Key Beliefs Underlying Students’ Behaviour and Decisions towards HIV/AIDS: Implications for Educational Interventions

  

    
Major Themes 
    
Minor Themes 
    
Labels 
  
  

    
1.Key    Lessons 
    
Teachers’    attitude
      

        
Responsibilities    Motivated to train 
        
Confidence & comfort
        
School    environment
      
      
Age    appropriate
      

        
Parental    support 
      
    

      
Happy to teach: contribution to development; Enthusiasm: opportunity to help
    
      
Altruism- concern and affection
      
Natural- interest in child development
      
Passionate: Interest based on threat of HIV
      
Educate anytime there is an opportunity
      
Coordinators trained but not enough
      

        
Confident, comfortable with sex    education at school but not detailed enough
      
      
Uncomfortable at home (taboo subject): cultural    sensitivity
      

        
Students old enough for HIV education
      
      
HIV not a subject
      
Students don’t get all information
      
Changes advocated for effectiveness
      

        
Parental confidence in teachers to teach sex    education
      
      
African culture- parents encourage to advice and    discipline bad behaviour
  
  

    
2.The Way Forward 
      
Values 
      
Important  influence
      
 
    
 
      

        
Religion
        
Socio-cultural values
        
Threat
      
      
d) Futurist expectation    and  responsibility 
      

        
Good education 
        
Future 
        
Marriage 
      
    

      
Majority belong to religious organizations
    
      
Fear of God
      
Religious leaders revered
      

        
Marriage important
      
      
Relations with the opposite sex too early
      
Love relationships not common but worrying,    Society against sex before marriage: virginity, abstinence preferred
      
Parents proud of such children;
      
Respect for parents and authority
      

        
Everybody is at risk, preserve future generation:
      
      
stigmatization
      

        
Future leaders, responsible    citizens, focus on education, insurance for success
      
  

Table 2:  Analysis of teachers’ interviews.

Discussion

The discussion is based on the major themes derived from both focus group discussions (Table 1) and interviews: key lessons and the way forward.

Key lessons

Among what was taught and learnt were lifestyle and relationships, concerns, who is at risk, why/how HIV spreads and how to avoid HIV/AIDS. Teachers were enthusiastic about equipping students, the future leaders, to make informed decisions and avoid dangers. They had parental support to teach sex education and HIV, though not into much detail due to cultural sensitivity and their own cultural inhibitions.

There was much concern that it is not a good testimony for Obuasi to have many infected people and still counted among the “hotspots”. Key statements include: “HIV has given Obuasi a bad name”; “what is going on at Obuasi is not good, we have to do something about it to stop the bad name”; “Ghana will not be respected if HIV is a problem”; “we have to try every means to prevent it”. A student expressed a feeling which seems to typify their sense of responsibility with a popular saying: “a good name is better than riches”. Personally, if they are able to avoid what is “bad”, they will get good recommendation and be useful for society. A teacher also stressed, “Children are the future leaders and expected to be responsible citizens to build strong families.” Though these portray a strong sense of personal and social responsibility, and consciousness towards community and country about the threat HIV poses, by inference, the respondents’ opinion added to the problem of stigmatisation.

There was concern for social justice and care for the infected, yet, there was a high sense of stigmatization. Statements… if I get that disease, it will bring shame to my family; it is very risky to live with them especially in the classroom and teachers, for instance said: … people who have HIV will be shunned; society will shun you; you will look and feel awkward in society are pointers to how the infected are perceived: stigmatised, they would not like to associate with such persons. Teachers’ view showed that such people are labelled by society as “spoilt” and “shunned” by society.

To a question, “who do you think can get HIV”, respondents generally indicated everyone and health professionals but emphasised on “prostitutes” and fornicators. Among the reasons given why HIV spreads, they stated, uncontrollable feelings, prostitution, “gold money” misapplied, indiscriminate sex, irresponsibility and wickedness, lack of protection and “bad” relationships.

The use of “bad” and its implicit meaning was quite strong among respondents. They stressed they have to avoid “bad life, bad association, bad practices and bad influence so they could avoid HIV”. Individuals associated “bad” to having sex or a “boy/girlfriend” or doing anything detestable, which they reckon contrast their values and societal norms. Related to the typical use of “bad”, a girl stated, some people have started doing some things which are very “bad”; another added: I do once a while advise friends whose lifestyle I see to be “basabasa” (immoral), I advise them to be careful with boys…

The sentiments expressed with the use of “bad”, is similar to a Ghanaian study [25] where respondents believed that HIV illness was associated with leaving a basabasa life and with travelling outside Ghana. “Basabasa” in Akan means improper conduct, and when used in relation to sexual behavior, implies prostitution, promiscuity, or extramarital affairs. Somehow, HIV is inherently associated with doing “bad” things; therefore people infected or affected could be stigmatized.

