Accra, Ghana, notes that the majority of women in the Ghana Widows Association (resident in Accra-Tema metropolitan area) lapsed into prostitution after the death of their husbands (Asamoah-Adu et al., 1994). A Ministry of Health study in Zambia estimates that 16% of Zambian households might be headed by widows in the future (Hunter & Williamson, 1994). 2.7 Current State of Knowledge 2.7.1 Review of the Literature on HIV and STD Studies Conducted on Adolescents with Special Emphasis on Studies Conducted in Africa Pertaining to Adolescent Knowledge. Attitude, and Sexual Risk Taking. Sexual risk taking is common among teenagers, regardless of the existence of AIDS or of the knowledge of its consequences. In Namibia, 37% of 12 tol8 year-old adolescents reported that they had had sex, nearly half of them with more than one partner. Most said they believed that their own partners had other partners too. In Tanzania, 12% of teenage males and 37% of the 20 to 24 year-old males reported that they had multiple sex partners in the last year. In Mali, two out of five sexually active boys in their teens said they last had sex with a prostitute 50 or casual partner (UNAIDS, 1997). Nzyuko et al. (1997) conducted a cross sectional study of 200 adolescents (52% female) to determine the demographic characteristics and HIV-related risk behaviour of adolescents (age 15 to 19) frequenting three truck stops—Malaba, Sachangwan, and Mashinari— along the Trans-Africa Highway in Kenya. Eighty nine per cent of the participants were out of school. Sentinel surveillance data collected among pregnant women in the rural districts where two of the truck stops are located indicate HIV prevalence as high as 10% to 20%. A standardized questionnaire assessing the participants' demographic characteristics, HIV/ATDS knowledge, attitudes and beliefs and sexual behavior was administered to the participants. To prevent the over-recruitment of adolescents involved in the sex trade, beer halls and other areas associated with the sex trade were avoided whjpn recruiting study participants. In addition, no recruitment was done at night, since the researchers assumed that the 15 to 19 year old adolescents on the street at night were likely involved in the sex trade. The researchers were interested in three behaviors: having sex with truck drivers; receiving money or gifts in exchange for sex; giving money or gifts in exchange for sex. The researchers found that females tended to initiate sexual activity earlier than males. More females than males had ever had sex at a truck stop and females reported a median of 20 sexual encounters in the two previous months preceding 51 the survey compared to only six reported encounters for males. In addition, 14% of the subjects reported having anal sex. Sexually transmitted diseases were common (52% of the females and 30% of the males reported ever having an STD), especially gonorrhoea, which the respondents reported treating with self-medication. Analysis of three major behavioral risk factors indicated that 46% of the females usually had sex with truck drivers, 78% of the females usually received money or gifts for sex and 59% of the males usually gave money or gifts for sex. Based on these three behaviors, the authors conclude that older adolescents, those not in school and those not living with relatives are more likely to be at risk. Ndeki, Klepp, Seha and Leshabari (1994) administered a survey to students in grade six and seven in one of 18 randomly selected primary schools in the Arusha and Kilimanjaro regions of Northern Tanzania using the World Health Organization's knowledge, attitudes, beliefs, and practices (KABP) survey instrument. They found that overall, knowledge of ADDS was low, even though the students reported being exposed to several sources of AIDS information. Patullo, Malonza et al. (1994) report that questions of knowledge were answered correctly by an average of 77.1% of the students, when they administered a questionnaire to students in 11 Kenyan secondary schools. Students' knowledge was deficient in the following areas: the inability of mosquitoes to transmit the virus, the protective effect of condoms, the lack of 52 protection from medications, the fatal and incurable nature of AIDS and the fact that those infected with HIV may appear healthy. Overall 48.7% of the students (25.3% of males and 71.3% of females) reported no prior sexual activity. Multiple sexual partners as a risk factor was reported by 41.2% of males but only 7.3% of females. Sixty per cent of the students admitted never using condoms during sex and only 6.8% of those with multiple partners used them all the time. The authors conclude that even though Kenyan students showed a high level of knowledge regarding HIV and AIDS, there was a sizable number who admitted to extensive sexual experience, but who were not using condoms, thereby putting themselves at risk. Asindi, Ibia and Young (1992) report that while general awareness of AIDS was fairly good, detailed knowledge was riddled with misconceptions and confusions. In a study of 738 secondary school adolescents in Calabar, Nigeria, about 30% did not know that AIDS existed in Nigeria. Most of those who had heard about AIDS knew that the major modes of transmission are promiscuity, blood transfusion, and sharing injection needles and syringes. However, some still incriminated toilet seats, eating utensils, hand shaking, and kissing. Only 31% were aware of the protection offered by condoms. To protect themselves 45% preferred abstinence, restricting sex to only one sexual partner, and only 3.6% would use condoms. As to what should be done to prevent the spread of AIDS, 53 the respondents prescribed isolation (37%), treatment (34%), and killing (14%). About 77% said they would stop seeing friends and 63% would reject relatives who develop AIDS. In order to determine knowledge, attitudes, and practices connected with high risk factors pertaining to HIV/AIDS in a rural community, six senior medical students interviewed a random sample of 89 adult males in a rural community in the Dembia district of Ethiopia. About 74.2% reported having heard something about AIDS. Eighty males (89.9%) did not know about condoms. Among those that did, the most common sources of information were close friends, health workers, schoolteachers and the radio. The attitude observed was that as many as 60.7% were afraid of getting AIDS but 7.5% had practiced extramarital sex in the past three months (Ismail et al., 1995). Kapiga, Lwihula, Shao and Hunter (1995) interviewed 2,285 women at three representative family planning clinics between February 1991 and June 1992, in order to identify predictors of having only one sex partner in the last year and to assess knowledge and use of condoms among women of reproductive age in Dar-es-Salaam, Tanzania. Although knowledge of sexual transmission of AIDS was very high, less than half of the respondents (42.5%) mentioned the use of condoms as an ATDS-preventive measure. Only 4.6% of the women interviewed were regular users of condoms, while 19.8% were occasional users of condoms. But the 54 57.5% who had never used a condom reported not using it because "men did not like them." Other reasons given for the lack of condom use were that they "were using other contraceptive methods" (28.7%), respondents "don't like condoms" (5.5%), they "trusted their partners" (5.3%), and "because condoms make sex less enjoyable" (4.1%). The better educated and the younger men were more likely to use condoms for AIDS prevention, even though the overall number of use was very small. The investigators also found that 14.8% of the women reported having more than one sex partner in the last year. This behavior was more common among unmarried women living together with their male partners (increased by 210%); HIV-positive women (increased by 120%); and women with STDs (increased by 50%). The fact that the unmarried women living together with their partners had higher condom use compared to married women suggests that they may perceive themselves at risk since the relationship is unstable, or they may have the power to suggest condom use compared to women in permanent relationships. In a cross-sectional study of 306 youth in secondary school in Ibadan, Asuzu (1994) notes that although 277 (85.3%) of the adolescents had heard about AIDS, only 18 (6.8%) could name the virus. However, 190 (71.4%) identified sexual intercourse as the principal way of transmitting the infection. One hundred and sixteen (43.6%) of the respondents believed that chastity was the most effective means of controlling the AIDS epidemic and 152 (57.1%) actually 55 planned to practice abstention. However, 38 (14.3%) thought AIDS control through the promotion of chastity was unrealistic. While none admitted to being homosexual, 5 (1.9%) claimed to feel sexually excitable or attracted by both sexes, at least sometimes. Lema & Hassan (1994) interviewed 675 male and female adolescents, age 10 to 19, who were attending the adolescent antenatal clinic, Special STD and Skin Disease Clinic in Nairobi during a period of four months in 1991. Using a semi-structured questionnaire, the researchers sought to find out the level of awareness of these adolescents with regard to STDs, HIV infection, AIDS and contraception. They also wanted to determine the relationship of awareness with sexual behavior and contraceptive practice. Adolescents constituted 27.6% of those attending the clinic (52.9% were female, and 41.2% were male adolescents). The majority were unemployed and few were students in schools in Nairobi. The authors report that 70.4% of the group mentioned gonorrhoea as a sexually transmitted disease, but only 54.3% mentioned AIDS. A majority of these adolescents had started coitus very early and were involved with many partners. They have not changed their behavior even though their partners belonged to the high-risk groups for HTV infection as well as STDs. 56 Richter, Strack, Vincent, Barnes, and Rao (1997) surveyed 307 adolescents, age 13 to 19, from Ahmadiyya Secondary School, Masoila Lungi; Marampa Islamic Secondary School, Lunsar; and Ansarul Islamic Secondary School, Lungi, in the Port Loko district, in the rural Northern province of Sierra Leone, to determine their sexual and AIDS-related knowledge, attitudes, and behaviors. They found that 89% of the boys and 68% of the girls had experienced sexual intercourse, with first intercourse at mean ages of 14.4 for boys and 15.1 for girls. The age range at first intercourse was 5 to 19 years for both sexes. In addition, 48% of 132 sexually active boys and 63% of 84 sexually active girls reported having only one sex partner during the three months preceding the survey, while 30% of the boys and 24% of the girls reported having had two or more partners. Concerning the sexually active, 65% of 144 sexually active boys and 35% of 98 sexually active girls reported having three or more sex partners over the course of their lifetime. The condom is the preferred method of contraception for both sexes during their first and most recent sexual experience, with 42% of the sexually active respondents reporting condom use during their most recent sexual encounter. The most frequently reported sexually transmitted diseases (STDs) among boys were gonorrhoea and HIV/AIDS at 10% and 6%, respectively. Among girls, 4% reported syphilis and 4% reported HIV/AIDS. Trichomoniasis, chlamydia, herpes, and genital warts were reported by 1% to 4% 57 of the males and females. In the study population, 64% of the females and 46% of the males reported having been forced to have sex. Alcohol and drug use before sex were more common among the females than among the males. There was also low reported use of other birth control methods and low knowledge scores on pregnancy prevention, HIV/AIDS, and STDs. Agyei, Epema and Lubega (1992) conducted a study aimed at exploring the knowledge and attitudes of adolescents (15 to 19 years old) and young adults (20 to 24 years old) towards sex and contraception (condoms). They also determined the level of knowledge and attitudes towards sexually transmitted diseases (STDs) as well as the prevalence of the latter among the sexually active adolescents and young adults. A sample of 4,510 respondents (1,545 males and 2,965 females), age 15 to 24, from urban and rural areas were interviewed. The majority of the adolescents and young adults surveyed have a negative attitude towards the use of condoms, although most of them agreed that they prevent STDs. Over 95% of the respondents have heard about STDs. Their level of knowledge is relatively high, slightly higher for urban residents and for young males. Approximately 21% of the male and 8% of the female respondents admitted having ever contracted a STD. The gap between contraceptive knowledge and practice was rather wide. Only a small proportion of the respondents were using condoms at the time of the survey. 58 Barker and Rich (1992) note that continuing high rates of adolescent childbearing in sub-Saharan Africa indicate a need for improved understanding of factors affecting adolescent sexuality. As traditional cultural influences on adolescent sexuality in Africa have diminished, peer interaction and modern influences have gained importance. As a result, they conducted a study to assess peer interaction and societal factors and their impact on adolescent attitudes toward sexuality and contraception. The authors conducted a series of single-sex focus-group discussions with in-school and out-of-school youth in urban and rural areas of Kenya and Nigeria in 1990. They report that out-of-school youth generally receive information on sexuality and family planning from peers (and the media), while in-school youth receive information in school, although not necessarily relevant or correct information. Young women interviewed perceived unwanted early childbearing as something that affected them. Young people had, however, better information and more positive attitudes about induced abortion than about family planning. Mafany, Mati & Nasah (1990) examined the level of knowledge, attitudes and practices related to sexually transmitted diseases (STDs) among secondary school students in the Fako district, in Cameroon. A substantial proportion of the respondents were sexually active and had concurrent sexual partners. Although 70% of the respondents claimed they knew about STDs, not more than 16.1% 59 could name any one common STD or give its signs or symptoms. Knowledge about prevention and complications of STDs was equally poor. The schoolteacher was the principal source of information, followed by magazines or books. Among the respondents who had had an STD, only 8% had consulted an STD clinic; 13.6% and 15.4% respectively went to a doctor or hospital; 19% had gone to chemist shops; and 43% received no treatment. Different studies reviewed indicate that in some regions in sub-Saharan Africa, knowledge of HIV transmission and symptoms remains low (Ndeki, Klepp, Seha, & Leshabari, 1994; Asindi, Ibia, & Young, 1992; Lema & Hassan, 1994; and Asuzu, 1994). These studies demonstrate that adolescents in Africa, just as elsewhere, are at high risk of acquiring HIV through sexual risk taking. AIDS education has been shown to increase the use of condoms in high-risk groups such as gay men and commercial sex workers. In some studies, however, it is clear that people may hear about AIDS but may still engage in risk taking behavior that fosters transmission. The question becomes why? Thus, the role of human behaviour as well as the role of gender, and the socio-cultural norms and values bearing on sexual relations, need to be explored. A thorough search of the literature has shown no research on out-of-school adolescents' knowledge, attitudes and behavior with regard to AIDS. The closest were Nzyuko et al. (1997) and the Lema and Hassan's study (1994), neither of 60 which were population-based studies and Barker and Rich study (1992) was on attitudes towards sexuality and contraception. Other related studies were conducted with street children or homeless children (Luna & Rotheram-Borus, 1992; Johnson et al 1996; Anarfi, 1997; Swart-Kruger & Richter, 1997; Clatts & Davis, 1999). What is the likelihood that the out-of-school adolescents have adequate knowledge about ADDS, modes of transmission, and how to reduce their own risk behavior? Is it likely that because they are not in school when they hear about ADDS, they may not take it as seriously as they should? We may also ask whether there are other competing interests which give rise to a propensity to take risks among adolescents. This is one of the contributions to knowledge that this research will seek to fulfill. Knowledge of HJV does not necessarily lead to behavior change, even though such knowledge is a prerequisite to acting safely (Rotheram-Borus, Koopman, & Bradley, 1989). Furthermore, being highly informed does not necessarily translate into positive attitudes toward prevention (Brown & Fritz, 1988). Even when people are afraid of getting AIDS, some still have unprotected sex in situations of risk. For women with little or no power over sexual decisions, practicing marital sex may constitute the highest risk especially those married to men who have extramarital affairs. In spite of this, knowledge can influence safe behavior in taking fewer sexual partners, increasing use of condoms, and 61 decreasing casual sexual encounters, all changes leading to an overall reduction in risk. Catania et al. (1990), using the AIDS Risk Reduction Model (ARRM), argue that people who have extensive knowledge and who perceive their sexual behavior to be problematic may be moving towards, but not fully achieving, behavioral change. Although these individuals' knowledge levels would not predict their current behavior, it would be erroneous to conclude that knowledge does not eventually lead to change. The review of the literature on HIV/AIDS has shown that persistent sexual risk taking behavior may be attributed to a host of factors, enumerated and discussed below. Erroneous risk perception and susceptibility: This is a factor in sexual risk taking behavior (Lowy and Ross, 1994; Bledsoe, 1990; Prohaska et al., 1990; Joseph et al, 1987; Bauman & Siegel, 1987). With regard to erroneous risk perception, a study of gay men by Lowy and Ross (1994) report that there is not a close match between what is epidemiologically accepted as risk behavior and what respondents regard as risk behavior. Gay men tended to use their own definitions of what constitutes risk. For example, variables such as age, appearance, diction, partner's knowledge of HIV, being the insertive partner in anal intercourse, past history of unprotected anal intercourse, sexual arousal and relationship status were used to assess risk. These variables were then constructed by an individual into a hierarchy of risk. These are in consonance with what Levine and Siegel (1992) called "folk 62 constructions" of risk of HIV transmission in analysing the justifications of gay men for engaging in unprotected sexual behaviors and sexual encounters. According to Lowy and Ross (1994), the men classified risks into two categories: acceptable risk and significant risk. Lowy and Ross (1994) contend that even awareness of the need for self-protective action does not guarantee avoidance of risky sexual encounters, thus reducing the risk of HIV infection. Some gay men, well informed about the avenues of HIV infection, seem to take risks in the face of this knowledge. In the Ghanaian context, the "folk constructions" of risk of HIV infection by heterosexual men include going in for younger girls, because they may not have had many lifetime sexual partners. Men also believe that a younger woman is not a prostitute or has never traveled to Abidjan or Nigeria or abroad, especially Western Europe, where they might have engaged in prostitution. Bledsoe (1990) outlines another element in erroneous risk perception in the African heterosexual context. Some African men take only plump women as sexual partners because weight loss is considered to be a sign of AIDS (in certain parts of sub Saharan Africa AIDS is known as "slim disease"). They also deny dangers when they have unprotected sexual affairs with casual lovers rather than prostitutes. Men have not reduced their number of sexual partners, but turn away from prostitutes and move to "low risk pools". For example, in order to avoid AIDS, older men go after schoolgirls, who represent the largest pool of unattached 63 In addition it is important to recognize that individual behaviour takes place in specific contexts, the components of which may be amenable to modification with subsequent positive influences on the likelihood of behaviour change and maintenance (Hankins, 1998). Thus HIV risk reduction can take place only if structural and contextual factors, including the overarching cultural context and social factors that contribute to risk behaviour are addressed. Some of these include "social pressures; cultural expectations; usual or expected cultural scripts or conventions influencing sexual negotiation; economic factors reducing access to condoms; laws and regulations that marginalize certain social groups, including women, limiting their access to information, services and options; political and religious ideologies restricting access to information about the full range of safer behaviours; and resource constraints leading to inadequate services for sexually transmitted diseases and ineffective condom and other prevention strategies" (Aggleton et al , 1994). Bledsoe (1990) also outlines another element in erroneous risk perception in the African heterosexual context. Some African men take only plump women as sexual partners because weight loss is considered to be a sign of AIDS (in certain parts of sub Saharan Africa AIDS is known as "slim disease"). They also deny dangers when they have unprotected sexual affairs with casual lovers rather than prostitutes. Men have not reduced their number of sexual partners, but turn away 64 from prostitutes and move to "low risk pools". For example, in order to avoid A I D S , older men go after schoolgirls, who represent the largest pool o f unattached young women in urban areas. Existence of dependency relationships: This has been suggested by Awusabo-Asare, Anarfi, & Agyeman 1993; Mason 1994. This becomes apparent in sub-Saharan Africa in sexual relationships among older males and younger girls. Often, a law on statutory rape does not exist or, i f it exists, is hardly enforced. Dependency relationships between older males and younger females are also established by the early marriage o f girls, or in arranged marriages between families. They are often related to economic survival, since the older male may be employed and able to provide economically for the young woman. Male and female roles in society: With regard to gender roles, social norms tend to dictate that the male be the sexual aggressor. Conquests are considered more significant than relationships. This translates into communication remaining at a minimum (Carroll, Vo lk & Hyde, 1985). When there is strict adherence to prescribed role behavior, partners engage in sexual encounters devoid of discussions pertaining to past sexual experiences, abstinence or the use o f condoms (Rotheram-Borus, Mahler, & Rosario, 1995). Stereotypical sex roles, such as female passivity and denial o f sexual activity, leads to the reluctance o f women to ask men to use condoms (Rotheram-Borus, Mahler, & Rosario, 1995). 65 Condom use: For example, Bledsoe (1990) outlines some of these bariers in the African context: condom use denies a man his right to procreate children and a "woman who manages to convince a new partner to use condom initialy must soon remove the barrier" (p. 270). Women who ask for condom use are seen as promiscuous/prostiutes, an implication that make many young women avoid condoms completely. Condom use may also signal a desire to end a relationship. Or a woman who uses condom may have an outside lover. She may also suspect that her partner has HIV, or she herself may have HIV. Some of Bledsoe's findings (1990) are consistent with Gomez and Marin's findings (1993) pertaining to the issue of gender and power in safe sex, in a study of whether women can demand condom use. They report that 65% of women in the study group never used condoms with their steady male partner and are more likely to use condom with their steady partner under the folowing conditons: belief that their partner wil not get angry or violent at condom use request; have a positve atitude toward use; belief that peers use condoms; have a high self-eficacy to insist on use; and have multiple partners. In addition, until the advent of the female condom (which is not widely used, so most people in developing countries wil take years to see one), it is the responsibilty of the man to acquire the condom, pay for it or get it for free, and wear it during the sexual encounter. He may get upset if a sexual partner asks that 66 he uses a condom. In Ghanaian society, it is difficult if not impossible for a woman to enter a store and purchase a condom, since women are not expected to initiate sex. Thus in a relationship where the man is in control and he does not like condoms (since wearing condoms diminishes sexual pleasure in men and somewhat in women), he won't take the extra step to buy it or acquire it for free, and use it during a sexual encounter. Studies conducted in sub-Saharan Africa and elsewhere have demonstrated that condom acceptance and use in a relationship is primarily a function of male acceptance (Allen et al., 1992; Allen et al., 1992; Stein, 1990). Remoteness of negative consequences: Kirby and DiClemente (1994), citing a 1988 US General Accounting Office Report, state that "numerous studies in psychology and health education have demonstrated that people are less likely to avoid a risk when the negative consequences are remote — both unlikely and in the distant future" (p. 130). Based on the factors outlined above about sexual risk taking behavior in spite of knowledge, I have developed a questionnaire that is both closed- and open-ended, and includes other variables, which go beyond ADDS knowledge per se, to examine the determinants of sexual risk taking behavior in the era of HIV/AIDS in adolescents in the three electoral constituencies in Ghana. 2.7.2 Conceptual Framework While it is generally believed that knowledge about HIV will lead to taking 67 preventive measures to avoid infection, this does not appear to be the case (Ismail et al., 1995; Kapiga, Lwihula, Shao & Hunter, 1995; Brown, DiClemente & Beausoleil, 1992; Keller et al., 1991; Goodman & Cohall, 1989). In addition, the significant role knowledge plays in reducing HIV infection is said to decrease over time (Becker & Joseph, 1988) and knowledge alone cannot overcome barriers to continuing change, since sexual behavior may be also linked to economics, gender relations and other complex socio-cultural factors (McGrath et al., 1993). Thus, Weeks et al. (1995) suggest perceived self-efficacy as an important mediating variable between knowledge acquisition and change in risk behavior. For the purpose of this study, 3 psychosocial health behavioural frameworks were reviewed for consideration as the conceptual framework (The Health Belief Model (HBM), The Theory of Reasoned Action (TRA) and the ADDS Risk Reduction Model (ARRM)). These models employ constructs derived from rational choice models of health seeking and view behaviour as the outcome of a cognitive process in which the costs of performing a particular health action are weighed against possible benefits (Kline & VanLandingham, 1994). The ensuing discussion is a critical review of the Health Belief Model and The Theory of Reasoned Action. The review is to demonstrate their strengths and weaknesses and the reasons for their inappropriateness as the framework for this study. 68 2.7.2.1 The Health Belief Model In the 1950s, the US Public Health Service programs achieved limited successes due to the failure of large numbers of eligible adults to participate in tuberculosis screening programmes provided at no charge, in mobile X'ray units conveniently located in various neighbourhoods (Rosenstock, Strecher, & Baker, 1994). The programme operators were concerned with explaining people's behaviour by illuminating those factors that were facilitating or inhibiting positive responses. This gave birth to the H B M which was initially developed in the 1950s by a group of social psychologists in the US Public Health Service (Hochbaum, 1958, Rosenstock, 1966; 1974). Beginning in 1952, Hochbaum (1958) studied probability samples of more than 1200 adults in 3 cities that had conducted recent TB screening programs in mobile x'ray units. He assessed their "readiness" to obtain X'ray which included their beliefs that they were susceptible to tuberculosis and their beliefs in the personal benefits of detection. Since Hochbaum's survey, many investigators have helped to expand and clarify the model and to extend it beyond screening behaviours to include all preventive actions to illness behaviours and sick-role behaviour (Becker, 1974; Becker & Maiman, 1980; Janz & Becker, 1984; Kirscht, 1974; Rosenstock, 1974). Using H B M in its present form it is believed that when individuals regard themselves as susceptible to a health condition, they will take action to prevent, 69 screen for, or control it. In addition, they will also take action if they believe the health condition to have potentially serious consequences; if they believe that a course of action available to them would be beneficial in reducing either their susceptibility to or the severity of the condition, and if they believe that the anticipated barriers to (or costs of) taking the action are outweighed by its benefits (Rosenstock, Strecher & Becker, 1994). Thus the components of H B M can be summarised as follows: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, other variables (for example sociodemographic factors such as educational attainment which are believed to have indirect effects on behaviour by influencing the perception of susceptibility, severity, benefits, and barriers) and self efficacy. The latter was added in 1977 (Bandura, 1977) because the original focus of the early model was on circumscribed preventive actions, usually a one-shot nature, for example, accepting or screening test or immunizations. These actions were generally simple behaviours for most people to perform. Since it is likely that most prospective members of target groups for those programmes had adequate self-efficacy for performing those simple behaviours (which often involved receiving a service), that dimension was not even recognised (Rosenstock, Strecher & Becker, 1994). The figure (next page) illustrates the components of HBM. 70 Background Perceptions Action Threat Perceived susceptibility (or acceptance of diagnosis) Perceived severity of ill-health condition Sociodemographic factors (e.g. education, age, sex, race, ethnicity Expectations Perceived benefits of action (minus) Perceived barriers to action Perceived self-efficacy to perform Cues to Action • Media • Personal Influence • Reminders Behaviour to reduce threat based on exoectations Figure 2.1: Schematic diagram of the components of the Health Belief Model Janz and Becker (1984) reviewed findings of studies that utilised H B M from 1974 to 1984. They stated that H B M has been used in other studies such as preventive health and screening behaviour such as influenza inoculations, Tay -Sachs carrier status screening program, practice of breast self-examination, and attendance at screening programmes for high blood pressure. Other preventive health behaviours were seat belt use, exercise, nutrition, smoking, visits to 71 physicians for check ups, and fear of being apprehended while under the influence of alcohol. Sick-role behaviour encompass studies such as compliance with hypertensive regimes, diabetic regimes, end stage renal disease regimens, medication regimens for parents to give their children with otitis media, weight loss regimens, and medication regimens for parents to give asthmatic children (Janz & Becker, 1984). These results from prospective and retrospective studies provided substantial empirical support for HBM. "Perceived barriers" was the single most powerful predictor of behaviour. Even though "perceived susceptibility" and perceived benefits" were important overall, "perceived susceptibility" was a stronger predictor of preventive health behaviour than sick-role behaviour, while the reverse was true for "perceived benefits". Overall, "perceived severity" was the least powerful predictor; however, this construct was strongly related to sick-role behaviour (Rosenstock, Strecher, & Becker, 1994). 2.7.2.2 Discussion of the Strengths and Limitations of the H B M The H B M posits that individuals will modify their behavior if they have knowledge of a disease and believe that its effects are severe; that they are susceptible to it; that preventive measures are effective; that they possess self-efficacy to take preventive measures; that health care and advice are accessible; that normative support for behavior change exists; and that there are few barriers to action. (Janz 72 & Becker, 1984; Rosenstock, Strecher, & Becker, 1988). The H B M has been shown, however, to be weak in designing interventions, particularly with U.S. adolescents. Kirby et al. (1994) note that with regard to adolescents, although knowledge about sexual topics may be a precursor to behavior change, it appears to be weakly related to adolescent sexual behavior ~ in one meta-analysis the change was small (0.17). They contend that even though educational outcomes such as changes in attitudes, norms, skills and intentions may be precursors to behavior change, they are not adequate indicators of change in actual behavior. Perceptions of peer group behavior ("all my friends are sexually active") influence directly not only the target individual's behavior ("I want to be accepted"), but also the perception of risk associated with this behavior ("If they do it, it must be safe"). Thus, perception of peers is not simply an intervening variable, but a primary and powerful social force operating within the adolescents milieu that exerts considerable influence on their actions and attitudes (Fisher, 1988). Moreover, the maintenance of behaviour change that is needed for HIV prevention may be determined by more socially complex interactions between adolescents and their environment than those specified in the HBM. As noted by Brown, DiClemente and Reynolds, "the practice of condom-protected sexual intercourse requires continual elicitation of a risk-reduction behavioural response performed as part of a social interaction (between two people) which is firmly 73 based in cultural mores and norms" (1991, p. 53). In addition, DiClemente et al. (1992) in one cross-sectional study among inner city minority adolescents found that those who perceived cost of condom use was lowest (low perceived barrier to using condoms) were more likely to report being consistent condom users. However, Rosenstock et al. (1994) report that the relationship between perceived barriers and ADDS preventive behaviours have been mixed across both longitudinal and cross sectional studies. Furthermore, the cues to action construct of the H B M model have not been shown to be consistent. For example, Hingson et al.'s (1990) study of adolescents reports that the fact that adolescents had discussed ADDS with friends or a physician was positively associated with condom use, but negatively associated with knowledge of someone with AIDS. In addition, in a study of gay men, the summed score of questions, such as how many close friends had ADDS Related Complex, how many had AIDS, and how many had friends who had died from AIDS or ARC in the past year (in deriving the cue to action construct) did not predict ADDS preventive behaviour changes (Aspinwall et al., 1991). 2.7.2.3 The Theory of Reasoned Action The TRA was first introduced in 1967 (Ajzen & Fishbein, 1980; Fishbein, 1980; 1967; Fishbein & Ajzen, 1975). It is a general theory of human behaviour that deals with relations among beliefs, attitudes, intentions, and behaviours. The 74 theory assumes a causal chain that links belief to behaviour. This behaviour is ultimately determined by a cognitive structure composed of underlying behavioural and normative beliefs. In the final analysis, the changed behaviour is primarily a matter of changing this cognitive structure (that is changing the underlying beliefs). The theory is useful in terms of designing an intervention that includes informational, educational, or communication component. The underlying theory is that to change or maintain a given behaviour in a given population, one must first understand the determinants of that behaviour in that population. The T R A has been used successfully to predict and explain why people have (or have not) engaged in different facets of human behaviour: smoking (Chassine et al 1981; Fishbein, 1980); drinking (Budd & Spencer, 1985); signing up for a treatment programme (Fishbein, Ajzen & McArdle, 1980); using contraceptives (Fisher, 1984); dieting (Saltzer, 1978); wearing seat belts or safety helmets (Allegrante, Mortimer & O'Rourke, 1980; Budd, North & Spencer, 1984; Fishbein, Salazar, Rodrigues, Middlestadt, & Himelfarb, 1988), exercising regularly (Goldin & Shepard, 1986); voting (Bowman, Fishbein, 1978); breastfeeding (Manstead, Proffitt, & Smart, 1983); buying various goods and services (Ryan, 1982); donating money to university library (Middlestadt, 1990); and choosing a career (Greenstein, Miller, & Weldon, 1979). The figure (next page) illustrates the components of the TRA. 75 The person's beliefs that the behaviour leads to certain outcomes and his evaluations of these outcomes The person's belief that specific individuals or groups think he should or should not perform the behaviour and his motivation to comply with the specific referents Fig. 2.2: A theory of reasoned Action: Factors determining a person's behaviour The first step in applying the TRA is to select and identify the behaviour (s) of interest. The TRA postulates that a full identification of any behaviour requires consideration of the four elements of action, target, context, and time. That is, every action occurs with respect to some target, in a given context, and at a given point in time. For example, using a condom is a different behaviour from carrying or buying a condom (a change in action); going to an STD clinic is a different behaviour from going to a family doctor or going to an HIV counselling and testing site (a change in target); using a condom with a spouse or long term partner is a different behaviour from using a condom with a casual partner of commercial sex worker (a change in context); and an example of a change in time going to an Attitude toward the behaviour Relative importance of ammdinal and normative considerations Subjective norm Intention Behaviour w STD clinic on a Tuesday morning which is a different behaviour from going to the same STD clinic on a Saturday afternoon (Fishbein, Middlestadt & Hitchcock, 1994). Also there are differences between using condom the next time "I have vaginal sex with my main partner" is a different behaviour from using condom every time "I have vaginal sex with my main partner" (a different type of change in time). The TRA assumes that most socially relevant behaviours are under volutional control and therefore the most immediate determinant of any given behaviour is the intention to perform or not to perform that behaviour. The intention is said to be a function of two determinants: one personal in nature and the other reflecting social influence. As regards the personal nature considerations, the individual is said to have positive or negative feelings with respect to performing the behaviour in question. This factor is termed "attitude towards the behaviour". The factor that reflects social influence is the person's perception of social pressure put upon him/her to perform or not to perform the behaviour. This factor is termed subjective norm because it deals with perceptions of what others think one "should" or "ought" to do (Fishbein, Middlestadt, & Hitchcock, 1994).. Thus generally speaking, individuals will intend to perform a behaviour when they have a positive attitude toward performing it and/or when they believe that their important others think they should perform it. This salient referent influences 77 one's subjective norm. These salient outcomes/referents vary from behaviour to behaviour and population to population. For example an individual thinks about different consequences when he considers using a condom with a spouse or long term partner (loss of trust) compared to a casual or one time partner. The theory notes that the outcomes and referents that are salient vis-avis either of these behaviours are quite likely to differ depending on the gender, culture, and socio economic status of the population of interest. In summary, the theory postulates that to be effective, an intervention must have an impact on a person's beliefs. By changing behavioural or normative beliefs, one can change corresponding attitudes and/or subjective norms, and by changing attitudes and/or subjective norms, one can change corresponding intentions. Moreover, if one changes a behavioural intention, this should influence the performance of the correspondent behaviour. 