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African Population Studies/Etude de la Population Africaine, Vol. 12, No. 1, March/mars 1997 Sexual Behavioural Factors Predisposing "Street-involved" Youth in Accra to HIV/AIDS Infection John K. ANARFI and B.N. APPIAH Institute of Statistical, Social and Economic Research, University of Ghana, Legon Code Number: ep97004 Abstract The study covered 250 respondents from ages 10 to 24 and comprised 175 males and 75 females. The source of data was a survey conducted in 1992 on the out-of-school youth in Accra and risk-taking behaviour. The survey instrument was a structured questionnaire with focus group discussion as supplement. The respondents were of very low socio-economic status that cut across education, occupation and residential background and had probably resulted from similar low level education of parents and loose family bonds. The combined effect of these appeared to have forced the respondents to take up early responsibility for their own lives in occupations and environment that reinforced and sustained a condition of sexual vulnerability among the youth. This was further to be aggravated by the respondents' forward motivated sexual perception which eventually manifested in a state of rampant and unprotected sexual relations. Risk reduction was virtually non-existent because STDs/AIDS were perceived to be diseases of commercial sex workers. Implications of the findings call for intervention efforts both specific to the group and the general population. However, in addition to AIDS campaign efforts, solutions to adverse social and economic conditions that predispose the youth to high-risk environment and risk-taking sexual behaviour are called for in the long term. Une étude a été menée en 1992 sur le comportement sexuel risqué des jeunes ayant abandonné l'école à Accra. les personnes intérrogées ont un statut socio-économique très bas qui provient probablement d'un faible niveau de l'origine socio-économique des parents et généralement de liens familiaux lâches. L'effet conjugué de ces facteurs semble avoir contribué à la vulnérabilité sexuelle des jeunes. Cela devait être aggravé davantage par la motivation sexuelle précoce des personnes interrogées qui s'est finalement manifestée par le caractère généralisé et non protégé des rapports sexuels. La réduction du risque était pratiquement inexistante parce que les MST/SIDA étaient perçus comme des maladies propres à ceux qui s'adonnent au commerce du sexe. Ces conclusions appellent des efforts d'intervention spécifiques au groupe et à la population globale. Outre les efforts déployés dans le cadre de la campagne anti-Sida, il est nécessaire d'aborder les conditions sociales et économiques défavorables qui prédisposent la jeunesse à un environnement à haut risque et à un comportement sexuel risqué. Introduction and background In Ghana, more than 2,000 youths between ages 10 and 24 years are reported to be presently HIV/AIDS-infected. This number, believed to be rather conservative, forms 16 per cent of the reported number of cases in the country (Obimpeh 1994). Since the advent of the economic recovery programme, several youths have been thrown into the streets peddling for survival. Such youths are often characterized by boredom, lack of parental control and supervision and lack of commendable residential arrangements. These factors are likely to make them vulnerable to high risk- taking sexual behaviour with implications for HIV/AIDS infection. Ironically, in the area of AIDS control, such youths are often not a target group. Indeed, most studies on AIDS have concentrated on the so-called sexually high-risk groups. Recently, some researchers called for the redirection of attention from the behaviour of individuals and groups towards the institutions and environments within which they operate so that the conditions under which the behaviour occurs could be studied (Muir, 1991). Writing on AIDS in Uganda, Barnett and Blaikie (1992) observed that, because of civil disruption, war, smuggling and unequal access to economic resources, "the question has become less that of a certain sexual behaviour being risky since all sexual behaviours are risky in the high-risk environment" (Barnett and Blaikie, 1992:68). The present study therefore adopted the environmental approach. Given the fact that sexual activity is the commonest way of spreading HIV infection, it is envisaged that the sexual behavioural characteristics of the youth vis-a-vis the environment within which they operate would have implications for the spread of the disease. This paper examines the socio-demographic and sexual behavioural characteristics of "street-involved" youths in Accra that could have implications for infection and spread of HIV/AIDS. Following this introduction is a description of the setting within which the target group operated, their socio-demographic background as well as the socio-economic status of their parents. The assessment of their knowledge about human sexuality and their sexual behaviour and practices are taken up next. These are followed by a review of their perception about sexually transmitted diseases and their risk of acquiring sexually transmitted diseases, including AIDS. An attempt is then made to evaluate their risk reduction behaviour. The paper ends with an evaluation of