Research Review 19.1 (2003) 27-45 TO CHANGE OR NOT TO CHANGE: OBSTACLES AND RESISTANCE TO SEXUAL BEHAVIOURAL CHANGE AMONG THE YOUTH IN GHANA IN THE ERA OF AIDS John KwasiAnarfi Abstract Ghana has one of the highest levels of reported cases of HIV/AIDS in the West African sub-region. The majority of infected persons are in their twenties. Young people are particularly vulnerable to STD/HTV infection for a number of reasons, They are confronted with complex and interlinked bio-social, economic and political structures and community, factors. Although they are aware of STD/HIV, they do not practice safe sex or do not use condom consistently. They are more reluctant than older ones to seek treatment for STDs partly because of the attitudes of the older people, the health care providers and the general society to adolescent sexuality or may not be able to afford services. The paper is based on data collected from in- and out-of-school youth at the national and regional levels on their perceptions and reactions to the epidemic. Field work was done in five out of ten regions in Ghana using both qualitative and quantitative instruments. The issues covered included their current attitudes and behaviours related to HIV/AIDS, their reaction to the need for change and their perceived constraints/barriers to behaviour change. HIV/AIDS education messages have not taken the specific concerns of the young people into consideration. Most out-of-school youth are cut off from the mainstream educational and health care facilities. Young people are receptive to AIDS-related messages when they are made part of the planning and implementation of programmes. Attempts at initiating behavioural change in the youth must take into consideration all the complex factors. The source of, and the agents for change, must be seen to be credible and the effort must be reinforced and sustained. The problem may be of barriers than just resistance/refusal of change on the part of the youth. Introduction When writing in 1992, Caldwell et. al. observed that there are 3 ways by which the long-term impact of HIV/AIDS on Sub-Saharan Africa could be averted. They included: 1. The possibility of a biomedical break through producing effective vaccines in sufficient quantities and cheaply enough to cover the whole region; 2. The possibility of a massive behavioural change; and 3. The possibility of the disease burning itself out. The first possibility is still a mirage while projections indicating the third are not fully convincing. In all probability and in practical terms, it is the second which holds more promise to the region, but this has happened to only a limited extent among the younger population in Uganda and perhaps in Tanzania. In Ghana, the statistics paint a gloomy picture. Since the first AIDS cases in 1986, the epidemic has spread slowly but steadily. Sentinel surveillance data indicate that HIV prevalence in the 15 to 49 year old age group in Ghana rose from 2.7% in 1994 to 4% in 1998 and is still 27 increasing. Although changes may be small or non-existent from year to year, the overall trend of rising prevalence clearly shows an epidemic that is still worsening in Ghana. It has been estimated that HIV prevalence for 15 to 49 year olds will increase from 4% in 1998 to 6.4% in 2004, 8.2% in 2009, and 9.5% in 2014. The figures indicate that the number of infected people in the population would increase from 430,000 in 1999 to 720,000 in 2004 and to 1.36 million in. 2014. Results from studies on Ghanaian youth aged 10 to 24 in 1992, 1995 and 1998 show that there has not been any meaningful change in HIV/AIDS-related behaviour over time (See Table 1). Within the period, the proportion of sexually active young people dropped sharply from 83% in 1992 to 53% in 1995, only to rise again to 63% in 1998 (Anarfi and Antwi 1995; Anarfi 1997; 1998). Similarly, there has not been any change in the mean age at sexual debut, hovering around 14 years to 16 years. Throughout the period, the proportion of the youth who are aware of HIV/AIDS has remained very high almost reaching 100% at the end of the period. Unfortunately, current use of the condom has declined and that was over the period when the proportion of sexually active population among the youth interviewed actually appreciated. The above statistics indicate that there has not been any significant change in behaviour related to HIV/AIDS among Ghanaian youth, despite a high level of awareness. Table 1: Sexual Behaviour and Other Indicators over time: 1992,1995 and 1998 Indicator Proportion sexually active Mean age at first sexual experience Awareness of AIDS Ever use condom, Use condom occasionally (last 3 Months) 1992 83% 16 years 98% 34% 19% 1995 53% 14.5 years 98% 28% 21% 1998 63% 16 years 99.7% 35% 12% Sources: Anarfi and Antwi 1995; Anarfi 1997; Anarfi and Kannae 1999 Related Literature and the Conceptual Framework East Africa is one region of the continent where HIV/AIDS has had a lot of impact. Many countries in that region have responded positively to the epidemic by way of interventions. The result is that almost everybody is aware of the causes and means of transmission of HIV/AIDS. In spite of this, for a very long time there was not any significant change in behaviour due to a number of reasons. One reason often cited was unemployment and lack of recreational facilities, which made the youth vulnerable to early sexual activities because they were idle most of the time. Related to sexual activity is the fact that the youth often indulge in unprotected sex. They do not think and plan about having sex and also tend to have multiple sexual partners (Amuyunzu-Nyamongo et. al. 1999). Cultural inhibitions do not allow the youth to discuss with their parents, teachers and religious leaders about sex. Some people believe that the disease is contracted as a result of curses or breaking of social norms. Young people in East Africa and indeed elsewhere in stib-Saharan Africa, also see themselves as indestructible and believe that HIV/AIDS is God's punishment for sexual sins hence it does not affect good people (Amuyunzu-Nyamongo et al 1999), High illiteracy levels also hinder information sharing on HIV/AIDS and STDs. Illiterates are denied access to detailed and elaborate information in print and electronic media that are increasingly used by the government and other development agencies. Related to high illiteracy rates are misconceptions regarding HIV/AIDS, the use of condom and the effect of sex information on the young which act as hindrances to behavioural change, The youth do not see 28 Research Review 19.1 (2003)27-45 the need for protected sex and rely on conventional stigmas such as physical discomfort or endangering trust as reasons to avoid condoms. Another hindrance is poverty. It is a barrier at the national, community and individual levels. Lack of resources for health services and for dissemination of appropriate health education materials, prevent sensitization regarding HIV/AIDS and other STDs. Added to that is the lack of political will, which is a hindrance to young people\s effective behaviour change. Some countries in East Africa find it hard, to admit the magnitude and impact of HIV/AIDS because they need to maintain a particular international image, thereby not according it the seriousness it requires (Amuyunzu-Nyamongo et. al. 1999), From the late 1980s, the AIDS information campaign in Zimbabwe did not make any positive impact due to several reasons. One was that HIV education was strongly prescriptive and biomedical in nature, and was mainly communicated through one mass medium and one-way lectures (Karla 1999). In addition, HIV/AIDS remained highly stigmatized, related to promiscuity and prostitution and difficult to acknowledge at personal level. Among married couples, there was the problem of difficulties in discussing sex, the association between condoms and promiscuity, and reduction of fertility. Many people with HIV and their family members in Zimbabwe are