2.7.2.4 Discussion of the Strengths and Limitations of the TRA The TRA proponents contend that information and education interventions can be highly effective behaviour change devices. However, the information must address the behavioural and normative beliefs underlying what one wishes to change. For example, if an epidemiological research has identified a behavioural risk factor, the goal of the intervention should be to change that behaviour. To do this the 78 intervention should attempt to increase intentions to perform or not to perform the targeted behaviour. If the intention is under attitudinal control, the intervention should try to change behavioural beliefs about the advantages and disadvantages of performing the behaviour. If the intention is primarily under normative control, the intervention should try to change normative beliefs that specific referents think one should or should not perform the behaviour. According to TRA, for the intervention to be successful, decisions about specific behavioural of normative beliefs to address should not be based on intuition but must be determined empirically (Fishbein, Middlestadt & Hitchcock, 1994). In spite of the above strengths, the TRA was not used in this study. This is because the primary focus for the study was sexual risk taking. The usage of condom or lack thereof was added in order to determine the proportion of sexually active adolescents who had ever used condom. The study was not designed to test intentions of condom use in future sexual encounters. In addition, to effectively use TRA, will require condom use questions to cover "action, target, context and time". For example, questions would have to elicit responses relating to casual partner, long-term partner, and commercial sex workers (context). Furthermore, the theory is predicated on the assumption that the most immediate determinant of any given behaviour is the intention to perform or not to perform that behaviour. However, it is noted that sex is the interaction between a minimum of two people, 79 thus, changing intentions to real goals (for example avoid HIV), and/or engage in a class of behaviour (for example practice safe sex), may seldom be an effective strategy for producing change in specific behaviour. As a result of the inadequacies of H B M and T R A the A R R M was considered the appropriate model to use in this study. As explained earlier A R R M is the best framework of the study because it integrates key psychosocial behavioral concepts from rational choice health-seeking models and applies them to the study of HJV-related sexual risk reduction. This makes it different from H B M or TRA, which have been used for other studies not necessarily HIV. Furthermore, A R R M is process-driven and it recognizes the sexual partner's role in risk reduction whereas for H B M or TRA, it is only the individual who takes the decision. 2.7.2.5 The ATOS Risk Reduction Model (ARRM) A R R M as a model has been utilized in previous studies as a framework for predicting factors associated with condom use and multiple sexual partners. Since its development by Catania et al. (1990), the utility of the A R R M has been used to identify variables predicting behaviour change in women in Kigali, Rwanda (Lindan et al., 1991); to examine condom use in a sample of 215 HIV-infected women in 80 New Jersey (Kline & Van Landingham, 1994); in a survey of 5,494 women in one urban and two rural sites in Bas, Zaire; to understand factors that may be related to motivation for behavior change (Bertrand et al., 1992), to examine the psychosocial factors associated with multiple partners (Dolcini et al., 1995); as a framework to examine sexual behaviour change for risk reduction among urban Baganda women in Kampala, Uganda (McGrath et al., 1993); to examine the psychosocial correlates of HIV risk behavior among non-injection, cocaine-dependent, heterosexual men in treatment (Malow & Ireland, 1996); and for predicting condom use with not-in-treatment, crack cocaine smokers and intravenous drug users (Bowen & Trotter II). In this study, A R R M is used as a framework to examine behavioral change as regards condom use in out-of-school and in-school adolescents, age 10 to 19, in Ghana. It is also used in addition to other variables with regard to sexual risk taking. Catania et al. (1990), in outlining the ARRM, propose three processes that may be involved in people's efforts to reduce high-risk sexual behaviors. The three-stage process involves the labelling of high-risk sexual behaviors as problematic; making a decision to change high risk behaviors and committing to that decision; and seeking and enacting solutions directed at reducing high risk-activities. Figure 2.3 (next page) gives an overview of A R R M and the different stages. 81 Figure 2.3: Overview of A R R M stages The relevant variables the model identifies supporting change include: knowledge of the risks associated with various sexual practices; ways of incorporating low risk sexual activities into one's sexual relationships in a satisfying manner; perceptions of susceptibility to contracting rJJV; perceived costs and benefits associated with reducing high risk and increasing low risk sexual activities; self-efficacy beliefs; emotional states; and social factors including verbal communication skills, reference group norms, help seeking processes and social support (Catania, Kegeles, & Coates, 1990). Self-efficacy, a component of the A R R M and HBM, is one of the relevant constructs of social cognitive theory. The theory postulates that human behavior 82 results from a constant interaction between a person and his or her environment (Bandura, 1994). Other constructs include behavioral capability, expectations, expectancies, self-control and performance, observational learning, reinforcement, and managing emotional arousal. Self-efficacy is considered the most important prerequisite for behavior change. Self-efficacy is defined as the confidence the individual feels about performing a particular activity, and is a function of how much effort is invested in a given task, and what levels of performance are attained. When a single task is performed and repeated, it builds a person's self-efficacy, which in turn affects task persistence, initiation and endurance, which promote behavior change. To achieve self-directed change, people should be equipped not only with reasons to alter risky behavior, but should also be given behavioural means, resources and social support to do so. Bandura (1994) argues that there is a major difference between possessing self-regulative skills and being able to use them effectively and consistently under difficult circumstances. Success requires a strong belief in one's efficacy to exercise personal control. Given perceived self-efficacy, individuals are expected to exert control over their own motivation, thought processes, emotional states and patterns of behavior: "Peoples' belief about their capabilities affect what they choose to do, how much effort they mobilize, how long they will persevere in the face of difficulties, whether they engage in self-debilitating or self encouraging thought patterns, and 83 the amount of stress and depression they experience in taxing situations" (p.26). People see no point in even considering altering habits detrimental to health when they believe they cannot exercise control over their own behavior or the behavior of others. Knowledge per se about safe sex guidelines can easily be achieved relative to behavior change, but equipping individuals with the skills and self-efficacy that enable them to put the guidelines consistently into practice in the face of counteracting influences is the essential problem. Difficulties arise in following safer sex practices, because self-protection often conflicts with interpersonal pressures and sentiments. For example, an individual may not practice safe sex because of coercive threat, allurements, desire for social acceptance, social pressures, situational constraints, fear of rejection, and personal embarrassment. All these factors can override the influence of the best and most informed judgement. Thus, in social cognitive theory and control over HIV, perceived self-efficacy is key in the adoption and maintenance of self-protective behavior. "Even though individuals acknowledge that safer sex practices reduce risk of infection, they do not adopt them if they believe they cannot exercise control in sexual relations" (p. 29). According to Bandura (1994), this has been corroborated in other research: for example, perceived self-efficacy to negotiate condom use predicts safer sex in adolescents and adults; and among drug users, perceived self-efficacy predicts success in regular use of clean needles and condoms with sexual 84 partners. Thus, perceived self-efficacy is related to self-protective behavior, both concurrently and longitudinally (Bandura, 1994). As stated earlier in this section, the A R R M has been specifically developed to examine the process of sexual risk reduction. Three stages have been proposed (labelling, commitment to change, and enactment) and will be discussed below. 2.7.2.6 Stage 1 ofthe A R R M (labelling). Stage 1 of the A R R M rests on the premise that to avoid HIV infection, the individual at risk must acknowledge that the behavior he/she is engaging in is problematic. This may occur because changes in knowledge or perceived susceptibility. In the perception of HIV as problematic, it is conceived that the individual learns that AIDS is sexually transmitted, examines his/her sexual behavior, labels the behavior as risky, and in turn begins to feel anxious about his susceptibility to contracting HIV. When these conditions exist, the individual will label his or her behavior as problematic (Catania et al., 1990). Once the person labels the behavior as problematic, then he or she moves to the commitment stage. Sometimes the individual may see the problem, but may not be committed to change if the costs are too high, the benefits too low, or the person does not believe that he or she has the ability to make the change (Bowen and Trotter, 1995). 85 The individual's sexual partner(s) and friends may have a significant impact on the labelling process. Furthermore, the process may be influenced through subsequent relabelling of high-risk behaviors as being low risk or the use of other cognitive coping modalities, such as denial and avoidance. For example, denial can come in the form of "Most people exaggerate the threat of AIDS" (Catania et al., 1990). Social networks and norms are also thought to influence the labelling of risk behavior through disapproval of high-risk activities and approval of safe behaviors. For example, people who request sex partners to use condoms may also be subject to negative consequences. Some partners may view this request as indicating a lack of trust in his or her sexual conduct outside the relationship and refuse to cooperate with the desired change (Catania et al., 1990). 2.7.2.7 Stage 2 of the A A R M (commitment to change). This is the intervening decision-making stage between perceiving a health problem and taking action on the problem. It involves reaching a firm decision to make behavioral changes and strongly committing to that decision. This decision-making process may also include the alternative outcomes of remaining undecided, waiting for the problem to rectify itself, or resigning one's self to the problem situation. In the commitment stage, the person may not be committed to change his or her behavior if the costs are too high, the benefits too low, or the person 86 does not believe that he or she has the ability to make the change. Thus, there is the evaluation of the pros and cons of change and the development of self-efficacy concerning his or her ability to make the desired changes (Bowen and Trotter, 1995). It is imperative to note that in matters of sexual behavior, the decision to remain committed to change is complex. For example, smoking cessation which involves a single action, is different from decisions concerning sexual relations (Catania et al., 1990). This is because sexual behaviour encompasses a host of actions: high-risk activities (such as unprotected anal sex, fisting, use of sex toys, douching, unprotected oral sex, and having multiple partners) and behaviors that reduce the risk of HIV transmission (such as mutual masturbation, massage and condom use). Furthermore, the individual in matters of sexual relations will need to consider making these changes across very different socio-sexual contexts (for example, long-term relationships versus "one nighters"). Thus, the diversity of sexual behaviors and the social conditions under which they occur complicate the decision process. Catania et al. (1990) posit that the psychological and social costs and benefits of two distinct sets of behaviors, high and low risk sexual activities, may need to be explored before the person makes a commitment to change. Three factors may affect this: First, the subject may ask, "Will my enjoyment of sex be affected by the changes I might make?" Then, "Will the changes be successful in reducing my risk of HIV infection?" and finally, "Can I 87 perform or learn to perform the actions that will lead to change and obtain the outcomes I want?" 2.7.2.8 Stage 3 of the A R R M (enactment). Once the person is committed to change, the enactment stage begins. It is composed of three phases: seeking information, obtaining remedies, and enacting solutions. According to Catania et al. (1990), these phases are separated for conceptual purposes, but they may occur concurrently. Moreover, some individuals may skip phases. For example, a person may move directly to enacting solutions when a sexual partner knows about safe sex and has purchased condoms. When an individual goes through the three phases, in the information-seeking phase, he or she may begin gathering ideas and others' opinions on ways to change high-risk behaviors (information acquisition may also be passive; for example, from T V or radio). In the phase two of this stage, some individuals or couples may need to make numerous efforts to obtain solutions through self-help, informal social support, and professional helpers, before success is achieved. These attempts may involve the need to circumvent financial, environmental, and psychosocial barriers, for example, by obtaining professional services (Catania et al., 1990). In stage three, behavior change may be more difficult to achieve 88 compared to the goals set at earlier stages of the change process. Some individuals will be unable to achieve change, because they are unsuccessful in eliciting needed information to help them solve their problem, are unable to obtain help in producing workable solutions or lack the skills that require complex negotiations with one's sexual partner(s) who may not have the same degree of commitment to pursuing change. It has been shown that when couples jointly confront a problem, there generally is a mutual basis for enacting steps to change their behaviors. Failure to engage one's partner in safe sex practices may reduce the probability that either partner will adopt safe practices, and enhance the possibility of contracting HIV, especially if one's partner continues to perform unsafe activities with others. Thus, people who wish to reduce their risk of HIV infection must convince their sex partners to change their behavior or choose abstinence. The ability to engage one's partner in a policy of mutually safe behaviors most likely depends on one's ability to communicate verbally about sexual issues. The inability to discuss sexual matters in a constructive problem-solving manner may reduce the sexual partner's participation in the task of reducing high-risk behavior, thereby undermining the change process. Catania et al. (1990) recognize that there are some factors that affect movement from stage to stage. They contend that several other internal and external motivators might play important roles in maintaining adequate motivation 89 over time. These include emotional states, factors such as drug consumption that influence emotional states, and both formal and informal environmental cues that stimulate thinking about one's sexual behavior and options for a change. For example, high levels of distress and other aversive emotional states (fear, anxiety) may increase the perceived seriousness of a problem and facilitate over time, the continued labelling of one's risk behavior as problematic. Emotions may also play a role in achieving a commitment to change by influencing self-efficacy. According to Catania et al. (1990), the three processes described above (labelling, commitment and enactment) are neither unidirectional nor non-reversible. For example, when an individual has a great difficulty in altering his behavior, he or she can re-label it as non-problematic or reduce his or her commitment to change. Furthermore, the stages may not be invariant, as some individuals may not perceive their behavior as problematic, but nonetheless come to change their activities because of the prodding of a highly motivated sexual partner. Overall the purpose of the A R R M is to understand why people fail to progress through the change process. The authors posit that from an intervention standpoint, it is imperative to understand the different conditions that influence the outcomes of the various stages of the change process. Failure to correctly identify the position a person occupies in the change process may waste intervention resources (Catania et al., 1990) and may also increase dropout rates from programs that expect too much, 90 or deliver too little to a confused and disappointed audience. The use of the A R R M as a framework in this study does not constitute a formal test of the ARRM, but can offer further insight into the cross-cultural validition of its utility in an adolescent population in sub-Saharan Africa. As already mentioned, socio-cultural and gender issues are expected to influence sexual behavior in the studied population. It is important to recognize that resistance to behavior change may be attributed to societally accepted gender roles and other cultural factors. There should be a paramount recognition of this factor. There are obvious differences between males and females in socio-cultural norms and values pertaining to sexuality. For behavior modification to be effective in combating ADDS, behavior change should occur in both males and females. If only women change, a need remains for their partners to change as well (McGrath & Rwabukwali et al., 1993). Consequently, focus group discussions and informal meetings were conducted with adolescents to get insight into issues and ideas that could be incorporated into the survey instrument to address those issues not covered in the A R R M model (such as location — rural or urban, in-school or out-of-school ~ and socio cultural norms). These notions and ideas are discussed in the methodology section of this thesis and will be evaluated as part of the formal hypothesis tests. 91 C H A P T E R 3 Research Setting This chapter provides an in-depth analysis and discussion of the Ghanaian adolescent and his/her environment. It examines the social organisation, cultural beliefs and norms of the communities in the research setting specifically and the whole of Ghana generally. The chapter concludes by providing information on the Ketu South, Upper Denkyira and Offinso South districts with regard to demographic characteristics (population size, rural/urban classification, age and sex distribution), school enrolment, health facilities, prevalent diseases, the top ten causes of morbidity and mortality, the prevalence of AIDS, problems in the health delivery system, water supply, and the overall pattern of health expenditure. 3.1 The Adolescent in Ghana 3.1.1 The adolescent population in Ghana The 1993 Ghana Demographic Health Survey (GDHS) revealed that one in every five persons was an adolescent aged 15-19. This demographic structure has continued for many years. In 1992, 45% of Ghana's population of 12 million was under age 15 while only 4% was over age 64 (UN Demographic Yearbook, 1994), a situation similar to many developing countries. Only about 57% of the school-age population benefits from basic elementary education (Nabila, Fayorsey and Pappoe, 1997). In addition, only 32% of the students finishing six years of primary education can be accommodated at the JSS (middle) school level. Of those in JSS, only 40% continue their education at SSS institutions. The ratio 92 of male to female students at the three levels (primary, JSS and SSS) has been consistent since 1989, with females constituting the majority of dropouts (55:45 at the primary level; 59:41 at the JSS level and 67:33 at the SSS level). According to the GDHS of 1993, only 51% of males and 29% of females aged 12-19 were attending school. Lack of parental care, child labour, and the short-term gratification of making money are factors related to these low enrolment numbers. The labour law of 1967 stipulates that "until the apparent age of 15 years, a child may only be employed within his own family, in light work strictly of an agricultural or domestic nature. Working for pay is permitted, within limits, for persons between 15 and 18 years" (NLCD 157, 1967). However, in spite of this provision, it was found in 1997 that 7.7% of children aged 7-14 were economically active (Nabila, Fayorsey and Papoe, 1997). In rural areas these numbers were found to be much higher - 21% of males and 15% of females aged 7-14 were economically active. For those aged 15-19, 48% of males and females in total were economically active in rural areas compared to 28% countrywide. Most of these children sell petty things such as ice water, newspapers and bread or provide services such as polishing pedestrians' shoes. In spite of the above apparent "employment", the Ghanaian adolescent is confronted with chronic unemployment brought about by the IMF and World Bank's economic policies of structural adjustment. It is estimated that for every unemployed adult there are four unemployed youths (GLSS 3, 1991/92; Fayorsey, 1995). Even when adolescents have undergone apprenticeships in specific trades, lack of capital makes it impossible for them to start earning a living in their learned trade. The result is a drift into urban centres where they engage in the buying and selling of odds and ends or face 93 unemployment. These economic issues have implications for health seeking and sexual behaviour. 3.1.2 The sexuality of the Ghanaian adolescent Blanc and Rotenberg (1992), utilizing the 1988 Ghana Demographic Health Survey (DHS), found that the median age at first sexual intercourse for girls was 16.7 years while the median age at marriage was 18.2 years. In 1988 births to women aged 15-19 contributed 13% of all births (National Research Council, 1993). The 1988 GDHS showed that by age 20, about 63% of women had married and 51% had given birth and that 8.8% of unmarried women aged 15-19 had given birth. In 1992, of those aged 15-19, 60.5% reported having experienced sexual activity —33% had had sexual intercourse between ages 15 and 17, and by ages 18 to 19 the percentage had risen to 60.5%. By age 20, more than 85% of all women had experienced sexual activity and 22% had become mothers. In addition, according to the GDHS (1993), one-third of all births in Ghana are among young women aged 15-24. The above statistics clearly show that there is an early onset of sexual activity, which exposes the teenage population to unwanted pregnancy and STDs, including HIV/AIDS. Poverty, lack of parental care, and peer pressure lead adolescent girls in particular to enter into sexual relationships (Nabila, Fayorsey, and Pappoe, 1997). The class of 1994 University of Ghana medical students found that most teenage girls reported having boyfriends for financial reasons, sexual satisfaction, future partnerships, company, or simply because of yielding to peer pressure (Nabila, Fayorsey, and Pappoe, 1997). The dating norms are that most single women expect economic support from their male 94 partners especially when the man is working. Ankomah (1999) also confirms this norm when he discusses the apparent powerlessness of young women in premarital sexual exchange relationships in urban Ghana, where many sexual relationships are contracted with material gain in mind. There is sexual exchange where sexual services are exchanged for material gain - a situation quite different from prostitution, as it is understood in Europe or the US. Peer pressure can stem from name calling such as "you are jimmy jimmy" (a fool, an idiot) if you have not had sex by a certain age, through to being called "anti so" (anti-social), or extend to the belief that the female sexual organ could become as solid as a stone, which would make it impossible to be penetrated by a man and hence prevent future pregnancies. These shared beliefs have been handed down from generation to generation. It is important to recognize that they pervade because Ghana is a society in which the discussion of matters of sexuality between generations is minimal. The median age at first birth is 20.3 years, with variations depending on whether the female lives in a rural or an urban area and on her level of education (Nabila, Fayorsey and Pappoe, 1997). Among those with no education, 33% begin childbearing during their teenage years, with the median age at first birth being 19.8; while among those with a secondary education or higher, only 6% become mothers as teens, with the median age at first birth being 23.2 (GDHS, 1993). Thus education has a significant impact on maternal age at first birth and with high dropout rates, especially among young women, the issue becomes critical. It is important to note that the role of education in decreasing fertility is not due to the structured environment education provides but it has 95 to do with voluntary termination of pregnancy, which is known to be high among females who are in school compared to their counterparts who are not in school. Not much is known about the age of sexual debut among boys. However, McCauley and Salter (1995) believe it is at a younger age than among females. Nabila and Fayorsey (1995) reported a median age of 16 years and that by 19 years, 99% of adolescent boys had experienced sexual activity. In another survey, they found that among young people aged 10-20, 85% of those who had had sex were not attending school (Nabila, Fayorsey, and Pappoe, 1997). 3.1.3 STDs in Ghana and the Ghanaian adolescent STDs have been causes of morbidity in Ghana for a long time. Gonorrhea is the most well known STD - a survey carried out by Awusabo-Asare and Anarfi (1995) showed that it was known by 93.6% of males and 88.9% of females. These figures would suggest high rates of infection but according to Awusabo-Asare and Anarfi (1995), of the 1,364 males and 1,034 females surveyed, only 28.5% of the males and 4.6% of the females indicated ever having been infected. However, the authors suspected that the numbers might be higher. The low rate reported could be due to massive self-medication or likely because of the high prevalence of asymptomatic or unrecognized infection. For those infected with STDs, the choice of treatment is the pharmacy shop or chemical seller, the purchase of antibiotics from street vendors mixed with palm wine, or traditional herbs. Adu-Sarkodie (1997), in a study of 764 patients (384 men and 380 women) presenting at Komfo Anokye Teaching Hospital in Kumasi, found that 74.5% admitted to attempting self-medication before reporting to the clinic. Of these, 272 men 96 had a urethral discharge (65% gonorrhea, 25% non-gonococcal urethritis, 10% others); 314 women had a vaginal discharge (40% candidiasis, 25% trichomoniasis, 15% bacterial vaginosis, 15% gonorrhea, 5% non-specific genital infection); 75 patients had a genital ulcer (25% syphilis, 25% chancroid, 15% herpes genitalis, 5% lymphogranuloma venereum, 5% scabies, 15% non-specific genital trauma); while 103 had other genitourinary problems. Of these patients, 201 (26.3%) had taken one anti-microbial only, 158 (20.6%) had taken two, 123 (16%) had taken three, and 87 (11.3%) had taken more than three. Adu-Sarkodie (1997) concluded that a significant number of patients had self-medicated with inappropriate doses and had come to the clinic because their symptoms had not abated. As noted in the literature review section, most STDs do not present symptoms in females and most do not know they are infected unless informed by their male sexual partners. Nabila, Fayorsey, and Pappoe (1997) contended that although many Ghanaians have heard of STDs, detailed knowledge of transmission and symptoms of gonorrhea, herpes and syphilis is generally low among all ages and very poor among adolescents in particular. In focus group discussions they found most of the adolescents participating mentioned that they usually learn of diseases such as gonorrhea, syphilis, and AIDS informally rather than in formal or structured settings. Among adolescent girls, only one-third were aware of any STD apart from ADDS. Moreover, adolescents complained that most of the programmes on radio and T V dealing with such subjects are in English and since most of them do not attend school and do not understand English, they have little opportunity for receiving information on reproductive health and STDs. 97 3.2 AIDS Epidemiology in Ghana Ghana is a West African country with a population of 18 million inhabitants. As a country, Ghana is at a relatively early stage of the HIV/AIDS epidemic, with a medium HIV prevalence of about 4% (Ghana National AIDS Control Program, 1998). The major modes of transmissions for HIV in Ghana are heterosexual and mother-to-child transmission. In March 1986, the first case of AIDS was reported in Ghana (Anarfi, 1993) and a total of 43 cases were reported in that year. In the same year, the Ministry of Health instituted a surveillance system, whereby AIDS became a reportable disease (Ghana National AIDS Control Program, 1996). At the onset, 89% of the diagnosed cases were females who had a history of living outside the country, and almost all were involved in commercial sex in their countries of residence (Konotey-Ahulu, 1989). The proportion of people with AIDS who have a history of staying outside the country has declined from 89% in 1986 to 56% in 1990. In 1993, about 60% ofthe known cases of AIDS and HIV-positive patients were people with a history of travel outside Ghana (Anarfi & Awusabo-Asare, 1993). These changes are significant, since they indicate that diffusion of the disease is taking place primarily within the country and that Ghana has passed the introductory stage and is well into the propagation stage in the spread of AIDS (Anarfi, 1993). As of December 31, 1994, the number of reported AIDS cases was 14,986, representing a 8.2% cumulative increase over the 1993 data. By December 1996, the number rose to 20,859, with a female to male ratio of 2:1 (Ghana National AIDS Control Program, 1996). At the end of 1998, there were 29,546 reported cases (see table 3.1). These data may not represent the correct state of affairs for the following reasons: (1) Under-reporting is likely, since some cases do not end in the hospitals. (2) There are deaths from competing causes. (3) There are inadequate testing facilities to diagnose AIDS. 98 (4) Physicians are reluctant to record an AIDS diagnosis because of the stigma attached to the disease. (5) The disease has not come to the attention of the AIDS Surveillance Unit. Thus, it estimated that less than 50% of all cases have been reported (Ghana National ATDS/STD Control Program, 1996). The proportion may be, however, less than 1 in 10, as it is estimated that at the end of 1999, there were 340,000 adults and children living with HIV in Ghana (330,000 adults, age 15 to 49, of which there were 180,000 women, age 15 to 49, and 14,000 children, age 0 to 14). In response to the HIV crisis, the Ministry of Health instituted 22 sentinel surveillance systems in the country. Twenty of these sites are antenatal clinics and the remaining two sites are STD clinics in Accra, the capital city, and Kumasi, the capital of the Ashanti region, and the second largest city in Ghana (Ghana National ATDS/STD Control Program, 1995). The 1994 sentinel data show that the proportion of pregnant women who are HIV positive ranges from 2% to 4%, with a low rate of 1% in Tamale and Nalerigu, and 10% in Agomanya. In 1998, HIV prevalence ranged from 2% to 7% among pregnant women who were screened. Outside of the major urban areas, HIV prevalence also increased from 1% in 1991 to 3% in 1998 among pregnant women who were screened. Using these data and adjusting to generalize for Ghana as a whole, it is estimated that, as of 1995, there were about 390,000 people in Ghana with HIV infection (Ghana National ATDS/STD Control Program, 1995). It can be noted that there are constant revisions in the estimated figures as more accurate information becomes available. As stated earlier, sentinel surveys at antenatal clinics may underestimate the population prevalence as demonstrated in a study in the Mwanza district of Tanzania (Borgdorff et al., 1993). Like elsewhere in sub-Saharan Africa, almost 90% of all cases occur in adults of age 20 to 49. It should also be noted that there is a gender differential in the distribution of the ages at which infection peaks. For females, it is between age 25 to 29 and for males, 30 to 34. This implies that on average, females are infected at an earlier age than 99 males. Table 3.1 (below) depicts the distribution of ADDS reported cases by gender and age categories since the inception of the epidemic. Table 31: Cumulative ADDS cases in Ghana (1986-1998) Age Group (yrs) Female Male Total %to overall 0-4 163 154 317 1.1 5-9 51 29 51 0.2 10-14 62 20 62 0.2 15-19 603 77 603 2.0 20-24 2,878 535 3413 11.6 25-29 4,449 1,798 6,247 21,1 30-34 3,849 2,490 6,339 21.5 35-39 2,782 2,296 5,078 17.2 40-44 1,621 1,324 2,945 10.0 45-49 1,042 980 2,022 6.8 50-54 691 469 1,160 3.9 55-59 307 221 528 1.8 60+ 329 226 555 1.9 Not stated 145 81 226 0.8 Total 18,846 10,700 29,546 100 Politically, Ghana is divided into 10 administrative regions. Table 3.2 gives the regional distribution of ADDS cases in Ghana and the rates per 10,000 people. The Ashanti and Eastern regions represent 48% of all cases. Of equal significance is the changing distribution of cases per region from 1996 to 1998. The northern region experienced a 640% increase and the Upper East region, a 272% increase. It is likely these may be due to a reporting bias rather than to an increase in incident cases. The population used in computing the rates is based on the 2000 census. The underlying assumption in the computation of the rates is that there is minimum migration. Based on the rates calculated, the Ashanti, Eastern and Upper East regions were considered high 100 HIV prevalence areas (17.1 to 27.9 cases per 10,000 people); the Brong Ahafo, Greater Accra, Central and Northern regions were classified as medium prevalence areas (10.4 to 15.8 cases per 10,000 people); and the Northern, Volta and Upper West regions were categorized as low prevalence areas (6.2 to7.6 cases per 10,000 people). Table 3.2 Reported Cumulative AIDS Cases and Rates in Ghana by Region (1986-1998) Region (population) # of cases (rate per 10,000 people) % of total cases Ashanti (3,187,601) 8,892 (27.9) 30.1 Brong Ahafo (1,824,822) 2,740(15.0) 9.3 Central (1,580,047) 1,844(11.8) 6.2 Eastern (2,108,852) 5,282 (25.0) 17.9 Greater Accra (2,909,643) 4,585 (15.8) 15.5 Northern (1,854,994) 1,153 (6.2) 3.9 Upper East (917,251) 1,564(17.1) 5.3 Upper West (573,860) 439 (7.6) 1.5 Volta (1,612,299) 1,037 (6.4) 3.5 Western (1,842,878) 1,924 (10.4) 6.5 Not Stated 86 0.3 Total (18,412,247) 29,546 (16.0) 100 HIV prevalence among sex workers increased from 2% in 1986 to nearly 40% in 1991. By 1997, HIV prevalence among sex workers tested in Accra had reached 73%. Furthermore, HIV prevalence among STD clinic patients in Accra increased from 2% in 1988 to nearly 9% in 1991. In 1998, HIV infection among female STD patients tested in Adabraka, in the greater Accra region, had reached 27%. The AIDS Control Program in Ghana further estimates that with a rise in HIV prevalence of 6.5% to 8% by the year 2005, estimated cases of HIV would rise from 390,000 in 1994 to 750,000 by the year 101 2000 and reach 1.25 million by the year 2010 (Ghana National ATDS/STD Control Program, 1995). As in other countries in sub-Saharan Africa, AIDS will impact negatively on population size and growth, adult death rate, infant and children under 5 mortality and child survival. It will also slow the economy, lead to increase in AIDS orphans, and increase demand for health services. The table below depicts expected population growth with and without AIDS to the year 2010 (National AIDS Control Programme, 1996). Table 3.3 Expected Population Growth — Comparative Table Year Population (no AIDS) Population (AIDS) 1995 16 million 2000 19.79 million 19.46 million 2010 25.89 million 24.54 million Without AIDS, the number of deaths among young adults, age 15 to 49, was expected to be 62,000 and increase to 63,000 a year by the year 2010. However the presence of AIDS would increase this number to 132,000 a year by the year 2010. AIDS cases were expected to occupy 20% of hospital beds in 1994, a figure estimated to increase to 50% by the year 2000 and 90% by the year 2010. Without HIV, the rate of TB infection would be limited to 0.2% of the population, which would mean around 20,000 to 30,000 new cases a year. The additional number of TB cases caused by HIV infection would be about 36,000 a year. The nature of sexual contacts in Ghanaian society increases the likelihood of HIV propagation. Marriages contracted under customary law could develop into polygyny, which is defined as the male tendency to seek multiple partners (Anarfi & Awusabo-Asare, 1993). In addition, the young age of Ghana's population, coupled with the early 102 onset of sexual activity demonstrated by survey research (for example DHS), gives cause for concern that a significant proportion of Ghanaian men and women are at risk of acquiring HIV. 3.3 Ethnic and social organisation Three major religious groupings are found in Ghana - 64% of the heads of households are Christians, 18% practice traditional religion, 14% are Moslems and the other 4% are of various smaller religious groups (GDHS, 1994). Four main marital systems operate - civil, traditional, Christian, and Islamic. Traditional marriage requires the payment of a bride price where the man pays the parents of the bride a given sum of money and other items. Marriage then transfers rights and the man has absolute rights over the wife's sexual services. Whether a patrilineal (Ketu South) or matrilineal (Upper Denkyira and Offinso South) society, issues of fertility are generally in the domain of the extended family. Thus couples are pressured to have children and increase the family size. As a result, the use of condoms as a family planning tool is not generally accepted. This practice clearly has implications for HIV and STD transmission. The differences in the inheritance systems (matrilineal versus patrilineal) need to be addressed as they impact on the outcomes of the study. There are different views or value systems relating to virginity and sexuality between the 2 cultural organisations. For example among the southern Ewes (of which Ketu South is part), traditionally, it is a taboo to have sex before marriage (Nukunya, 1969). However, among the Akans (of which Upper Denkyira and Offinso South are part) the taboo is sex before puberty (nubility) rites. An individual who has sex before nubility rites requires cleansing 103 (kyiriba). The implication is that even though modernization has brought changes in matters of sexuality, and premarital sex is still frowned upon, the degrees of social sanctions may be different depending on the linearity of the area. The general argument is that the Akans are more flexible in matters of sexuality. Some authors have reported on these differences and the way they affect sexual behaviour. Addai (1999) explores the relationship between ethnicity and sexual behaviour, that is age of sexual debut before 17 and premarital sexual experience, using data from the 1993 Ghana Demographic and Health Survey in women of reproductive age (15-49). All ethnic groups show substantial sexual experience before age 17 and premarital sexual engagement. It was found that ethnicity impacts on sexual behaviour especially for ever-married women and that groups that practice matrilineal and patrilineal systems show differences in the likelihood of having sex before age 17. The pro-natalist attitudes of the matrilineal Akan (Upper Denkyira and Offinso South) vis-a-vis the patrilineal Ewe (Ketu South) may also impact on the outcomes of interest in this study. Pro natalist or desire to have children impacts on sexual behaviour and indirectly on sexual risk taking as regards the use of condoms and other contraceptives. Klomegah (1999) using data from the 1993 Ghana Demographic and Health Survey reports that contraceptive use among women is quite low and the reasons most frequently cited for non-use of a modern birth control method are the desire to have children, lack of knowledge about contraceptives and health concerns. Even though in Ghana traditionally sexual decisions are made by men, in the matrilineal system the children belong to the woman's clan. Garcia Clarke (1994) in her "Onions are my Husband," contends that the matrilineage provides a real safety net for 104 most urban Asante (matrilineal/Offinso South) women against the risks of divorce, illness, or bankruptcy and raising children is an Asante woman's most important contribution to her lineage, since they are its future members. Mikell (1990) questions the stereotype that women in matrilineal Akan communities (for example Ashanti and Brong) have more access to economic resources than women in patrilineal communities in Ghana. He argues that, despite Akan women's theoretical access to land, trading, and family leadership roles, they remain economically more dependent, and impoverished female-headed households have been on the rise. Gratia Clarke (1994) also found that men traders reported financial backing from their mothers much more often than women traders reported help from fathers or male relatives such as matrilineal uncles (p. 334). Clarke however adds that for the typical Asante woman the use rights she retains in lineage resources are more important to her long-term work and survival strategies. The Asante women are more likely to live in houses owned by lineage kin than to inherit them. Returning to the hometown remains an important fall-back strategy, whether as a short-term refuge, a long term career change, or a retirement option. Hometown land claims preserve the possibility of food farming, at least at the subsistence level. With this cultural conditioning, the females in the matrilineal systems are believed to be more autonomous than their counterparts in the patrilineal systems. Open parental-adolescent interaction in matters of sexuality is taboo. The word sex is considered sacred and certain questions asked by adolescents are quickly brushed off. An adolescent who persistently asks sex-related questions is branded a "bad" boy or 105 girl (Nabila, Fayorsey and Pappoe, 1997), and parents do not even tell their children about the changes they go through during puberty. In the case of girls, most of them are told at menarche: "you are now a woman and should fear and avoid men. If you have sex you will become pregnant." Throughout Ghana the traditional attitude is to frown on premarital sexual relationships even though they are prevalent. However, this disapproval applies more to females than to males. There is no inhibition pertaining to male sexuality with concurrent partners as polygamy is widely practiced. As a result, males often take concurrent partners as proof of their prowess, even though their female partners usually resent such attitudes. Manhood may be conferred by having many girlfriends or even a child since the absence of offspring may imply an incapability of fathering a child. Thus using condoms may not be in a young man's best interest since he then cannot show his virility. However, when he makes a girl pregnant, with the consequences of financial and social sanctions, the unmarried male may have already proved his manhood to his peers and others. Traditionally such unwanted pregnancies automatically resulted in marriage; however, in modern days the boy may refuse to marry the girl even though he has claimed responsibility of fatherhood. To the young adolescent woman, school represents an avenue for her to leave her area of residence, get a higher education and a better job, and live in an urban environment. Early pregnancy and childbearing means an end to these dreams since being pregnant while a student (in elementary or high school) exacts the penalty of being expelled. Because of this penalty, schooling leads to the postponement of marriage; however, schooling does not affect sexuality of females because the number of years of education achieved by females is low. A number of females who attend school end at the 106 basic level and that is around age 15 or 16 and that is when they start having sex. Thus the link is not there for majority of females. The options for prevention of unwanted pregnancy are limited since oral contraceptives are often nonexistent or too expensive. Thus the only alternatives are abstinence or the use of the rhythm method. The rhythm method as a means of birth control is not very reliable and also carries the consequences of STDs, the risk of becoming pregnant and abortion. Abortion, even though widely practiced, is still proscribed in Ghana and is a first-degree felony which carries a penalty of not less than ten years for the provider and participant. Illegally induced abortions carry significant risk as they may be performed by unqualified personnel and under unsanitary conditions. Hence they may lead to complications which can account for future fertility problems - an important issue because marriages do not last long if the woman does not reproduce. In the Ghanaian context, marriage is not properly established until the birth of the first child, when the supreme purpose of marriage, which is procreation, is practically and symbolically affirmed. From the above discussion it can be noted that the adolescent woman is confronted with how to balance all these competing pressures while at the same time meeting the sexual demands of her boyfriend who may be far older, working, and providing her with economic support. 