On the issue of condom use, respondents had seen condoms before in their lessons and knew it protects against sexual infections, but indicated “it is not 100% safe”; “it is for those who are willing to risk their life”. Some were indifferent and wondered why educators say much about condoms instead of focussing on prevention: if educators want us to abstain, why are we being taught about condoms? Teachers’ focus was mostly on prevention and counselling without major highlight on condoms use. Though they mention condom in the course of education, they disliked any elaboration. A teacher stated that our culture does not encourage these things. Another had problem talking about condoms in details because, he argued, “it is like telling them to go ahead with sex”. They stated, some people talk about condoms “as if that is the best preventive step.” They showed strong preference for abstinence because the students are too young to engage in sex.

Teachers’ attitude suggests a concern about a potential conflict between teaching about both abstinence and condoms as preventive methods similar to the students’. They feared that telling them about condoms would encourage them to be sexually active and provide them with an excuse not to take the abstinence message seriously. It has been argued by Stein and Wang [26] that how teachers teach is influenced by their attitudes towards it; their attitudes and experiences affect their comfort with, and capacity to teach… HIV/ AIDS, suggesting teachers may not teach what affect their comfort ability.

The way forward

The following represents respondents’ views and intentions to halt HIV spread. Fundamentally, they believe that teen abstinence is the best choice with the potential to fully protect and act as a preventive measure. Reasons advanced to support teen abstinence which could all be considered as values include, “keeping traditional values for social approval, religion, and preventing danger to achieve future expectation.”

The values mentioned include marriage as an honor, abhorrence of premarital sex and cherishing virginity. These must be pursued according to respondents, to gain social approval: pleasing family to gain recommendation and respect. Marriage was considered as an honor to the individual and to the family; therefore each growing child has that hope to meet parental expectation. What seemed evident and important to them was a strong conviction that sex should not be practiced outside marriage; “it is a sin and a disgrace to the family, more so as teenagers”.

They also mentioned virginity as a cherished reality, because it protects and stressed that there are many virgins in Ghana, though some friends may tease, others appreciate and encourage. In keeping virginity before marriage, they indicated one gains self-respect and is respected in marriage. The influence of friends to engage in sexual activities is a reality but some stressed individuals must be independent, consider what is good for oneself, be assertive, choose own goals and purposes, take personal responsibility and resist temptation. A girl emphatically stated, “you have to avoid such people who try to influence you with bad ideas.”

They acknowledged that though abstinence is difficult and comes at a cost, it’s possible if one “tries hard”. Underlying the belief of voluntarily refraining from sexual activity are statements such as: these days it is sensible to abstain from sex until one gets married; it is against my values to have sex as an unmarried teenager.

These values were echoed by the teachers: …society is against sex before marriage and abstinence is preferred. They claimed, the norm is, that …a child who has a “boy/girlfriend” is seen by society as spoilt because sexual practices at their age could give them many problems: health and studies could be affected; parents are proud of children who abstain; such children honor their parents by showing respect… Teachers’ emphasised their belief: prevention is better than cure; prevention is the key and children must avoid sex.

Despite responses and attitude in favor of sexual abstinence, others, especially the girls group, suggested some people were in relationships: It is difficult to spot them but some are here; I have seen people in relationships; some have started doing things which are very bad; when we come for evening classes you can see some people hiding in some corners. The teachers corroborated, expressing concern about the lifestyle of some pupils. Their anecdotal evidence indicate some are having “secret” pre-marital sex: At JHS they think they are old enough, playing games as if they are married; some have boy/girlfriends so we educate them to know the consequences of what they are doing; I have heard, seen some myself and convinced that they are true... We try to counsel them against such practices; Some do get pregnant in the course of writing exams or after; Looking at the way some dress and behave, especially outside school, you can easily tell that a few have boy/girlfriends; …some are more than adults by their mannerisms; …an estimate of about 15% of the boys and 10% of girls are associated with these lifestyles and behaviours.

Teachers’ views support pupils’ views that love relationships exist among pupils, a development which they considered worrisome and could be a major problem. Their evidence corroborates with Kabiru and Ezeh’s study [27], where 85% of Ghanaian male respondents aged 15-19 years reported no previous sexual activity, an indication that about 15% have had sexual debut.