fatalistic, believing that nothing can be done to prevent it, or that it is a punishment inflicted by God for individual or social wrongdoing. There are others also who refuse to accept the biological origin of the disease. Some HIV-positive persons, therefore, see condom use as socially risky or with little to be gained (Karla 1999). There is an element of helplessness on the part of women as far as prevention of spread of HIV is concerned. In non-marital relationships women's ability to prevent the spread of infection is limited by their economic dependence on their partners. Their socio-economic dependence on men means that when; partners are uncooperative women are left with the choice of continuing the relationship without condoms or breaking it off completely (Karla 1999). From the Zimbabwean study it was concluded that barriers to sexual behavioural change after HIV diagnosis in sub-Saharan Africa stemmed from women's lack of sexual decision-making power, men's dislike for condoms and denial of HIV. In addition, HIV positive people who did not disclose their HIV status feared that proposing to use condoms would raise their partner's suspicion, and lead to social rejection and stigma. In recent years, the HIV epidemic in South Africa has rocketed unceremoniously. This is despite the fact that HIV is a frequent topic of discussion among young people and a matter which figures prominently in their sexual life histories. To date, many South Africans view HIV infection with a mixture of fatalism, helplessness, fear and even disbelief in its existence. Despite widespread education efforts, public sentiments towards H1V/A1DS and individuals affected by it remain extremely negative (Varga 1999). The preference for "dry sex" without the use of a condom, lead to easier transmission of the epidemic. In Zulu youth culture, condom use suggests promiscuity and lack of trust; hence there is continued emphasis on unprotected sex as proof of love and commitment. The concept of a successful man in South Africa entails demonstration of multiple sexual conquests, hence most men have affairs indiscriminately and this has contributed to the huge leap in infection (Varga 1999). Other hindrances to positive behavioural responses to HIV/AIDS, as elsewhere in Africa, include gender imbalance in sexual decision-making. For example, Zulu men are permitted and even encouraged to have multiple sexual partners. But it is a damnable act for a woman to do so. Coercive sex is also viewed as acceptable by both young men and women and generally seen as a 29 male mandate. Such belief provides forced sex with considerable social legitimacy (Varga 1999). Among the urban youth, poor communication over the circumstances of intercourse also acts as a barrier to HIV-related behaviour change. The youth simply do not discuss how and when sex will take place and are unprepared for it when it happens. In such a situation, peer pressure is the order of the day, which always supports the status quo. Culture and religion have also played a part in the general tinder-reaction to HIV/AIDS in sub-Saharan Africa. Traditions that suggest that death is not final and hence not so fearful or alternatively that its timing is preordained and so inevitable, are great barriers to positive change. Similarly, some people have also associated the epidemic with witchcraft and so it cannot be avoided (Caldwell et. al. 1992). People's attitudes and perceptions have also played a role in perpetuating the spread of HIV/AIDS. People feel ashamed at admitting to a sexually transmitted disease and young men especially feel that they are invincible or immune to infection. Discussion of the subject of AIDS is minimal even among health personnel in Africa. This is compounded by the fact that rural populations have low levels of education and usually regard AIDS as a disease of urban promiscuity (Caldwell et. al. 1992). An unfortunate situation is that most Africans do not believe that HIV is the sole cause of AIDS deaths, and most are not completely convinced that no indigenous or bio-medical care exists or will not soon be found. These facts, combined with the reluctance to discuss the disease, mean that little pressure is put on African governments to move faster to contain the epidemic. The governments in turn fear provoking a crisis situation in their countries, and they know they have insufficient resources to meet such a crisis. They also fear the loss of tourist revenue if there is too much publicity (Caldwell et. al. 1992). In Zambia as in much of the world, there is a strong belief in a host of spirits. It is believed that if the living refuse to listen to demands of the ancestral spirits then they inflict more drastic punishment on the people. It was within, this context that ritualistic cleansing was practiced in Zambia. This ritual was expected in order to "chase" the spirit of the diseased from the clan and especially the spouse. The rapid spread of HIV/AIDS in Zambia was attributed in part to the practice of sexual ritual cleansing. In the face of the escalating rate of the spread of the disease, however, the practice has been modified somewhat (Malungo 1999). In Nigeria, denial of the existence of the fflV/AlDS in the country was very widespread until the death of the famous musician Fela Anikulapo Kuti, who died of AIDS In 1997. Since then awareness of the disease has been very high. In spite of the acceptance that AIDS is now real in Nigeria, there has been resistance to social and behavioural change. Sex with prostitutes, casual sex, indiscriminate and unprotected sex and multiple sexual partners put men at risk of infection with HIV. Many men still believe that sex with only one person is not of man's nature and that sex with multiple partners or prostitutes cannot lead to AIDS if care is taken (Ombuloye and Oguntimehin 1999). A formidable barrier to the control of HIV/AIDS is found in the community-health services interface. An enhanced and properly worked out interaction between the community and health service providers is very crucial in disease control. This interaction facilitates openness and understanding, which are very important in the dialogue or rapport requisite for the work of service providers. Unfortunately, there is a perceived weakness or shortcoming of the staff in the public health delivery system. These include lack of privacy, bad quality of care and equally bad attitudes (Bengt 1999). The result is that traditional healers and private medical practitioners are preferred alternatives. Unfortunately these two categories of caregivers have not been involved so much in the fight against HIV/AIDS in many African countries. 30 Research Review 19.1 (2003) 27-45 One of the frightening aspects of the AIDS disease is its ability to spread at an alarming rate within a given population. As observed above, in Ghana the disease is quickly spreading and could assume epidemic proportions soon if not controlled, It is therefore, appropriate to examine the factors within the social structure that have aided the spread of the disease and appears to make it difficult for people, particularly the youth, to effect, any meaningful change in their sexual behaviour. One way is to look at the concept of sexuality now as against the background of sexual morality observed in traditional times. Restraining factors Sex is an inescapable aspect of human society. The way it is interpreted, however, differs from country to country and among individuals, Society, in its move to ensure rale and order has not left sexuality to nature. In every society there are rules that govern proper conduct. In Ghana, social norms and rules existed in traditional times, which restricted one's sexual behaviour. There was very little sexual activity permitted or encouraged before marriage and even after marriage. Among many ethnic groups, sexual activity before marriage was prohibited and frowned upon. Pre-nuptial chastity was very much valued among the ethnic groups of the south. A distinct