3.4 The Three Areas of the Study There are 110 administrative districts in Ghana and 200 electoral constituencies. This study was conducted in three constituencies from three separate districts (please see the Appendices for maps of the areas: Ketu District, Appendix 6; Upper Denkyira District, Appendix 7; Offinso District, Appendix 8; and Offinso District Health Facilities 107 Map, Appendix 9). Ketu District is inhabited by the Ewe speaking people, Upper Denkyira by the Denkyiras and Twifo, and Offinso by the Asantes. Whereas the Ewes have patrilineal inheritance, the other two districts have a matrilineal system. The districts are similar in terms of urban-rural dichotomy. Economic activities are mainly agriculture, with light or cottage industry in all three areas and mining operations added to the Upper Denkyira District. These 3 areas were selected because they were geographically far from each other, were not studied by other HIV researchers or by others in other academic disciplines. 3.4.1 Ketu District: Some of the information in this section has been taken from a document entitled Ketu District Assembly Medium Term Development Plan (1996-2000), prepared for the District Assembly by the RehoConsult Group located in the regional capital, Ho. The Ketu South Electoral Constituency is part of the Ketu District. It covers an area of approximately 1,130 square kilometres (436 square miles) in the southeastern part of the region. It is one of the 12 administrative districts in the Volta Region of Ghana, a region which has accounted for 1,037 of the 29,546 cumulative ADDS cases in Ghana since the inception of the epidemic in 1986. The Volta Region ranks the ninth lowest out of ten administrative regions in Ghana in terms of ADDS cases with the rate of 6.4/10,000 people. Hence the region was considered a low prevalence area for the purposes of this study. 108 3.4.1.1 Population characteristics In 1970 the population was 132,537 (47% males, 53% females); in 1984 it increased to 180,309 (47% males, 53% females); and in 1996 it was projected to be 234,000 (47.4% males, 52.6% females). Although there was census in 2000, at the time of writing this thesis the final breakdown in terms of age and gender was not available hence the need to use the figures in the last census (1984) and the projected figures. The district's annual rate of population growth is 2.2%, which is higher than the rate of growth experienced by the Volta Region as a whole. In 1970-76, the male to female ratio of those aged 15 and above revealed that the area experienced a large population loss due to out-migration. However, estimation of migration from the 1984 population census indicates that with a male to female ratio of 100:103 the district experienced a small gain in population. It is being suggested that in-migration from the Republic of Togo, a neighbouring country which shares a 40 kilometre border with the district, could account for this increase. This scenario has implications for HIV infection since Togo represents one of the epicentres of HIV infection in West Africa. Male circumcision is universal in the area. The predominant religious affiltiaion is Christianity (Catholic, Protestant and Apostolic). Few engage in traditional religion worship and there are some Moslems as well as a minimal number of atheists in the district. 3.4.1.2 Urban-rural split In 1984, over 97% of all the communities had populations of less than 1,000. Since it did not attain the threshold of 5,000, which qualifies in Ghana as the first 109 yardstick in designating a town an urban area, there were only three settlements in the district that could be classified as urban. Even though in 1984 only three settlements could be termed urban by the end of 1996, seven settlements achieved urban classification. These significant annual rates of urban growth experienced in the district from 1984 to 1996 range from 2.1% to 5.9%. In 1970, 84% of the district and 84% of the Volta region could be classified as rural. By 2,000 only 62.5% of the district could be classified rural compared to 75% of the Volta Region. It can therefore be noted that the district is becoming urbanised faster than the rest of the Volta Region. However, growth in these centres in the district was not accompanied by physical planning, the provision of social and utility services (especially potable water), or the establishment of productive ventures for employment. Table 3.4 below shows the district's population density per square kilometre compared to the rest of the Volta region and country (Ghana). Table 3.4 Population density (per sq/km): Ketu compared to Volta Region and Ghana Site Area (sq kms) 1984 1996 2000 Ketu District 1,130 160 207 227 Volta Region 21,165 57 70 70 Ghana 238,533 51 69 76 3.4.1.3 Economic activity in the district According to the Ghana census of 1984, of the 83,346 males aged 15 and over, 98.2% were employed and of the 48,239 females, 98.8% were employed. However, 18% of the population aged 15 years were unemployed or could be termed economically 110 inactive. There is relative poverty in the area, defined as when people are poor in relation to the average standard of living in their country and when they lack the goods and services needed to live a fulfilling life. It is estimated that school age children constitute 26% of the population. Thus 44% of the population could be termed to be economically inactive or dependent. The 56% of the population that are economically active work in areas that are characterized as low productivity, particularly agriculture - 50% of the working population are engaged in agriculture (farming and hunting). Fishing accounts for 2.9%, salt winning (manufacturing), mining and quarrying contribute 0.1% and manufacturing contributes 16.7%. Manufacturing activities consist of the manufacture of food, clothes, wood and furniture, and metal products. About 19.8% are engaged in the wholesale/retail trade and in the hospitality industry. The rest of those who are employed are involved in transport, finance, social and personal services, public administration and defence, electricity, and gas construction. Since the area shares a border with Togo, a member of the Francophone CFA currency zone, and given that the CFA is a more stable currency than the Ghanaian currency (the cedi), there is brisk business, legal and illegal (smuggling), between the two countries, which accounts for the low unemployment rate in the district. It is not uncommon to see Ghanaians travel 170 kilometres from the capital Accra to the district to cross the border to Lome (the capital of Togo), where they buy merchandise for resale in Ghana. Citizens from the Ghana side of the border aid these people in their smuggling activities. I l l 3.4.1.4 Education As of 1996, the total number of first cycle (primary and JSS) schools was 198 with an enrolment of 37,191 for primary schools and 11,161 for Junior Secondary Schools, giving a total enrolment of 48,352. This enrolment is less than the number who should be in school since there are about 60,800 children aged 6-14 in the district. In addition, it is known that children cross the border from Togo to Ghana attend school. There are ten second cycle institutions in the district distributed as follows: four senior secondary schools, three secondary-technical institutes, two commercial schools, and one technical-vocational institute. 3.4.1.5 Health delivery services At the apex of the health delivery structure is the District Health Management Team (DHMT), which is headed by the District Medical Officer of Health (when available). The D H M T consists of technical and professional personnel from the various divisions of the Ministry of Health such as the Maternal Child Health/FP, Environmental Health, Nutrition, Health Education, Medical Care and Biostatistics. The D H M T also coordinates the activities of the various divisions and collaborates with other health-related sectors for the promotion of health development and the prevention of disease. To facilitate the management of health delivery in the district, five health zones have been created. A sub-district Health Team (SDHT) under the supervision of the D H M T manages each health zone. The SDHT's membership is derived from the heads of the various health units that operate from the health institutions within each zone. 112 There are ten health posts in the district, five MCH/FP clinics, five private hospitals and fifteen private clinics. The top 14 causes of morbidity in the district can be classified into three categories: water-related or waterborne diseases (malaria, bilharzia and skin diseases), diseases associated with unsanitary, personal, domestic and environmental practices (intestinal worms, diarrhea diseases), and AIDS. In addition, the district recorded the highest number of ADDS cases in the Volta Region in 1994 (85%), even though the number is low compared to other parts of the country. Most morbidity and mortality are preventable diseases based on current medical knowledge (malaria, intestinal worms, diarrhea diseases, yaws, septicaemia, and malnutrition are all preventable). The top 14 causes of morbidity and mortality show that there is a serious gap between health care capacity and the ability to deliver adequate and affordable health care to all of the communities. Other problems the health sector has to contend with are the number of destitute people, including street children, and the number of inpatients who leave the hospital against medical advice apparently to avoid paying bills. The major determinants of ill health in the district can be attributed to three main factors: 1. In 1984, only 28% of the district's population had access to pipe-borne water or boreholes (deep well water). It can be noted that over 70% of the population continue to depend on unsafe sources of water. Even with pipe-borne water, the supplies are inadequate. Hand-dug wells provide water for 50.5% of the population (456 of the localities, serving 91,087 people), while 20% of the population depends on dams, dug-outs and rivers (unsafe sources). The streams that provide mainly surface water are seasonal, serving as water sources to many communities during the rainy season. 113 During the dry season, settlements that depend on these streams have to resort to dams, dug-outs and hand-dug wells. 2. There is malnutrition in the district as a result of poverty. The M C H clinics recorded moderate to severe malnutrition among children aged 0-5 in 1995, with 24% ofthe children being moderately malnourished and 8% being severely malnourished. 3. Domestic rubbish is, in general, disposed of on nearby farms and in bushes surrounding residential houses. A UN1CEF survey of the district in 1985 revealed that 67% of the communities did not dispose of their rubbish at designated rubbish dumps. The result is fertile breeding grounds for flies and other vectors. According to the survey, 39% of the population had traditional pit latrines that were heavily used, while 60% defecated freely in the surroundings of their settlements. The result is that rains can wash excrement into sources of water, such as streams, dug-outs and dams, that serve as drinking water. 3.4.1.6 Cultural and social organisation The seven traditional areas of the district are characterized by patrilineal inheritance. Both nuclear and extended family systems are present. Individual and clan ownership of land is common, while traditional rule by chiefs is practiced. The rights of the individual to property, free speech and practice of other human rights are recognised in the various communities. 114 3.4.1.7 Constraints facing the district The rates of population growth and urbanisation, the high population density on usable land, the high unemployment rate and migration, and public health issues such as lack of potable water are some of the issues the district is currently facing. 3.4.2 Upper Denkyira District: Information from this section is drawn from a document produced by the District Assembly entitled District Profile: Current Status. The Upper Denkyira Constituency is part of the Upper Denkyira District. It covers an area of approximately 1,700 square kilometres in the Central Region of Ghana. The district is one of the 12 administrative districts in the Central Region, a region that has accounted for 1,844 of the 29,546 cumulative AIDS cases in Ghana since the inception of the epidemic in 1986. The Central Region ranks the sixth lowest out of ten administrative regions in Ghana in terms of AIDS cases with the rate of 11.8/10,000 people. Hence the region was considered a medium prevalence area for the purposes of this study. 3.4.2.1 Population characteristics In 1960 the population of the district was 34,011, in 1970 it was 44,498, and by 1984 it was 68,329, showing an annual rate of growth of 3.1%. With this rate of growth, the 1999 population was expected to be around 98,561. The high growth rate experienced by the district was due to extensive in-migration because of the boom in farming and gold-mining activities. So extensive was this in-migration between 1960-1970 that the district recorded an inter-censual percentage increase in population of 115 30.8%. Between 1970-1984, the increase was 52.9%. The annual rate of growth of the district is 3.1%, which is the same as the country as a whole but is higher than the rate of growth experienced by the Central Region as a whole (1.4%). According to the 1984 census, there were 35,928 males to 32,401 females yielding a sex ratio of 111:100, which compares to the national ratio of 97:100 and the regional ratio of 96:100. The economically active population (15-64 years) constitutes 49.9% of the total population in the district while the inactive segment constitutes 50.1%. This inactive population includes 47.2% below age 15 and 3.0% above age 65. This high dependency ratio means that each economically active worker supports one dependent on average. Male circumcision is universal in the area. The predominant religion is Christianity (Catholic, Protestant and Apostolic). Few engage in traditional religious worship and there are some Moslems as well as a minimal number of atheists in the district. 3.4.2.2 Urban-rural split Apart from the district capital Dunkwa, all the settlements are considered rural (using the urban population threshold of 5,000). Based on the 1984 census, the rural population in the district forms 75.3% of the population and is distributed by gender as follows: rural (27,530 males, 23,894 females); and urban (8,424 males, 8507 females). In the rural areas, males constitute 54% of the population and females 46%. In Dunkwa, the only urban centre in the district, males constitute 49.8% of the population and females 50.2%. 116 3.4.2.3 Economic Activities Agriculture is the main source of livelihood in the district. Some of the land is under forest reserve, 45% is reserved for mining concessions, and settlement and total arable land for cultivation forms 44%. Most of the population spend close to 61% of their income on food (excluding food items obtained from the farm), 12.4% on clothing, 5.7% on education, 5.2% on health, 5.3% on transport, 3.3% on energy, 0.5% on housing, 1.3% on water, and 5.7% on other expenses. According to the 1984 census, 68% of the economically active individuals were involved in agriculture. This percentage has remained stable to the extent that in 1998, 66% of the population was still engaged in the agricultural sector. The major crops cultivated in the district include cash crops such as cocoa, citrus, oil palm, and food crops such as cassava, plantain, maize and cowpeas. Cocoa alone covers 56.3% of cultivated land, next is cassava at 7.5%, others like rice, yam, and pineapple at 20.9%, and oil palm at 6.3%. Constraints faced by food and cash crop farmers include: lack of credit and inadequate supply and high cost of farm inputs such as seedlings and implements to expand and maintain farms; transport; poor roads; and lack of storage facilities. Industrial activities in the area include mining and quarrying, manufacturing, construction, and artisan work. The district is endowed with the minerals gold, clay, kaolin, bauxite, and manganese, which abound in commercial quantities. Quarrying consists mostly of extracting sand and gravel from riverbeds for use in the construction of houses and roads. 117 Apart from the district capital Dunkwa, none of the settlements in the district enjoy the services of telecommunications. Even in the capital the telecommunication system is fraught with problems. There is only one post office in the district and three postal agencies in three other settlements. The postal agencies merely sell stamps and distribute mail. The result is that citizens have to rely on transport owners and drivers to deliver messages and letters, a system which is very unreliable. Like Ketu District, the main sources of energy are electricity, fuel wood, sunlight, generators and kerosene. Sunlight is used mostly for drying clothes and food crops, and for domestic activities such as cooking, lighting and heating. Electricity is a major source of energy for industrial activities, especially in the mining sector. 3.4.2.4 Education As of 1996, there were 215 first cycle schools in the district with an enrolment of 22,208 for primary schools and 5,517 for JSS giving a total enrollment of 27,725. First cycle schools can be found in almost all the settlements. Nursery school constitutes 34% ofthe schools, primary 41%, JSS 23%, SSS 1% and vocational 0.4%. There are three SSS and one vocational institute. Total student enrolment in 1996 was 28,944 with males constituting 54% and girls 46% of the enrolment. Even though this is above the national average of 36.6% for female enrolment, females are still underrepresented compared to boys. However, this ratio is not uniform across all the categories. The gap between males and females widen from JSS through SSS. It can also be noted that only one-third of the pupils in primary school proceed to JSS. Some of the reasons are that after primary education pupils move outside the district to further their education; there is a 118 preference of investing in male over female education; and parents may have negative attitudes towards the education of girls 3.4.2.5 Health services There are two hospitals, three health posts, four clinics, one health centre, and one each of maternity clinic, mobile clinic, and sickbay in the district. There two hospitals (one government and one private) both located in Dunkwa the district capital. Transport difficulties make delivery of healthcare out of reach of most rural dwellers. One result is a high reliance on self-medication, especially among farmers where daily purchases of drugs from peddlers is a common practice. The supply of health personnel is woefully inadequate. There are two medical officers and a dental surgeon and no gynecologist/obstetrician. The doctor-patient ratio was 1:49,280 in 1996, which is far below the WHO minimum of 1:10,000. The ratio is also below the 1992 national average of 1:20,859. There are 65 nurses throughout the district, yielding a nurse-patient ratio of 1:1,516. In terms of morbidity and mortality, it is noted that of the total 7,593 outpatient visits, malaria constituted 69%, anemia 4.5%, gynecological disorders, skin diseases, pregnancy related complications, and diarrhea diseases each accounted for 3.5%, upper respiratory tract infections 2.5%, measles 2.1%, accident/fracture/burns 1.8% and others 6%. The major determinants of ill health include poor nutrition, poor sanitation and other environmental/occupational hazardous activities such as mining, which is suspected to be associated with upper respiratory tract infections. 119 1. In most areas, drinking water is drawn from wells, rivers, streams and boreholes. Most of the rivers and streams are polluted due to unsanitary conditions and mining activities. A major river, River Offin, is highly polluted because it was heavily dredged for gold and polluted with hard chemicals (mercury, for example). Other water bodies are polluted with waste disposal. As a result, women and children have to trek long distances to fetch water. This takes productive time away from all concerned including school children who end up going to school late and being tired when in class. 2. Malnutrition in this district is a result of poverty and dietary habits. Secondary protein sources such as beans and peas do not form part of the common menu. According to hospital statistics, 30.1% of the children who present are at risk of malnutrition and 33.8% are already malnourished. Micronutrient malnutrition (iron deficiency) is the cause of 37.2% of total admissions at the children's ward. 3. There are unsanitary living conditions due to lack of adequate sanitary facilities. Toilet facilities are mainly pit and pan latrines, Kumasi Ventilated Pit Latrines (KVTP) and Vault. These have no indoor plumbing. The facilities are inadequate; hence most communities use refuse dumps, railway lines, bushes and riverbanks as places for human waste disposal. Outbreaks of cholera are rampant in some of these communities. In addition, there is a poor drainage system; hence, stagnant water and pools of dirty water around dwelling units are common sights and serve as fertile breeding ground for mosquitoes. 120 3.4.2.6 Constraints facing the district The main constraints facing the district are the rate of population growth; the high unemployment rate and the high percentage of the population living at subsistence levels; deforestation and degradation of the soil, which is followed by erosion and flooding; surface mining with cyanide, which poses a tremendous hazard to the ecosystem; and the digging of pits for mining, which serve as breeding grounds for mosquitoes. There is also a contagion of burili ulcer. Since this district has mines, it attracts commercial sex workers, which has implications for HIV in the district. 3.4.3 Offinso District: The information from this section is drawn mainly from Profile on Offinso District, a document produced by the Offinso District Assembly (1996). Offinso South constituency is part of the Offinso District, which is located in the extreme northwestern part of the Ashanti Region of Ghana. The district is one of the 17 administrative districts in the Ashanti Region, a region which has accounted for 8,892 of the 29,546 cumulative ADDS cases in Ghana since the inception of the epidemic in 1986. The Ashanti Region ranks the highest out of 10 administrative regions in Ghana in terms of AIDS cases with the rate of 27.9/10,000 people. The region, apart from having the highest per capita HIV infections in Ghana (27.9/10,000), also accounts for 30.1% of all ADDS cases in the country. It is therefore considered a high prevalence area for the purposes of this study. 121 3.4.3.1 Population Characteristics This district is also characterised by a rapidly increasing population over the various inter-censual periods. In 1960 it had a population of 34,952, in 1970 it was 56,319, and in 1984 it was 104,815. The inter-census increase experienced from 1960-1970 was 61.13% and from 1970-1984 was 86.1%. The annual growth rate was 4.48% between 1970-1984, which provided a projected population of 170,818 in 1995. This growth rate was higher than the rate experienced throughout the whole of the Ashanti Region for the same period (2.5%). Migration due to farming activities accounted partly for this massive growth. The male-female ratio of the district stood at 104:100, which was different from the regional and nation levels (both 97:100). The high male ratio in the district reflects the migrant farming population. Migrant male farmers usually leave their female partners at home or in secure environments until economic conditions at their new locations prove sustainable. Only then do their female partners and dependents join them. This situation has implications for HJV/STD propagation as men turn to commercial sex workers or other women who are not their spouses. Male circumcision is universal in the area. The predominant religious practice is Christianity (Catholic, Protestant and Apostolic). Few engage in traditional religion and there are some Moslems as well as a minimal number of atheists in the district. 3.4.3.2 Urban-rural split There are 126 settlements in the district with 86 (68%) of them with fewer than 500 people. About 52% of the total population is in settlements with populations below 1,000 people. This pattern has been dictated because the migrant farmers who come to 122 work on cocoa plantations prefer to be closer to their farms and hamlets. The settlement pattern within the district can be described as linear as most settlements are strung along the Ghana-Burkina Faso Highway. In 1960 there was no settlement that could be classified as a town but by 1984 it had 3 towns and in 1995 there were 4 towns. However in the Ashanti region in 1960 there were 12 towns, and by 1984 there were 26 and in 1995 there were 27 towns. Thus there was a greater urbanization in the whole of Ashanti region overall than in the Offinso District. It also shows that whereas the towns are increasing gradually in population, rural areas are growing quickly. This is characteristic of rural agricultural districts. In addition, the district experienced greater population densities over each census period than the Ashanti Region as a whole, as illustrated in Table 3.5 (next page). Table 3.5 Population distribution and density (Offinso and Ashanti) Year Offinso District All of Ashanti Region Pop/km % increase Pop/km % increase 1960 28.0 45.5 1970 45.0 60.7 60.8 33.6 1984 83.5 85.5 85.7 40.95 1995 136.1 63.0 112.3 31.0 From the table above, it is obvious that the Offinso District, compared to the rest of the Ashanti Region, has become densely populated, and with its accompanying health and social implications. 123 3.4.3.3 Economic activities in Offinso District Over 70% of the economically active population are farmers. The major crops cultivated are cassava, maize, plantain, oil palm, cocoa, rice and cashews. There is limited fishing and animal production although poultry farming is carried out on a very small scale. There is no large-scale industry. The two medium size industries involve wood processing. There are cottage industries ranging from corn milling, cooking oil extraction, coffin making, dressmaking, tailoring, and vehicle repairs. Commercial activity in the district is quite low. Commercial stores are located along the main transportation arteries. These commercial centres serve as nerve centres or interchange points for the distribution of both manufactured and agricultural goods. There were more females employed than males (31,135 versus 29,043) in 1984. Of the 1034 unemployed, women account for 504 (48%). Women are engaged in farm labour, in the informal sector such as charcoal and firewood selling, and in small-scale industries like oil palm extraction and pottery. The district is bissected by the main highway from Accra (the capital of Ghana) to Kumasi to the north (the Trans-African highway serves as the main gateway to the Ashanti Region from the Northern and Brong-Ahafo Regions). Electricity is provided but mainly in the urban settlements. The district covers an area of 1,255 square kilometres, which is 5.2% of Ashanti Region's total area. There are two post offices and postal agencies in three other towns. Telephone or telecommunication services are extremely limited. Vegetation is mainly semi-deciduous, which is interspersed with thick forests. There are eight main forest reserves and the vast stretch of forest has provided a base for robust logging industry. 124 3.4.3.4 Education As of 1995 the district had 207 first cycle schools with 25,161 pupils (93.5%) out of a total enrolment of 26,897 students in the district. Females accounted for 46.5% of the enrolment at the basic level. There were seven second cycle (SSS) with a population of 1,471, of which 38.4% were females. There are no public libraries in the district. Senior secondary school (SSS) accounts for 5.5% of total enrolment with special school (handicapped) enrollment being 1%. There is a gender imbalance in school enrolment in the district between males and females. The male-female gap widens with school level -from a low of 6.8% at the basic school level to 23.4% at the high school level. These female participation rates of 46% and 38.4% are comparable to the national levels of 45.5% and 33.1% respectively. Similar to the other districts, the decline in enrolment for the female group can be attributed to higher dropout rates due to unplanned pregnancy, lack of funds and the need to provide family support. Apart from using diminishing school enrolment to determine drop-out rates, examination results are also yardsticks to be used in Ghana's educational system. From basic education, students can enter high school only upon achieving a minimum grade level. In the district over the three-year period from 1993 to 1995, 22%-34% of the students did not make the minimum qualification to proceed on to high school. It is believed by community leaders that some of the factors attributable to this high failure rate are unplanned pregnancy, in the case of females, poor academic performance of students, peer group influence, lack of vision regarding benefits derived from education, and poor economic background, which militate against paying maximum attention to 125 school work. The other reason for the wide margin between the enrolment in first cycle schools and second cycle is due to the fact that people tend to send their children to urban areas for their SSS education where facilities are better. 3.4.3.5 Health Services Health delivery is based on the three-tier hierarchical system described as follows: Tier A is made up of traditional birth attendants, (registered) trained and untrained, community clinics, dressing stations and primary care centres. This tier deals with minor ailments and the dressing of wounds. When sickness becomes severe patients are referred to Tier B. There are 17 traditional birth attendants in the district. Tier B is made up of health centres or health posts. This tier also deals with cases which no longer require hospital stay or treatment. There are five health centres, one maternity and child health centre, two primary health care centres, and two dressing stations. Two private clinics are being operated by non-qualified personnel and are considered illegal by the Ministry of Health. Tier C is the hospital. There is only one hospital, St. Patrick's Hospital at Offinso-Maase, built and managed by the Catholic Church. The distribution of health facilities in the district reflects what pertains to Ghana as a whole. The higher medical care centres are concentrated in the urbanised areas whereas the rural areas depend on first-aid clinics and traditional birth attendants. Residents in rural areas have to travel over 17 kilometres to the nearest health centre or hospital. With the poor state of the road network in rural communities, health services remain inaccessible to the majority of the district's population, the rural poor who need the services the most. 126 The district has six doctors, giving a 1:28,470 doctor-patient ratio. This ratio, which is considered favourable, can be attributed to St. Patrick's Catholic Hospital. Statistics show that from November 1995 to April 1996, 29,077 persons presented at the various health facilities in the district. Malaria is the most prevalent disease, accounting for 41% of hospital attendance, followed by diarrhea, upper respiratory tract infections and pregnancy-related disorders, which accounted for 11%, 7.2%, and 5.6% of outpatient morbidity respectively. The major determinants of ill health can be attributed to three main factors: 1. Only 39.5% of the population has access to potable drinking water. All others depend on streams. Even in towns that have pipe-borne water, the supply systems are highly irregular and unreliable. These towns supplement their potable water with bore-holes and wells. In the dry seasons, water shortages become acute and women and children travel five kilometers in some areas in search of water. 2. Malnutrition in the district as a result of poverty and dietary habits. 3. There are unsanitary living conditions due to lack of adequate sanitary facilities. For example, there are only eight KVTPs in the district and most are in institutions. The public pit latrines are the most common toilet facility and are available in 84% of the settlements. With increasing population and demand to use these toilet facilities there is defecation in the surrounding bushes, open spaces and refuse dumps. There is also uncontrolled dumping of solid waste and the main form of solid waste management in the district is the burning of refuse. The above impact the health of the population. Other problems in the health sector include the lack of adequate medical care, the prevalence of environmentally 127 preventable diseases, high maternal and child mortality, and low nutritional levels, especially in children. 3.4.3.6 AIDS in Offinso South Constituency As stated earlier, the Ashanti Region led Ghana in cumulative ADDS cases from 1986-1998, (8,892 or 30.1%). The only hospital in the district, St. Patrick's, is located 40 kilometres from Kumasi, the regional capital. The hospital is located in Maase, 2 kilometres off the Kumasi-Tamale road. This hospital was started as a clinic by nuns from Ireland in 1957 and was upgraded to the status of Diocesan hospital in 1978. From July 1993, the hospital embarked on counseling HIV patients and giving palliative care. Pre- and post-test counseling are provided, in an effort to advise patients of their HIV status and let them come to terms with the disease (Osei Kwame, 1999). The counseling objective has been to forestall exploitation by traditional healers and spiritual churches who hold themselves out as knowing how to cure ADDS. The total number of patients counseled from July 1992 to May 1999 was 474 (284 females and 160 males). The hospital could only document 68 deaths during the period since most patients go home to die and the hospital lacks logistics such as vehicles to follow-up cases or provide home-based care. As stated earlier, this is the only hospital serving a population of 200,000 and covering a widely dispersed community. The hospital also screens blood before transfusion. In 1996, of the 906 pints of blood screened, 66 (7.3%) were found to be reactive to HIV. The hospital is confronted with the shortage of HIV manuals and diagnostic kit supplies. Even when HIV reagents are available, storage is a problem because of frequent electricity failure and no alternative sources of supply. The perennial 128 problems encountered by the hospital are providing health services for HIV patients in the district who have no funds to pay for services; lack of funds in general since most of the patients are indigent; sporadic sources of power supply; and intermittent shortages of HIV reagents needed for blood screening. It is noted that of the top 10 causes of hospital admissions in 1996 malaria constituted 32.2%, anemia 17.5%, pneumonia 9.8%, convulsion 9.6%, diarrhea 8.7%, upper respiratory tract infection 5.5%, febrile illness 5.4%, hernia 4.6%, hypertension 3.5% and enteric fever 3.2%. Ofthe total 103 deaths reported by the hospital in 1996, anemia was associated with 17.5%, enteric fever 16.5%, meningitis 13.6%, respiratory infection 11.7%, pneumonia 10.7%, malaria 8.7%, HIV 6.8%, gastroenteritis 5.8%, cardiovascular accidents 5.8% and febrile illness 2.9%. Table 3.6 (next page) gives a summary of some of the similarities and differences between the three districts which constitute the study site. 129 Table 3.6 Summary of some o f the similarities and differences between the three districts which constitute the study site Characteristic Ketu South Upper Denkyira Offinso South All of Ghana Area (Size) sq km 1,130 1,700 1,255 238,533 Population (2000) 234,674 107,642 137,689 19 million Annual growth rate 2.2 3.1 4.5 3.1 Pop. density /sq km 208 63 109 69 Male:Female ratio 100:103 111:100 104:100 97:100 # of urban settlements 7 1 4 142 % Pop urban:rural 33.7: 66.3 24.7 : 75.3 unavailable 37:63 % employed in agriculture 50 66 70 61 % access to safe water 28 (1984) unavailable 39.5 70 % malnourished children 24% 33.8 unavailable 26 Doctor: patient ratio unavailable 1:49,280 ('96) 1:28,470 ('96) 1:20,859 ('92) First cycle school enrolment 48,352 27,725 25,161 75% Second cycle school enrolment 2,710 1,219 1,471 34% 130 CHAPTER 4 Methodology This chapter discusses the methods used and justifies their use. It consists of brief descriptions of the questionnaires, the sample selection and the classification of what constiutes a rural or an urban area. Issues relating to hypothesis generation, pre-testing and sample selection are also discussed. The chapter concludes with discussions of methodological issues that may have an impact on outcome, ethical considerations and informed consent. The methodology of this thesis is composed of two parts. Part 1 consists of questionnaire development (pre-testing/revision, sampling, and questionnaire administration) and Part 2 describes the data analysis. 