Religion was mentioned as a key value: all respondents stated they belong to a group, attend meetings and enjoy a personal relationship with God portraying both personal and institutional modes of religiosity. Among reasons why religion is vital to them were: to please God, church and family. Teachers also held strong views of religious influence among students and predominance in the social set up: religion plays a role and have influence on what pupils think and do. They stated, that non-denominational worship is conducted every Friday morning to teach them how to live and relate to each other; in the social set up you can see how people are religious in the way they talk, and on the media. Another indicated …for those who are not involved in any relationships, it may be due to the influence of their religious beliefs or churches. Some are really so religious that they will not entertain any boy-girl relationship at all.”

On the role of religion in HIV education, a teacher stated: I know about the key religions: Moslems don’t encourage sex before marriage likewise Christians. So religion encourages and helps prevention of HIV because Christians will shun you when they see you in a relationship outside marriage. I do not see anything wrong if religion can help us fight the disease, we should do more. Because they belong to a religious group, respondents indicated, that they are taught and expected to avoid sex before marriage, especially, as young people; it is a sin against God; they could be suspended; it shames the individual; the family, church and parents will not be happy. If they abstain, God will bless them, they can have better relationship with God; improve prayer life and better future. The responses indicate instructions at religious centres, school and home which put much emphasis on abstinence and consequences of sex outside marriage.

There was a sense that delaying gratification could help them prevent infection and pregnancy so they could pursue higher education, which could guarantee better future, good marriage and other benefits. Views suggest futuristic concerns and expectation are possible if they could prevent danger. Respondents stressed, feelings can be and have to be overcome and mentioned some qualities of intrinsic worth such as self-control and ability to resist temptation, sacrifice, and drawing strength from God. These suggest a kind of delaying gratification and sacred sacrifice: giving up something ‘good’ for something ‘better’ in future [28].

Values have been projected as the way forward but in a multicultural society like Ghana undergoing rapid change, a question is raised, “which cultural norms and values are being affirmed and who chooses?” [29]. Recommendations in Ghanaian studies [27,30] endorsed abstinence until marriage as a preferred mode for HIV prevention based on the reasons: too young for sex, fear of HIV/ pregnancy and on religious basis and advocated same, to serve as the basis “to spearhead the drive toward abstinence and restore pride in virginity”. However, virginity, which is an honour of the female and a way to gain the respect of the family of the would-be husband, is considered as double sexual standard for males and females, whereby parents expected only daughters to be virgins [31].

Conclusion and Recommendations

In conclusion, respondents have stressed the essence and role of values in making decisions suggesting such to drive the focus to curb the HIV incidence. The teachers similarly, advocated sociocultural values be emphasised in HIV education, claiming such values reflect what is important in Ghana irrespective of tribal or religious differences. The integrated theory [4] and integrated valueexpectancy theory [7] served as framework explaining respondents’ intentions. Underlying their resolve are psychosocial concepts such as attitudes/beliefs, self-efficacy, subjective norms and motivation. The position of respondents suggests a preference for the promotion of prevention instead of protection, abstinence instead of condom use, generally, explained within cultural frameworks of value-based and futurist expectations. If they respect their body and keep virginity till marriage, it pleases the family and God. Consequently, they gain social approval and receive God’s blessing. Further, they avoid negative consequences (HIV and teenage pregnancy), and are able to pursue progressive education, which could guarantee better future and marriage.

The evidence suggests religion, is an important constituent in the life of the adolescent, which Regnerus et al. [32] indicate reduced problems such as sexual permissiveness, teen pregnancy and increases self-esteem. Individuals who are religiously devoted average begin having sex later and have fewer sexual partners if they have to, than the less devoted. A parallel study observed religiosity having the potential to promote positive attitudes and behavior among adolescents in health-based problems, including HIV though it could not be a guarantee, as a ‘magic wand’ to solve all related problems [33]. The evidence does not support the prospect of attaining abstinence for all; some religious people may abstain but not all religious people will.

Prevention was preferred protection, and abstinence, considered the best and only option that guarantees 100% prevention from HIV. Emphasis on abstinence despite perceived prevailing sexual activities among respondents does not offer a comprehensive solution. Condom use, which could offer protection for the sexually active is not highlighted, a potential to endanger the sexually active and make them vulnerable. For those who abstain, it is not certain what they will do in spite of their convictions, especially when they progress to boarding senior high school, away from scrutiny of parents or religious groups.

The complexity of adolescent sexual behavior raises a major concern; any personal and cultural inhibitions, therefore need to be reconsidered. Given this problem, a multi-faceted solution is advocated. Involving religious leaders/groups and health professionals in HIV education could ensure a comprehensive education. Teachers’ role in school-based education is crucial: continuous training and resourcing will help them to effectively teach and address potential conflict between abstinence and condoms use, as methods of preventing HIV transmission.

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