traditional rite socially adhered to was the puberty rite. The purpose of this rite was to mark a young girl's coming of age in terms of physiological development. A striking feature of the rite was the announcement of the girl's chastity. Among the Asante (a matrilineal group), candidates found to be non-virgins were killed or driven out of the tribe (Fiawoo 1982). This is because the rite was socially approved as acting as a guiding force for a chaste, pure, dutiful and respected woman and wife in the future. Among the Nzema (of the extreme south- west of the country) also much emphasis was placed on pre-marital chastity of young girls. Infringement of the rules pertaining to their observance was regarded as a serious offence. Examples of the seriousness attached to pre-marital sex, divorce and adultery can also be found among patrilineal groupings both within and outside Ghana. Gluckman (1958), in a famous article described the Zulu social structure as highly regimented with drastic steps taken to enforce morality. So severe were these measures that adultery on the part of a woman was punished with flogging with thorny bushes and also by thrusting cactus into her vagina. Children born outside or before marriage were also not given any place in the estate of their genitor (Nukunya 1992). Among the patrilineal Anlo tribe of Ghana, it was traditionally the practice for a girl of puberty age to go through a ceremony known as Nudodo. This ceremony announced to the whole village that the girl had reached marriageable age. The girl was paraded through the village dressed in rich beads. Until the performance of this ceremony, an Anlo girl could not be courted, but once done she could be courted and receive suitors. Marriage between an Anlo girl and her approved suitor also had to be subjected to certain laid down procedures. Most important was the consummation ceremony which testified to the faithfulness of the betrothed bride. The main idea behind this ceremony was the public declaration of the bride's virginity. The establishment of a girl's virginity was an occasion of great pride for the bride and her parents. She was honoured and lavished with many gifts. On the other hand, a girl who had premarital intercourse was disgraced and her seducer charged and fined for fornication (Nukunya 1969). Such was the emphasis placed on the consummation ceremony that many girls kept themselves pure and chaste so as not to bring dishonour to themselves and their parents. Permissiveness From a formerly restrictive stance, Ghanaian society has become more permissive in its attitude to sexual and immoral behaviour. The acceptance of and actual frequency of premarital sex have increased markedly. With the impact of western education, Christianity and urbanization, there has come to be an appreciation of western culture that has resulted in the gradual erosion of conventional traditional norms governing sexual morality. The anonymity of 31 urban life and consequent reduction in parental supervision has resulted in more promiscuous behaviour among the youth. Presently, one of the major social problems facing the Ghanaian society is teenage pregnancy. Many young girls today have sex before marrying. In A$ante traditional society, the basic formality for the establishment of a marriage required the payment of tiri nsa (head wine). Often a "knocking fee" (which consists of a bottle of schnapps) was paid before the sum for the tiri nsa was agreed upon. Traditionally, the "knocking fee" established the man's intention to marry and the girl's family's acceptance of him as a prospective bridegroom. It did not entitle him to a sexual relation with the girl (Church 1978). These days, however, because of the greater sexual freedom enjoyed by the youth, there are many who take the fee as giving them freedom to have sex with the girl. Often these relationships do not result in any marriage contract, but instead, cases of unwanted pregnancy and sexually transmitted diseases (Gyepi-Garbrah, 1985). Another example of the breakdown of the conventional norms governing sexual immorality can be evidenced in the present societal attitude and cultural interpretation of the Dipo cult, which forms an important aspect of Krobo1 culture. As a puberty rite, the Dipo ceremony aimed at tutoring young girls between the ages of 14 and 20 years in housekeeping, cooking and parenting. This normally lasted a year, at the end of which the girls emerged skilled, well-fed and ready to be courted by the young men and be married. They also had small scarifications on their wrists and at the back of their waist to signify to people that they had gone through the Dipo ritual and therefore could be courted. Girls without these scars had to be left alone. Dipo, as practiced today only lasts for about five days and involves girls as young as eight years old. It is no longer a preparation for good marriage but a license for early sexual activity. In the past, girls who had not gone through the Dipo ritual and became pregnant were banished from the tribe - a threat which helped to protect girls from early pregnancy and sexually transmitted diseases (Hampton 1990). Nowadays, due to the early age at which girls are initiated, early pregnancy is no longer frowned upon. With the present high degree of sexual permissiveness, many assume that once they have undergone the Dipo rituals they may begin sexual activity. Again, with the few employment prospects in the Krobo area many young ladies having justified themselves by having gone through the Dipo rituals, leave the country to work in the neighbouring countries as commercial sex workers. Currently some of the highest cases of AIDS are found among the Krobos in the Eastern Region of Ghana. To some extent, it couild be said that AIDS spread and HIV infection in the Krobo area are due to the present cultural interpretation of the Dipo cult and the practice of commercial sex. Commercial sexual activity is an ever-present problem in Ghana currently. The practice has prevailed mainly as a result of economic handship, favourable societal attitudes and misconceptions about the profession. In the Krobo area for instance, commercial sex appears to be a socially approved way of life. This is probably due to the fact that many of the sex workers return home from their sojourns abroad with rich clothes, jewelry, and a well kept appearance that speaks of success. Unfortunately, this attracts the other young women in the towns and villages, most of whom happen to be unemployed. With the outbreak of AIDS, more and more migrants are returning home sick with the disease. Some are compelled to sell the property they acquired in migration to get money to pay their medical bills but to fio avail (Anarfi 1990). 1 The Krobo are part of the Adangme ethnic group occupying a stretch of land with about half of it over the eastern end of the Akwapim hills and the other half over the plains ending in the Volta lake. Its major towns, Somanya and Krobo Odumase, lie about 70km north east of the nation's capital* Accra,. To the south and east they share boundaries with other Adangme tribes like the Shai and Ningo and to the west with Akan-speaking groups like the Akwapttns and the Akyem, 32 Research Review 19.1 (2003) 27-45 Beliefs and other promotional attitudes Beliefs in the life of any group of people are important in understanding their way of life, their interactive processes with one another and their relationship with the environment. In Ghana, there are no strong religious beliefs against immoral sex. In a different way, however, certain beliefs have been responsible for the careless and persistent sexual habits of certain individuals. For instance, there is a cultural perception about death which appears fatalistic. This belief is reflected in a popular Akaii proverb that says owuo atwedee baako mfo (the mounting of death's ladder is not undertaken by an individual), a belief held by both educated and uneducated. This philosophy may underlie the failure of all