4.1 Parti: Questionnaire development This research sought to use the ADDS Reduction Risk Model (ARRM) and the psychosocial corelates of HIV risk behaviour to examine adolescent residents in three electoral constiuencies in Ghana. However, it is not an atempt to validate the model. This model built on the HBM (Janz and Becker, 1984) and Bandura's self-eficacy theory (Bandura, 1977 and 1994). The ARRM model posits that there are many mediating variables associated with HIV risk reduction. These include knowledge regarding HIV transmission; response eficacy (the 131 belief that an effective preventive action is available); perceived susceptibility to contracting HIV; anxiety regarding HIV-related health consequences; self-efficacy (the belief that one can adopt and maintain preventive behaviour or the degree to which a person is confident in his or her ability to overcome a specific challenge); and sexual communication skills to negotiate safer sex with one's sexual partners. However, as stated earlier, the model lacks socio-cultural norms as it was not developed specifically to address issues in the sub-Saharan context. To incorporate the variables that address socio-cultural norms into the survey instrument, exploratory interviews and focus group discussions were conducted to identify critical contextual issues and information. Exploratory interviews were conducted with a total of four small groups. The groups were segregated by gender (two all male and two all female) and each group consisted of a convenience sample of three to four participants. The discussions were undertaken in an informal setting and organised in a sequential way. For example, the first group was asked about girlfriends, relationships, and parental control, initially in a casual way. As the conversation progressed and participants became comfortable, more specific questions regarding sexuality were asked. Issues covered included categories of girlfriends^yfriends (those you need to protect yourself from when having sex and the degree of protection), AIDS, notions of how AIDS is transmitted, ideas about the human body in terms 132 of getting pregnant, attitudes about teenage pregnancy, and attitudes towards people with AIDS. The second group was asked questions related to condom availability, money to buy condoms, parental control, and fear of parents' reactions regarding early onset of sexuality. The third group was questioned on attitudes towards condoms specifically and family planning in general. The fourth group was asked questions relating to cultural and societal perspectives regarding sex and individual practices in spite of these cultural norms, pregnancy, and sexually transmitted diseases. The benefit derived from asking the groups different questions is that more questions/issues were covered within a short time. These issues were then explored in the focus group discussions. In addition to the sequential exploratory work, three focus group discussions (two all male groups and one female group) were conducted, with seven to nine adolescents in each group. In these discussions, information derived from the four exploratory interviews was probed further. Issues explored were reproductive health, what individuals consider to be risk factors for HIV infection, and whether risk factors include physical characteristics (for example, being plump instead of slim or very young and beautiful), and social status and religion (traditional versus non-traditional) of the sexual partner's family. For example, some traditional beliefs are that having pre-marital sex with girls whose parents are traditional healers could be hazardous to one's life because the father could 133 spiritually "harm" the boy, or sleeping with somebody's wife could be deadly or lead to STDs. Some of these beliefs are shared and some are not depending on one's family, religion, or parental educational background. As a result of the exploratory work, focus groups discussions, the review of the literature, and personal experience, additional questions were incorporated into the survey instrument. Issues such as gender, urban versus rural, current living arrangements, sources of regular spending money, where respondents sleep at night, in school versus out of school, and constituency (study area) emerged as relevant. Other supplementary issues identified as important and some specific to Ghanaian culture were included such as parental discussions with children with respect to matters of sexuality; beliefs about the causes of illness (fate or witchcraft); attitudes toward fidelity in sexual relationships; the rumours/facts about "cures" for AIDS; the reasons for delay or early onset of sexuality; perceptions about condoms; perceptions regarding the existence of AIDS in Ghana; the role of prostitutes as a cause of HIV; and the perceived distinction between HIV and AIDS. All these variables and issues were used in conjunction with the A R R M framework to generate a comprehensive questionnaire designed to provide data regarding the specific hypotheses described in Chapter 1. Although there is adequate information in the literature relating to AIDS knowledge and condom use among adolescents in sub-Saharan Africa, there is a 134 paucity of information on out-of-school adolescents and the two studies that looked at this group were not population-based. Furthermore, little research has been done on adolescents in Ghana with regard to sexual behaviour in the current context of FJJV/AIDS and condom use. In addition, the published literature reveals that the A R R M framework has been used in studies to predict behaviour change of women in Kigali (Rwanda), women in Zaire, and Baganda women in Uganda. However, these results cannot be generalized to Ghana for at least two reasons. First, there are significant cultural differences between the aforementioned countries and Ghana, thus modifying sexual practices relating to HIV risk perception and minimization. Second, the prevalence of HIV is far lower in Ghana than in Rwanda, Uganda and Zaire. No studies have been reported using the A R R M model to predict behaviour change in adolescents whether they are in school or out, not only in Ghana but elsewhere in sub-Saharan Africa. This study seeks to contribute to knowledge by addressing these gaps. 4.1.1 Pre-testing/Revision Since the various components of this survey were collected from different sources, contain culturally sensitive questions, and have come from different populations, it was necessary to pilot test them. Content validity was addressed in the questionnaire by ensuring that all relevant key areas identified in the detailed 135 review of the literature on AIDS and other publications from WHO specifically dealing with adolescents and ADDS were included. Construct validity was addressed by ensuring that most of the items in the questionnaire were based on theories or literature. The survey instruments were pilot tested in two districts with demographic and cultural characteristics similar to the research sites. Initially the English version of the questionnaire was pre-tested on 30 students, then an additional 20, then another 10. After each testing episode the responses were critically examined. The reason for this approach was that it makes each testing unique and we have three episodes rather than a single test on 60 students. The questionnaire administered to out-of-school adolescents was translated from English into Ewe (Ketu South constituency language) and Twi (language spoken at Upper Denkyira and Offinso South constituencies) and then translated back into English (by different people in order to determine whether the translations were consistent and to ensure that the meaning of all survey items had been preserved). The translation was done to ensure that the administrators of the questionnaire did not give different interpretations of the questions as well as the answers when administering to out-of school adolescents. Health personnel and teachers not in the study area also reviewed these translated questionnaires for content validity and consistency. The translated questionnaires were again pilot tested on 20 out-of-school 136 adolescents (10 boys and 10 girls) by four interviewers in different constituencies with the same cultural and social organisations. Issues of ambiguity were addressed and additions and deletions were made. One month after pre-testing in schools, the translated versions were pre-tested on 18 (30%) of the same students in one-on-one interviews in order to determine whether significant differences would be found between self-administration in English and one-on-one administration in the local dialect. This was also considered a form of test-retest; no major differences were observed between responses given by the students on key variables such as ever having had sex, condom use, number of sexual partners, and self- perceived health status as they all yielded reliability coefficients of 0.85 or higher between the two versions. 4.1.2 The Questionnaire (Appendix 2) The questionnaire has eight main themes and was organised to elicit information on the following issues: • General demographic information (age, gender, residency, education, religion, parental education, and occupation). • Self-perceived health status. • Constructs ofthe AIDS Reduction Risk Model. (Catania et al, 1990). The questions on the A R R M model are derived from the literature and have already 137 been assessed for reliability and used by other investigators. The questions are distributed throughout the questionnaire and are variables hypothesized to be associated with behaviour change: (knowledge about high risk behaviour and routes of transmission, belief in incurability of AIDS, self-efficacy, peer norms in support of behaviour change, perception and source of risk, communication with sexual partners, attitude towards and use of condoms, and having known someone with AIDS). Self-efficacy and exercise of control constructs (Bandura, 1994). [Questions 110-124]. Knowledge of HIV/AIDS and other STDs-modes of transmission, symptoms, curability and non-curability, and personal history of STDs. Sexual practices or behaviour including: age at first intercourse; number of partners; relationship with partner (regular, casual); paid sex; and condom use. Attitudes about condoms and PWAs in addition to reproductive health knowledge, peer norms (attitude towards premarital sex and gender issues in a relationship). Communication about AIDS has a set of items that measured the capacity of the respondents to talk to parents, peers, and partners about HIV. 138 4.1,3 Feasibility Issues During pre-testing an assessment was made of all aspects of the data gathering process. For example, were all selected sample subjects present at school on the day of the administration of the questionnaire? It was noted, as might be expected, that some of the students sampled on the day of the administration of the questionnaire were not in school. As a result, during actual fieldwork an additional two or three people were randomly selected in each class to replace any subject who might not be in school. In addition, an assessment was made to determine whether during pre-testing all the questions were answered, and if not, whether it was due to difficulty in understanding the questions, cultural or behavioural sensitivity, or lack of sufficient time. Furthermore, the research assistants were asked whether the sequence of the questions, clarity of wording, or prompting was required on any question. After pre-testing, some questions were reworded and some words, which were mainly western terminology, were changed. Although there was confidence after pre-testing that the instrument would be easy to administer with the in-school adolescents, a problem arose at the first school of administration (a rural school). The students were not able to understand some words in the questionnaire. Pre-testing did not catch this 139 problem it was administered in urban schools which had higher reading standards. As a result, in all schools where the survey was subsequently administered, we explained the meaning of the following words and phrases: hugging someone with HIV (q25), piercing the ear (q35), heterosexual sex (q56), IV drugs (q57), and oral contraceptives (q61). 4.2 Sampling Overall 1435 adolescents aged 10-19 were sampled and interviewed from July 1998 to June 1999. 4.2.1 Study population: inclusion and exclusion criteria The study was a cross-sectional survey of adolescents (in-school and out-of-school) aged 10-19, residing in the three electoral constituencies studied. In-school adolescents were defined as those who were enrolled in school at the time of the study and out-of-school adolescents were those who had never been to school, had only an elementary school education and had not continued, or had dropped out of secondary school. 4.2.2 Rural-Urban classification The towns in each constituency were classified into urban or rural settlements. Where possible, the population figures provided in publications by the 140 district assemblies (cited in Chapter 3) were used as a first step in determining which settlement could be defined as urban versus rural. Where a town/settlement was not in the publication, population estimates were supplemented by computing projected populations. In Ghana, an urban settlement must have a minimum population of 5,000, otherwise it is defined as a village or rural settlement. All the towns or villages in each constituency were listed using the information provided in a publication of the Ghana Census Bureau called The Gazetteer. The last census was held in Ghana in 1984 and the next one was held in 2,000. The 1984 Gazetteer designates the total population of each town/settlement. The 1970 population census was used as a base and computations for 1999 were made using the 1984 population census figures. The growth rate method (exponential, Pi/Po = e rt) was then used to estimate the population for the year 1999. This method assumes the growth rate of the population to be constant over the years. This projected population and a cutoff figure of 5,000 was the first designation in determining whether a settlement qualifies as urban or rural. Other additional variables considered in rural/urban designation were availability of potable water, electricity and the presence of a post office. With this method, settlements were classified as urban or rural and sampled accordingly. In Ghana, 67% of the overall population lives in rural areas. However, since AIDS is more of an urban problem, the sample was weighted toward urban respondents. Thus 60% of the study 141 participants were urban residents and 40% were from the rural areas. 4.2.3 Sampling of in-school adolescents Adolescents in school were selected from all the junior and senior secondary schools in the electoral constituencies. In-school adolescents were divided into junior secondary (JSS) and senior secondary school (SSS) students. In Ghana, the majority of schools at the senior secondary school level are boarding schools. It is, therefore, possible for non-residents of the area of study to be enrolled as students in the school. In most cases the numbers of non-resident students were very few and were thus excluded before selecting the sample. However, in one particular school in Ketu South constituency, students throughout the country enroll. To avoid selecting non-residents, we obtained a list of students who came only from the local constituency then selected the sample. A listing of all schools and enrollment in each constituency was obtained from the Statistical Division of the District Headquarters of the Ministry of Education. There are on average 30 junior secondary schools (JSS) in each constituency, and four-five schools each were randomly selected in the urban and rural categories. Schools were then selected to ensure the inclusion or representation of rural and urban schools on the 60%-40% distribution. However, 142 with regard to senior secondary schools, there were three to six in each constituency hence all of them were sampled for participants. Samples from each school were proportionally weighted as to the total student population in the constituency. There are three grade levels each at the JSS and SSS levels. The sample at each grade level was selected based on the proportion of students at that grade level to the total school enrolment. The same procedure was adopted in the selection of male and female students. In each school, the enrolment register per class, which has the list of all students in alphabetical order, was used to select study subjects by using a random number table (Armitage and Berry, 1985). 4.2.4 Sampling out-of-school adolescents Since there was no list available for selecting out-of-school participants, they were selected from a random sample of households in each ward of the district utilising neighbourhood demarcations. None of the youth live in "informal" accommodation, makeshift housing or group homes since the study was conducted in the areas in Ghana where there are no street kids or homelessness. Where a selected household had two out-of-school adolescents, only one was chosen by a toss of a coin. If the residence had more than two out-of-school adolescents, the choice was made by throwing a die. 143 4.2.5 Questionnaire administration The revised pre-tested questionnaire was administered in order to ensure confidentiality, anonymity and privacy. In order to avoid the situation where students might treat the survey questionnaire like an examination and hence give responses they felt were expected, cluster sampling by classroom was specifically not used and no teachers were present. In addition, all study participants in a given school had the questionnaire administered in one room irrespective of grade level and the students were told not to treat the questions like an exam. Where the sampled population was too large to be accommodated in one classroom, the students were divided into two rooms. The in-school adolescents had the questionnaires administered at school and the out-of-school participants at home by the Research Assistant. No other person was present in administration of the questionnaire. The nature of housing (compound) made it possible to create a private place and administer the questionnaire without being overheard by others. There was no problem obtaining informed consent from parents since the traditional authorities, health administrators, and politicians were aware of the study and they informed the citizenry about the need to participate in the study. The concept of social process was seriously considered in the administration of the questionnaire. Each participant was assured of confidentiality 144 and anonymity. They were informed that participation was entirely voluntary, they were at liberty to opt out of the study at any time and refusal to take part or complete the questionnaire would not jeopardize the participant's schooling or stay in the community. In order to avoid the situation where students might treat the survey questionnaire like an examination and hence give responses they felt were expected or what their teachers wanted, no teachers were in the classroom. 4.3 Methodological issues that may have an impact on outcome measure Prior to conducting this study it was recognised that one major problem in research on sexual practices stems from the lack of gold standard for validating self-reported sexual behaviour (Catania, Gibson, Chitwood and Coates, 1990; Dare and Cleland, 1994; Konings, Bantebya, Carael, Bagenda and Mertens, 1995). However, Torabi and Yarber found a high degree of reliability and validity among teenagers relating to attitudes about HIV prevention. In addition, high internal consistency estimates for AIDS knowledge and attitude scores have been reported in another study (Carabesi, Greene, and Bernet, 1992). Davoli and others (1992), in a study of Italian secondary school students, found a high degree of reliability between self-administered questionnaires and interviews; however, respondents seemed to provide more socially desirable answers (for example, underreporting coital experience and overreporting condom use) when interviewed as compared 145 to the questionnaire. In addition, Zimet (1992), in his review of AIDS knowledge surveys, found that the internal consistency reliability measures reported for surveys among adolescents ranged from a low of 0.72 to a high of 0.80. In the study on African adolescents, Seha and others (1994) found that ACDS-related knowledge and attitudes toward engaging in sexual behaviour had acceptable reliability and construct validity when compared with similar surveys in western countries. Furthermore, James, Bignell, and Gillies (1991) reported on the reliability of self-reported sexual behaviour when they analysed self-administered questionnaires and interview-based results. This study was conducted in Nottingham (UK) among people aged 16-54 attending a genitourinary clinic. They found that only consistent data were produced for sexual orientation. Level of agreement was, however, lower in specific areas, notably condom use in vaginal intercourse and oral sex in men. They also found that some sexual behaviours were reported significantly more frequently in interviews than in questionnaires, namely body massage, active oral sex, passive oral sex, body kissing, biting or scratching for pleasure and vaginal penetration with fingers. The questionnaire, however, did not elicit information on the sex of respondents' partners or the partners' sexual orientation. In spite of the support the above studies give to reliability of reported 146 sexual behaviour when participants are interviewed one-on-one and through self-administered questionnaires, it is recognised that there could be methodological issues which could affect the outcome of sexual behaviour research. Measurement error may because of the following: refusing to answer a question; underreporting actual activity levels by denying having performed a behaviour that has in fact been performed; admitting but underreporting the actual frequency; and admitting a behaviour they have never really performed (over-reporting). Other factors that may influence measurement are recall, self-presentation bias (for example, the degree to which the questions elicit fear or approval seeking), motivational issues and the respondent's ability to understand what is being asked in an interview or read in a questionnaire (Catania et al., 1990). In spite of these well-known problems, the magnitude of the social and medical implications of sexual behaviour have forced researchers to continue research using questionnaires and interviews (Fife-Schaw and Breakwell, 1992) since they cannot observe. 4.4 Ethical considerations, confidentiality, and informed consent With regard to in-school adolescents, the school authorities gave informed consent on behalf of the parents. In addition, school authorities emphasized to students that participation was voluntary, responses would remain confidential, and refusal would not jeopardize their schooling or standing in the community. 147 Participants were told they had the right to refuse or withdraw their consent at any time. Either of these actions would not prejudice their right to education or belonging in the community. They were assured that the record of each interview would include only the study identification number and participants' names and identity numbers would only be linked on a master list retained by the researcher. This assurance was also repeated on the front page of the questionnaire and was read before students started answering the questions. 4.5 Part 2: Data Analysis This section contains a description of data preparation (coding, for example) followed by different sections for each research question identified in Chapter 1. Within each subsection are specific hypotheses, where appropriate, and descriptions of the relevant statistical tests. 4.5.1 Database preparation The answers to the closed-ended questions were recorded on a scannable form called the General Purpose Data Sheet 1 form # 19543 developed by National Computer Systems (please see Appendix 3). The form has four blank areas that were used to record any general comments the respondents wanted to make. These responses have the advantage of capturing information not elicited 148 from the structured format. In addition, each respondent was provided with blank sheets of paper to record responses to the open- ended questions. The quantitative data obtained from the questionnaire was scanned into a computer and later converted into a spreadsheet and analysed using Statistical Package for Social Sciences (SPSS) version 9 (SPSS, Inc., Chicago, Illinois, USA). 4.5.2 Analysis for research questions The analysis has been organised according to the specific research questions derived from the literature as outlined in Chapter 1. Individual items were aggregated into scales whenever possible (for example attitude towards condoms, or PWAs). Cronbach's alpha was calculated to assess the internal reliability or consistency of each scale. The following results were obtained for the scales: attitudes towards PWAs (Cronbach's alpha = 0.397), self-efficacy and exercise of control (Cronbach's alpha = 0.756), and attitudes towards condoms (0.9171). 4.5.2.1 Research Question 1 What are predictors of FJJV/AIDS knowledge in this adolescent population? While the research question focuses on predictors of HIV/ADDS knowledge, descriptive data were also calculated to provide a snapshot of ADDS 149 knowledge in the population. The factors were examined separately as individual hypothesis tests. In Stage 2 the variables were entered into a multiple logistic regression model to determine the predictors of AIDS knowledge while controlling for confounders such as age, sex, education, and location. Based on the literature and exploratory studies the following are hypothesized as factors likely to affect AIDS knowledge: being in school, being male, being an older adolescent, being a resident of an urban area, and being a resident of Offinso South (representing the highest prevalence area in this study). To test the above hypothesis and answer related questions there were modules in the questionnaire testing knowledge of AIDS and other STDs such as gonorrhea, syphilis, chancroid, chlamydia, and yeast infection. The AIDS knowledge module consisted of 42 items divided into three sections. The questions had possible choices of "True, False, and Don't Know". "Don't Know" as an option was included to reduce the probability of guessing, as guessing causes some variation in performance from item to item, which tends to lower the test reliability (Nunnally, 1967). All correct responses were scored as one (1), and incorrect and "don't know" responses were scored as zero. Scores were computed by summing up all correct responses to generate an overall score for each study participant. The scores were categorised into three segments: those scoring 50% or less were classified as having "low" HIV/AIDS knowledge, those 150 scoring 51% to 74% were classified as "intermediate" or "medium" knowledge, and those scoring 75% or more were deemed to have "high" knowledge. To identify specific gaps in knowledge, an analysis was undertaken on each question to find out those questions which were consistently answered correctly and/or incorrectly. In addition chi-square analysis was used to examine the relationship between AIDS knowledge (relating to misperceptions involving transmissions through casual contact) and each of the 4 questions assessing negative attitude toward PWAs. In testing the hypotheses, data were analysed by contingency table analysis except for t tests as appropriate for continuous data (for example, age). Chi Square (X 2) tests were used for differences in proportions and for categorical variables. The Fisher's exact test was used when frequencies were less than five. All statistical tests were two-tailed and alpha = 0.05 or less was considered significant. The hypotheses were tested to determine the following differentials on the knowledge of AIDS and other STDs: gender (males versus females); location (urban versus rural); residence (Ketu South versus Upper Denkyira versus Offinso South); young adolescent (10-16) versus older adolescent (17-19); JSS versus SSS; and ever had sexual intercourse versus never had sexual intercourse. In the second stage of hypothesis testing, comparisons were made between those classified as having "low knowledge" and those having "high knowledge". 151 All the A R R M variables in addition to factors identified in the bivariate analysis as significantly associated with AIDS knowledge (that is, those attaining p = 0.05 or less) were grouped into the following five natural categories described below. The model was built in two stages. In Stage 1, each group was entered into a separate multivariate logistic regression model where the outcome variable was high AIDS knowledge as a dichotomy (no = 0 and yes =1). Group 1: Socio-economic status of parents: maternal education and occupation, paternal education and occupation, and religion. Group 2: Study participants' socio-economic variables: living arrangement (with which parent he/she stays), where he/she sleeps at night, age, employment status, and educational level. Group 3: A R R M variables (knowledge of safer sex guidelines or sexual behaviours that transmit HIV), multiple partners, belief in one's personal susceptibility to HIV, and believing that having ADDS is undesirable, perceived barriers to condom use, the perceived efficacy of condoms in preventing the transmission of ADDS, self-efficacy score entered as a continuous variable, perceived barriers to condom use and efficacy of condoms formed part of the twelve-item scale which assessed attitudes towards condoms, sexual communication variables (communication about sex/ADDS which measures the capacity of participants to talk to parents, peers, partners about sex and HIV infection). Group 4: Heard of HIV, knowing anyone who can cure ADDS, hearing of anyone who can cure ADDS, preventive measures taken to avoid HIV, ever had sex, ever heard of condoms, age of first sex and reasons for first sex, reproductive health knowledge score, STD knowledge score, and having heard of syphilis, gonorrhea, chancroid and yeast infection. Group 5: Fatalism (beliefs that fate decides who gets HIV no matter what, that mosquitoes can transmit HIV, or that HIV can be transmitted through witchcraft, hence there is little an individual can do to forestall infection), cues to action (relative/friend/colleague has ADDS, personally knowing someone with ADDS), 152 media exposure to AIDS, belief that HIV is a man-made virus, and media exposure to ADDS information. In the second stage, the independent variables attaining p = 0.05 or lower in each model were retained and entered into a single final multivariate logistic regression model while controlling for potential confounders such as age, gender, location and educational status which were maintained in all the models. Adjusted Odds Ratio (OR) and their corresponding 95% confidence limits were computed to assess the magnitude of each variable's effect. 4.5.2.2 Research Question 2 What factors predict condom use in this adolescent population? Are there specific reasons for non-use of condoms? Are the research subjects aware that ADDS is incurable as of now and condoms are the only barriers to infection in those who have unprotected sex when there is a possibility of HIV transmission? The following are hypothesized: in-school adolescents are more likely to use condoms than out-of-school adolescents; urban residents are more likely to use condoms than their rural counterparts; and residents of Offinso South (high ADDS prevalence location) are more likely to use condoms than their counterparts in Upper Denkyira and Ketu South. In the primary analysis, cross-tabulations with chi square tests of significance 153 were performed to determine the following differentials on condom use: ADDS knowledge score, gender (males versus females); location (urban versus rural); residence (Ketu South versus Upper Denkyira versus Offinso South); young adolescent (10-16) versus older adolescent (17-19); and age of first sexual intercourse being less than 15 versus 15 and greater. The three conceptual categories of ARRM-labeling, commitment to change, and enactment-were used in the bivariate analysis in addition to other variables derived from the literature, focus group discussions, and preliminary interviews which explored the association between the psychosocial characteristics and condom use or non-use. • Problem Labeling. This was examined using the three factors the model considered as being influential in the recognition and labeling of high-risk behaviours: knowledge of safer sex guidelines or sexual behaviours that transmit HIV; belief in one's personal susceptibility to HIV; and belief that having ADDS is undesirable. • Commitment to change. This stage is a mediating stage between labeling (problem perception) and taking preventive action (enactment). This category of variables includes perceived barriers to condom use, the perceived efficacy of condoms in preventing the transmission of ADDS and self-efficacy beliefs concerning one's ability to make the desired changes. The self-efficacy score was included as a continuous variable. The perceived barriers to condom use 154 and efficacy of condoms formed part of the twelve-item scale that assessed attitudes towards condoms. The respondents were asked to rate 12 attitudinal items along an ordinal three-point scale: "agree, disagree, and don't know"(3 points-agree, 2 points-don't know, and 1 point-disagree.) Missing values were scored as "don't know". Scores of 27-36 from summed responses were reported as reflecting negative attitude towards condoms, scores of 24-26 were considered as being indifferent or no opinion towards condoms, and scores of 12-23 were considered as having positive attitude towards condoms. The coefficient alpha for attitude towards condoms was 0.9171. • Enacting solutions or taking action. Sexual communication variables were utilised to assess predictors of condom use and communication about sex/AIDS, which measures the capacity of participants to talk to parents, peers, partners about sex and HIV infection. The self-efficacy score (Appendix 5), derived from fourteen questions (questions 110-124) related to self-efficacy and exercise of control, was included in the model as a continuous variable. Self-efficacy has been shown in other studies to be a predictor of risk reduction because it relates to the individual's perceived ability to negotiate condom use with his or her sexual partner. In the first stage of hypothesis testing, comparisons were made between those 155 classified as having "never used condoms" and those "ever used condoms". All the A R R M variables, in addition to factors identified in the bivariate analysis as significantly associated with condom use (that is, those attaining p = 0.05 or less), were grouped into the five natural categories described below. The model was built in two stages. In Stage 1, each group was entered into a separate multivariate logistic regression model where the outcome variable was condom use coded as a dichotomy (no = 0 and yes =1). Group 1: Socio-economic status of parents: maternal education and occupation, paternal education and occupation, and religion. Group 2: Study participants' socio-economic variables: living arrangement (with which parent he/she stays), where he/she sleeps at night, sources of spending money, age, employment status, and educational level. Group 3: Self-perceived health status, heard of HIV, heard of AIDS, hearing of anyone who can cure ADDS, knowing anyone who can cure ADDS, self-perceived risk for HIV infection, multiple sexual partners, preventive measures taken to avoid HIV, age of first sex and reasons for first sex. Group 4: ADDS knowledge score, self-efficacy/exercise of control score, reproductive health knowledge score, scale measuring attitude towards condoms, and STD knowledge score. Group 5: Fatalism (beliefs that fate decides who gets HIV no matter what, that mosquitoes can transmit HIV, or that HIV can be transmitted through witchcraft, hence there is little an individual can do to forestall infection), cues to action (relative/friend/colleague has ADDS, personally knowing someone with ADDS, talking about ADDS with family, media exposure to ADDS, talking about ADDS with acquaintance, and talking about ADDS with sexual partner), belief in the efficacy of condoms in preventing HIV infection, main reasons for condom use, belief that one is the only sexual partner of present partner, belief that sexual practice is safe for avoiding HIV infection or transmission, and media exposure to 156 AIDS information. The independent variables attaining p = 0.05 or lower in each model were retained and entered into a single final multivariate logistic regression model controlling for potential confounders such as age, gender, location and educational status which were maintained in all the models. Adjusted Odds Ratio (OR) and their corresponding 95% confidence limits were computed to assess the magnitude of each variable's effect. 4.5.2.3 Research Question 3 What are the determinants of sexual risk taking in this adolescent population? This was addressed in a two-stage process. While the research question focuses on predictors of sexual risk taking, descriptive data were calculated to describe sexual risk taking in the population. The factors were examined separately as individual hypothesis tests. In Stage 2 the variables were entered into a multiple logistic regression model to determine the predictors of sexual risk taking while controlling for confounders. Based on the literature, it was hypothesized that many factors would affect sexual risk taking-for example, being a resident of an urban area. To identify determinants of sexual risk taking, a scale to measure sexual risk taking was developed (please see Appendix 4). The questions were answered 157 by subjects who reported ever having sexual intercourse (N = 541 [38.1% of the study participants], 200 in-school and 341 out-of-school]. Since the participants were teenagers, longer years of sexual activity were not considered as likely to produce less accurate recall as they relate to lifetime sexual partners. This is because the participants were not likely to have sexual experience exceeding a period of six years. The scale consisted of 16 items but not all the questions were relevant to all the participants (for example, questions on paid sex). All the items were scored on a 0-5 scale with a higher score denoting a higher degree of sexual risk taking. Cronbach's alpha was calculated to assess the internal reliability or consistency of the sexual risk taking behaviour scale (Cronbach's alpha = 0.719). Behaviours addressed in determining sexual risk taking were: • sexual partners: number of sexual partners in past month, past six months, past year and lifetime partners; • condom use/non-use: with regular partner, casual partner, new partner, and commercial sex worker; • paid sex and non-paid sex with condom use and non-use. Scores were expected to range from 0-31. In Stage 2 of the analysis, the scores were divided into quartiles. The upper 25th percentile and bottom 25th percentile were dichotomised into "no sexual risk taking" (0) versus "sexual risk 158 taking" (1) respectively. The two groups were compared using contingency tables on A R R M and other independent variables as a first step to identify the predictors of sexual risk taking in this population. Variables which attained p = 0.05 or lower were included in the multivariate logistic regression model as independent variables with the dependent variable as sexual risk taking. The self-efficacy score (Appendix 5) derived from fourteen questions (questions 110-124) related to self-efficacy and exercise of control was included in the model as a continuous variable. Self-efficacy has been shown in other studies to be a predictor of risk reduction because it relates to the individual's perceived ability to negotiate condom use with his or her sexual partner. In the second stage of hypothesis testing, comparisons were made between those classified as being "low sexual risk takers" and those who are "high sexual risk takers." All the A R R M variables, in addition to factors identified in the bivariate analysis as significantly associated with sexual risk taking (that is, those attaining p = 0.05 or less), were grouped into the five natural categories described below. The model was built in two stages. In Stage 1, each group was entered into a separate multivariate logistic regression model where the outcome variable was sexual risk coded as a dichotomy (low = 0 and high =1). Group 1: Socio-economic status of parents: maternal education and occupation, paternal education and occupation, and religion. 159 Group 2: Study participants' socio-economic variables: living arrangement (with which parent he/she stays), where he/she sleeps at night, age, employment status, and educational level. Group 3: A R R M variables (knowledge of safer sex guidelines or sexual behaviours that transmit HIV), multiple partners, belief in one's personal susceptibility to HIV and believing that having ADDS is undesirable, perceived barriers to condom use, the perceived efficacy of condoms in preventing the transmission of AIDS, self-efficacy score entered as a continuous variable, perceived barriers to condom use and efficacy of condoms formed part of the twelve-item scale which assessed attitudes towards condoms, sexual communication variables (communication about sex/AIDS which measures the capacity of participants to talk to parents, peers, partners about sex and HIV infection). Group 4: Heard of HIV, knowing anyone who can cure AIDS, hearing of anyone who can cure ADDS, preventive measures taken to avoid HIV, ever had sex, ever heard of condoms, age of first sex and reasons for first sex, reproductive health knowledge score, STD knowledge score. Group 5: Fatalism (beliefs that fate decides who gets HIV no matter what, that mosquitoes can transmit HIV, or that HIV can be transmitted through witchcraft, hence there is little an individual can do to forestall infection), cues to action (relative/friend/colleague has ADDS, personally knowing someone with AIDS), media exposure to ADDS, belief that HIV is a man-made virus, media exposure to ADDS information, belief in the efficacy of condoms in preventing HIV infection, main reasons for condom use, belief that one is the only sexual partner of present partner, belief that sexual practice is safe for avoiding HIV infection or transmission, and belief that one's chances of getting HIV is due to one's behaviour. In the second stage, the independent variables attaining p = 0.05 or lower in each model were retained and entered into a single final multivariate logistic regression model while controlling for potential confounders such as age, gender, location and educational status which were maintained in all the models. Adjusted 160 Odds Ratio (OR) and their corresponding 95% confidence limits were computed to assess the magnitude of each variable's effect. 161 CHAPTER 5 Results This chapter discusses the findings, categorized under demographics and predictors of ADDS knowledge (descriptions, gaps in knowledge, other sexually transmitted diseases, attitude towards people with ADDS). It also examines attitudes towards condoms and the utility of the ADDS Risk Reduction Model as a framework to analyze behaviour change leading to risk reduction through condom use. Finally, it looks at predictors of sexual risk taking behavior, first-time sexual experience — age, and reasons for first sexual encounter « attitudes towards premarital sex, and peer norms in the Ghanaian adolescent population. 5.1 Socio-demographic Information Overall, 1,435 participants, age 10-19, were interviewed. Table 5.1 denotes the demographic characteristics of the study participants. Twenty respondents were excluded from analysis because they had exceeded the age limit. Of the study's participants who were sampled, all the in-school adolescents agreed to participate. Five of the out-of-school adolescents refused to participate because they had prior commitments and had no time to sit through the interview process. This yielded an overall response rate of 99.7%. There were 795 males (56.2%) and 620 females (43.5%), with five hundred and five (35.7%) residing in rural areas and 910 (64.3%) residing in urban areas. Of the study's 1,415 participants, 750 (53%) were currently in school and 665 (47%) were not in school. A further analysis showed that 69.9% were either in school, employed or learning a trade and 30.1% were out of school, unemployed and not learning. Fifty-nine (4.2%) ofthe 162 respondents have never had any education, 168 (11.9%) had only primary school or makaranta (Islamic school) education, 764 (54%) have junior secondary school education, and 423 (29.9%) had senior secondary school education. The mean age of the respondents was 16.6 years (s.d. 1.9). About 14.7% were 14 or below, and those between 15 and 19 constituted 85.3% of the distribution. Those under age 16 were 45.5% of the sample and those between the age of 17 and 19 constituted 55.5% of the sample. Forty-four (3.1%) of the respondents were not religious, 40 (2.8%) believed in traditional worship, 148 (10.5%) were Moslems, 372 (26.3%) described themselves as Catholics, 365 (25.8%) were Apostolic and 446 (31.5%) were of the Protestant faith. A third (33.3%) of the participants' mothers had no formal education, 13.3% had primary education, 34.7% had middle school education, 13.9% had secondary, technical, nursing or commercial school education, and 4.9% had polytechnic/university/graduate education. Seventeen percent (17%) of the fathers had no formal education, 7.9% had primary, 38.2% had middle school education, 19.9% finished secondary, training, technical or nurses' training school, and 17% have polytechnic education and higher. The most common occupation for mothers was in commercial activity, such as trading (50.5%). While 28.6% of the mothers engaged in farming, 8.3% were teachers, 5.6% housewives, 3% clerical workers, and 2.2% artisan. Only 0.6% engaged in professional or technical occupations. A little over 1 in every three of the respondent's father engaged in farming (37.2%), 14% teaching, 12.1% were artisans, 11.2% engaged in commercial activity, 10.1% in clerical work, 6% were unemployed or deceased and only 5% engaged in a professional occupation or in the technical field. 