programmes aimed at arousing behavioural change among Ghanaians so far, Another factor that may be considered promotional in the spread of AIDS in Ghana surrounds the institution of marriage as perceived and practiced by the various ethnic groupings in Ghana. As in many African societies, polygynny is accepted in all the ethnic groupings in Ghana. As a result, there is the tendency for men to use polygamy as an excuse for promiscuity in as much as a man may be finding another wife (Bleek 1976). This degree of liberty enjoyed by most married men is partially due to the dominant position a man holds in African societies. In most instances, the authority structure of the home is vested in the man. Apart from this, husbands seem to have more rights conferred on them by marriage. In theoiy, both the wife and the husband are entitled to sexual satisfaction from each other. However, a wife's sexual rights in her husband are not absolute since African marriages are potentially polygynous. In cognizance of this, extra-marital affairs of a husband are often not considered a breach of the marital bond. In fact, polygamy is perceived by some as a check on prostitution (Vellenga 1983). In view of their position in African marriages, wives have very limited control over the extra marital affairs of their husbands. The danger to which they are exposed is worsened by the fact that most Ghanaians detest the use of contraceptives particularly condoms as a result of traditional beliefs, ignorance and mainly because they are not comfortable with it and therefore do not protect themselves and their partners during sexual intercourse. In many strongly patrilineal societies, such as the Anlo of Ghana where marriage confers uxorial rights unto the man, it is inconceivable for a woman in such a"marriage to refuse to have sex with the husband. Sexual intercourse becomes a marital duty and a wife has to perform this duty irrespective of the husband's promiscuous behaviour. This expection can be explained by the traditional cultural interpretation placed on female sexuality which is still upheld by a lot of Ghanaians. Traditionally the sexual act was regarded as a service. In the traditional courtship system a man exchanged valued gifts in return for sexual services based on lines of reciprocity. In marriage the reciprocity involved the exchange of the woman's sexual and procreative services in return for maintenance (Dinan 1983). Wives, therefore, had to comply with their husbands, leaving them with very little control over their sexuality. At present, the traditional dominance and supervision over the wife by the husband has been reduced due in part, to a wife's economic autonomy and independence (Asante 1978). A woman may now have the right to refuse the sexual advances of her partner. The vulnerability of women Despite this, there is the tendency for women to still continue to have sex with promiscuous partners. One major reason for this relates to the fear of divorce and its consequences. Divorce, particularly when it occurs during a woman's reproductive years, could result in extension and relaxation of a woman's subsequent sexual network. This comes about because by her new status she is liable to remain and be subjected to erratic relations with men or she may remarry into polygynous unions where she could be subjected to the often frustrating experience of competing with co-wives for her husband's sexual services. In view of this some women would tolerate their husband's promiscuous life just so that they can remain in the marriage. 33 Many women are again trapped with insensitive partners as they seek to avoid having children with, different fathers and avoid destabilizing the psychological and emotional balance as well as the economic welfare of their children. Also important in the consideration of the above is the essence of marriage and reproduction upheld by the Ghanaian society. The society treasures marriage and childbirth but apprehends spinsterhood and barrenness (Gaisie 1968). Evidence from the Ghana Fertility Survey (Ghana 1983) and the Ghana Demographic and Health Survey (Ghana 1989) has shown an increase in the proportion of women with eleven and more years of education in polygynous unions. This increase appears to be related to the fact that marriage is a desired status in Ghanaian society and women irrespective of educational or employment status could find themselves in polygynous unions, or continue living or sleeping with a promiscuous husband to avoid being single. Church (1978) has also observed that although there is a noticeable bias in favour of monogamy amongst young people, the unmarried and those whose marriages were in the early stages, they would not object to polygamy so long as the prospective husband was able to maintain the wife and her family well. Much as marriage is cherished in all Ghanaian societies, divorces are also common and seem to be on the increase of late (Kusi-Appiah 1979; Bleek 1987). In the past divorce was considered a taboo which regulated to an extent a couple's behaviour. Among the matrilineal Akan, rampant divorces have been observed to be the outcome of the emphasis put on the lineage to the detriment of the marital union. A woman remains a member of the matriclan whether in or out of marriage. The breakdown in customary law and procedures governing marriage has also resulted in the escalation of divorces in all societies at present. The danger for the spread of AIDS is that remarriage is common and in fact widely practiced, a situation of widespread serial polygyny. The explanation for the almost universal remarriages is based on the belief that a divorced woman is considered as living in an uncompleted home and was, therefore, not given much respect in Ghanaian society. Thus, divorced persons remarry to avoid shame and disrespect. Women again stand the risk of AIDS infection on resuming sexual relations with their partners after their period of postpartum abstinence. Usually it is the practice for men to have sexual partners other than their wives during this period (Bleek 1987; Caldwell et al 1989). In some societies such as the Meru of central Kenya this practice of substituting other women for wives during postpartum abstinence has become institutionalized (Mwambia 1989 quoted in Caldwell 1989). For most wives, there is very little they can do about their husbands' extramarital affairs. There are some who even encourage their husbands to have sex outside just so that their marriage will not suffer Economic factors Economic necessity has been found to drive people into certain occupations that may put their health at risk (Karla n.d.). In Ghana, the desire for material wealth on the part of youthful women in a situation of inadequate decent jobs has resulted in a transactional type of sexual relation, of "sugar daddies" and "gold diggers" (Dinan 1983). The women involved in this relationship are mostly single with no immediate plans or intention to settle down and marry but are interested in finding patrons to aid them in their career advancement and occupational statuses. In return for these material benefits these women provide sexual services for their partners or sugar daddies, that is, rich older men. Bleek (1976) and Akuffo (1987) have observed that such transactional relations start early when young girls sleep with their boyfriends in return for small gifts and presents. Dinan (1977) explains that the desire of most women to remain in relationships without emotional attachments has been conditioned by their disillusion about marriage in the contemporary Ghanaian society. Marriage no longer gives women the social and economic security it is supposed to give as men do not marry for love and companionship but only to serve their selfish interest. As stated above, education has contributed to the escalation of transactional sex in the Ghanaian community in recent times. Not only has education increased the number of years 34 Research Review 19.1 (2003) 27-45 between puberty and marriage, it has also imposed new tastes on the aspiring young women which they find difficult to contain without support. Certainly, parents are not willing to take on these extra demands in the face of the high cost of schooling and general maintenance. Female students, including university students, have been known to indulge in transactional sex. It has become fashionable for these young women to have "sugar daddies" in town. They are attracted into such relationships by the gifts offered them. Young students who enter the institutions see the expensive and beautiful clothing worn by such women and the weak-willed are also attracted into such relationships. Others, though, enter into them as a result of peer pressure and the need to affiliate with a certain group or be accepted by them. Although it is socially unapproved, ignoring it and acting as though the problem does not exist has rather made this kind of relationship become engrained in the university communities, One worrying aspect of the whole relationship is that the men involved are almost always married men who have only come to seek them as outside wives or mistresses.{Bleek 1976). The contemporary Ghanaian society is caught up in a kind of dilemma often observed with societies going through transition. On the one hand, the young people have attained a certain degree of sexual permissiveness as a result of a breakdown of some of the restrictive practices. On the other hand, the older people have not been able to break away from some of the traditional notions. For example, discussion on sexual matters between the generations is still unknown in many Ghanaian homes. This has made the issue of sex education a very sensitive issue in Ghanaian society at present. There is still the belief that sex education will arouse some curiosity in children and result in their desire to experiment. In a study among the Anfoega Ewes it was noted that no formal education was available on the acceptable form of sex due to the fact that the people believed education on sex matters would make the youth curious and want to experiment (Drobo 1971). The problem is further compounded by the very little and in some cases lack of sex education in the curriculum and training programmes of most schools. The end result is that many young boys and girls rely on friends, the mass media and films for their source of information (Douchebe 1987). And when they have learnt, they want to experiment, often with disastrous results. The problem with the youngsters, particularly the girls, is that they are ignorant about the hormonal changes taking place in relation to their physiological development and are therefore unaware of the implications resulting from their sexual relationships with boys. What is particularly worrying is that most of these teenagers experiment with more than one partner and often do not protect themselves by using a condom (Anarfi and Antwi 1995; Anarfi 1997). Results of a study conducted among selected students in the Central Region of Ghana indicate that socio-economic conditions influence people's attitudes to life (Awusabo-Asare et al 1999). For instance, some young people were pressured by their teachers, schoolmates, friends, relatives and neighbours to have sex with them. In some cases, the need to sell or give away sex to survive has contributed to the huge leap in infection of HIV/AIDS. Some of those affected with the disease contended that in spite of the spread of HIV people need to survive and could die from anything including AIDS. Dying from AIDS, they argued, is not different from death from other conditions. According to them whatever you do you will die, and the cause of death does not matter. This belief explains the misunderstanding or lack of motivation for behavioural change in the existing socio-economic circumstances. From the foregoing, it is clear that certain socio-cultural factors and economic conditions favour the spread of AIDS in Ghana. Some of these factors have to do with institutions and structures in the society such as marriage especially polygamy, the culture of silence adopted by society towards sex education among the youth, a breakdown in puberty rites and economic motivation on the part of young girls and women in the society. 35 Conceptual Framework; This study adopts a conceptual framework developed by Mann and Tarantola (1996) to discuss the vulnerability of young people to HIV infection. The framework is based on the view that there are three broad sources of vulnerability to HIV infection among young people (see for instance, Awusabo-Asare et al, 1999; Twa-Twa, 1997) Susceptibility and Vulnerability Two concepts have emerged in the literature with regards to HIV infection around the world in general and in sub-Saharan Africa in particular. Those are susceptibility and vulnerability. Susceptibility refers to the likelihood that an individual or society will experience the epidemic, while vulnerability is defined as a range of factors which renders an individual or a group incapable of making and effecting free.and informed decision, unable to take advantage of existing structures and receive adequate support. (Mann and Tarantola 1996). Vulnerability is thus the converse of empowerment. Within the context of HTV infection, susceptibility is at two levels. These are individual and societal susceptibility to infection. Individual susceptibility is the biological and social potential for an individual to be prone to HIV infection, while social susceptibility is related to the relative wealth and power as well as the relative potential for effective mobilisation of resources and influence, gender relations, livelihood strategies and cultural values. Vulnerability, as defined above, according to Mann and Tarantola (1996) exists at three inter- dependent levels. These are individual, social and programme-related vulnerabilities: 1. Personal (individual) vulnerability has two components, namely cognitive and behavioural factors. Cognitive factors involve informational needs and the ability to utilise information. Behavioural factors include: • Personal characteristics such as emotional development, perception of risk and attitudes, toward risk-taking; personal attitudes to sex and sexuality. • Personal skills involve ability to negotiate for a wide range of risk-reduction behaviours such as abstinence or condom use. 2. Programmatic vulnerability encompasses the processes and activities that are available for reducing or resolving personal vulnerability. This involves the provision of information and education, counselling and peer support and skill training in sexual issues. 3. Societal vulnerability on the other hand involves the socio-cultural, economic, political and environmental factors that make a society or group within that society particularly susceptible to adverse effects of any event. One can identify the categories of the population that are likely to be susceptible and vulnerable to any phenomenon such as HTV infection. In our system, women, children and young people are more vulnerable than any other group because of their basic biology, the perception of society and the unequal access to resources. Young people are also likely to be vulnerable due to their perception of risk-taking behaviour (Anarfi, 1999; Mann and Tarantola, 1996). Available evidence also suggests that while some organizations may wish to undertake education programmes on HIV/AIDS, they are in most cases constrained by budgetary and management difficulties. Faced with conditions of low funding and budgetary cuts, such organizations are less likely to give priority to HIV/AIDS issues. Such conditions have created programme-related vulnerability in countries generally and in the organizations in particular. 