163 The study's participants were distributed as follows: Ketu South, 470 (259 males, 211 females); Upper Denkyira, 462 (274 males, 188 females); and Offinso South, 483 (262 males, 221 females). Table 5.1 shows the percentage and numerical distributions of the general demographic characteristics of the sample, as distributed in the three areas studied and classified by gender. Residents of Ketu South constituted 33.2% of the total population, Upper Denkyira represented 32.6% and Offinso South 34.2%. Table 5.1: Comparison of Socio-demographic Variables ofthe Study's Participants According to Site and Gender Demographic Variables Ketu South (N = 470) Males Females Upper Denkyira (N = 462) Offinso South (N = 483) Males Females Males Females Total in sample 259 211 274 188 262 221 Mean Age 17.09 16.89 16.35 15.83 16.82 16.29 (S.d.) (1.68) (1.67) (2.07) (1.88) (1.88) (2.0) % % % % % % 10-16 32.0 41.2 45.3 62.2 40.1 51.1 17-19 68.0 58.8 54.7 37.8 59.9 48.9 Location Urban 66.0 64.5 65.0 65.4 61.5 63.8 Rural 34.0 35.5 35.0 34.6 38.5 36.2 Ever had sex Yes 49.0 47.4 38.3 29.8 30.5 32.1 No 51.0 52.6 61.7 70.2 69.5 67.9 Educational status Currently in school 64.1 45.0 52.2 61.7 52.7 41.6 Currently out of school 35.9 55.0 47.8 38.3 47.3 58.4 Employment Status Employed: non sch. only 40.9 59.1 40.0 29.2 32.3 24.8 Unemployed: non sch. only 48.3 51.7 60.0 70.8 67.7 75.2 Education No education 4.6 9.0 1.1 3.2 3.1 5.4 Makaranta/primary 8.9 13.3 10.2 11.2 11.5 17.2 JSS (1-3) 41.7 51.2 62.0 59.6 54.6 55.7 SSS (1-3) 48.8 26.5 26.6 26.1 30.9 21.7 164 Table 5.1: Comparison of Socio-demographic Variables of the Study's Participants According to Site and Gender (continued from page 164) Ketu South Upper Denkyira Offinso South Demographic Variables (N = 470) (N = 462) (N = 483) Males Females Males Females Males Females Religion Atheist/no religion 3.9 4.7 2.2 1.1 4.6 1.8 Traditional 8.5 5.2 0.4 0.5 1.1 0.9 Catholic 35.9 40.8 21.2 29.8 16.8 15.8 Protestant 26.3 29.4 30.3 31.9 34.0 38.0 Apostolic 23.2 17.1 31.0 28.7 24.4 29.9 Moslem 2.3 2.8 15.0 8.0 19.1 13.6 Maternal Education No education 39.8 42.7 27.7 22.3 38.2 27.1 Primary school 17.0 11.8 9.5 13.3 13.0 15.4 Middle school 26.6 27.5 44.9 34.6 35.1 38.0 Sec/tech/com/Trg 12.0 13.3 13.1 20.2 11.8 14.5 Polytech & Higher 4.6 4.7 4.7 9.6 1.9 5.0 Paternal Education No education 18.1 23.2 11.3 10.6 22.1 16.3 Primary school 9.3 6.6 6.6 8.5 7.3 9.5 Middle school 36.7 41.2 36.5 32.4 40.1 41.6 Sec/tech/com/Trg 17.8 15.2 27.4 23.4 19.5 15.4 Polytech & Higher 18.1 13.7 18.2 25.0 11.1 17.2 Paternal Occupation Unemployed/Deceased 5.8 8.5 5.8 3.7 6.5 5.4 Trader 14.3 15.2 9.1 9.6 7.6 11.8 Farmer 33.6 34.1 28.8 28.2 52.7 43.9 Artisan 13.1 14.2 16.4 9.0 9.2 9.5 Clerical 5.4 4.7 17.2 20.7 6.1 7.7 Teacher 17.0 14.7 12.8 14.4 11.8 14.5 Professional/Technical 7.7 6.2 6.6 8.0 3.4 2.3 Other 3.1 2.4 3.3 6.4 2.7 5.0 Maternal Occupation Housewife 6.6 4.3 5.1 5.3 5.7 6.3 Trader 60.2 65.4 • 50.0 50.0 37.8 41.2 Farmer 16.2 17.1 28.8 22.3 46.9 37.6 Artisan 1.5 2.4 2.2 2.7 1.5 3.2 Clerical 3.1 2.8 4.0 4.8 1.1 2.3 Teacher 8.5 6.2 8.8 12.2 5.7 9.0 Professional/Technical 0.8 1.4 0.4 1.6 0 0 Other 3.1 0.5 1.1 1.1 1.1 0.5 165 5.2 Household Composition An analysis was done to determine whether linearity affects household composition and women's financial autonomy. As demonstrated in the table 5.2 (below) no clear pattern emerges from the data. Table: 5.2: Household Composition by Constituency Living Arrangement Ketu South Upper Denkyira Offinso South N (%) N (%) N (%) Mother only 150 (31.9) 100(21.6) 167 (34.6) Father Only 51 (10.9) 33 (7.1) 26 (5.4) Mother & Father 196(41.7) 244 (52.8) 174 (36.0) Others 73 (15.5) 85 (18.4) 116 (24.0) Total 470 (100) 462 (100) 483 (100) Furthermore, no clear pattern also emerges from the data among the 3 areas studied as regards the control of household finances as illustrated in table 5.3 (below). Table: 5.3 Control of Household Finances Gets spending money from Ketu South Upper Denkyira Offinso South N (%) N (%) N (%) Mother only 144 (30.6) 104 (22.5) 120 (24.8) Father Only 47 (10.0) 59(12.8) 61 (12.6) Mother & Father 220 (46.8) 219 (47.4) 200(41.4) Other relatives 41 (8.7) 40 (8.7) 49(10.1) Boyfriend/Girlfriend 8(1.7) 5(1.1) 17(3.5) Others 10(2.1) 35 (7.6) 36 (7.5) Total 470 (100) 462 (100) 483 (100) 166 5.3 AIDS Knowledge and Understanding The main sources of information for acquiring AIDS knowledge in this population were the radio (86%), television (84%), schools (76%), doctors/healthcare workers (75%), friends/acquaintances (69%), books (68%), newspapers/magazines (62%), family members, such as aunts, cousins, and other relatives (65%), and community agencies (57%). On the whole, 90% of the study's participants had heard about AIDS, but only 62.3% about HIV. The difference between hearing about AIDS and HIV may be due to the fact that in Ghana, AIDS is used rather than HIV to describe the condition. No statistical differences were observed between gender or location in terms of those who had heard about AIDS. AIDS knowledge scores ranged from 0 to 42 (mean score: 25.69; sd: ± 7.71; median score: 27) with only two subjects (one male and one female) scoring 40 points out of a total 42. Of the 17 participants who scored zero (0) on the knowledge score, 13 (76.5%) were males. Close to one in four (23.7%) respondents (N = 335) obtained scores which could be classified as low knowledge (0% to 50%); 51.8% (N = 733) scored between 51% and 74% (classified as having medium knowledge); and 24.5% (N = 347) can be deemed to have high knowledge. In spite of the high percentage of the study's participants who had heard about HIV, only 77.2% of the respondents were aware of the incurability of AIDS. Fifteen percent (15.4%) of the study's participants indicated that they heard somebody could cure AIDS and 13.2% stated they knew somebody who could cure AIDS. Of the people believed to cure AIDS, 43.5% stated medical doctors, 29.2% indicated herbalists/traditional healers, 20.2% mentioned spiritualists/Osofos (a local name for priests of charismatic churches) and 4.8% said mallams (spiritualists of the Moslem 167 faith). Furthermore 29% of the respondents expressed their belief in fate as the ultimate determining factor, whether or not one contracts AIDS. In addition, 36% of the respondents believed that no matter what some people do, they would never get sick. Sexual abstinence was mentioned by 76.2% as a means of preventing AIDS. Other means of prevention mentioned were: the use of condoms during sex (72.1%), fidelity to the same partner, (69.5%), not sharing needles (69.5%), and reduction in the number of sexual partners (49%). To determine whether the study's participants who recognize the fatality of AIDS had translated this knowledge in change behavior, the following question was asked: "Since you first heard about AIDS, have you done anything to avoid catching the virus yourself or to prevent someone else from getting it from you?" Sixty one percent (61.1%) responded in the affirmative, with 14.1% indicating that the changes started within the last 12 months, while 48.4% indicated that they had started the changes more than a year ago. 5.3.1 Gaps in AIDS Knowledge and Prevention To identify gaps in the participants' ADDS knowledge, each question was analyzed to find out those questions that were answered mostly right, and those answered mostly wrong. The results obtained appear in tables 5.4, 5.5, and 5.6. Although 78% to 86% of the participants knew that ADDS could be transmitted through contaminated blood, sharing unsterilized needles with someone who has the virus, or having unprotected sex with an infected person, they also held many misconceptions. While 85.2% knew that there was a blood test for HIV, 58% thought that one could tell if people were infected simply by looking at them. Forty seven percent (47%) thought that there was a vaccine that could prevent ADDS and 22.8% thought that ADDS 168 could be cured. One student respondent wrote: "I read in the newspapers that there is a vaccine called A Z A T which can cure ADDS/HIV if detected early." Another wrote: "I read in the papers that a medicine called zidovudine can cure ADDS." Moreover, two out-of-school adolescents stated: "There is no disease that cannot be cured by a herbal preparation," and "herbs can cure all diseases." Table 5.4 Analysis of AIDS Transmission Knowledge Questions (N = 1415) A person can get infected with H I V % Correct % Wrong By sharing toothbrushes 18.7 81.1 By piercing the ear 28.7 71.2 By donating blood 34.6 65.4 By kissing 44.1 55.9 By sharing cups, glasses, forks, or other utensils 45.7 54.1 By witchcraft 46.8 53.1 By being bitten by a mosquito 47.2 52.7 By using the same toilet seats with someone who has the virus 55.3 44.7 By hugging someone with HIV 61.8 38.2 By accidental contact with the blood of someone who has the 61.9 38.0 virus By being in the same room with someone with HTV 62.0 37.9 By wearing clothes used by an infected person 62.0 38.0 Through breastfeeding 66.1 33.8 By shaking hands with someone who has the virus 67.3 32.7 By receiving a blood transfusion 78.1 21.8 By using unsterilized needles or any other instrument used by 80.4 19.5 someone who has the virus By having unprotected sex with a prostitute 82.3 17.7 By having sex with someone who has the virus 86.4 13.6 Casual contacts, such as wearing clothes worn by a HIV-positive person, sharing drinking glasses, utensils, public toilets, being in the same room with someone who is infected or hugging someone with the virus, were also perceived as potential sources of infection by 38% to 54% of the respondents (see table 5.5). In addition, whereas 52.7% of respondents erroneously believed ADDS could be transmitted through mosquito bites, 53.1% thought that ADDS could be contracted through evil brought on an individual by 169 supernatural means, such as witchcraft. There were no gender or location differentials regarding AIDS and witchcraft, but a statistical significance was observed between in-school and out-of-school adolescents on this question. Out-of-school adolescents were more likely to agree that someone could get infected with HIV by witchcraft (60.9% versus 46.3%; p < 0.001). Table 5.5: Analysis of the Questions on General Knowledge of AIDS (N = 1415) | % Correct | % Wrong, I can tell if a person has HTV by the way he or she looks. 42.0 58.0 A person can be infected with HTV and not have a 47.4 52.6 disease/illness. There is a vaccine that can prevent AIDS. 53.4 46.6 AIDS can be cured if detected early. 54.8 45.2 AIDS is especially common in older people. 57.1 42.9 A person can change his or her sexual behavior to reduce the risk 60.2 39.8 of getting HTV. Condoms can prevent infection by the virus. 66.4 33.6 A healthy-looking person with the virus can pass it on. 69.8 30.2 AIDS is caused by a virus. 70.2 29.8 AIDS destroys the body's ability to fight disease/illness. 73.7 26.3 There is no cure for AIDS. 77.2 22.8 You can have HTV/AIDS and not know it. 78.2 21.8 Having many sex partners increases the risk of getting HIV. 80.6 19.4 A pregnant woman infected with the virus can pass the virus to 81.2 18.8 her baby. There are tests that can show if a person has the AIDS virus. 85.2 14.8 Table 5.6: Analysis of AIDS Prevention Questions (N = 1415) People can protect themselves from AIDS by | % Correct |% Wrong, Never using PV drugs 32.5 67.5 Asking more questions 37.9 62.1 Having heterosexual sex only (sex with opposite sex) 39.0 61.0 Using contraceptive foam or jelly 48.1 51.9 Decreasing the number of sexual partners 49.2 50.8 Using oral contraceptives 50.5 49.5 Keeping to only one recognized partner 66.8 33.2 Never sharing needles 69.5 30.5 Using condom during sex 72.1 27.9 Abstaining from sex 76.2 23.8 170 The question of whether issues pertaining to HIV should be taught in schools, attracted a positive response of 88%. Apart from school, respondents believed that teaching should occur in hospitals (37%), at home (31%), in churches and mosques (19%), in market areas (6%), and at other places where people congregate (6%). Other possible places mentioned were workplaces and apprentice shops. There was an overwhelming preference for medical personnel to lead in this effort, as they were perceived as authorities on HIV (68%), followed by teachers (14%), parents (10%), church officials (6%), and peers (1.2%). Some respondents listed district assembly men (elected local politicians), directors and managers who could also teach issues relating to HIV in the workplace. 5.4 Other Sexually Transmitted Diseases Apart from HIV/AIDS The misperceptions with regard to STDs were high, as 60% of the respondents thought a man could always tell if a woman had a sexually transmitted disease and 49% believed that if symptoms of an STD disappear, it means the infected person no longer has the disease. Some held the mistaken belief that STDs could be cured with vigorous sex (44%) or that an amulet or charm worn around the waist/neck of an individual during a sexual act could protect him or her against an STD (11.3%). When asked about other STDs, 74% of the respondents acknowledged hearing about gonorrhoea, 50.5% about syphilis, 48% about yeast infection, 5% about chlamydia and 4% about chancroid. An analysis of urban/rural differentials yielded a statistically significant result at p < 0.001 across all the STDs, except yeast infection where no differences were observed. When in-school adolescents were compared with those not in 171 school, however, significant differences were observed with regard to syphilis, chancroid and yeast infection (p < 0.001). As demonstrated in tables 5.7 to 5.13 (found in Appendix 1), a significant number of the respondents lacked correct knowledge about transmission, curability and symptoms of other STDs. Respondents indicated sexual intercourse as the means of disease transmission with regard to STDs. Misconceptions remain, however, as things such as juju (voodoo), punishment from God, adultery, eating a lot of sweets and swimming in rivers were believed to cause STDs. Relying on herbal preparations and using antibiotics mixed with local foods (kenkey) were identified as means of treating STDs. 5.5 Attitude Towards People With AIDS (PWAs) As derived from the questionnaire participants were not sympathetic towards PWAs. Table 5.14 below shows respondents' answers to four out of five questions that sought to tap attitude towards PWAs. Table 5.14: Participants' Attitude Towards PWAs Issue Yes No Don't know % % % Willing to take care of family member with AIDS 54 36 10 PWAs should be allowed to keep their status secret 30 55 15 PWAs be allowed to continue working with others 25 60 15 PWAs should be isolated 66 25 9 The majority of the respondents were of the view that people with HIV should not keep their status secret, but that others should be informed. In response to whether PWAs should receive health care like everybody else, 23% expressed the view that it should be the same, 25% indicated it should be more, but 41% stated that PWAs should receive less 172 health care, while 10% had no opinion. When chi-square analysis was used to examine the relationship between misperceptions involving transmissions through casual contact and each of the 4 questions assessing negative attitude toward PWAs there were significant associations between scoring high on misperceptions and having negative attitude towards PWAs (p <0.001 on all questions). Some of those who indicated that PWAs should receive the same health care as everyone, and almost all who indicated less care, argued that PWAs would eventually die, so it did not make economic sense to waste scarce resources caring for them. Some of the specific comments made were: "They are on the verge of death, so no need to waste medicine on them"; "Those who have the virus will soon die, so they need no medicine"; "They should be kept isolated so that they stop spreading the disease." Asked whether they consider ADDS to be a problem in Ghana, 80% said yes, and 13% reported that they could not tell. The respondents were further asked to indicate in their own words why they held such a view. Respondents specified that they had heard on the radio, TV, and print media that half of Ghana's population was dying from ADDS and that a minimum of 600,000 to 9.5 million of an adult population of 19 million were living with HIV. ADDS was viewed as a public health menace because of the following additional reasons: the definite and premature mortality associated with AIDS; AIDS was killing students who were deemed future leaders of the country, as well as many others, mainly in the commercial towns; mortality from AIDS was not seasonal but occurred throughout the year; there is no medicine to cure AIDS; trepidation and apprehension that those infected were knowingly and unknowingly spreading it to the unsuspecting public; expecting mothers were infecting their unborn children; concern that government was 173 spending limited and scarce resources not only on educating people about ADDS, but also caring for PWAs who will eventually die anyway despite the care they receive; and that these scarce resources spent on PWAs could be used in development. In addition, PWAs were a burden to relatives, who had to care for them, feed and clothe them, and take care of their orphaned children when they died. Participants mentioned other devastating effects of AIDS in Ghana, such as reducing the population in the country as well as decimating skilled labour, especially those in the 25 - 40 age group. There was the concern that sooner than later, no skilled workers would be available in Ghana, since AIDS would kill most of them. Adolescents were also concerned that the long incubation period for HIV made it possible for anyone infected to spread it to many partners he or she sleeps with, whether or not condoms were used. The result is that ADDS puts the whole country at risk, not only the sexually active, but also those who have not engaged in sexual intercourse and intend to marry in the future. Both boys and girls mostly blamed women for the propagation of ADDS in Ghana. Reasons cited for the propagation of AIDS could be categorized into three dimensions: economics, morality and education, even though these three issues were not mutually exclusive. Adolescents stated that because the rate of unemployment was very high, parents have shirked their responsibility in caring for their children, who end up fending for themselves. Thus, in the absence of job opportunities in Ghana, women and girls prostitute themselves in the country and abroad (in Ivory Coast, Togo and Nigeria and even in Europe, notably Holland, Germany and France). These commercial sex workers (CSWs) become infected and pass the infection to their unsuspecting sexual partners in 174 Ghana. Those respondents who had moral concerns stated that there were too many fornicators, promiscuous, and sex-crazed boys and girls who indulge in indiscriminate sex, especially those between age 10 to 19 in Ghana. Whether people get the infection through promiscuity or sex for money, the respondents contended that once infected, some of them do not want to die alone and deliberately engage in unprotected sex to infect non-suspecting partners, since they believed somebody had also infected them. Finally, participants believed that lack of basic education had made it difficult for the uneducated to get AIDS prevention messages, since most of the messages are written in English and hence the uneducated cannot take precautions and may be at risk of getting infected. 5.6 Predictors of AIDS Knowledge The hypotheses were tested in two stages. The first stage examines the hypotheses in a series of independent univariate and bivariate analyses. For example, we examine whether boys will have higher knowledge scores than girls or whether those sexually active will have higher knowledge score than those who have never had sex. In the second stage, the significant results from the bivariate stage were integrated into a multivariate model. As stated in Chapter 1, the following hypotheses were tested as shown in the table 5.15 next page. Table 5.15 (next page) characterizes the differences in AIDS knowledge scores (mean, median, and range) on demographic variables of sex, age, location, sexual activity, educational status, and study site. 175 Table 5.15: Distribution of AIDS Knowledge Score by Key Demographic Variables Characteristic Mean score Median Range Mean 95% Confidence Statistical (s. d.) score difference Interval of the differences significance Gender Males (N = 795) 26.52 (7.50) 28 0-40 1.89 1.09, 2.70 p< 0.001 Females (N = 620) 24.62 (7.86) 26 0-40 Age 10-16 (N = 629) 23.67 (8.33) 25 0-40 3.63 2.84, 4.41 p< 0.001 17-19 (N= 786) 27.30 (6.77) 28.5 0-40 Location Rural (N = 505) 25.57 (7.40) 27 0-38 0.18 0.66, 1.02 p = 0.669 Urban (N= 910) 25.75 (7.88) 27 0-40 Ever had sex Yes (N= 539) 27.10 (6.35) 28 0-39 2.28 1.46, 3.10 p< 0.001 No (N = 876) 24.82 (8.33) 26 0-40 Educational Status In school (N = 750) 25.90(7.17) 27 0-40 0.46 0.35, 1.27 p = 0.262 Out of school (N = 665) 25.44 (8.29) 27 0-39 Educational level JSS (N =766) 25.75 (6.82) 26 0-40 2.49 1.68, 3.29 p.< 0.001 SSS (N = 423) 28.24(6.71) 30 0-40 Study Site Ketu South (N = 470) 25.31 (8.43) 27 0-38 24.54, 26.07 p< 0.001 Upp. Denkyira (N = 462) 25.08 (7.82) 26 0-40 24.36, 25.79 Offinso South (N = 483) 26.64 (6.74) 28 0-38 26.04, 27.24 176 5.6.1 Stage 1: Univariate/Bivariate Tests (1) In-school adolescents are likely to have higher AIDS knowledge than their counterparts who are out of school. There was no significant difference between the mean scores of the two populations (p = 0.262). (2) Boys will score higher than girls on the AIDS knowledge questions. There was a statistically significant difference between the mean score of males and females as males were more likely to obtain higher scores than female participants (26.5 versus 24.6; p < 0.001, 95% CI 1.088-2.698). (3) Those who reside in the Ketu South constituency will have the lowest score followed by those in Upper Denkyira, whose score will be less than those resident in Offinso South. This pattern is expected because the people resident in areas of high HIV prevalence may be more knowledgeable than those in low HIV prevalent areas. When scores are compared among the three study locations, a statistically significant difference was found (p <0.001, F = 21.29). Although there were no statistical difference between Ketu South and Upper Denkyira (mean score 25.3 versus 25.1; p = 0.67, 95% CI 0.82-1.28), a statistical significant difference was observed between Ketu South and Offinso South (25.3 versus 26.7; p = 0.007, 95% CI 0.364 - 2.30) and Upper Denkyira and Offinso South (25.1 versus 26.7; p < 0.001, 95% CI 0.633 - 2.50). Although these differences were statistically significant, we could say they were really not clinically significant, because the differences were really small and attained significance simply because of the large sample size. 177 (4) Young adolescents (10 to 16) will score less than older adolescents (17 to 19). There was a statistically significant difference in mean scores between those age 10 to 16 and 17 to 19, as those between 17 to 19 were more likely to score higher (27.3 versus 23.4; p < 0.001, 95% CI 2.84- 4.41) than those between age 10 to 16. (5) Those who have had sexual intercourse will score higher than those who have never had sexual intercourse. The differences were statistically significant, as those who had had sex were more likely to have higher knowledge scores than those who had never had sexual intercourse (27.1 versus 24.5; p < 0.001, 95% CI 1.46-3.10). 5.6.2 Comparing Low Knowledge and High Knowledge Scores Comparisons were made between those classified as having "low knowledge" (those scoring 0% to 50%) and those having "high knowledge" (those scoring 75% to 100%). This yielded a total of 682 subjects, with 382 being male and 300 females. Cross-tabulations were made and data were analyzed by contingency table analysis, as shown in table 5.16 (pages 179 to 181) with the corresponding p values. Chi Square (X 2) tests were used for differences in proportions and for categorical variables. The Fisher's exact test was used when frequencies were less than five. All statistical tests were 2 tailed and alpha = 0.05 or less was considered significant. 178 1 Table 5.16: Comparison of Key Variables Between Respondents who Attained Low and High Knowledge ADDS Scores Variable Low Knowledge High knowledge p value n(%) n (%) Gender Male 153 (40.1) 229 (55.9) <0.001 Female 182 (60.7) 118 (39.3) Location Rural 124 (52.1) 114(47.9) 0.254 Urban 211 (47.5) 233 (52.5) Constituency Ketu South 131 (50.6) 128 (49.4) Upper Denkyira 119(52.9) 106 (47.1) 0.104 Offinso South 85 (42.9) 113 (57.1) Current Age 10-16 203 (66.8) 101 (33.2) <0.001 17-19 132 (34.9) 246 (65.1) Ever had sex Yes 90 (37.3) 151 (62.7) <0.001 No 245 (55.6) 196 (44.4) Age at first sex <=15 38 (48.1) 41 (51.9) 0.016 >15 43 (31.6) 93 (68.4) Educational Status In school 182 (49.9) 183 (50.1) 0.677 Out of school 153 (48.3) 164 (51.7) Educational level No education 31 (93.9 2(6.1) Primary/makaranta 65 (81.3) 15 (18.8) <0.001 JSS 183 (52.6) 165 (47.4) SSS 56 (25.3) 165 (74.7) Employment Status In school/employed 238 (49.6) 242 (50.4) 0.709 Out of sch/Unemployed 97 (48.0) 105 (52.0) Religious Affiliation Atheist/No religion 14 (70.0) 6 (30.0) 0.007 Traditional religion 17 (77.3) 5 (22.7) Catholic 101 (52.9) 90 (47.1) Protestant 95 (42.2) 130 (57.8) Apostolic 78 (48.1) 84 (51.9) Moslem 30 (48.4) 32 (51.6) Paternal education No education 79 (62.7) 47 (37.3) <0.001 Primary 35 (64.8) 19(35.2) Middle school 117 (46.1) 137 (53.9) Sec/Trg/Nurses/Tech 54 (40.9) 78 (59.1) Poly/Univ/Grad 50(43.1) 66 (56.9) 179 Table 5.16: Comparison of Key Variables Between Respondents who Attained Low and High Knowledge AIDS Scores (continued from page 179) Variable Low Knowledge High knowledge p value n (%) n (%) Maternal Education No education 140 (41.8) 102 (29.4) Primary 48 (14.3) 39 (11.2) Middle school 99 (29.6) 138 (39.8) Sec/Trg/Nurses/Tech 36(10.7) 57 (16.4) Polytech/Univ/Grad 12 (3.6) 11 (3.2) Paternal Occupation Unemployed or deceased 21 (6.3) 21 (6.1) Non Professional 230 (68.7) 206 (59.4) 0.024 Professional/Technical 84(25.1) 120 (34.6) Maternal Occupation Housewife 30 (9.0) 19(5.5) Non Professional 279 (83.3) 272 (78.4) 0.001 Professional 26 (7.8) 56 (16.1) Heard somebody can cure AIDS Yes 56 (16.7) 42(12.1) 0.054 No 279(83.1) 305 (87.9) Know somebody who can cure AIDS Yes 55 (16.4) 24 (6.9) O.001 No 280 (83.6 323 (93.1) AIDS can be spread by witchcraft Yes 108 (32.2) 62 (17.9) <0.001 No 227 (67.8) 285 (34.9) Fate Decides who gets HIV Yes 95 (28.4) 81 (23.3) 0.138 No 240 (71.6) 266 (76.7) Relative/Friend/Colleague has AIDS Yes 25 (7.5) 24 (6.9) 0.882 No 310(92.5) 323 (93.1) Talk about HIV with friends and acquaintances Frequently 65 (19.5) 164 (47.3) <0.001 Rarely 89 (26.6) 109(31.4) Not at all 180 (53.9) 74 (21.3) Talk about HIV with family members Often 116(34.7) 180(51.9) Once in a while 53 (15.9) 83 (23.9) O.001 Not at all 165 (49.4) 84 (24.2) Belief that HIV is a man-made Yes 105 (33.3) 106(31.7) 0.488 No 210 (66.9) 228 (68.3) Belief that AIDS is a problem in Ghana Yes 181 (59.5) 305 (90.0) <0.001 No 123 (40.5) 34 (10.0) 180 Table 5.16: Comparison of Key Variables Between Respondents who Attained Low and High Knowledge AIDS Scores (continued from page 180) Variable Low Knowledge n(%) High knowledge p value n(%) Self perceived risk of HIV in a month Sure Not sure Will never catch HTV Self perceived risk of HIV in a year Sure Not sure Will never catch HTV Have taken steps avoid HIV Yes No 86 (52.1) 124 (56.1) 115 (41.1) 92 (54.1) 122 (55.7) 113 (40.5) 195 (38.9) 138 (79.8) 79 (47.9) 97 (43.9) 165 (58.9) 78 (45.9) 97 (44.3) 166 (59.5) 306 (61.1) 35 (20.2) 0.002 0.001 <0.001 Other STDs: Ever heard of Gonorrhea Yes No Syphillis Chlamydia Chancroid Yes No Yes No Yes No 178 (37.7) 154 (74.8) 94 (30.4) 238 (64.5) 13 (30.2) 319(50.2) 8 (34.8) 324 (49.5) 294 (62.3) 52 (25.2) 215 (69.6) 131 (35.5) 30 (69.8) 16 (49.8) 15 (65.2) 331 (50.5) <0.001 <0.001 0.011 0.166 Yeast Infec. Yes No 119(40.9) 213 (55.0) 172 (59.1) 174 (45.0) <0.001 181 5.6.3 Stage 2: Multivariate Analysis to Determine Predictors of AIDS knowledge The variables which attained a statistical significance level of p = 0.05 or lower in the bivariate analysis were examined to determine the predictors of high knowledge in this population of 682 Ghanaian adolescents. The variables that were significant in the bivariate analysis include: gender, age, level of education, maternal occupation, knowing a friend, a relative or acquaintance having AIDS, having heard that somebody can cure ADDS, knowledge of gonorrhoea and syphilis, having talked about HIV with family, having talked about HIV with friends and acquaintances, and believing that one can get ADDS through witchcraft, believing that ADDS is a problem in Ghana, that fate decides who gets HIV and that the individual had little control over whether he or she gets infected. These variables were then entered into a multivariate logistic regression model to predict high ADDS knowledge, while controlling for potential confounders such as sex, age, location, constituency, educational status and level of education. Because of missing data, the number in the final model decreased from 682 to 619. The results obtained are shown in table 5.17. 182 Table 5.17: Predictors of High HIV Knowledge Among 619 Ghanaian Adolescents Variable Coefficient S. E. P value Odds Ratio (95% CI) Gender 0.006 Male (reference) 1.00 Female -0.642 0.238 0.53 (0.33 -0.83) Age 0.011 1.00 10-16 (reference) 17-19 0.640 0.252 1.90(1.16-3.11) Location 0.528 Rural (reference) 1.00 Urban -0.150 0.238 0.86 (0.54-1.37) Constituency 0.805 1.00 Ketu South (reference) Upper Denkyira -0.074 0.299 0.805 0.93 (0.52- 1.67) Offinso South 0.285 0.303 0.347 1.33 (0.73-2.41) Education 0.005 No education (reference) 1.00 Primary/makarata 1.002 0.873 0.251 2.72(0.49- 15.07) JSS 1.819 0.826 0.028 6.17(1.22-31.11) SSS 2.345 0.852 0.006 10.43(1.97-55.41) Paternal Education 0.660 No education (reference) 1.00 Primary -0.006 0.506 0.991 0.99 (0.37-2.68) Middle School 0.341 0.357 0.339 1.41 (0.70-2.83) Sec/Trg/Nurses/Tech 0.452 0.439 0.302 1.57 (0.67-3.71) Poly/Univ/Grad 0.022 0.486 0.964 1.02(0.39-2.65) Maternal Education 0.558 No education (reference) 1.00 Primary -0.264 0.362 0.466 0.77(0.38- 1.56) Middle School 0.068 0.301 0.821 1.07 (0.59- 1.93) Sec/Trg/Nurses/Tech 0.330 0.460 0.473 1.39(0.57-3.43) Poly/Univ/Grad -0.722 0.740 0.329 0.49 (0.11 -2.07) Maternal Occupation 0.402 Housewife (reference) 1.00 Non Professional 0.361 0.445 0.418 1.43 (0.60-3.43) Professional 0.800 0.599 0.182 2.23 (0.69 - 7.20) Paternal Occupation 0.669 Unemployed/Deceased (ref.) 1.00 Non Professional -0.249 0.490 0.612 0.78 (0.30-2.04) Professional -0.005 0.548 0.993 1.00 (0.34-2.91) Religion 0.156 Atheist/no religion (reference) 1.00 Traditional religion -0.686 0.999 0.492 0.50 (0.01 -3.57) Catholic 0.326 . 0.798 0.682 1.39 (0.29-6.62) Protestant 0.789 0.801 0.325 2.20 (0.46 - 10.57) Apostolic 0.895 0.798 0.262 2.45 (0.51 - 11.70) Moslem 0.461 0.854 0.589 1.59 (0.30-8.45) 183 Table 5.17: Predictors of High HIV Knowledge Among 619 Ghanaian Adolescents Continued from page 183 Variable Coefficient S. E. P value Odds Ratio (95% CI) Can get AIDS thru witchcraft Yes (reference) No 0.617 0.273 0.024 1.00 1.85 (1.09--3.17) AIDS is a problem in Ghana Yes (reference) No -1.399 0.316 < 0.001 1.00 0.25 (0.13--0.46) Ever had sexual intercourse Yes (reference) No -0.575 0.252 0.023 1.00 0.56 (0.34 -0.92) Ever heard of syphilis Yes (reference) No -0.826 0.227 < 0.001 1.00 0.44 (0.28 -0.68) Know anybody can cure AIDS Yes (reference) No 1.209 0.358 0.001 1.00 3.35(1.66 - 6.75) Talk about HIV with family Often (reference) Once in a while Not at all 0.566 0.053 0.377 0.308 0.174 0.93 0.029 1.00 0.09 (0.91 0.86 (0.58 -3.41) - 1.93) Talk about HTV to friends and acquaintances Frequently (reference) Rarely Not at all -0.204 -0.925 0.301 0.332 0.010 0.499 0.005 1.00 0.82 (0.45 0.40 (0.21 -1.47) -0.76) Can avoid HTV Yes (reference) No -1.111 0.282 <0.001 1.00 0.33 (0.19 -0.52) Self perceived risk of HTV in 30 days Sure (reference) Not sure Will never catch HTV -0.830 -0.224 0.373 0.473 0.056 0.026 0.635 1.00 0.44 (0.21 0.80 (0.32 -0.91) -2.02) Self perceived risk of HTV in a year Sure (reference) Not sure Will never catch HTV 0.750 0.712 0.375 0.473 0118 0.045 0.133 1.00 2.12(1.02 2.04 (0.81 -4.41) -5.15) Constant -2.894 1.282 0.024 184 Statistically significant differences were observed for gender (p = 0.006), age (p = 0.011), level of education (p = 0.005), believing that one can get AIDS through witchcraft (p = 0.024), believing that AIDS is a problem in Ghana (p < 0.001), having had sexual intercourse (p = 0.023), having heard about syphilis (p < 0.001), thinking that somebody can cure AIDS (p < 0.001), talking about HIV with friends and acquaintances (p = 0.010), and believing that one can avoid AIDS (p < 0.001). Girls were 47% less likely to have a score higher than boys (p = 0.006, OR = 0.53, 95% CI = 0.33 - 0.83). Compared adolescents between age 10 tol6, respondents in the 17 to 19 age group were two times more likely to score higher (p = 0.011, OR = 1.90, 95% CI = 1.16-3.11). Respondents who did not believe that one could get HIV through witchcraft were two times more likely to get a higher score than their counterparts who believed otherwise (p = 0.024, OR = 1.85 95% CI 1.09 - 3.17). Similarly, those who did not believe AIDS was a problem in Ghana were 75% less likely to get a score lower than those who believed otherwise (p < 0.001, OR = 0.25, 95% CI 0.13 - 0.46). Those respondents who had never had sexual intercourse were 44% less likely to score higher than their counterparts who have had sexual intercourse (p = 0.023, OR = 0.56, 95% CI = 0.34 - 0.92). Respondents who had never heard of syphilis were half as likely to score higher than those who have heard of syphilis (p < 0.001, OR = 0.44, 95% CI 0.28 - 0.68). Respondents who disagreed with thinking that anyone could cure AIDS were three times as more likely to score higher than their counterparts who believed otherwise (p < 0.001, OR = 3.35, CI 1.66 - 6.75). Participants who did not believe they could avoid HIV were 185 67% less likely to obtain a higher HIV knowledge score than those who believed otherwise (p < 0.001, OR = 0.33, 95% CI 0.19 - 0.57). Statistically significant differences were also observed for education, having discussed HIV with friends and acquaintances, disagreeing that HIV can be contracted through supernatural means such as witchcraft, and believing that one could avoid HIV. Compared to those who have never been to school, those who have attained at least primary school education, or the Islamic equivalent of primary school (makaranta), were almost three times more likely to have a high score (p = 0.251, OR = 2.72, 95% CI 0.49 -15.07); those in junior secondary school were almost six times more likely to score high (p = 0.028, OR = 6:17, 95% CI 1.22 - 31.11); and those who had senior secondary school were almost ten times more likely to achieve a high score (p = 0.006, OR = 10.43, 95% CI = 1.97-55.41). Participants who did not believe in the supernatural (witchcraft) as the likely cause of AIDS were almost two times more likely to score higher than their counterparts who believed otherwise (p = 0.024 O R = 1.85, 95% CI = 1.09 - 3.17). Respondents who never discussed AIDS- related issues with their friends were 60% less likely to have higher knowledge than their counterparts who frequently discussed it (p = 0.005, OR = 0.40, 95% CI = 0.21 - 0.76). No statistically significant differences were observed for location, parental education and occupation, religious affiliation, having discussed ADDS with family members, and self-perceived risk of contracting HIV. There were, however, elevated odds ratios relating to maternal occupation and religious affiliation. Compared to respondents whose mothers were housewives, those whose parents were non-professional 186 and professional were almost one and a half times and two and a half times respectively likely to score higher. Similarly, those who are religious were one and a half times to two and a half more likely to score higher than their counterparts who have no religious beliefs. 5.7 Condom Use 5.7.1 Knowledge of Condoms A significant proportion of respondents have heard of condoms (87%), but fewer (72%) had seen one. Respondents indicated drug stores/pharmacies as known sources of where condoms could be purchased (78%), hospitals/clinics (45%), shops (21%), bars (23%), and community centres (15%). Other areas mentioned were "drinking bars, hotels and any areas frequented by prostitutes." 5.7.2 Reasons for Condom Use/Monogamy and Condom Use Among the 539 respondents who have had sex, 56.9% never used condoms in their sexual relations, even though 64.9% agreed that they could rely on condoms to protect them from STDs and 78% correctly stated the efficacy of condoms in preventing HIV transmission. Of the 223 participants who have ever used a condom, 28.5% reported having used condoms for contraception. Fewer participants reported using condoms for STD prevention (6.1%), for the prevention of AIDS (11.5%), and only on occasions when partners insisted on use (0.6%). Twenty-six per cent of the respondents indicated that they use condoms with their regular sexual partners, 56% never did, and 5.6% used them sometimes. Reasons given 187 for not using condoms were that couples were boyfriend and girlfriend (32.9%), couples were in a long-term relationship with commitment to be married (23.5%), sex felt better without a condom (25.5%), partners are both HlV-negative (10%), and partners trusted each other in a mutually monogamous relationship (8.1%). 5.7.3 Condom Use/Non Use and Concurrent/Casual Sex Partners When stage 2 of the A R R M (decision to change) was examined using the data on condom use with occasional sexual partners and commitment to behavioral change, there was a statistically significant difference with regard to condom use between those who indicated that, since hearing about AIDS, they had taken preventive measures and those who did not (p = 0.001). This did not extend, however, to avoiding sex with others who were not regular partners, as 44.3% of the respondents had had sexual intercourse with someone other than their regular partner in the 30 or more days preceding the survey. There was no statistically significant difference between those who indicated that they had not taken any preventive measures and those who took preventive measures while having sex with others (p = 0.918). Furthermore, 8.3% of the respondents admitted having sexual intercourse with somebody else other than their regular sexual partner in the seven days preceding the survey; 10.8% admitted doing so within the last four weeks and 25.0% stated they did more than a month ago, as far back as the time that they first engaged in sexual intercourse. Close to a third (28.6%) of the respondents stated they had met these casual partners for the first time. Of the respondents who engaged in this type of encounter, 63.4% reported using no condom. Reasons given for not using condoms were: 188 respondents said that condoms were not available (29.4%); they did not like condoms (29.4%); they did not care (16.8%); they found condoms were too expensive (12.6%); or they had a partner who objected (11.8%). In addition, participants were asked if they had casual sex with partners and whether condoms were used. A casual partner was defined as "any man or woman you have sex with just for one encounter and never continue in a relationship." In Ghana, this is referred to as "hit and run". Of the 65 who admitted ever engaging in casual sex, 42 (64.6%) did not use condoms in the sexual encounter. The majority stated that seeking maximum sexual pleasure was the reason for non-condom use (57.1%), and 30.4% indicated that they just did not care at the time. Participants were also asked to indicate the number of casual partners they have had in a given reference period. The minimum and maximum obtained were: one week (1 to 3), one month (1 to 6), and one year (1 to 11) with 3 to 5 partners being the highest frequency stated anytime greater than one week. 5.7.4 Attitude Toward Condoms Amongst respondents who were sexually active and who used condoms at least once, (n = 539), 51% were of the view that sex does not feel good with condoms, that condoms were physically uncomfortable (51%), and having to stop and put on condoms takes the fun out of sex (49%). Forty per cent (40%) agreed that they found it embarrassing to talk to sex partners about condoms, 39.6% found it comfortable, and 20.3% gave "don't know" as an answer. Whereas some 42.6% agreed there was no need to use condoms if they used other forms of birth control, 32.4% disagreed with this view, 189 and 25% indicated they had no opinion. Even though 68% of the sexually active respondents agreed they could rely on condoms to protect them against STDs, 37.8% agreed they did not need to use condoms with sexual partners they have been with for more than three months. 5.8 Predictors of Condom Use The hypotheses were tested in two stages. The first stage examines the hypotheses in a series of independent univariate and bivariate analyses. In the second stage, the significant results from the bivariate stage were integrated into a multivariate logistic regression model to determine predictors of condom use. As stated in Chapter 1, the following hypotheses were tested. 5.8.1 Stage 1: Bivariate Tests/ Comparison Between Condom Use and Non Condom Use and Sexual Activity In the bivariate analyses, comparisons were made between sexually active respondents who reported having used a condom and those who had never used one. This yielded a total of 223 (had used a condom) and 294 (had never used a condom). Bivariate analyses were done between the two groups and the results obtained are shown in table 5.18 (pages 191-193) with corresponding p values whenever appropriate. 