36 Research Review 19.1 (2003) 27-45 From the above, it could be seen that under-reaction to the HIV/AIDS epidemic could come from any or all the three sources, namely, individual, societal or programmatic (i.e. government) level. The under-reaction may manifest itself either in the form of resistance or obstacles to change. Resistance connotes: • Active refusal to change • Awareness of the need to change but not changing • Awareness of the means of changing but not using/applying them • Having the power to effect change but not using it Obstacles on the other hand imply: • Inability to change although willing to change, due to; - absence of relevant information - inability to utilize information (e.g. due to lack of education) - unavailability of programmes for reducing/resolving vulnerability - lack of political will - societal norms and expectations which support entrenched behaviours The Study Sources of data The paper is based on data collected from in- and out-of-school youth at the regional level on their perceptions and reactions to the HIV/AIDS epidemic. Fieldwork was done in five out of the ten regions of Ghana namely, Greater Accra, Eastern, Ashanti, Northern and Upper East Regions. In effect, therefore, each of the three ecological zones of Ghana, comprising the Coastal Zone, the Forest Middle Zone and the Savannah North Zone, was covered in the study. The choice of study areas in each of the selected regions was basically purposive. In Greater Accra, Ashanti, Northern and Upper East Regions, the capitals were, selected together with a smaller settlement close to it to give the study urban and rural dimensions. In the Eastern Region Krobo Odumasi and Somanya were purposively selected as the study areas. These are the capitals of the two Krobo districts, Manya and Yilo, which for a very long time have been the epicentre of the HIV/AIDS epidemic in Ghana. These are two contiguous towns with several satellite villages surrounding them. In fact, selection of subjects for the in-depth interviews spread to some of the satellite villages to satisfy the rural-urban approach design of the study. Both quantitative and qualitative methods.were used in the collection of data. In addition to questionnaire interviews, 50 young people aged 10 to 24 years were engaged in in-depth interviews, 10 in each selected region. Views were also sought from old people, particularly in the northern regions. These are the areas of Ghana, which are still very traditional The idea was, therefore, to capture more information on traditional beliefs and practices related to sexuality to supplement whatever was obtained from the young people. The issues covered included their current attitudes and behaviours related to HTV7AIDS, their reaction to the need for change and their perceived constraints/barriers to behavioural change. This paper is based on the results of the in-depth interviews. Knowledge, Attitude and Misconceptions Results The young people interviewed confirmed most of the issues raised in the literature, as reviewed above. All of them were aware of HIV/AIDS and most of them had fairly good 37 knowledge about the mode of transmission and methods of prevention. Some of their comments were quite revealing and the following was a typical example: In our conversation if someone mentions a girl who is suspected or said to have died of AIDS, there and then we discuss about it and educate ourselves about the mode of transmission; if someone has AIDS and uses a blade and another person also uses the same blade then he can get infected with AIDS. Or if any woman has it and you the man sleeps with her it will infect you. There were, however, some serious misconceptions. The comments by a young man interviewed at the Kantamanto Market in Accra illustrates this point: I think we get it from some of the foods we eat. Some are not suitable. When asked to explain the kind of food that can cause AIDS he added: You can see that not all the food sold in the market are suitable for us. For example pig feet from insanitary areas (gutters, toilets and refuse dumps). So if you eat pork you can get it. It brings minor diseases which lead to AIDS. In addition to these clear misconceptions, they either overtly or covertly, seemed to blame females for the spread of the disease. Males were the main culprits. For example, when asked to show his source of information about HIV/AIDS a young man from the Northern Region remarked: We always hear from Accra and campaign leaflets that we should control ourselves to prevent AIDS. It further says that AIDS is contracted by sleeping with a woman. So it is not advisable to be jumping from one woman to another. On where the young women get the disease from, the same young man added: We hear that the women go abroad and have sex with dogs and when they come back home and sleep with another man then the disease is transferred to him. In the northern part of the country there is the general belief that HIV/AIDS originates from "French", that is, the neighbouring Francophone countries Burkina Faso and Cote d'lvoire. To a street youth in Accra, the people who are at risk of getting AIDS are "Those females who practice prostitution around circle. They spread the disease. Also those girls who wear short skirts". Explaining the role played by short dresses he added: They attract men. There was an instance when a man picked a girl from here (i.e. the street) and, according to the girl, the man turned to a beast and had sex with her. She said the man covered her eyes so she could not see the actual animal and this can lead to AIDS. The idea that females are to blame for HIV/AIDS was strongest in the north and it came out strongly in the interviews with older people. They attributed the cause of AIDS to women and some even call it "women sickness", implying that it is mostly carried by women and distributed to men who are promiscuous. Protection In that respect some of the girls who were willing to protect themselves had taken pains to understand some of the circumstances that could lead them into danger. A 19 year old female student illustrated some of the circumstances vividly in the following words: I will not accompany friends to a boy's room and if I go I will make sure I sit in the sitting room. Also I will not go to a club house with friends to drink and even if we are drinking minerals in a group and I am going to visit the ladies I will make sure I take my drink along or drink all before going to urinate. If you 38 Research Review 19.1 (2003)27-45 don't do that the boy will put a drug in your drink and later you will not know where you are and he will have sex with you. In general terms, however, they did not do much to protect themselves. Although most of the young people interviewed perceived themselves as being at risk of contracting HIV, they did not appear to have any fear when going to have sex and by implication, do not immediately think of using condom for protection. The reason often given for this attitude was that their partners were faithful. A young girl said she did not use condom when having sex because her boyfriend "does not look like someone infected with the HIV/AIDS". Others depend on instant emotional feelings to determine whether to have sex with a person or not, or whether to use condom. For example, a young man said if he did not experience any fear when he comes into contact with a girl then it means there is no danger of HIV/AIDS. Such attitudes certainly border on misconceptions. Obstacles to Change The young people raised a number of issues that could count as obstacles to any desire they may have to want to change. Some of them relate to their parents. In all the regions, the young people interviewed complained of parents' inability to shoulder all their responsibilities towards their children thereby resulting in some of them ending up in the street with the girls resulting to selling sex for survival. Girls are more vulnerable in this respect since, in the face of limited resources, fathers prefer to harness all their resources to finance a male child's education to a girl child's. Many parents think that educating a girl would not benefit them directly as the girl would later marry and leave them. The general neglect of the girl child has compelled some of them to find any means to survive. In the words of a young man interviewed at Agormanya, the young girls especially are using sex as a means of living, because there are no jobs and their parents too are unable to take care of them. The young people alluded to the kind of training they receive from their parents as some of the obstacles in their way. A young man on the street in Accra was at pain when trying to explain why some girls enter into commercial sex. Hear him: Some parents do not give their children good training and when the'children grow up they involve themselves in bad things. He added: Some fathers do not spend time at home with the children. Some mothers also push their daughters into sexual relations. And this encourages them to become prostitutes- they put on dresses which attract men to approach them for sex. Some of the young people related the failure of their fathers to take up their responsibilities towards them to polygyny and the resultant large family sizes. A male street youth in Accra put it this way: Some fathers have many wives and there are many problems at home and the children feel uncomfortable. The child has to leave home and struggle on his own. Societal Influence The young people observed that the general social environment in which they live is a great hindrance to their attempt to change their sexual behaviour. They complained a lot about the films that are shown in cinema houses and on the television. A young Ga female observed, "the foreign films show too much sex. After watching such films some people are unable to control their urge for sex". A similar observation was made about the type of music that is being sold to the public in recent times. The same girl made reference to a song by one Rex Omar, which is titled Te wo kete ka, which translates as, "recoup what has been invested in buying a mat." 39 •• I Another dimension of societal influence was observed among the youth who spend most of their time on the street. These young people have developed their own sub-culture and operate within it. A 20-year-old girl interviewed at the Central Business District of Accra offered a good illustration of the influence when she said: If you are 20 years and above and you have never had sex your friends will be teasing you that 'as for you, you are wasting your time and your vagina hole will block'. Still on people who choose to stay as virgins till late another had this to say: People tease them. They say they are either impotent or barren in the case of man and woman respectively. Peer influence was not found only among the street youth. It appeared to be even stronger among students. In the words of a 19 year old female student, You may be a good girl at home but when you go to school you will have friends who are bad and they will force you into it. They will teach you everything about sex and ask you to pick a boy friend. In some cases, they will rather look for a boy for you. If you are not careful and you listen to them you will become pregnant but they have drugs for abortion. The same girl explained further: Sure if you are in school and you are not that type and they are not your friends, they fear to come near you but if you give yourself to them they will spoil you. They will be teasing you that you are "bush", you don't have a boy and you are stupid. They will tell you that if you pick a boy, he will give you plenty of money and take you for shopping. So if you are not an intelligent girl they will spoil you. Death The young people interviewed generally confirmed what Awusabo-Asare et. al (1999) observed in their study in the Central Region of Ghana. There was the general belief that death is pre-ordained and that it will come when it will come. In the words of a 24-year-old man, " we cannot do anything about death, because whatever the case may be you will die". Most of the people interviewed therefore said that they did not fear to die. Perhaps this was related to the belief that death was not completely final and that it was a kind of transfer from one place to the other on the same earth. In the words of a young woman if a person dies, he will go and settle at another place where people do not know that he is dead. The few who feared to die were more concerned about the family members they would leave behind, especially mothers. They felt that they should not die before their mothers. Fingers were also pointed at the government when some elderly people interviewed in the north made reference to some inadequacies in the AIDS intervention programmes in the country. An old woman from Bawku complained that the education on AIDS has not gone down well in the villages. She said most of the educational programmes are done on television, radio and in the newspapers. Meanwhile people in the villages cannot even afford their daily meals let alone talk of getting television or radio so as to hear about education on AIDS. So much was said about poverty and related problems and how they have worsened the vulnerability of the youth to HIV infection. An elderly woman in the north opined that because of poverty the young people run away from their parents when they are still minors. They move to the urban areas like Accra, Kumasi and even Cote d'lvoire to look for jobs for survival. Because these people are away from their parents, they tend to lose that parental control and advice, and when they later get jobs and some money the boys in particular are unable to resist the temptation of going in for sexual partners who are readily available. In his observation, a 40 Research Review 19.1 (2003) 27-45 young man interviewed in Accra remarked, "because of financial problems, although people are aware of AIDS in the whole area, they are still having sex here and there because of money," Influence of Western Education Discussion and Conclusion In traditional times, life was a continuous training. It was the duty of parents especially and all adults in the extended family to ensure that children grew to become responsible adults. It was also the responsibility of parents (and also uncles in matrilineal societies) to ensure that young people get themselves established in life. Since the unit of production was the family, all enterprises were family owned. As heads of families, fathers/uncles controlled incomes that accrued from the enterprises. Land has been the central focus of the livelihood of all tribal societies as it is their main support line. In all the tribes in Ghana, land is communally owned and is held in trust by the family elder, abusuapanin, among the Akan. Although every member of the family has right to the land, permission must be sought from the abusuapanin before a piece can be occupied. Again, the basic requirements of tools, seeds and money (and sometimes a helper in the form of a wife), must be provided by elders, mainly fathers and uncles. The nature of the arrangement was such that young people were obliged to bid their time until they were sponsored. A major feature of the arrangement was that parents looked for partners for their sons. In a few cases, young men could identify their partners but they were Obliged to seek the approval of parents. The arrangement did not give young men control over when to marry. When a young man got married depended on when parents have accumulated enough and have identified a right partner. The practice of polygyny meant that available marriageable young women were competed for by both young men and old men including already married ones. That always put the older men in a more advantageous position in that they already commanded some wealth. Of course the status of the father of the prospective young suitors counted in their favour* parents of the girls were also inclined to give in to the older men seeing them to be more responsible. Perhaps this explains the older age at first marriage of males in most traditional societies. Western education has changed the situation