190 Table 5.18: Comparison of Socio-demographic and AJDS-related Changed Behavior on Condom Use Variable Had Ever Used a condom p value Yes No n (%) n(%) Gender Male 136 (44.7) 168 (55.3) 0.379 Female 87 (40.8) 126 (59.2) Location Rural 76 (41.5) 107 (58.5) 0.586 Urban 147 (44.0) 187 (56.0) Constituency 115(53.0) Ketu South 102 (47.0) Upper Denkyira 66 (42.3) 90 (57.7) 0.246 Offinso South 55 (38.2) 89 (61.8) Current Age 10-16 40 (31.0) 89 (69.0) 0.001 17-19 183 (47.2) 205 (52.8) Age at first sex <=15 77 (41.4) 109 (58.6) .271 >15 114(46.7) 130 (53.3) Educational Status In school 55 (28.9) 135 (71.1) <0.001 Out of school 168 (51.4) 159 (48.6) Educational level No education 12 (60.0) 8 (40.0) 0.066 Primary/makaranta 21 (30.4) 48 (69.6) JSS 123 (44.9) 151 (55.1) SSS 67 (43.5) 87 (56.5) Employment Status 0.029 In school/employed 131 (39.6) 200 (60.4) Out of sch/Unemployed 92 (49.5) 94 (50.5) Religious Affiliation Atheist/No religion 7(41.2) 10(58.8) Traditional religion 7(38.9) 11 (61.1) Catholic 51 (39.5) 78 (60.5) 0.858 Protestant 65 (42.8) 87 (57.2) Apostolic 64 (45.1) 78 (54.9) Moslem 29 (49.2) 30 (50.8) Paternal education No education 43 (43.4) 56 (56.6) Primary 11 (28.9) 27 (71.1) Middle school 98 (44.3) 123 (55.7) 0.415 Sec/Trg/Nurses/Tech 33 (41.8) 46 (58.2) Poly/Univ/Grad 38 (47.5) 42 (52.5) 191 Table 5.18: Comparison of Socio-demographic and AJDS-related Changed Behavior on Condom Use (continued from page 191) Variable Had Ever Used a condom p value Yes No n(%) n(%) Maternal Education No education 86 (44.8) 106 (55.2) Primary 25 (33.3) 50 (66.7) Middle school 77 (47.5) 85 (52.5) 0.142 Sec/Trg/Nurses/Tech 27 (36.5) 47 (63.5) Polytech/Univ/Grad 8 (57.1) 6 (42.9) Paternal Occupation 18 (54.5) Unemployed or deceased 15 (45.5) Non Professional 139(41.6) 195 (58.4) 0.641 Professional/Technical 69 (46.0) 81 (54.0) Maternal Occupation Housewife 12 (40.0) 18 (60.0) Non Professional 182 (41.9) 252 (58.1) 0.195 Professional 29 (54.7) 24 (45.3) Sexual partners past 30 days 0 - 1 187 (42.6) 252 (57.4) 2 - 4 22 (51.2) 21 (48.8) 0.045 5 and more 6 (85.7) 1 (H.3) Sexual partners past 6 months 0.309 0 - 1 179 (43.0) 237 (57.0) 2 - 4 25 (46.3) 29 (53.7) 5 and more 12 (60.0) 8 (40.0) Sexual partners past year 0.731 0 - 1 164 (43.4) 214(56.6) 2 - 4 36 (45.6) 43 (54.4) 5 and more 17 (50.0) 17 (50.0) Lifetime sexual partners 1 110(40.6) 161 (59.4) 0.208 2-4 71 (49.3) 73 (50.7) 5 and above 35 (14.5) 40 (53.3) Heard somebody can cure AIDS Yes 33 (36.7) 57 (63.3) 0.173 No 190 (44.5) 237 (55.5) Fate Decides who gets HIV Yes 52 (36.4) 91 (63.6) 0.055 No 171 (45.7) 203 (54.3) Believe that AIDS is a problem in Ghana Yes 172 (42.1) 237 (57.9) No 46 (49.5) 47 (50.5) 0.193 Relative/Friend/Colleague has AIDS Yes 21 (35.6) 38 (64.4) 0.214 No 202 (44.1) 256 (55.9) 192 Table 5.18: Comparison of Socio-demographic and AIDS-related Changed Behavior on Condom Use (continued from page 192) Variable Had Ever Used a condom p value Yes n (%) No n(%) Preventive measure taken to avoid HIV Yes 160 (48.3) 171 (51.7) 0.001 No 63 (33.9) 123 (66.1) Talk about HIV with sexual partner Frequently 90 (48.1) 97 (51.9) <0.001 Rarely 63 (58.9) 44 (41.1) Not at all 70 (31.4) 153 (68.6) Talk about HIV with friends and acquaintances Frequently 84 (40.8) 122 (59.2) 0.014 Rarely 81 (52.6) 73 (47.4) Not at all 58 (36.9) 99 (63.1) Talk about HIV with family members Often 104 (43.2) 137 (56.8) Once in a while 55 (48.2) 59(51.8) 0.353 Not at all 64 (39.5) 98 (60.5) Self-perceived risk of HIV in a month Sure 72 (45.6) 86 (54.4) Not sure 64 (39.0) 100 (61.0) 0.376 Will never catch HTV 84 (45.7) 100 (54.3) Self-perceived risk of HIV in a year Sure 68 (40.0) 102 (60.0) Not sure 62 (40.8) 90 (59.2) 0.189 Will never catch HTV 91 (48.7) 96 (51.3) Know anybody who can cure AIDS Yes 26 (36.1) 46 (63.9) No 197 (44.3) 248 (55.7) 0.195 HIV knowledge scores Low 18(21.7) 65 (78.3) Medium 126 (43.9) 161 (56.1) <0.001 High 79 (53.7) 68 (46.3) Belief in the efficacy of condoms against STDs Yes 164 (48.4) 175 (51.6) No 56 (35.7) 101 (64.3) 0.009 Fear of AIDS has changed people's sexual behaviour in this area Agree 146 (48.5) 155 (51.5) Disagree 77 (35.6) 139 (64.4) 0.004 Ever heard of syphilis Yes 128 (43.4) 167 (56.6) No 90 (42.1) 124 (57.9) 0.786 Attitude towards condoms Negative 101 (57.4) 75 (42.6) Neutral 56 (30.9) 125 (69.1) <0.001 Positive 66 (41 3> 94 (58 8) 193 The variables in the ARRM and others, which attained p = 0.05 or lower in the bivariate analysis, were examined to determine the predictors of condom use (stage 3 of the ARRM) in this population of 539 sexually active Ghanaian adolescents. These variables were entered into a final multivariate model, while controlling for confounders, such as gender, age, constituency, educational status, and location. The number decreased from 539 to 513 adolescents in the final model, because of missing data. Variables with statistical significance were: educational status (p = 0.002); reliance on condoms as a protective measure against STDs (p = 0.019); having discussed AIDS with friends and acquaintances (p = 0.004); having discussed ADDS with a sexual partner (p < 0.001); having a positive attitude toward condoms (p = 0.004); and self-efficacy (p < 0.001). Table 5.19: Predictors of Condom Use Among 513 Adolescents in Ghana Variable Coefficient S. E. p- value OR (95% CI) Gender Male (reference) Female 0.034 0.220 0.878 1.0 1.03 (0.67 -1.59) Age 10-16 (reference) 17-19 0.240 0.266 0.367 1.00 1.27(0.76-2.14) Location Rural (reference) Urban 0.075 0.228 0.742 1.0 1.08(0.69-1.69)) Constituency Ketu South (reference) Upper Denkyira Offinso South -0.170 -0.291 0.271 0.281 0.580 0.531 0.300 1.0 0.84 (0.50 - 1.44) 0.75 (0.43 - 1.30) Educational Status In school (reference) Out of school 1.147 0.363 0.002 1.0 3.15 (1.55-6.41) Employment Status Currently in school /Employed (ref) Out of school /Unemployed -0.247 0.272 0.364 1.00 0.78(0.46- 1.33) 194 Table 5.19: Predictors of Condom Use Among 513 Adolescents in Ghana (continued from page 1951 Variable No education (reference) Primary/marakanta JSS SSS Talk about AIDS with regular sexual partner Frequently (reference) Rarely Not at all Talk about AIDS with friends etc Frequentiy (reference) Rarely Not at all Have taken steps to avoid HIV Yes (reference) No Self efficacy score Knowledge Score Low (reference) Medium High Reliance on efficacy of condoms Yes (reference) No Fear of AIDS has changed peoples behaviour in this area Yes (reference) No Attitude towards condoms Negative (reference) Neutral Positive Constant Coefficient S. E. p- value OR (95% CI) 1.00 -1.467 0.613 0.170 0.23 (0.070 - 0.77) -0.970 0.558 0.083 0.38(0.12-1.13) -0.658 0.633 0.028 0.16(0.15-1.79) < 0.001 1.0 0.224 0.305 0.463 1.25 (0.69 - 2.27) -0.809 0.266 0.002 0.44 (0.26 - 0.75) 0.004 1.0 0.794 0.266 0.003 2.21 (1.31-3.73) 0.787 0.287 0.006 2.20 (1.25-3.85) 0.141 1.0 -0.352 0.239 0.70(0.44-1.12) 0.224 0.050 < 0.001 1.25 (1.14- 1.38) 0.370 1.00 0.465 0.332 0.161 1.59 (0.83 - 3.05) 0.435 0.374 0.245 1.55 (0.74-3.32) 0.019 1.00 -0.594 0.253 0.55 (0.34-0.91) 0.899 1.00 0.030 0.233 1.03 (0.65- 1.63) 0.004 1.00 -0.759 0.256 0.003 0.47(0.28 -0.77) -0.720 0.270 0.008 0.49 (0.29-0.83) 2.880 0.864 0.001 Out-of-school adolescents were three times as more likely to report ever using condoms than their counterparts who are currently in school (p = 0.002, OR =3.15, 95% CI = 1.55-6.41). 195 Participants who disagreed that they relied on the efficacy of condoms to protect themselves from sexually transmitted diseases including HIV were 45% less likely to report condom use compared to those who agreed with the statement (p = 0.019, OR = 0.55, 95%, CI = 0.34 - 0.91). In addition, self-efficacy score was a predictor in the model (p < 0.001) with the result that for every unit increase in the score the likelihood of using a condom increases by 25%. Communication with sexual partners and relatives/friends regarding HIV/AIDS attained statistical significance in the model (p = 0.004). Participants who stated that they rarely talked to their sexual partners about HIV were 25% more likely to report ever using condoms, compared to their counterparts who frequently discussed HIV with their sexual partners (p = 0.463, OR = 1.25, 95%, CI = 0.69 - 2.27). However, those who stated they do not discuss AIDS with their partners were 54% less likely to report condom use (p = 0.002, OR = 0.44, 95%, CI = 0.26 - 0.75). Participants who stated that they rarely talk to their friends about HIV were twice as likely to use condoms (p = 0.003, OR = 2.21 95%, CI = 1.31 - 3.73), compared with those who frequently do. Similar results occurred when a comparison was made between those who never discussed HIV with their friends or acquaintances and those who do it frequently. They were two times more likely to report condom use than their counterparts (p = 0.006, OR = 2.20, 95% CI = 1.25 - 3.85). Attitudes toward condoms was significant in the model in predicting condom use (p = 0.004). Those participants classified as having neutral attitude towards condoms were 53% less likely to ever use condoms, compared to those with a negative attitude (p 196 = 0.003, OR = 0.47 95% CI = 0.28 - 0.77). Those with a positive attitude were 51% less likely to report ever using a condom compared to those with negative attitude (p = 0.008, OR = 0.49 95% CI = 0.29 - 0.83). No statistically significant differences were observed for gender, location, constituency, age, AIDS knowledge score, data as to whether the fear of ADDS has changed sexual behavior in the study area, employment status, and the level of education attained. Condom use decreased with increasing level of education. Participants with primary education were almost 77% less likely to use condoms compared to their counterparts with no education. Similarly, those who had attained junior secondary school and senior secondary school education were 62% and 85% less likely respectively to use condoms, compared to their counterparts who never had any education. Thus, the longer they stay in school, the less they were ever likely to use a condom. 5.9 Sexual Risk Taking 5.9.1 First Sexual Experience The percentage of sexually active adolescents in the population was 38.1% (N = 539). The sexually active sample was 57.9% male and 42.1% female, which is no different from the gender distribution of the study (56.2% male and 43.5% female). The majority of the respondents of both sexes had their first sexual experience with someone of the same age (66.6% of the boys, 54.7% of the girls) with 8.6% of the male respondents and 5.7% of the female respondents reporting they could not remember. Female respondents, however, were more likely than boys to have had their first sexual 197 experience with older partners (19.8% versus 6.2%) and more likely to have married partners (4.7% versus 0.3%). Furthermore, it was found that before age 15, boys were more likely to engage in sexual intercourse than girls (24.4% versus 14.5%). Table 5.20 illustrates the age of first sexual intercourse between male and female respondents. Table: 5.20: Age at First Sexual Intercourse Males Females Total Age in years n(%) n(%) n(%) < 15 >=15 Age not stated 76 (24.4) 187 (60.0) 49(15.6) 33 (14.5) 148 (65.2) 46 (20.3) 109 (20.2) 335 (62.1) 95 (17.7) Total 312 (59.2) 227 (40.8) 539 (100) Whereas 84.4% of the boys and 80.9% of the girls indicated that their first sexual partner was someone they knew 8.8% of the boys and 12.6% of the female respondents admitted meeting their partner for the first time and 6.5% of the males and 4.7% of the females reported they could not remember. An analysis was done to determine whether area of residence (patrilineal versus matrilineal) has any effect on age at first sexual intercourse. Overall no statistical significant difference was observed (p = 0.224). However, in Ketu South (patrilineal) the proportion of adolescents whose age at first sexual intercourse was 16 and over was 60.4%. In the matrilineal areas (Upper Denkyira and Offinso South) the proportions were Upper Denkyira 51.1% and Offinso South 55.7%. When the analysis was restricted to only females, the results obtained were as follows: Ketu South 64.1%, Upper Denkyira, 55.6%, and Offinso South 61.5%. 198 The reasons why they had their first sexual experience were varied and described in table 5.21. A little over a third (37.8%) of the participants had their first sexual experience for pleasure and another 23.2% succumbed under peer pressure. A female participant wrote: "It is a fashion to do it at 16 in this area." Almost a third ofthe female respondents were forced into having their first sexual intercourse (raped). Table: 5.21: Reasons for Engaging in Sexual Intercourse the First Time Bovs Girls N = 284 (%) N = 208 (%) Friends convinced me/peer pressure 65 (22.9) 49 (23.6) Wanted to know how it feels 144 (50.7) 42 (20.2) Was forced to do it 23 (8.1) 63 (30.3) Did it for money 4 (1.4) 21 (10.1) Did it for fun 47 (16.5) 33 (15.9) Missing 29 19 Statistically significant results were obtained by analysing reasons for first sex by linearity (p < 0.001). The results show the following: of those forced to have sexual intercourse, 57% were from the patrilineal area (Ketu South) and 22.1% were respondents from Upper Denkyira (matrilineal) and 20.9% were from Offinso South (matrilineal). In addition, 50.2% of those from Ketu South engaged in first sexual intercourse either for fun or "trying to find how it feels" but in Upper Denkyira and Offinso South the percentages were 58.4% and 55.8% respectively. Of equal significance are those respondents who had first sexual experience because of monetary considerations: 16% were from the patrilineal area (Ketu South) and 48% from Upper Denkyira and 36% from Offinso South. A further look at within constituency reveals that of those who had sex in Ketu South, 1.8% did it the first time for money, 8.3% in Upper Denkyira and 7.0% in Offinso South. 199 5.9.2 Attitude Toward Premarital Sex In the population (n = 1415), almost equal proportions of respondents agreed that boys should not have sex before they get married (67%) and girls should not have sex before marriage (69%). When these responses were classified by sex, no significant differences were found between male and female respondents. There were no statistically significant differences between males and females as to whether boys and girls should have sex before marriage. In addition, no differences were observed between male and female respondents' answers to the question: "Sex before marriage is OK for males but not for females" (p = 0.121). On the other hand, significant differences were noted when the respondents were asked to identify other people's attitude or opinion by answering the question, "Most people of my age think it is O K to have sex before marriage." Analysis revealed that males were slightly more likely than females to disagree with the statement (36.1% versus 31.0%, p = 0.025). Respondents believed that one could still have fun in a relationship without having sex (58%) and just over a third (35%) thought having a sugar daddy or mommy is a good way to have nice things like clothes. There were no significant differences between males and female respondents on these two questions (p = 0.245 and p = 0.10 respectively). Attittude towards premarital sex was also explored in the context of patrilineal or matrilineal systems. No statistical significant differences were observed in the study areas regarding whether boys should have sex before marriage (p = 0.322) or girls should have sex before marriage (p = 0.149). 200 5.9.3 Attitudes and Beliefs about Sexual Relationships: Peer Norms Fifty-eight per cent of the respondents agreed that in a sexual relationship, most women are not faithful, that is, have other sexual partners. When the responses were analyzed by gender, there was a statistical significant difference across gender (p < 0.001) as 65% of the males agreed with the statement, 13% disagreed and 23% stated they could not tell. Of the females, 50% agreed, 23% disagreed and 28% stated they could not tell. When the analysis was restricted to only those who previously had sexual relationships, the results were similar: 70% agreed that women were not faithful in a relationship, 21% thought they were, and 9% indicated that they could not tell. However, when sub-group analysis by gender was done on those who previously had sexual intercourse, the results were statistically significant (76% of the males versus 61% of the females agreed, 15% males and 29% females disagreed, p <0.001). A subsequent question asked whether men were faithful in a relationship: 62% indicated that they were not, 14 % stated they were and 24% stated they could not tell. When the responses were analyzed by gender, no statistical significant differences were found (p = 0.122). When the analysis was restricted to only those who previously had sexual intercourse, the results were similar: 75% agreed that men were not faithful in a relationship, 16% thought they were faithful and 9% stated they could not tell. Similarly, when the subgroup analysis was done by sex and previously having sexual intercourse, there was no statistical significant difference as 72% of the males agreed with the statement and 18% disagreed, while 79% females agreed and 13% disagreed (p = 0.188). 201 5.9.4 Comparison Between Sexually Active Males and Females on Key Demographic Variables Table 5.22 shows the comparison between sexually active males and females on key demographic variables: location, age, constituency, and in-school or out-of-school status. From the table it can be noted that even though statistically insignificant, a higher proportion of sexually active females were in the younger age group than males. In addition, a lower proportion of sexually active females were in school compared to males. Table 5.22: Demographic Characteristics Between Sexually Active Males and Females CN = 539) Males Females P -value n(%) n(%) Location Rural 110(35.3) 83 (36.6) P = 0.755 Urban 202 (64.7) 144 (63.4) Education In school 122 (39.1) 77 (33.9) P = 0.218 Out of school 190 (60.9) 150 (66.1) Age 10-16 yrs 64 (20.5) 72 (31.7) P = 0.003 17-19 yrs 248 (79.5) 155 (68.3) Study Site Ketu South 127 (40.7) 100(44.1) P = 0.068 Upper Den 105 (33.7) 56 (24.7) Offinso South 80 (25.6) 71 (31.3) 5.9.5 Sexual Experience and Religious Affiliation A further analysis of those who never had sex, in relation to age of first sexual intercourse and religion, yielded results that demonstrated that religion has no bearing on when adolescents become sexually active or whether or not they engage in sexual intercourse (Table 5.23). It is noteworthy that the reasons some respondents outlined for 202 not getting involved in sexual activity were based on religious prohibitions regarding premarital sex. One respondent wrote: "Premarital sex is against biblical teachings." Another stated holding "religious considerations from biblical teachings...no adultery or fornication." Table 5.23: Never Had Sexual Intercourse and Age at First Sexual Intercourse by Religious Affiliation Religion Never had sex (n = 876) Age at first sexual intercourse (n = 539) Total (n= 1415) (%) 5-15 (%) 16-19 (%) Missing age (%) Atheist/no religion 24 (54.6) 11(25.0) 6 (13.6) 3 (6.8) 44 (100) Traditional 22 (55.0) 4(10.1) 11 (27.5) 3 (7.5) 40(100) Catholic 237 (63.7) 35 (9.4) 74 (19.9) 26 (7.0) 372 (100) Protestant 291 (65.2) 58(13.0) 70(15.7) 27(6.1) 446 (100) Apostolic 215 (58.9) 57(15.6) 67(18.4) 26 (7.1) 365 (100) Moslem 87 (58.8) 27(18.2) 24(16.2) 10(6.8) 148 (100) Total 876 (61.9) 192(13.6) 252 (17.8) 95 (6.7) 1415 (100) • Note: percentages are totaled across table within religion so as to compare trends in age of first sexual intercourse from one religion to another. 5.9.6 Analysis of the distribution of age-pattern and Ever having sex in the study areas As demonstrated in Table 5.24 (next page) the results reveal that the differences in the proportion of respondents who previously had sex can be attributed to differences in the age pattern. For two of the three electoral constituencies, the percentage of respondents in the 17-19 year age group is higher than the 10 -16 year age group. However, for all three electoral constituencies, the percentages of respondents who had ever had sex in the 17-19 year group are significantly higher (about twice) than the corresponding percentage for the 10-16 year group. For example, 64% of respondents in 203 KS belong to the 17 - 19 years age group and 76% of these respondents ever had sex, whereas only 48% of respondents in the 10-16 year group ever had sex. Similarly, in Offinso only 31% of respondents in the 10-16 year group ever had sex compared to 57% in the 17-19 year group. It is clear that sexual activity increases with age as can be noted in table 5.24 below. Table 5.24 Distribution of age-pattern and ever having sex in the study areas Age group 10-16 17-19 Electoral constituency KS 1 UD 2 OF 3 KS 1 UD2 OF 3 Number in age group 170 241 218 300 221 265 Percentage in age group 36% 52% 45% 64% 48% 55% Number ever had sex 82 82 68 226 161 150 Percentage ever had sex 48% 34% 31% 76% 73% 57% Legend: 1 (Ketu South); 2 (Upper Denkyira); 3 (Offinso South) 5.9.7 Concurrent sexual partners Of the 510 respondents who answered the question regarding the number of sexual partners in the previous year, 393 (77.1%) reported having only one sexual partner, 82 (15.2%) reported two to four partners, 20 (3.7%) stated five to seven partners, and 15 (2.8%) reported eight or more. There were no statistically significant differences between out-of-school and in-school adolescents. At the time of the survey more than one half (52.1%) of the sexually active boys had sex with more than one partner, compared to only one third of the girls. The mean number of lifetime sexual partners for males was 1.85 and for females 1.46 and significant at p < 0.001. 204 An analysis was done to determine whether linearity has any effect on having more sexual partners. Study participants from Upper Denkyira have more than one lifetime sexual partner (46%) compared to residents of Ketu South (26%) and Offinso South (36%). Table 5.25: Lifetime Sexual partners by constituency of residence Lifetime Sexual Partners (only females) Constituency N (%) 1 partner N (%) 2-4 partners N (%) 5 or higher Ketu South 74(74.0) 17(17.0) 9 (9.0) Upper Denkyira 27 (54.) 20 (40.0) 3 (6.0) Offinso South 41 (64.1) 17 (26.6) 6 (9.4) When lifetime sexual partners were compared with some key demographic variables, except for the in-school versus out-of-school variable, statistically significant results were obtained across all the categories: sex, as more males than females are likely to have more sexual partners (p < 0.001); location, as those in rural areas have more lifetime sexual partners than urban residents (p = 0.028); and study site (p = 0.009). Two questions sought to determine whether sexual partners knew their partners were having sexual relations with others. The question, "Are you the only sexual partner of your regular partner?' was asked to determine the attitude of the respondents regarding being in a relationship and being aware that a partner may have other sexual partners. Of the 426 respondents, 63.2% agreed they were certain that they were their lovers' only sexual partners, and 36.8% admitted they were aware that their regular sexual partners had other lovers. The reasons assigned by those who believe their partners were monogamous were as follows: trust, love, sincerity, reliability and faith in their partners. Those (36.8%) who admitted they were aware of their partners' unfaithfulness attributed a minimum of one to a maximum of five partners to their lovers. Reasons 205 given for this belief were that a partner could not be trusted, was not faithful, liked sex too much, liked people of the opposite sex too much, had been seen frequently with members of the opposite sex, was most often not at home when surprise visits were paid, partner, was beautiful so other men were bound to chase her, once slept with a friend when he was out of town, was reported by other people in town as having loose sexual behavior, was caught with other men/women, went out late in the night, and felt estranged in the relationship. When participants were asked to state the number of other sexual partners they knew or believed their lovers had in the past year, the following results were obtained, as shown in Table 5.26. It is also possible that these partners may not all be concurrent, but could have predated the relationship. Table 5.26: Mv Regular Sexual Partner Has Other Partners in the Past Year Boys Girls Total N (%) N (%) N (%) None 175 (71.7) 123 (67.6) 298 (70.0) 1 47(19.3) 37 (20.3) 84(19.7) 2 14(5.7) 13(7.1) 27 (6.3) 3-5 5 (2.0) 5 (2.7) 10 (2.3) >5 3(1.2) 4 (2.2) 7(1.6) 5.10 Predictors of Sexual Risk Taking The hypotheses were tested in two stages. The first stage examines the hypotheses in a series of independent univariate and bivariate analyses. The univariate analysis is restricted to only the number of sexual partners. The bivariate analyses encompass the scores that were derived from the operational definition of sexual risk taking as described 206 in Chapter 4. Those falling in the lower 25% and upper 25% were categorized as low and high sexual risk takers respectively. In the bivariate analyses, for example, in-school adolescents were hypothesized to be in the lower spectrum of sexual risk taking, compared to out-of school adolescents. In the second stage, the significant results from the bivariate stage were integrated into a multivariate model to determine predictors of sexual risk taking. As stated in Chapter 1, the following hypotheses were tested. 5.10.1 Stage 1: univariate/bivariate tests. (1) Before age 15, the proportion of males who will be sexually active will be higher than females. There was a statistically significant difference, as more males had an earlier age of first sexual intercourse than their female counterparts (24% versus 14.5%, p = 0.01). (2) More males will report having more sexual partners than will females. More males than females reported several sexual partners. The differences were statistically significant (1.85 versus 1.46, p < 0.001). (3) Rural residents would report more lifetime sexual partners than urban residents. The differences were significant at p = 0.05, as the mean number of lifetime sexual partners was 1.80 for rural residents and 1.62 for urban residents. (4) Out-of-school adolescents were likely to report more sexual partners than in-school adolescents. The differences were not significant at p = 0.218, as the mean number of lifetime sexual partners reported by out-of-school adolescents was 1.73 compared to 1.62 reported by the adolescents who are currently in school. (5) Those resident in Ketu South constituency (low prevalence) will have more sexual partners than those residing in Upper Denkyira (medium prevalence) and those 207 residing in Offinso (high prevalence area). Statistically significant differences were observed across the three study site, p = 0.009. When Ketu South was compared to Upper Denkyira, significant differences were observed. The mean lifetime sexual partners reported were 1.55 and 1.73 respectively yielding a p value of 0.002. When Ketu South was compared to Offinso South, the differences were not significant (1.73 versus 1.55, p = 0.078). Similarly, no statistically significant differences were observed between Upper Denkyira residents and Offinso South residents in the number of lifetime sexual partners reported (1.86 versus 1.73, p = 0.241). 5.10.2 Comparison Between Low and High Sexual Risk Takers To further test the other hypotheses, a comparison was made between those classified as high sexual risk takers and those considered low sexual risk takers. The classification was based on the bottom 25% scoring as low risk takers and the top 25% scoring as high-risk takers. Bivariate analysis was done between the two groups (N = 256) and the results obtained are shown in table 5.27 (pages 209-211), with corresponding p values where appropriate. 208 Table 5.27: Comparison Between Low and High Sexual Risk Takers on Key Variables Variable Low sexual High sexual p value Risk Taking Risk Taking n (%) [N=123] n (%) [N=133] Gender Male 73 (44.0) 93 (56.0) Female 50 (55.6) 40 (44.4) 0.077 Location Rural 42 (44.2) 53 (55.8) Urban 81 (50.3) 80 (49.7) 0.345 Constituency 49 (39.5) Ketu South 75 (60.5) Upper Denkyira 26 (35.1) 48 (64.9) 0.001 Offinso South 22 (37.9) 36(62.1) Current Age 0.085 10-16 23 (38.3) 37(61.7) 17-19 . 100 (51.0) 96 (49.0) Age at first sex < 0.001 <=15 38 (34.9) 71(65.1) >15 70 (58.8) 49 (41.2) Educational Status In school 44 (41.5) 62 (58.5) 0.078 Out of school 79 (52.7) 71 (47.3) Educational level No education 5 (50.5 5 (50.5) 0.100 Primary/makaranta 16 (55.2) 13 (44.8) JSS 58 (41.1) 83 (58.9) SSS 44 (57.9) 32 (42.1) Employment Status 92 (52.6) 0.771 In school/employed 83 (47.4) Out of sch/Unemployed 40 (49.4) 41 (50.6) Religious Affiliation 7 (58.3) Atheist/No religion 5(41.7) Traditional religion 5 (50.0) 5 (50.0) Catholic 40 (59.7) 27 (40.3) Protestant 26 (42.6) 35 (57.4) 0.344 Apostolic 34 (46.6) 39 (53.4) Moslem 13 (39.4.) 20 (60.6) Paternal education No education 26 (45.6) 31 (54.4) Primary 8 (53.3) 7 (46.7) 0.793 Middle school 43 (44.3) 54 (55.7) Sec/Trg/Nurses/Tech 26 (52.0) 24 (48.0) Poly/Univ/Grad 20 (54.1) 17 (45.9) Maternal Education No education 52(51.5) 49 (48.5) Primary 10 (30.3) 23 (69.7) 0.180 Middle school 34 (46.6) 39 (53.4) Sec/Trg/Nurses/Tech 21 (52.5) 19 (47.5) Polytech/Univ/Grad 6 (66.7) 3 (33.3) 209 Table 5.27: Comparison Between Low and High Sexual Risk Takers on Kev Variables (continued from page 209) Variable Least sexual High sexual p value Risk Taking Risk Taking n (%) [N=123] n (%) [N=133] Maternal Occupation Housewife 9 (52.9) 8 (47.1) Non Professional 103 (47.9) 112(52.1) 0.899 Professional 11 (45.8) 13 (54.2) Paternal Occupation 9 (69.2) Unemployed/Deceased 4(30.8) 0.417 Non professional 83 (49.7) 84 (50.3) Professional 36 (47.4) 40 (52.6) Living arrangements 46 (54.8) Mother only 38 (45.2) Father only 8 (40.0) 12 (60.0) Both father & mother 51 (51.5) 48 (48.5) 0.744 Other relatives 24 (51.1) 23 (48.9) Non relatives 2(33.3) 4 (66.7) Self perceived health status 65 (48.1) Very healthy 70 (51.9) Healthy 29 (43.9) 37 (56.1) Fairly healthy 13 (38.2) 21 (61.8) 0.534 Not healthy 6 (60.0) 4 (40.0) Don't know 5 (45.5) 6 (54.5) Heard somebody can cure AIDS Yes 19 (36.5) 33 (63.5) 0.063 No 104 (51.0) 100 (49.0) Know somebody can cure AIDS Yes 9 (22.5) 31 (77.5) <0.001 No 114(52.8) 102 (47.2) Fate Decides who gets HIV Yes 31 (39.2) 48 (60.8) No 92 (52.0) 85 (48.0) 0.60 HIV and witchcraft Yes 44 (44.9) 54 (55.1) 0.034 No 79 (50.0) 79 (50.0) Belief in efficacy of condoms Yes 79 (45.9) 93 (54.1) 0.331 No 41 (52.6) 37 (47.4) Relative, friend or colleague has AIDS Yes 7 (23.3) 23 (76.7) 0.004 No 116(51.3) 110 (48.7) Fear of AIDS has greatly changed sexual behaviour in this area Agree 80 (53.3) 70 (46.7) 0.044 Disagree 43 (40.6) 63 (59.4) Preventive measure taken to avoid HIV Yes 74 (46.0) 87 (54.0) 0.385 No 49 (51.6) 46 (48.4) 210 Table 5.27: Comparison Between Low and High Sexual Risk Takers on Key Variables (continued from page 210) Variable Low sexual High sexual p value Risk Taking Risk Taking n (%) [N=123] n (%) [N=133] Talk about HIV with sexual partner Frequently 46 (48.9) 48 (51.1) 0.069 Rarely 24 (49.0) 25 (51.0) Not at all 26 (46.9) 53 (53.1) Talk about HIV with friends and acquaintances Frequently 59(54.1) 50 (45.9) 0.152 Rarely 33 (47.8) 36 (52.2) Not at all 31 (39.7) 47 (60.3) Talk about HIV with family members Often 64 (52.0) 59 (48.0) Once in a while 32 (57.1) 24 (42.9) 0.020 Not at all 27 (35.1) 50 (64.9) HIV knowledge score 0.006 Low 18 (36.7) 31 (63.3) Medium 67 (45.0) 82 (55.0) High 38 (65.5) 20 (34.5) Attitude towards condom scale Negative attitude 42 (50.6) 41 (49.4) 0.771 Neutral 45 (48.4) 48 (51.6) Positive 36 (45.0) 44 (55.0) Perceived risk of infection (in a month) Sure 24 (28.9) 59(71.1) Not sure 37 (48.1) 40 (51.9) <0.001 Will never catch HTV 58 (65.2) 31 (34.8) Perceived risk of infection (in a year) Very Sure 24 (27.0) 65 (73.0) Not sure 37 (47.4) 41 (52.6) <0.001 Will never catch HTV 60 (70.6) 25 (29.4) Ever heard of syphilis Yes 66 (48.2) 71 (51.8) 0.847 No 54 (47.0) 61 (53.0) Reasons for first sex Friends convinced me 22 (50.0) 22 (50.0) Find out how it feels 45 (40.4) 68 (59.6) Was forced to do it 21 (55.3) 17 (44.7) 0.116 Did it for money 4 (36.4) 7(63.6) Did it for fun 26 (61.9) 16(38.1) 211 5.10.3 Stage 2: Multivariate Analysis in Detennining Predictors of Sexual Risk Taking The variables that were found to be significant in the bivariate analysis (table 5.27) and the natural groupings as described in chapter 4 at p = 0.05 or lower were examined to deterrnine the predictors of sexual-risk taking in a population of 256 adolescents. These variables were entered into a final multivariate model, while controlling for likely confounders such as sex, age, constituency, educational status, and location. The results of the final model are shown in table 5.28. Due to missing data the final model had only 223 adolescents. Table 5.28: Predictors of Sexual Risk Taking Among 223 Adolescents in Ghana Variable Gender Male (reference) Female Coefficient -0.854 S.E. 0.436 p- value * 0.040 OR (95% CJ) 1.00 0.41 (0.17-0.96) Age 10-16 (reference) 17-19 -0.231 0.482 0.632 1.00 0.79(0.31-2.04) Location Rural (reference) Urban -0.483 0.399 0.226 1.00 0.62 (0.28 - 1.35) Constituency Ketu South (reference) Upper Denkyira Offinso South 1.639 1.474 0.516 0.528 0.003 0.001 0.005 1.00 5.15 (1.87-14.15) 4.37 (1.55 - 12.29) Educational Status In school (reference) Out of school -0.647 0.458 0.157 0.157 1.00 0.52 (0.21 - 1.28) Age of first sexual intercourse < = 15 (reference) 15 and higher -1.302 0.410 0.001 1.00 0.27(0.12-0.61) Relative or friend has AIDS Yes (reference) No -1.045 0.647 0.025 1.00 0.23 (0.07 - 0.83) Know somebody can cure AIDS Yes (reference) No -0.2.614 0.690 < 0.001 1.00 0.07 (0.02 - 0.28) 212 Table 5.28: Predictors of Sexual Risk Taking Among 223 Adolescents in Ghana (continued from page 212) Variable Perceived risk of contracting HIV in the next 30 days Coefficient S.E. p-value 0.823 OR (95% CI) Very Likely (reference) Not Likely Will never catch fflV -0.125 0.399 0.709 0.971 0.860 0.681 1.00 0.88 (0.22 - 3.54) 1.49 (0.22 - 10.00) Perceived risk of contracting HIV in the next year 0.018 Very Likely (reference) Not Likely Will never catch HIV -1.427 -2.677 0.687 0.970 0.038 0.006 1.00 0.24(0.06-0.92) 0.07(0.01-0.46) Talk about HIV with family Often (reference) Once in a while Not at all 0.554 1.514 0.517 0.479 0.007 0.284 0.002 1.00 1.74(0.63-4.79) 4.54(1.78- 11.61) HIV and witchcraft Yes (reference) No 0.431 0.436 0.324 1.00 1.54(0.65-3.62) Fear of AIDS has greatly changed sexual behaviour in this area 0.927 Agree (reference) Disagree 0.038 0.415 1.00 1.34(0.46-2.35) HIV knowledge score Low (reference) Medium High -0.156 -0.278 0.542 1.453 0.906 0.774 0.658 1.00 0.86 (0.30 - 2.48) 0.76 (0.22 - 2.60) Self Efficacy Score -0.081 0.077 0.291 0.92 (0.79 - 1.07) Constant 6.067 1.453 0.000 * p values based on Wald's test 213 Statistically significant differences were observed for constituency (p = 0.003), sex (p = 0.040), age of first sexual intercourse (p = 0.001), having a relative, a friend, or an acquaintance who has ADDS (p = 0.025), thinking somebody can cure AIDS (p < 0.001), self-perceived risk of contracting HIV in the next year (p = 0.018), and having discussed HIV with family (p = 0.007). Girls were 59% less likely to engage in sexual risk-taking behavior compared to boys (p = 0.040, OR = 0.41, 95%, CI = 0.17 - 0.96). Residents of Upper Denkyira were five times more likely to engage in sexual risk taking, compared to their counterparts in Ketu South (p = 0.001, OR = 5.15, 95%, CI = 1.874 - 14.146), while residents Offinso South were four times more likely to engage in sexual risk taking behavior than their Ketu South counterparts (p = 0.005, OR = 4.37, 95%, CI = 1.550 - 12.293). Participants who had sexual intercourse after age 15 are 73% less likely to be sexual risk takers, compared to those whose age of sexual initiation was 15 or less (p = 0.001, OR = 0.27, 95%, CI = 0.12 - 0.61). Those who did not have a relative, a friend or an acquaintance infected with AIDS were 74% less likely to be sexual risk takers, compared to those who knew their relatives or friends or acquaintance had AIDS (p = 0.025, OR = 0.23, 95%, CI = 0.07 - 0.83). Participants who acknowledged that they did not know of anyone who could cure AIDS were 27% less likely to be sexual risk takers, compared to those who stated they knew somebody who could cure ADDS (p < 0.001, OR = 0.07, 95%, CI = 0.02 - 0.283). Self-perceived risk of contracting HIV in the next year attained statistical significance (p = 0.018). Respondents who stated they were not likely to contract HIV were 76% less likely to engage in high-risk behavior, compared to those who indicated 214 otherwise (p = 0.038, OR = 0.24, 95%, CI = 0.06 - 0.92). However, those who indicated that they will never catch HIV were 93% less likely to be risk takers than those who perceived they were "very likely" to contract HIV (p = 0.006, OR = 0.07, 95%, CI = 0.010-0.46). Communication about AIDS with family members attained statistical significance in the model (p = 0.007). Participants who indicated that they only discussed HIV/ADDS once in a while with their family members were almost twice as likely to be sexual risk takers, compared to those who often talk to their family about AIDS, (p = 0.284, OR = 1.74, 95%, CI = 0.63 - 4.79). Similarly, those who have never discussed AIDS with their family members were almost five times as likely to be sexual risk takers, compared to those who discuss AIDS often with their family members (p = 0.002, OR = 4.54, 95%, CI = 1.78 -11.61). Educational status, age, location, perceived risk of contracting HIV in the next 30 days, belief that one can contract HIV through witchcraft, belief that the fear of AIDS has greatly changed sexual behavior in the area of research, self-efficacy score, and ADDS knowledge score were not statistically significant in the final model. 5.10.4 Summary of Findings Tables 5.29 to 5.31 (pages 216-217) report the summary findings of the three topics covered in this study (predictors of AIDS knowledge, condom use and sexual risk taking). 215 Table 5.29: Predictors of fflV Knowledge Variable Odds Ratio (95% CI) Sex Female vs Male 0.53 (0.33-0.83) Age 17-19 vs 10-16 1.90(1.16-3.11) Education Primary/makarata vs No education JSS vs No education SSSvs No education 2.72 (0.49 - 15.07) 6.17 (1.22-31.11) 10.43 (1.97-55.47) Can get AIDS through witchcraft No vs Yes 1.85 (1.09-3.17) AIDS is a problem in Ghana No vs Yes 0.25 (0.13-0.46) Ever had sexual intercourse No vs Yes 0.56 (0.34 - 0.92) Ever heard of syphilis No vs Yes 0.44 (0.28-0.68) Know anybody can cure AIDS No vs Yes 3.35 (1.66-6.75) Talk about HIV to friends and acquaintances Rarely vs Frequently Not at all vs Frequently 0.82 (0.45 - 1.47) 0.40(0.21-0.76) Can avoid HIV No vs Yes 0.33 (0.19-0.57) 216 Table 5:30: Predictors of Condom Use Variable OR (95% CI) Educational Status Out of school vs In school 3.15(1.55-6.41) Talk about AIDS with regular sexual partner Rarely vs Frequently Not at all vs Frequently 1.25 (0.69-2.27) 0.44 (0.26 - 0.75) Talk about AIDS with friends etc Rarely vs Frequentiy Not at all vs Frequently 2.21 (1.31-3.73) 2.20(1.25-3.85) Reliance on efficacy of condoms No vs Yes 0.55 (0.34-0.91) Attitude toward condoms Neutral vs Negative Positive vs Negative 0.47 (0.28 - 0.77) 0.49(0.29-0.83) Self efficacy score 1.25 (1.14- 1.38) Table 5.31: Predictors of Sexual Risk Taking Variable OR (95% CI) Sex Female vs. Male 0.41 (0.17-0.96) Constituency Upper Denkyira vs. Ketu South Offinso South vs Ketu South 5.15 (1.87-14.14) 4.37(1.55- 12.23) Age of first sexual intercourse 16 and higher vs < = 15 years 0.27(0.12-0.61) Relative or friend has AIDS No vs Yes 0.23 (0.06-0.83) Know somebody can cure AIDS No vs Yes 0.07 (0.02 - 0.28) Perceived risk of contracting HIV in next year Not likely vs. Very Likely Will never catch AIDS vs. Very Likely 0.24 (0.06 - 0.92) 0.07(0.01-0.46) Talk about HIV with family Once in a while vs. Often Not at all vs Often 1.74(0.632-4.793) 4.54(1.778- 11.610) 217 CHAPTER 6 Discussion In this chapter, we revisit the overview and purpose of the study, discuss the major research findings and compare them to the research conducted in the adolescent populations, in general, and in sub-Saharan Africa in particular. Then, we discuss the A R R M variables of interest examined in the study. The major findings from the three models (ADDS knowledge, condom use as a behavioral change, and sexual risk taking) are explored within the context of other studies conducted in sub-Saharan Africa and elsewhere. Finally, we explore the implications of the findings with respect to ADDS prevention and education and discuss the limitations of the research work. The chapter concludes with what this study can teach us and suggests future areas of research. The purpose of the study was to identify the determinants of sexual risk taking in the face of HIV/AIDS in a population of in-school and out-of-school adolescents from three electoral constituencies in Ghana. The population consists of adolescents, age 10 to 19, who reside in the Ketu South (Volta region), Upper Denkyira (Central region), and Offinso South (Ashanti region) constituencies. The secondary objectives of the study were to identify factors that might influence the adoption of safe sexual behavior (that is, condom use and a reduction in the number of sexual partners), to describe the level of knowledge (e.g. transmission, susceptibility) of ADDS and other STDs in this adolescent population and to examine how prevailing beliefs (perceptions and misperceptions), practice systems, and attitude relate to sexual risk taking in the face of HIV/ADDS. The study has several strengths. First, because the sample was large and representative, sub-group analyses could be performed without losing power and hence, 218 allowed the identification of pertinent issues relating to each sub-group. Second, the A R R M framework, that was specifically designed for ADDS risk reduction, as well as other supplementary variables derived from the literature and exploratory interviews were used to identify predictors of behavior change (e.g. condom use) and sexual risk-taking behavior. The study also sought to identify the predictors of high-risk sexual behavior. Third, as a result of random sampling and the inclusion of all adolescents, regardless of whether they were in school or not, we should be able to generalize the results to almost all adolescents in Ghana. In spite of these strengths, the study has limitations that are discussed at the end of this chapter. It is also important to note some of the implications arising from the approach adopted in sampling. In the in-school adolescents, sampling at each grade level was based on the proportion of students at that grade level among the total school enrolment. Since boys are over-represented in school, this sampling method has implications for gender balance in the eventual study population. As a result, a substantial gender imbalance was observed in the in-school adolescents (60% boys versus 40% girls), while in the out-of-school group, the difference was not significant (52% boys and 48% girls). Thus, it is essential to take this imbalance into consideration when interpreting the results of the univariate and bivariate analyses relating to gender comparisons. 