in a number of ways. Young boys and girls are now kept longer in school thereby increasing the age at marriage for both of the sexes, There has emerged, as a result, an adolescent population again of both sexes. Education has also freed youngsters from traditional restrictions, bringing them together and giving them me opportunity to develop some intimacy — boyfriend and girlfriend relationships. Above all, western education has given young men the opportunity to develop their own careers and, thereby, accumulate money and other resources to be able to secure a wife. This in turn has freed young men from the control of parents in the choice of marriage partners. Young men now inform their parents of their intention to marry only as a sign of respect. In another sense Western education has expanded the information sphere of young people. They now have access to numerous sources of information. Increasingly, they are becoming able now to contain the extended period between menarche and marriage through the use of contraceptives. The expanded sphere also means that young men now have a wider range of partners to choose from well beyond their tribal areas. In a study in Sekondi-Takoradi by Busia in 1948, nearly one-third of the sample surveyed were in inter-tribal marriages (Busia 1950). Although people still prefer to marry from their tribe, public opinion encourages inter-tribal marriages, which has become a permanent feature of modern Ghana. 41 The Influence of Christianity Christianity has either added on or reinforced the changes brought on by education. One of the areas that have been influenced is pre-marital sex. There are no very forceful traditional customs or beliefs, which forbade premarital sex. Rather, what was abhorred was the practice of sexual intercomrse before a girl's puberty rites were performed (Sarpong 1977; Bleek 1987). A girl found pregnant before the puberty ritual had to go through a shameful purification rite after which she was banished together with the man responsible for the pregnancy. To prevent the stigma, which such ritual would bring to the family and the banishment of their children, parents ensured that their children stayed away from sex'befbre they had been taken through the puberty rites. It was believed that these practices put a check on pre-marital sexual activities and the resultant pregnancy. This is where Christianity seems to have had a headlong collusion with tradition in most Ghanaian tribes. Although Christianity itself is against pre-marital sex branding it as a serious sin (fornication), in Ghana, it has not supported the various puberty rites either. It considers them as pagan worship. They have either been stopped completely in some places or changed in others as a result of Christian influence, rendering them ineffective checks on pre-marital sexual activities; Like elsewhere in the world, Christianity has not been able to enforce its stand on no pre-marital sex either, leaving the contemporary Ghanaian society in a kind of ambivalence. Studies have revealed that there is still the belief that sexual relations and pregnancy must take place within socially recognized bounds. Also most people still feel that sexual intercourse should not be allowed until the girl's parents were informed of the relationship (Anarfi 1992: 237). Nonetheless, pre-marital sex goes on in all Ghanaian societies and teenage pregnancy is now a . major problem in the country. According to the latest Demographic and Health Survey of Ghana conducted in 1998, 14.1 per cent of girls below 20 years were either pregnant or were already. mothers(Ghana Statistical Survey 1999). this belief complaining bitterly about what they termed In other studies, it was observed that majority of Ghanaians believe that a woman should be a virgin and actually wanted their daughters to be virgins, at marriage. In fact older people were more inclined towards the "waywardness" of younger people (Anarfi 1992: 238). Interestingly, most of the women who claimed to be virgins at marriage said that it was because pre-marital sexual relations were against Christian teachings. Some traditional norms also still hold sway, such as the need to uphold family honour and the wish to win the respect of husbands at marriage. Such traditional and Christian values are still held against strong modernizing influences such as the belief that retaining ones virginal status in the contemporary world is impossible/difficult and the need for prospective couples to know themselves and gain sexual experience before marriage. Marriage itself is caught up in the transitional crisis too. In Ghana, a relationship between a man and a woman that has not been sanctioned by rites is not regarded as a marriage. Rather it is called mpena aware, i.e. a union of mutual consent among the Akans. Although mpena unions in Ghana were traditionally accepted as preludes to marriage, they are not sanctioned by Christianity. Currently, two main types of marriages are recognized in Ghana, Christian and civil marriages on one hand andl customary marriages on the other. The main difference between the two is that the former does not allow plural marriages and divorce while the latter allows both. There are also Muslim marriages but like customary marriages, they allow plural marriages as well as divorce. Perhaps because of its restrictions on plural marriages and divorce, Christian rnarriages have not caught up very well with Ghanaians of all tribes. The result is that despite its overwhelming presence in the country, Christianity has failed to make much impact on the form of Ghanaian marriages. It is now a common practice for people who profess to be Christians to invoke the customary practice of polygyny to support their extra-marital affairs. Another area in which Christianity has failed to make a meaningful impact is in the area of divorce. Both divorce and subsequent remarriage are common and relatively easy in Ghana, It 42 Research Review 19.1 (2003) 27-45 follows that high levels of both serial and parallel polygyny exist. Our studies confirmed that most Ghanaian women work to earn a separate income for themselves and their families, especially their children, even in marriage. They also confirmed that marriages are less stable among matrilineal than among patrilineal communities. Like pre-marital sexual relations, there are no very forceful traditional customs or beliefs, which forbade extra-marital sex. However, extramarital sexual relations for women have to be conducted rather clandestinely compared to men because public opinion is more tolerant of such behaviour by males. A married man commits no adultery if he sleeps with an unmarried woman. If such a relationship becomes public knowledge then the honour of his wife is considered to be defiled and it will be expected that he both compensate her and either break off the relationship or marry her lover. In the case of an extramarital affair of a married woman, both she and her lover are expected to compensate the injured husband. The lover will be fined for seducing the wife and she will be fined for defiling her husband (Rattray 1929). The post-partum sexual abstinence of wives has often given men the license to engage in extramarital affairs and society is generally tolerant of men engaging in it during this period. As part of the modernization process going on in the country the period of abstinence has become shorter than what obtained in traditional times. The length of female post-partum abstinence was observed to be as long as 6 months or more for first birth and at least 40days for subsequent births (Anarfi 1992; 240). In conclusion, young people in Ghana appear to have a formidable task in translating all the HIV/AIDS prevention messages into acceptable behavioural change. Young people put up some resistance to sexual behavioural change, some for the sake of pleasure they think they can get from sex and others as a matter of survival. 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