6.1 AIDS Knowledge. Behavioral Risk Reduction and Sexual Risk Taking The discussion of the research findings is divided into three related sections covering AIDS knowledge, behavioral risk reduction in the form of condom use, and sexual risk taking. 219 With regard to AIDS knowledge, statistically significant differences in knowledge were seen across gender, age, believing that one can get ADDS through witchcraft, believing that AIDS is a problem in Ghana, previously having sexual intercourse, having previously heard about syphilis, thinking that someone can cure AIDS, having discussed AIDS with a relative, friend or acquaintance, and having taken steps to avoid HIV. Significant predictors for condom use were being out of school, high self-efficacy, having discussed AIDS with relatives, friends or acquaintances, having discussed AIDS with a regular sexual partner, attitude towards condoms, and reliance on the efficacy of condoms to protect against STDs, including ADDS. Predictors of sexual risk taking were gender, constituency, age of first sexual intercourse, having a relative, friend or acquaintance who has ADDS, thinking that someone can cure ADDS, self-perceived risk of contracting HIV in the next year, and having discussed HIV with family. As already discussed, since its development by Catania et al. (1990), the A R R M been used in studies to examine behavioral change in some sub-populations (Kayemba, Lusamba & Bertrand, 1996; Bowen & Trotter, 1995; Dolcini & Coates et al. 1995; Blecher et al., 1995; McGrath et al., 1993; Bertrand et al., 1992; Boyer & Kegeles, 1991). In this study, the A R R M was used as a framework to examine behavioral change with regard to condom use in out-of-school and in-school adolescents, between age 10 and 19 in Ghana. The A R R M variables hypothesized to be associated with behavior change were examined: knowledge about high risk behavior and routes of transmission, belief in the incurability of ADDS, self-efficacy, peer norms in support of behavior change, perception and source of risk, sexual communication variables (communication about 220 sex/AIDS which measures the capacity of participants to talk to parents, peers, partners about sex and HIV infection), attitude towards and use of condoms, and having known someone with AIDS, knowledge of safer sex guidelines or sexual behaviors that transmit HIV, having concurrent sexual partners, belief in one's personal susceptibility to HIV, believing that AIDS is undesirable, perceived barriers to condom use, and the perceived efficacy of condoms in preventing the transmission of AIDS. 6.1.1 AIDS Knowledge The adolescents sampled in this population had a high awareness of ADDS and of some STDs, notably gonorrhoea and syphilis. Although 10% of the participants had not heard about AIDS, the findings suggest there is adequate knowledge of HIV in this population. As many as 80.4% mentioned sexual intercourse, and 86.4% identified the use of unsterilized needles as modes of transmission. In addition, two out of every three were able to correctly identify other non-sexual modes of transmission, such as mother-to-child transmission. This was unlike similar studies where there were deficiencies in knowledge of modes of transmission other than sexual intercourse (Kapiga et al., 1991; Maticka-Tyndale, 1994). There were, however, other definite gaps in knowledge: Misconceptions about infection through casual contact were common. Unfortunately, these knowledge gaps are consistent with other HIV studies carried on in other parts of the world. Lack of knowledge about STDs was also reported by Liao et al. (1997) in a study conducted in China, where about 25% of the respondents reported that they had heard about STDs, but believed that sharing food utensils (48%) and bath towels (22%) put them at risk of catching an infection. Such misperceptions were also noted by 221 Maticka-Tyndale et al. (1994), DiClemente et al. (1991), Goodman et al. (1989), and Hingson, Strunin & Berlin (1990). In these studies, people believe STDs could be contracted from saliva, toilet seats, donating blood and sharing kitchen utensils. Moreover, in our study, two out of every three participants believed that PWAs should be quarantined and that the government should not spend money to provide health care for them, since they would die anyway. This proportion was far greater than the 29.8% Patullo et al. (1994) observed in a study conducted among Kenyan secondary school students. Fifteen years into the epidemic in Ghana, it is surprising to have such gaps in knowledge. In addition, a statistically significant result confirmed an association between scoring high on believing that HIV can be contracted through casual contact and having a negative attitude towards PWAs. These misperceptions (e.g. contracting AIDS through casual contact) may explain the negative attitude in this population towards PWAs. In this study, the participants were also of the view that some PWAs, and especially commercial sex workers who contracted HIV, were either deliberately or inadvertently infecting the general population. These negative attitudes towards PWAs were not surprising, as they were consistent with responses to the questions in the knowledge section, where respondents incorrectly indicated that one could contract ADDS through casual contact (Kapiga et al., 1995; Nyachuru-Sihlangu & Ndlovu, 1992; Walrond et al, 1992; Goodman & Cohall, 1989). It seems reasonable to assume that these misperceptions are in part responsible for the negative attitude towards PWAs, especially since respondents were of the view that they should be quarantined. This is consistent with observations by Asindi, Ibia, & Young (1992) about adolescent 222 respondents in Nigeria who stated that they would stop seeing friends and would reject relatives who develop AIDS. Furthermore, it is likely that today's Ghanaian adolescents may not come into contact with their peers who are dying from ADDS. This is due to the fact that children infected from their mothers hardly ever live to adolescence, while the adolescents who are infected get into adulthood before ADDS manifest itself clinically. Hence there is the mistaken belief in the adolescent population that they are not vulnerable to HIV infection. Because ADDS in Ghana is associated with women who have been to Abidjan, the capital of Ivory Coast, where they engaged in commercial sex, it may be that the sexually active adolescents discount their own risk, because they do not identify themselves with the stereotype they hold of people who contract AIDS. This finding parallels the North American image of AIDS, formed in the early part of the epidemic in the U.S., as a disease primarily associated with gay males or intravenous drug users. Apart from gaps in knowledge, there were two questions to distinguish between the HIV and AIDS. Whereas 90% of the participants have heard of AIDS, only 62.3% had heard of HIV, thus indicating subjects inability to distinguish between the two. This may explain why in the Offinso South constituency, some participants denied the existence of ADDS, since according to them, some people in town were rumored to have contracted ADDS some years ago, but were still alive and looking healthy at the time of the study. Although prior studies have tested ADDS knowledge, almost all were descriptive in nature. In this study, multivariate techniques were used to determine predictors for ADDS knowledge. Predictors of high knowledge were being male, being an older 223 adolescent (17 and above), not believing that one can get AIDS through witchcraft, believing that ADDS is a problem in Ghana, having previously had sexual intercourse, having previously heard about syphilis, knowing that nobody can cure ADDS, having discussed ADDS frequently with a relative, friend or acquaintance, and having taken steps to avoid HIV. The differences between males and females regarding ADDS knowledge may possibly be explained by the fact that boys are more likely to be sexually active than girls. In Ghanaian culture, some people believe that not all sicknesses are disease-related. It is not surprising that believing witchcraft can cause ADDS was statistically significant in the model. Belief in the supernatural and predestination permeates Ghanaian society. It is common to ascribe ailments to witchcraft, voodoo and other supernatural sources. The people of Ghana, like other Africans, believe that some diseases occur through supernatural means (through a sorcerer, a witch, or a medicine man) and that STDs are supernaturally inflicted as punishment, for such offenses as sleeping with someone else's spouse, for example. This may explain why 53.1% of the respondents indicated that a person can get infected with HIV by witchcraft. Finding that such a high percentage of people attributes HIV/ADDS to the supernatural may underlie the fact that, unlike elsewhere in Africa, ADDS has not hit the general population. Such ideas about transmission were noted by Caprara et al. (1993) in the early days of the epidemic among the Bete and Baoule of Ivory Coast. Patullo et al. (1994) also reported similar findings in their study of Kenyan secondary school students. 224 It is possible that certain adolescents in this population have low incentive to engage in risk reduction, since 22.8% of the participants thought ADDS could be cured by spiritualists of the Christian or Islamic faiths or by herbalists. This finding remained significant in the model. The misinformation put forward by the mushrooming spiritual churches and charlatans in Ghana about their ability to cure AIDS may explain the source of this erroneous notion. In Ghana, it is not uncommon to read about such false claims in the media (appendix 8) or see them printed on billboards proclaiming cures for AIDS and other ailments. The purpose of these charlatans, of course, is to extort money from already desperate people, who are willing to try any therapy. 6.1.2 Condom Use It has been demonstrated that increased knowledge about AIDS is not a predictor for behavioral change (Keller et al., 1991; Hingson, Strumin, Berlin & Heren, 1990; DiClemente et al., 1991), although knowledge about the disease is a prerequisite for change. In this study, we found that participants acknowledged the existence of AIDS, had high transmission knowledge, had a very high perception of the morbidity of HIV/AIDS as problematic, and outlined numerous reasons why they thought so. Yet, although they labelled their behavior as risky, this knowledge and recognition did not translate into actions towards prevention, such as condom use. Thus, using the A R R M to examine the data, it is obvious that there are many barriers to risk reduction. These include attitude towards monogamy, attitude towards condoms, and perceived norms that dictate that condoms should only be used when engaging in sex with strangers and commercial sex workers. For example, 94.4% of the sexually active respondents have 225 heard of condoms, but only 41.4% have ever used them. These results are consistent with findings by other researchers, corroborating the fact that adequate levels of HIV knowledge regarding transmission does not necessarily lead to changes in behavior (Mallow & Ireland, 1996; Becker and Joseph, 1988). Even when condoms were used in this population, the concern was for pregnancy prevention rather than ATDS/STD prevention. According to the ARRM, committing to change one's risky behavior requires the individual to believe that there are benefits in the alternative behaviors. In this study, we found that even though 78% of this population believe in the efficacy of condoms in preventing HIV transmission, 49% think that condoms affect sexual enjoyment, and hence, do not use them because they see condom use as not beneficial. It is interesting to note that people with negative attitude towards condoms are more likely to report using them than those with neutral or positive attitudes. Some reasons may account for this. It is possible that respondents with negative attitude may have used condoms and did not like them. Or they consider condom use important despite their negative attitude (e.g. sex doesn't feel good when you use a condom or it is embarrassing to buy a condom in a shop etc). Let us note that the question that classified condom users versus non-users was simply "Have you ever used condoms?" with the elicited response of a "Yes" or a "No". It is therefore likely that those with a negative attitude used condoms only once and do not use them any longer but they still are classified as having used condoms. Furthermore, the results indicate that there are no structural constraints, such as money or availability, affecting the use condoms. Rather, the greater satisfaction 226 expected from sex without condoms was the driving force. This is consistent with DiClemente's (1991) and Kapiga et al. (1995), stating that individuals resist using condoms, because they perceive them negatively as causing a reduction in sexual pleasure or embarrassment when used. A statistically significant difference was obtained between participants who indicated that since hearing about ADDS they had taken preventive measures and those who did not. This may partly be explained by the fact that the measures taken may include the use of condoms. Our results show that sex without a condom with a regular partner is considered "risk free," since the partners believe they know each other. Thus with "known" partners, adolescents prefer "natural" or "raw," unprotected sex. Epidemiologists equate this type of sex with risky behavior, especially in non-mutually monogamous relationships. Amazingly, 76% of the boys and 61% of the girls who previously had sex gave a positive response to the question, which read "in a relationship most men or women are not faithful." It is difficult to reconcile the participants' total distrust of men and women with their refusal to wear condoms with a regular partner simply because they know each other. It is noteworthy that the attitude that condoms should be used only when having sex with casual partners, "loose" women, prostitutes, or women who are not well groomed permeates the cultural environment. These sexual partners were considered "risky", and hence, the requirement for self-protection. In spite of this norm, the study found that a significant number of those who had sex outside of their supposedly monogamous relationships did not use condoms during sexual intercourse with their casual partners. 227 Although overall condom use was very low in the sexually active population it is encouraging to observe, in the bivariate analysis, that there is increasing condom use for those who have had more sexual partners in two referenced periods preceding the study: within the previous 30 days and within the previous six months. This is because having more sexual partners without the use of condom may expose the individual to HIV infection. Furthermore it was observed in the bivariate analysis that people who stated that they talk rarely with their sexual partners and acquaintance and people who talk once in a while with family members about HIV/ADDS appear to use condoms more. Given the prevalence of HIV in sub-Saharan Africa and high exposure to the media, respondents might have talked about aspects of HIV, without necessarily discussing prevention. Discussions may possibly involve misperceptions, or relate to who has HIV, or address the effects of HIV on Ghana's population, without necessarily focusing on effective prevention through condom use. Even if respondents talked about prevention, this result then shows that discussion about prevention does not necessarily translate into condom use. It is also pertinent to examine the link between the use of condom (for protection against STD) and the desire to achieve fertility intentions. As stated earlier, majority of those who used condoms use it as for pregnancy prevention. In Ghana the total fertility since 1979/80 is as follows: 7.1 (1979/80); 6.4(1988 GDHS); 5.6 (1993); and 4.6(1998). Ghanaian demographers are not really certain as to why the decline but there is the suspicion of increase in the incidence of abortion. 228 6.1.3 Analysis from Multivariate Models (ARRM and condom use) In our multivariate analysis, after controlling for potential confounders including age, location, gender, educational status, and area of residence, the only A R R M variables predicting condoms use as a behavioral change in this population were self-efficacy, and sexual communication skills. In the Kigali study, which used the A R R M as a framework, the variables associated with behavioral change were: Knowing somebody with ADDS, having discussed ADDS with a male partner, and not believing that condoms were dangerous. In our work, however, only two A R R M variables proved significant in the bivariate analyses, but lost their significance in the multivariate model: ADDS knowledge score and talking about HIV with friends and acquaintances. All the other A R R M variables were not significant in the bivariate analyses when comparisons were done between having previously used condoms and having never used condoms. Other non-A R R M variables associated with condom use in the bivariate and univariate analyses that were tested in the logistic regression, but found not to be independent predictors, included age, employment status, number of sexual partners in the past 30 days preceding the survey, and having taken preventive measures to avoid HIV transmission or infection. Although gender was not a significant predictor of condom use in the final model, it was noted in this study that the proportion of females reporting their sexual partners ever using condoms was 40.8%, compared to 59.2% of sexually active women whose partners never used a condom. A similar observation was made among males, with 44.7% reporting condom use, compared to 55.3% never using condoms. This finding is consistent with other studies done in sub-Saharan Africa, whether or not they were conducted with adolescents or adults (Allen et al., 1993; Lindan et al., 1991; Carael et al., 229 1991; Goldberg et al., 1989; Konde-Lilule & Berkley, 1989). In a study with adults, the researchers noted that the female respondents were not using condoms, because men did not like them (Kapiga et al., 1995; Ismail, 1995), thus suggesting that men's negative attitude about condoms was a major barrier to increasing the acceptability of condoms among these women. Researchers postulated that the effectiveness of any program promoting condom use depends on its acceptance by male partners (Stein, 1990), which is supported by a Rwanda study, done in Kigali, that found condom use significantly increased when women were counseled together with their husbands (Allen et al., 1992). In our study of Ghanaian adolescents, however, the findings suggest that men may not be the only ones to hold negative attitudes towards condoms. It was found that 57.4% of the males and 42.6% of the females who are sexually active agreed that sex does not feel good with a condom. Thus, sex was not enjoyable to these women when their partners used a condom. It has been reported in previous studies that women are disadvantaged in negotiating safe sex, because of gender inequity and economic imbalance (Mason, 1994; Gomez, 1993; Kapiga, Lwihula, Shao & Hunter, 1991; and Bledsoe, 1990) or that the men may interpret a female request to use a condom as insulting and mistrustful (Larson, 1989). The findings of this study, however, point out that perceived lowered sexual enjoyment by both parties was the driving force behind lack of condom use. 6.2.1 Condom Use — Sexual Communication It is of great interest that sexual communication skills remained a significant variable in the model after controlling for potential confounders. This finding is underscored because, according to Catania et al.'s A R R M (1990), enacting solutions with 230 respect to sexual risk reduction is complicated by the social nature of sexual behavior and the need to obtain the cooperation of another person. Thus, it is imperative to communicate openly and effectively about sexual issues (Catania et al., 1990; Worth, 1990). Individuals may correctly label their behaviors as being problematic, make a genuine commitment to change, yet not achieve desired solutions, if they are unable to obtain their partner's cooperation through effective communication and persuasion (Kline & VanLandingham, 1994). Thus, communicating effectively with sexual partners is a major step in risk reduction. Kline and VanLandingham (1994) further contended that the effectiveness of sexual communication might be related to a large extent to the quality of the relationship between sexual partners. Women in stable, supportive relationships are likely to experience a greater ease of communication about sexual issues than women in relationships characterized by instability and conflict. Although this may be true in the Ghanaian context, additional barriers in communication may have to do with cultural norms, where matters of sexuality are hardly discussed between parents and children. Participants may have transferred this attitude into their own relationships with their partners. It is encouraging to note that in this study, those who discussed AIDS with their regular partners were more likely to use condoms, compared with their counterparts who did not. It is also interesting to note that those who indicated they rarely discussed AIDS with their sexual partners were more likely to use condoms than their counterparts who frequently had such discussions. We may speculate that this group of adolescents may not be in regular relationships, but have sex with casual partners or commercial sex workers, and hence use condoms without discussing AIDS. 231 6.2.2 Boarding School Effect In the bivariate analysis, a statistically significant result was obtained relating to condom use between sexually active participants who were in school or employed and those who were out of school or unemployed. This variable, however, did not attain significant level in the final model. It is likely that there is a co-linearity between this variable and the variable, in-school versus out-of-school, which however remained significant in the model predicting condom use. One surprising finding is that out-of-school adolescents were more likely to use condoms than in-school adolescents, even after controlling for confounders. This statistically significant difference in the use of condoms may be attributable to the apparent protection offered to adolescents in school. It is likely that those in school are in a sheltered environment, whereas their counterparts who are not in school are almost adults, who are taking care of themselves and have street smarts. It is also noteworthy that some of the schools surveyed were boarding schools: It is likely that there is no access to condoms on campus, unless a student brings them in when coming to school. In such a case, the student risks parents discovering condoms in his school luggage. Moreover, for fear of being discovered and reported to their parents, students in school cannot access the few family planning services available, where condoms can be obtained at very reduced rates. 6.2.3 Level of Education Our study found that the length of time respondents were in school negatively affected condom use, even after adjusting for age, gender, location and constituency. 232 Those who have never been to school were more likely to use condoms than their counterparts who have been to school, and the longer they stayed in school, the less likely they were to use condoms. This finding is very significant and confirms that knowledge per se does not lead to changed behavior. Since talking about AIDS with friends was a predictor of condom use in the model, it is obvious adolescents learn from their friends. This fact may warrant "appropriate" school-based interventions as a start. The advantage here is that schools deliver a captive audience. Unfortunately, universal schooling for adolescents is not a reality in developing countries, as it is in western societies. For example, in Ghana, although the government touts Free Compulsory Universal Basic Education (FCUBE), only 57% of the school-age children are actually in school. In the school environment, the students represent a captive audience that could receive vigorous STDs and ADDS education. At present, in the Ghanaian setting, there is limited ADDS education in the curriculum. It forms a component of sex education, but deals only with medical and biological facts. Abstinence is stressed, rather than a thorough provision of information on all the available options. This may explain why 30.3% of the in-school adolescents and 26.6% out-of-school adolescents have never seen a condom. Interviews with schoolteachers revealed that there were no avenues for teaching and counseling students on relationships and matters of sexuality. Such teaching could equip in-school adolescents with skills to negotiate safe sex or ward off unwanted sexual advances. Yet nothing is taught, except what is in the curriculum. Occasionally, some headmasters may advise the students about sexual behavior in the students' general assembly. In some schools, outsiders like health officials sometimes visit to give lectures on ITIV/AIDS. Unfortunately, this approach has not been consistent in all the schools visited. All 233 teachers interviewed for this study were of the opinion that sex education should form part of the curriculum, to teach students issues regarding sex. Since Ghanaian culture frowns upon discussions of sexuality, schools should fill the gap. Because of the lack of reproductive health services in Ghana, adolescents get most of their education from their peers in the street (informal environment). Even the limited AIDS education in schools starts late, at the junior or senior secondary school levels. However, as demonstrated by Nabila, Fayorsey and Pappoe (1997), most adolescents drop out of school at various grade levels. For example, only 32% of the boys and girls who complete primary education can be accommodated at the junior secondary school level. Of those in junior secondary school, only about 40% continue their education at the senior level. They drop out after the junior level, either because of lack of money or lack of academic interest. Thus, starting sex education at the senior level guarantees that the children who dropped out at lower levels will be missed. In the end, senior secondary school sex education reaches only 12% to 13% of all adolescents. Since there are dropouts at each educational level, it would be more appropriate to begin ADDS education programs at the primary school level, as is currently done in countries like Zimbabwe, Uganda, and Thailand. In the case of Ghana the question becomes how feasible is this approach? It is possible that one can learn from how these countries, which are also traditional societies, have been able to successfully implement this initiative. Furthermore, at present, school-based programs are limited, but of equal importance are out-of-school adolescents who are difficult to reach. In this study, confining ADDS education to adolescents attending school means missing 48.6% of out-234 of school adolescents who had engaged in sex and had never used condoms. There has been, however, a proliferation of F M stations nationwide. These stations could be a useful resource to disseminate information on safe sex throughout their programming. Let us also note that most ADDS education materials are in English, which may be an obstacle to comprehension for some who are less educated. Broadcasting ADDS education on the radio has the added advantage of facilitating the use of local dialects to disseminate information. Such broadcasts could potentially reach all adolescents, whether or not they are in school. Other avenues to reach out of school adolescents include places of apprenticeships, social gathering such as at funerals, festivals, outdoorings of newborns, soccer matches and other sporting activities, picnics, and markets. 6.2.4 Self-Efficacy and Enabling Environment It is noteworthy that self-efficacy, a positive attitude toward condoms and the belief that condoms could be relied on to prevent STDs and ADDS were significant predictors of condom use. Self-efficacy was significant in the final model after controlling for potential confounders. Self-efficacy has been described as the most important prerequisite for behavior change. It is defined as the confidence that a person feels about performing a particular activity. It also determines how much effort an individual invests in a given task and what levels of performance are attained. When the performance is repeated, the individual builds self-efficacy, which in turn affects task persistence, initiation and endurance, thus promoting behavior change. In this study, self-efficacy applies to condom use. When people lack a sense of self-efficacy, they do not manage situations effectively, even though they know what to do and possess the 235 requisite skills. Self-doubt overrides knowledge and self-protective action. Self-efficacy as predictor in the model is consistent with other studies carried out in different environments. Such studies have shown that adolescents are particularly at risk of HIV infection, because they frequently possess low levels of self-efficacy when it comes to refusing sexual intercourse and practising safer sex (Kasen et al., 1992). In this study, although the questions measured two domains of self-efficacy separately (refusal self-efficacy, which is the perceived ability to refuse participation in risk behavior such as sexual intercourse, smoking or drinking and use self-efficacy, which is the ability to obtain and use condoms), the scores were combined for analysis. Thus, it is necessary to discuss ADDS education with the goal of equipping the recipients to achieve both aspects of self-efficacy. Education can play a key role, if it is geared to equipping the target population with self-efficacy skills and a positive attitude towards condoms. The emphasis, however, needs to change, as most education programs now focus on providing AIDS knowledge, without thought to helping recipients achieve self-efficacy and change their attitude regarding condoms. The effects of self-efficacy and change in attitudes relating to HIV prevention may be at the micro level. At the macro-level, however, there must be the existence of an enabling environment, coupled with increased accessibility to prevention methods, in order to have an impact. In Ghana today, there is the lack of an enabling environment and access to the means of prevention. Gatekeepers, ~ older people, the religious leaders and government - play a major role in shaping this environment. Older people, for example, shy away from discussing sexual matters with the younger generation. This reticence and lack of openness permeates the environment. Adolescents who attempt to 236 be open about sexual matters are considered "bad". With regard to religious leaders, they adopt the stance that the only way to prevent AIDS is abstinence and nothing else. The government of Ghana took almost 14 years to come out with a policy on HIV/AIDS. Hitherto there was no commitment to HIV prevention; Once in a while, at best, government officials paid lip service to prevention. East and Central African governments in the early years of the HIV epidemic in those countries exhibited this complacency and denial of the threat of HIV. The consequences of those practices are now well known. Unfortunately, the government of Ghana did not learn from the experience of other governments. Even as Uganda's Museveni's role was being touted as crucial in stemming the HIV epidemic in Uganda, the Ghanaian political leaders did not take a cue from such success story. There is, however, a faint hope that with the policy on HIV, the relevant sectoral ministries will provide coordinated efforts to create an environment for prevention. For example, at present, the Ministry of Education provides ADDS education in one form or the other, and the Ministry of Health, through the National ADDS Control Program, collects statistics on ADDS cases. But little is done by the Ministry of Defense (which sends thousands of soldiers to the Middle East, Cambodia, Sierra Leone and other international U N peace keeping missions) or the Interior Ministry, which dispatches police to international peace missions abroad and also appoints them to refugee camps in Ghana. The Ministries of Agriculture and Mining and Energy also engage in activities with their employees, which can fuel the ADDS epidemic, but little is done to stress prevention. The lack of an enabling environment on the political front with the necessary coordination of different sectors runs contrary to U N ADDS' (1999, 2000) observation that interventions that are multi-level and involve a 237 variety of partners in an integrated fashion have demonstrated a higher rate of success than those that work in isolation. Thus, when the issue of an enabling environment is discussed in the Ghanaian context, it is important to differentiate between the conditions facing individuals and the socio-cultural, religious and political conditions, which also stifle initiatives for prevention. For example, at the individual level, economic constraints may force someone to engage in relationships they may otherwise have chosen not to pursue, as demonstrated by Anarfi (1997), when male street children stated they preferred sleeping with prostitutes, since they could not afford the costs associated with having a steady girlfriend. As for young women, many end up having relationships with older men, who might have extensive sexual experience or have several young women in concurrent relationships. Although relationships with these men puts the young women at higher risk of contracting FIIV, they also provide a secure source of income, which may otherwise not be available. 2.5 Sexual Risk Taking /Concurrent Partners In this study, most adolescents did not perceive having concurrent partners as problematic in terms of contracting AIDS or HJV. Their perception of risks in having concurrent partners centred on avoiding fights (for girls) and coping with supporting concurrent partners financially (for boys). The adolescents in this study expressed the following risks associated with having concurrent partners. One wrote: "You have to lie to all to be able to survive the game." Another reported: "You would be feeling weary or uneasy anytime you are with one partner." Another warned: "The partners may clash and engage in fist fight." The boys said: "It costs too much money to maintain many 238 girlfriends." Another added: "I have only 1 sexual partner because I have no money to give the others." Having concurrent partners was not considered risky in terms of STDs and HIV. Adolescents rather perceived problems to stem from maintaining the partners financially, or not being caught, or being the cause of a fistfight. Moreover, only 49.2% of the participants indicated a decrease in the number of sexual partners as an effective means of ADDS prevention. This suggests that this aspect of public awareness in AIDS prevention strategies is not as widely known as it should be. It may also explain why two in every three participants who engaged in casual sex never used condoms even though some of the study participants had as many as three to eleven casual partners in a six-month period. This clearly indicates that these adolescents are not practising "serial monogamy" (the practice of having one sexual partner at a time, but several in sequence), which is considered less risky for HIV infection, but are having concurrent partnerships, which is considered very risky for HIV infection. The latter can dramatically increase both the size and the variability of the epidemic (Hankins, 1998). The refusal to use condoms was also common in the 12 participants who had sex with commercial sex workers. Notwithstanding the fact that 27% of the participants felt they were at risk of acquiring HIV, let us note that sexual activity with concurrent partners or without condoms did not translate in their minds into increased personal risk. Thus, there is a huge discrepancy between real risk and perceived risk, with the result that adolescents fail to take appropriate precautions to minimize the risk. Moreover, in this population, neither having concurrent lovers nor casual partners led to increased condom usage. There were no decisions to change behavior to reduce the risk of infection in these cases. To explain this, we may speculate that those who show they are risk takers 239 by not using condoms may also have the propensity to have concurrent partners. One participant wrote, "I slept with three girlfriends this month alone without condom." But a female respondent recognized her risks and wrote: "I just broke with my boyfriend. He does not like using condoms, but has at least five girlfriends. I broke up with him, since I don't want any disease." Thus, based on the A R R M framework, we can conclude that these adolescents appear to be in a situation that is not supportive of change despite a reasonable general knowledge of HIV/ADDS (i.e. 77.2% of the participants knowing about the incurable and fatal nature of ADDS). There is a need to develop a full understanding of sexual risk-taking behavior by gaining insight into how individual sexual behavior relates to — and is affected by « cultural and socio-economic considerations (unemployment, poverty, gender roles). Because traditionally, parents shy away from discussing sexuality with their children, teenagers rely on their peers. As noted in this study, the information thus obtained may not be accurate. Sex is also perceived as a "secret" activity, and hence leads to no discussion with grown-ups. This lack of openness is transferred to relationships, to the extent that only 41.4% discuss HIV/ADDS with their regular sexual partners (45.8% of the boys and 35.6% of the girls). Lack of discussion can extend to lack of condom negotiation, even if a partner suspects unfaithfulness. In this study, 61.8% of the sexually active respondents were aware that their regular partners have other partners (62.9% of the boys and 60.9% of the girls), yet they were still in the relationship. This indicates acceptance of concurrent partners in a relationship. It is surprising that adolescent boys knowingly continue relationships with the girls and are fully aware they have other partners, since cultural norms dictate that 240 women should not openly have more than one lover. It is likely that in adolescence, it may be a difficult for boys to convince girls to have sexual relationships. In consequence, boys are willing to tolerate unfaithfulness because the competition to get girls is stiff. Age mixing reinforces such a scenario: Because adult men engage in relationships with younger girls, there remain fewer girls for adolescent boys. As a result of this artificial shortage, the boys may be more accepting of multiple, unsafe relationships. Once they get to adulthood and they are serious about a relationship, they no longer tolerate this situation. 6.3. Analysis from Multivariate Models on Determinants of Sexual Risk Taking In the multivariate analysis, after controlling for potential confounders like age, location, constituency, and educational status, the variables that were relevant predictors of sexual risk taking in this population were being male, being a resident of Upper Denkyira and Offinso South, being younger than 15 at the time of first sexual intercourse, perceiving a risk of catching HIV in the next year, not having discussed HIV with family, claiming to know somebody who can cure AIDS, and knowing a friend, relative or acquaintance who has AIDS. Other variables associated with sexual risk taking in the univariate and bivariate analyses that were tested in the logistic regression, but found not to be independent predictors, included belief that AIDS can be transmitted through witchcraft or through mosquitoes, belief that fear of ADDS has greatly changed sexual behavior in the study area, HIV knowledge score, and self-perceived risk of contracting HIV in the next 30 days. It is possible that the loss of power has an impact on some variables not becoming significant in the model. This loss of power occurred because, in 241 the bivariate and multivariate techniques, the analysis was restricted to only those whose score were in the lower 25% (low risk takers) and the upper 25% (high risk takers). Thus 50% of the respondents whose sexual risk taking score fell between 26% and 74% were excluded from the analysis. This approach, however, has made it possible to contrast between low and high-risk takers, which are the extreme sub-groups of interest. 6.3.1 Age of First Sexual Intercourse Starting to have intercourse at a younger age was a predictor of high sexual risk taking in this population. This must be cause for concern, especially when it has been shown in the study that a third of the females were introduced to sex through rape. In the sample, almost two out of every five participants were sexually active, and the median age of sexual intercourse for both sexes was 16 years. By age 15, however, 47% of the males had sexual intercourse compared to 38% of the females. This is consistent with data from Nabila, Fayorsey and Pappoe (1997) showing that although nobody really knows the age of boys' sexual initiation, it is suspected to be earlier than girls. A disproportionate number of boys reported sexual intercourse compared to girls (57.9% and 42.1% respectively) and the mean number of lifetime sexual partners was 1.85 for the boys and 1.46 for the girls. This shows that there was a marked sex differential of lifetime sexual partners for males and females. This is not accounted for, however, by the mean difference in age between males and females. In the population surveyed the boys were only 0.5 years older on average, but they reported a significantly greater number of sexual partners. In addition, the average age of first sexual intercourse for boys is younger than girls and more boys started having sex before age 15. The question 242 then becomes, with whom are these boys having sex? Apart from first time sexual partners, this study did not seek other demographic information on the participants' sex partners. It is therefore not possible to draw conclusions about people who may be influencing the sexual behavior of these adolescents. Are these findings arising because older females are having sex with younger boys? Or is it because boys are having sex with commercial sex workers? Or is this difference attributable to gender-specific reporting bias? For a variety of social/cultural reasons, boys are known to over-report while girls are known to under-report. The study made a determination to verify the existence of this bias. A cross tab was run on sexually active males with regards to their first-time sexual encounter to find out whether it occurred with an older person. The results indicated that only 6.2% of the boys had an older sexual partner. Since in Ghana, the norm in a sexual relationship is for the man to be older than the woman, it is likely that some of these boys may be having sex with commercial sex workers who are older than they are. It could not be determined whether past partners or current partners were commercial sex workers, although only 12 of the respondents indicated ever having sex with a commercial sex worker. Some participants reported that some boys have sexual relations with sugar mummies (grown-up women) who supply their needs. 6.3.2 The Environmental. Cultural and Economic Factors Heise (1988) stated that economic and cultural reasons including poverty, high illiteracy rates and lack of openness in discussing sex-related issues were major drawbacks to progressive ADDS health education taking place in the general population. Although premarital sex is frowned upon by traditions and customs, prohibitions against 243 it have ceased to be effective throughout Ghana. This relaxation" in sexual mores has not been accompanied, however, by increased openness to discuss sexuality with children. In chapter 3 (study site), a detailed discussion portrayed the environmental factors at play in the constituencies studied. These factors have an impact on HIV. All the following issues have an effect: high levels of unemployment and under-employment, a poorly educated population, a woefully inadequate supply of health personnel and health services delivery, lack of access to safe water, malnutrition, improper waste disposal leading to contamination of water resources, destitute citizens, street children and inpatients who leave hospital against medical advice apparently to avoid payment of bills. In addition, there are other factors in these areas which have been shown to facilitate HIV propagation in other studies conducted in sub-Saharan Africa: extensive migration, disproportionate ratio of men to women, sharing of ill-defined borders with countries of high HIV prevalence (Ketu South constituency and Togo), high prevalence and poor management of other STDs. Poverty is rife. As a result, many people don't know where their next meal will come from, and often see their fellow human beings die from conditions that medical intervention could have cured. Under such conditions, it is hardly surprising that AIDS is not perceived as being an immediate threat. In the multivariate analysis, gender was a predictor of high sexual risk taking, as males were more likely to be sexual risk takers than females. This is not surprising, due to the cultural environment in which the research was conducted. It is equally important to note, however, that the proportion of female adolescents receiving money or gifts in exchange for sex was 21.4%, while the percentage of boys who paid for sex with commercial sex workers was 20.7%. Moreover, 31% paid their girlfriends and 13.8% 244 indicated paying casual sex partners. There is the possibility that this concept of paying for sex may well not be understood by the respondents since the dating customs dictate that the male foots the bill. However, such high numbers give cause for concern, because they support the fact that there is a lot of age mixing in matters of sex in Ghana. In sub-Saharan Africa and in parts of Asia, husbands are often a decade or more older than their wives, on average, whereas this gap is only two to four years in other parts of the world (Cain, 1993). Experienced men who have a wealth of sexual experience with many partners have intercourse with young girls, who unknowingly may have already been infected by their earlier sexual liaisons with other older men. This may explain why in Ghana, just as in other African countries such as Uganda and Zimbabwe, the age where infection peaks for females is 24 to 29, but 30 to 34 in the male population. Anarfi and Awusabo-Asare (1993) reported the exchange of sex for money and cited earlier studies in Ghana conducted decades ago. In those studies, some schoolgirls reported that they had boyfriends who regularly gave them money or were in sexual relationships in order to get money to pay their school fees (Acquah, 1958; Akuffo, 1987). It is important to view these findings and issues in terms of the political economy of Ghana and the economic constraints facing the Ghanaian adolescent. The economic strangulation in Ghana brought about by structural adjustment policies make it difficult for parents to provide for young people. Since 1983, the World Bank and International Monetary Fund instituted Structural Adjustment Policies (SAP) in Ghana. Subsidies on basic items and necessities were removed, parents were asked to pay towards their children's education, which hitherto had been free, and health care delivery services switched to a cash-and-carry system. Yet, these economic policies have failed to boost family incomes. This 245 makes it difficult for many parents to provide a nurturing environment for their offspring. Hence, there is an increased likelihood that adolescents, and girls especially, will engage in relationships they would not otherwise engaged in simply to get money. These factors may elevate the risk of contracting HIV for girls, since it encourages them to engage in sexual behaviors at an earlier age and/or willingly select men who provide economic sustenance for them. 6.3.3 The Role of Political Economy Lurie, Hintzen and Lowe (1995) describe the role of SAP in possible fueling the AIDS epidemic. They stated that they did not posit SAPs as the sole cause of the epidemic, but in some cases, they suggested SAPs may have exacerbated pre-existing circumstances or simply failed to reverse adverse trends. For example, the breakdown of the health delivery systems that accompanied SAP inhibits surveillance and testing for HIV, and limits the HIV screening of blood used for transfusion (50% in some countries). Funding shortages also encourage people to reuse disposable syringes, potentially contributing to HIV transmission (Mann et al., 1986). In the Ghanaian context poverty became exacerbated because of the adoption of SAP in the early 1980s. Each year, increasing number of people falls below the poverty line. The poverty inflicted on its citizens by Ghana's wholesale adoption of the prescription of the International Finance Capital has not only resulted in parents' inability to provide economic sustenance for their children, but also has affected health seeking behavior. Children who have parents unable to provide may drop out of school or migrate to urban areas in search of non-existent jobs, sometimes becoming street children, or living on their own before attaining 246 majority. As stated by Nzyuko (1997) and Anarfi (1997), such circumstances become risk factors for behavior that predisposes poor children to high sexual risk. At present, the information collected on ADDS patients in Ghana is limited to gender, age, and area of residence (region). It does not distinguish among the social and income levels of the individuals afflicted by the disease. It is likely that AIDS may disproportionately affect the poor and disadvantaged in Ghana, because HIV transmission is mainly a behavioral issue. Anarfi (1997) reports that street children in Ghana had unprotected sex with commercial sex workers. The children believed, and rightly so, that it was cheaper to go to a prostitute than to have and maintain a girlfriend in today's Ghana. The ultimate objective in having a girlfriend was sexual intercourse. Therefore, if girls were expensive to maintain, the boys reasoned, it was better to hire prostitutes who would provide the same sexual service at more economical rates. As for the female street children engaged in prostitution in order to survive, they could not count the number of their clients because they were innumerable. With over 40% of her citizens living below the poverty line, it is clear Ghanaians are very poor. Poverty is associated with low education and the poor have fewer choices. Poverty is a double-edged sword when it comes to HIV infection. Some women may get involved in full-time or part-time commercial sex work. Some may be in relationships with male partners they would not have otherwise chosen, because they are economically dependent on these men. Once infected with HIV, poverty makes it more difficult to cope with HIV infection: lack of access to anti retroviral therapy, prohibitive costs in terms of health and social care, other indirect costs such as lost productivity (absenteeism), lost income, all contribute to poor people not being able to cope. 247 Furthermore, with the adoption of the cash-and-carry system in the health care sector, costs of treatment has become prohibitive, whether care is sought at a government or privately-owned hospital, although the latter is more expensive. As a result, people go to the drugstore, treat their ailments with herbs or self-medicate. They only go to the hospital when symptoms do not abate. The situation is serious, if viewed in light of the current three-pronged approach guidelines, developed by the World Health Organization, for containing the HIV epidemic: take measures to reduce HIV transmission, treat STDs, and reduce the number of sexual partners. The first and third approaches mainly target behavioral issues. The second approach requires action by government and health-care authorities. The proper treatment of STDs should incorporate an intensive countrywide surveillance system, which is lacking in Ghana right now. Adu-Sarkodie (1995) observed that, even in areas where there are STD clinics, the prohibitive costs of medical care, and the embarrassment of going to a hospital for STD treatment, make most people resort to self-medication. They buy medication from drug peddlers, whose drugs may be out of date. Mafamy, Mati & Nasah (1990) also reported that secondary students in the Fako District of Cameroun resorted to self-medication and preferred not going for treatment for STDs. Adu-Sarkodie (1995) found that people sought treatment at the hospital only after they had medicated themselves for STDs and symptoms had not abated. Moreover, the study reported that there was a lack of knowledge of STD symptoms and curability. People held the ingrained and mistaken notion that when the symptoms of a STD disappear, it means the infection has been cured. Such factors, coupled with the absence of STD monitoring, evaluation, and after-care surveillance by 248 the health authorities, could be a potential source of increasing vulnerability to HIV infection in Ghana. 6.3.4 Sexual Risk taking/Constituency of Residence Our initial hypothesis was that the presence of HIV in a given area might influence sexual behavior by decreasing the propensity to take risks. This was based on the assumption that the high incidence would create conditions for reflections and less risk taking. The results indicate, however, that the presence of HIV in a given area does not necessarily influence sexual risk-taking behavior. It was thought that residents of Offinso South (high prevalence HIV area) and Upper Denkyira (medium prevalence area) might engage in less risk taking behavior than the Ketu South (low prevalence) residents, but this does not seem to be the case. Rather, residents of Offinso South were four times and residents of Upper Denkyira, five times more likely to be sexual risk takers than those in Ketu South. Thus, the high HIV prevalence in Offinso South and Upper Denkyira may be attributed to the possibility that the inhabitants are high-risk takers. We may also suggest that, since it is very early in the epidemic curve, the high prevalence of HIV may not yet have triggered a change in sexual risk-taking behavior. Conventionally, one would have thought that having a friend, relative or acquaintance who has AIDS might deter adolescents from engaging in high-risk sexual behavior. The results from the multivariate analysis, however, show otherwise. We can speculate that people who are risk takers are more likely to have friends or relatives who may also be risk takers. It is also possible that there are not many community sanctions or concerns regarding risky behavior that leads to acquiring AIDS. Another plausible 249 explanation may be that those who have friends with AIDS have developed an erroneous risk perception. The HIV/AIDS epidemic has led to the re-assessment of socio-cultural practices and their implications for hindering or enhancing the spread of the epidemic. It is likely the political economy of the 3 areas may have contributed to the differences in the prevalence. Upper Denkyira, is a gold mining area with brisk activities and avenue for business and commercial sex work. Offinso is a vibrant farming area and close to Kumasi, the second largest city in Ghana, and located on the Kumasi-Tamale highway. On the other hand Ketu South, is a farming, fishing, and trading centre bordering with neighbouring Togo. This is an example of relatively well-endowed areas more prone to risk taking and possibly higher infections than less endowed areas. It is likely the differences in economic activities may contribute to the different levels of infection. There may be parallels here with South Africa and the sugar estates in Malawi and the copper regions in Zambia. Furthermore, the differences between the patrilineal Ewe and the matrilineal Akan have been discussed in chapter 3 of this thesis as they relate to pro natalist, female autonomy and cultural norms. Since the Akan (Offinso and Denkyira) are matrilineal, the females are more likely to be autonomous, probably have high self-efficacy and hence more likely to take initiative. Analysis of self-efficacy score however, shows Ketu South to have a higher mean self-efficacy score followed by Offinso South and Upper Denkyira. Thus the sexual risk taking is being driven not by self-efficacy but probably by cultural norms. They are more pro natalist or the desire to have children which belong to their clan impacts on sexual behaviour and indirectly on sexual risk taking as regards 250 the use of condoms and other contraceptives. There is an Akan proverb which says that one does not get a good marriage is one is afraid of divorce. People are willing to experiment and hence likely take risks. Under such circumstances, people at Denkyira and Offinso are more likely to take risks, and this will be independent of the level of prevalence. This reason in addition to the political economies of the areas under discussion may explain why there is still more sexual risk taking in the matrilineal areas even though there is higher HIV prevalence in those areas compared to the Ketu South which has patrilineal system. j Furthermore, there is usually a time lag in achieving behavioural change. For instance family planning was first introduced into Ghana in the 1960s, (e.g. Planned Parenthood Association of Ghana was formed in 1967). Yet as of 1998, only 13% of currently married women were using one modern contraceptive. If the evidence from Family Planning is anything to go by then the process of AIDS education and its impact may take some time. This may possibly explain why HIV in high prevalence is not imparting on condom use or sexual risk taking. Let us note also that the differences in the proportion of respondents who previously had sex may be attributed to differences in the age pattern profiles of the electoral constituencies. For example, in Ketu South, 76% of the respondents in the age group 17 to 19 previously had sex, compared to only 57% of respondents in the same age group in Offinso South, since only 64% of the respondents in Ketu South belong to that age group, compared to 54% in Offinso South. 251 6.4 Limitations of the Study This survey represents a cross-sectional study of in-school and out-of-school adolescents. The sample size is sufficiently large to represent junior secondary school and senior secondary school and out-of-school adolescents in the three constituencies studied. It may not necessarily, however, be representative of other adolescents in Ghana who may differ by geographic location (large urban cities or large trading centers), and the economic status of their parents. Still, the adolescents surveyed are resident in regions of low, medium and high HIV prevalence areas in Ghana. One drawback in using cross-sectional data in this study is that it measures AIDS knowledge, condom use and sexual risk-taking behavior at only one point in time. This knowledge or risk, however, may evolve with changes to exposure to AIDS-related information, new situations, the development of additional self-efficacy and exercise of control etc. Thus the determinants, which are statistically significant in these models, may change if measured at another point in time. In addition, while showing a relationship between constructs of the A R R M and other supplementary variables with regard to condom use, we can only speculate about the causal direction of this relationship. Thus a longitudinal cohort study may be necessary to validate whether high scores on this scale predict HIV sero-conversion or at least high incidence of sexually transmitted diseases. We already mentioned the fact that the A R R M lacks socio-cultural components. The model's emphasis on individual behaviors and choices, which disregards the influence that others have on behavior, is also a weakness. 252 When the two models ~ condom use and sexual risk taking ~ are compared, there are major differences. Only communication was relevant in both models. With regard to condom use, communication with a regular sexual partner and friends was significant. Similarly, communication with family was a predictor in sexual risk taking. In the sexual risk-taking model, five additional variables remained in the model after controlling for confounding. Whereas the model on predictors of condom use had a greater power (N = 513 out of 539 sexually active respondents), the model on sexual risk taking had less power (N = 223), because the comparison was made between the lower 25% score and the highest 25% score. The model regarding sexual risk taking may be more robust, since it encompasses scoring on variables such as sexual partners, casual sex, concurrent partners, sex with commercial workers and lack of condom use when having sex with lovers other than one regular sexual partner. It is possible that other variables may become significant with a higher power than what we used in the final model. Furthermore, the sexual risk taking scale addresses only heterosexual behavior, which is not the only route of transmission of HIV. Other routes such as blood transfusion, intravenous drug use, and unprotected anal sex by men who have sex with men (MSM) are not included in the scale. In the Ghanaian context, however, the blood supply is largely safe and IV drug and M S M are minimal, to the extent that they can be considered to be non-existent. It is encouraging that the domains dealing with sexual behavior achieved a high internal consistency. This result is good news because the issue of sex is basically a private activity and people are threatened or embarrassed when asked to reveal what they do, feel, and think during their sexual encounters. There are strong cultural taboos 253 surrounding direct observation of other people's sexual activities. Hence, researchers must rely on self-report. Privacy, embarrassment, and fear of reprisals are some of the reasons that may motivate people to conceal their true sexual behavior. Conversely, some may find it truly rewarding to embellish their sexual prowess. In addition, even when an individual wants to tell the truth there may be problems with recalling how often and with how many people they have performed specific sexual behavior. Consequently, to minimize measurement errors, there is a need to develop valid indices of self-reported sexual activities that index whether a person has performed a behavior (incidence) and how often he or she has performed it (frequency). Furthermore, measurement error may occur, because of the following: respondent's refusal to answer a question; respondents under-reporting their actual activity levels by indicating that they have never performed a behavior they have in fact performed; admitting to a behavior but under-reporting the actual frequency; and admitting a behavior they have never really performed (over-report). It is indeed difficult to detect when respondents are over-reporting or under-reporting their sexual behavior in any absolute sense. Other elements that have influences on measurement are recall (e.g. vividness and complexity of the behavior, emotions associated with sexual events), self-presentation bias (for example the degree to which the questions elicit fear or approval seeking), motivational issues, and the respondent's ability to understand what is being asked in an interview (Catania et al., 1990). For example, the respondent's willingness or ability to spend the effort needed to generate accurate information may influence measurement error. People with large numbers of sexual partners, for instance, may have to work 254 much harder to recall specific behavioral frequencies than people in long-term, mutually monogamous relationships. Although many people report being able to clearly remember certain sexual milestones (e.g. their first sexual experience) and negative sexual experience (e.g. rape), much of a person's sexual experience may begin to blur with time. Ability to recall may vary across sexual behaviors. For example, less frequent sexual acts may be estimated more accurately because they stand out as unique against the background of one's usual modal sexual behavior. Furthermore, pleasurable or negative emotions associated with one's sexual encounters may differentially influence recall. Biological markers can sometimes corroborate the validity of self-reported sexual behavior. For example, some researchers have demonstrated self-reported increases in frequency of safer sexual practices and decreases in unsafe practices to parallel declines in HIV sero-conversion in gay men in San Francisco, as well as declines in anal gonorrhoea rates. However, comparable data for teenagers, intravenous drug users and heterosexuals are lacking. In addition, biological markers are imprecise, cumbersome and expensive to apply in large population-based studies. 6.5 Conclusion and Recommendations This study was designed to identify the determinants of sexual risk taking in the face of HIV/ADDS in a population of in-school and out-of-school adolescents in three electoral constituencies in Ghana. It also sought to identify factors that might influence the adoption of safe sexual behavior (that is condom use and reduction in sexual partners) and find how adolescents challenge or reinforce these behaviors. The results of the study shed light on the lack of knowledge regarding HIV/AIDS and other STDs, the attitude 255 towards people with AIDS (PWAs), factors that determine sexual risk taking behavior, perception of risk, condom use and barriers to condom use in this population. The information gathered from this study can be used to improve efforts to increase condom acceptance and use, and reduce sexual risk-taking behavior in the Ghanaian adolescent population. The primary objectives are to reduce the number of adolescents who begin sexual intercourse in their teen years, increase condom use among those who have sex, and reduce the number of adolescents who have concurrent sexual partners. The results of our research lead us to state that a single message on AIDS prevention (for example, telling people to use condoms to prevent AIDS without understanding their attitudes towards condoms or their views on concurrent sexual partners) directed at adolescents is bound to fail in Ghana. It is also imperative to take cognizance of the cultural norms relating to the inheritance system vis-a-vis sexuality. AIDS education begins with knowledge of AIDS (transmission, susceptibility and prevention), but emphasis should be given to delaying the onset of sexual activity, removing factors that contribute to the negative attitude towards condoms, enhancing self-efficacy, increasing communication with sexual partners, encouraging open and free discussion of HIV and matters of sexuality with adults and sexual partners. AIDS education should also be tailored to address the societal peer pressures the adolescents confront in their environment (for example nicknames or derogatory comments the sexually active ones make against the non-sexually active) to let them not only to understand those pressures, but also learn to resist them. The focus should be on changing peer norms/misperceptions that give rise to risk taking, while enhancing self-efficacy. Messages should stress the adolescents' increased susceptibility to STDs and 256 HIV infection compared to adults since they are at the age they erroneously think they are invincible; they should accentuate the positive side of using condoms and counter the negativity associated with condoms in the culture right now. It remains imperative to consider individual and societal obstacles that impede AIDS prevention efforts in terms of condom use. Consequently, for any effective education regarding condom usage to take place, misperceptions have to be corrected. Enhanced efforts should be made to challenge and remove these misperceptions. A two-pronged approach needs be developed and tested. The first prong would focus on debunking all the misperceptions associated with condom use and hopefully, lead to increased condom acceptance. The second prong would work on minimizing the negative attitude leading adolescents to believe they cannot enjoy sex when they wear condoms. Since the major reason cited by participants to justify lack of condom use was that condoms hampered sexual pleasure, sex education should begin early and focus not only on STDs/AIDS, but also on pregnancy. Misconceptions about condom use may be heightened because of a lack of experience with them or lack of proper information. Condoms and other methods of family planning have been associated with promiscuity in the African environment and hence, not generally accepted. These inaccurate notions need to be addressed. At present, HIV prevalence in Ghana is relatively low compared to neighboring countries, Togo, Ivory Coast and Burkina Faso. In spite of this low prevalence, the number of AIDS cases is increasing. Whether or not HIV prevalence increases in Ghana depends on the interplay of many factors that facilitate transmission: individual and group sexual behavior, patterns of sexual mixing, levels of condom use, and the prevalence of other STDs, especially those with ulcerative symptoms. As stated by Hearst and Mandel 257 (1997), these factors can be influenced. Changes need not be sweeping in nature to have an impact: Even moderate changes affecting a combination of the above variables might make a difference between HIV prevalence stabilizing at 5%, instead of skyrocketing at 15%. Of serious concern is the fact that the number of full-blown AIDS cases increased from 14,986 in 1993 to 29,546 in 1998. While this possibly may be attributed to a reporting bias, it is more likely due to an increase in incident cases. Moreover, given the degree of sexual activity in the adolescent/Ghanaian population at large in terms of age mixing, sexual networks, and lack of condom use, either deliberate or through ignorance, the risk of acquiring HIV infection and disseminating it in the population is substantial. Ghana, like most African countries, is confronted with significant economic, social, and health problems. Since antiretroviral drugs that limit transmission and prolong the lives of HIV-positive people in western countries are not affordable for Ghanaians ~ neither for individuals nor for the government ~ AIDS prevention is the only plausible approach. Even with current agreements announced by Glaxo Wellcome and other phamaceutical companies to supply anti retroviral drugs at very low prices, only a select few can afford them in Ghana because the people are very poor. Overall in Ghana, 40% of the people live below the poverty line, which is defined as an annual expenditure of 700,000 cedis (the equivalent of a mere U.S. $100). This crippling burden of poverty is not evenly spread among Ghana's ten regions: While only 5% of the residents in the capital area are classified as poor, 27% to 88% of the people in each region live below the poverty line. In the three regions where the study took place, the percentages of people living below the poverty line were 38% for Ketu South (Volta), 48% for Upper Denkyira (Central Region), and 28% for Offinso South (Ashanti Region). 258 To implement an effective ADDS education program in Ghana, it is essential to understand the factors influencing the onset or delay of sexual activity. For example, there are different reasons as to why in-school adolescents and out-of school adolescents engage in sex, and different reasons accounting for boys and girls having their first sexual encounter, and of equal importance reasons why adolescents in patrilineal areas have first sex compared to their counterparts in matrilineal areas We know that one in three women first had sex because they were forced. Thus, equipping girls to avoid conditions that give rise to rape (for example, avoiding being in the same room alone with men, or reporting incidents of rape) or enhancing their self-efficacy and ability to protect themselves can contribute in delaying the onset of their sexual activity. In addition, there should environmental improvements to reduce the probability of rape. This can be done by anti-rape educational campaigns targeting men in the print and electronic media, review of sexual assault legislation and enforcement of legal measures. The law dealing with rape in Ghana stipulates as follows: "Whoever commits rape be guilty of a first degree felony and shall be liable on conviction to imprisonment for a term not less than five years and not more than twenty five years" [CRIMINAL CODE 1960, A C T 29 (Section 97)]. In the 1990s, the rape law has been revised and the amendment was meant to be very strict on rapists. This amendment was by A C T 458 2a - CRIMINAL CODE (AMENDMENT) A C T 1993. The new law stipulates that "Whoever commits rape shall be guilty of a first degree felony and shall be liable on conviction to imprisonment for a term of not less than three years and in addition to a fine not exceeding 500,000 cedis (local currency) and in default of the payment of the fine to a further term of imprisonment not exceeding the minimum imprisonment specified under this section". 259 At the time the legislation was passed the fine was the equivalent of $625 US but has now been devalued by inflation and at the present exchange rate to be equivalent to only US $72. An additional problem with the legislation is that it does not prohibit settling cases out of court. The offending party may offer monetary compensation to the victim's family and the case is removed from the legal system. This has to change since when the cases end in court the penalties of incarceration are stiff. An additional impediment in the enforcement of the rape legislation law is that these rapes are hardly reported. As for boys, one out of two had first sex out of curiosity, while peer pressure accounted for only 23% of the boys' decision to start sexual activity. The numbers for girls were one out of five did it for curiosity and 24% were influenced by peer pressure. The significant differences observed between reasons given for first sex between patrilineal inheritance area compared to matrilineal inheritance systems need to be recognized. These differences should be factored in tailoring any intervention program to these adolescents. Preventive messages that stress religious/moral values and abstinence might be successful and should continue to reach young adolescents, thereby reinforcing their decision not to get sexually active. It is necessary to target boys and girls who have never had sexual intercourse and let them know that, should they ever decide to have sex, they must use a condom. Then, the first time they engage in sexual intercourse they are protected against HIV. Thus, the strategies should seek to first influence adolescents to delay sexual intercourse and encouraging or convincing them to use condoms consistently as part of the sex act, should they decide to become sexually active. This scenario is possible if the benefits of condom use are stressed, while the misperceptions 260 are removed (e.g. if they are made aware that their first sexual intercourse could result in pregnancy or lead to contracting a STD or HIV). When they use condoms from the onset of sexual activity, they may not compare sex with condoms to sex without condoms negatively. With consistent messages that reinforce the need for safe sex, a new crop of condom users may be ushered into Ghanaian society. In addition, condoms should be readily available in stores. People should be taught how to use them properly. Re-use should be discouraged and females should insist that they witness the opening of the packaging to remove suspicions that the male user has already poked a hole in the condom. This study brought to the fore the need to consider social and individual obstacles to AIDS prevention, as it has been amply demonstrated that sexual relations do not operate in a vacuum: economics/poverty, social norms and cultural factors play a major role in the spread of AIDS. Poverty especially is a factor that appears to be acting as a major barrier in AIDS behavioral risk reduction. Thus, poverty reduction is an essential strategy that can remove economic constraints, hence indirectly influencing behavioral change. With regard to poverty, which drives some women into commercial sex work, the approach should be prevention of infection among those who are more likely to contract HIV and inadvertently spread it. Laga, Alary and Nzila (1994), Moses et al. (1991), and Ngugi et al, (1988) showed the cost effectiveness and success of this approach. It is therefore important to embark on policy of tolerance of sex workers, rather than misguided policies of harassing or arresting prostitutes, as the Ghana Police Service sometimes does. This approach is counterproductive and exacerbates the epidemic as people involved in the sex trade may choose to go underground. 261 Other relevant barriers include female financial dependence on paid sex, and negative attitude towards monogamy. Prevention messages relating to concurrent sexual partners should take into consideration that the tendency to have concurrent partners is a behavioral factor. Limiting the number of partners reduces the risk of being in contact with people who may be infected by HIV or other STDs, which are also implicated in HIV transmission. It is important to discourage people from having concurrent sexual partners in this population, especially since condom usage is very low. In addition, messages should emphasize the necessity to use condoms when sex occurs between partners who don't know their HTV status and are not in a mutually monogamous relationship. This study concludes that the presence of reverse causation when AIDS in the community does not by itself reduce sexual risk taking behavior. Therefore, it is wrong to assume that people will change their behavior when they know someone with AIDS. Given the current HIV situation in Ghana, ADDS education should be intensified to inform adolescents about the dangers of unprotected sex and reduce the prejudice towards PWAs by removing the perceived threat of contracting HIV through casual contact. Finally, since the community believes in the effectiveness of traditional medicine in the treatment of some ailments, including STDs, western medicine should interact with traditional healers to ascertain what works and what does not. There needs to be a confluence of interests in healthcare delivery, rather than the present conflict where medical professionals do not consider traditional healers as colleagues. In conclusion, the approach to AIDS prevention should be all-encompassing and comprehensive so as to contain the epidemic through intensive AIDS education, which 262 dwells minimally on knowledge, but seeks to enhance self-efficacy. Intervention methods should take cognizance of the fact that telling people to use condoms is not sufficient and that different factors determine decision to use condom during sexual intercourse..age, gender, nature of sexual relationship (age-mixing or paid sex), sex-role relationships to mention but a few. There should also be policies that mitigate poverty and economic inequality, strict enforcement of sexual assault legislation laws, as well as the adoption of an integrated health care delivery system that includes family planning, and the dissemination of correct and relevant materials on AIDS. At the same time the government and other stakeholders should seek to create the enabling environment which increases access to the means of prevention. 6.6 Dissemination of Research Findings When permission was being sought for the study, the local and national authorities expressed interest in getting report of the results and recommendations since no comprehensive population-based study has been done on HIV and adolescents in Ghana. The results from this study will be disseminated to the local authorities in the Ministries of Education, and the District elected officials (District Chief Executive and District Assemblies) and the respective Regional and District Medical Officers of Health in the areas the study has been conducted. They will be provided with study results in their respective areas in addition to the over all findings in the three areas. At the national level, the National AIDS Control Unit, the Ministries of Health and the Ministries of Youth and Employment will be provided with copies of what has been 263 learnt and recommendations. The following policy recommendations will be made to the respective entities 6.6.1 National AIDS Control Unit The data collected on HIV patients do not indicate information on migratory patterns, socio economic status, or employment status. Thus it is not possible to determine the effect of HIV on the various sectors of the economy. AIDS should be considered a developmental and health issue and the need for a multi sectoral approach (ministries of education, mines, agriculture, youth, defence) to combat the epidemic cannot be overemphasized. The As an agency in charge of collecting information on AIDS in Ghana it should be more proactive in its dealings in matters of HIV/ATDS. It is not surprising for government officials to report outrageous figures of HJV cases in Ghana without any scientific basis and go unchallenged. In addition, the agency should use the government machinery at its disposal to perpetually inform the country about incurability of ADDS and call on the authorities to clamp down on the charlatans who have billboards announcing that they could cure ADDS. Such reports give erroneous ideas to some people that AIDS could be cured and increases propensity for sexual risk taking. In the last 15 years (since 1985) the radio, TV, and billboards have been used to provide information on HTV/ATDS. Therefore HIV information is universal and the level of knowledge will be somewhat uniform in the country. Providing information is the first step in a five-stage process towards behavioural change. These are knowledge, approval (some don't believe the threat of AIDS), intention, practice and advocacy. Currently 264 most people in Ghana are at the knowledge stage. Possibly a few have moved to the approval and intention stages (to use condoms and reduce sexual partners). This should be the strategy to move people in the process rather than the present approach which only seeks to increase the awareness of AIDS. It should also provide funds and training for counselors so that people (especially those engaged in high risk behaviours) should see the need to go for voluntary testing. Other considerations should be legislation and outreach that diminishes drug peddlers in the street who sell antibiotics that claim to cure STDs. These activities by drug peddlers prevent adequate STD monitoring and treatment which have been blamed as pathways to HIV acquisition especially the ulcerative ones. 6.6.2 Ministry of Youth Since there is virtually no voluntary testing for HIV in Ghana except pregnant women who visit antenatal surveillance units, it is almost impossible to get adolescents who are HIV positive. By the time they are diagnosed with ADDS they have become young adults. The focus for intervention should be geared more toward the young adults and adolescents who can turn the tide of the epidemic around as observed in Uganda. This is because they are at a vulnerable age and may also have not yet formed their sexual habits. The Ministry will be informed about the high percentage of adolescents who are introduced to sex through rape. The Ministry has to get involved in advocacy work with other NGOs in changing the laws regarding rape and statutory rapes. Situations where parties get cases out of court to settle at home should not be legal in matters of rape. 265 Furthermore, the Ministry needs to educate parents to realise that we now live in a different era where matters of sexuality, if not discussed with children, could endanger their lives. In the short run peer education has been successful in some countries. The Ghanaian authorities could learn from these successes and duplicate these programs in Ghana while embarking on the long-term efforts to change parental attitude towards sex education. Finally, there is an explosive situation of street children in the urban areas (boys and girls) who are engaged in unprotected sex and commercial sex. There should be outreach programs to reach these kids who live day to day without any hope. 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