the implications of the above issues for the spread of HIV/AIDS. The setting and field work/data collection The areas selected for the study lie within the hub of brisk commercial activities which attract a teeming number of people during the day. A few makeshift structures add to the general atmosphere of sub-standard conditions. Sheds served as places of rest for most of the youth during the day. Although marijuana peddling and smoking is illegal in Ghana, these activities are done openly in and around such sheds. There was no regular pattern of activities for the day as they coped with their survival strategies. In the night, the frontage of shops and sheds in the markets offered shelter and tables served as beds for many. The need to get money in order to survive has forced some of them to go into socially unacceptable means of earning incomes -the boys into the sale of marijuana, petty stealing and swindling. Some of the girls were forced into "survival sex". The legitimate activities for earning a living included porterage, cleaning and sale of petty items in the street. Almost all of them were compelled to wake up early, sometimes as early as 4.00 a.m. before owners of stores and sheds arrived for work. They therefore spent the early part of the day roaming about before sunrise. This unavoidable situation made them fall foul of the law quite often as they usually encountered police on patrol. Some of the girls, in fact, moved from petty trading into commercial sex when their wares were allegedly seized by task force men. Under the circumstances, the life of such youths in Accra is one of continuous struggle for survival in an atmosphere of fear, intimidation, violence and vulnerability. The data for the study mainly came from questionnaire surveys and were supplemented with focus group discussions. The fieldwork was conducted between August 11 and 27, 1992 in the centre of Accra. Two areas, the Kantamanto and Agbobloshie markets and the transport stations adjoining them, were selected as the survey areas. One insider was contacted from among the target population and was used as the frontman. The sample technique was therefore mainly purposive but accidental and it covered those willing to provide information. A total of 250 respondents were interviewed. This comprised 175 males and 75 females. After the interview, four homogeneous groups of 8 individuals each, selected on the basis of age and sex, were engaged in focus group discussions. These comprised eight males and eight females selected from the target population within ages 10-24 and eight males and eight females above age 24 who were outside the study group but within the same environment. Results The median age for the group was 20.1 years with males being slightly older than females. The educational background of the respondents was rather low. About 91 per cent of them had gone through primary school out of which 46 per cent had post-primary school education including 9.2 per cent with some secondary or vocational education. The males were found to be better educated than the females. Eighty-five per cent of them were engaged in generally low level jobs that perhaps correlated with their poor educational background. The males were largely porters and petty traders and the females were more likely to be engaged in commercial sex. Such occupational background predisposed them to a life of continuous struggle for survival. The nature of their jobs brought them into contact with various persons some of whom were likely to take advantage of their financial inadequacy and vulnerability. The majority of the respondents (51 per cent) did not have any commendable residential arrangements and slept at various places including the market and bus stop, thus worsening their already vulnerable condition. In addition, virtually all of them spent the greater part of the day at the market, transport station and in the streets. Understandably, these were the places to which the nature of their jobs was likely to expose them to. It was further revealed that over 70 per cent of them provided their own meals, a further indication of independence and lack of support. In general, the socio-demographic background of the respondents showed a continuum of low educational background, poor income-generating jobs, appalling residential arrangements and a daily self-supporting life routine that kept them in the market and streets throughout the day and in the night. The educational background of their parents, as given by the respondents, showed a pattern that found its peak at the middle school level (43 per cent of respondents). It was further revealed that 20 per cent of the respondents did not know their parents' educational background. This implied a state of unfamiliarity with parents, a condition that perhaps found expression in the respondents' own poor educational background and lack of parental care. It also emerged that almost 60 per cent of the respondents' parents were no longer married and this probably had contributed to a situation where 69 per cent of the respondents did not have the benefit of joint parental upbringing, placement, support and supervision. In fact, 41 per cent of them stayed on their own and just about 44 per cent had same meaningful interaction with both parents. Reduced parental influence was further revealed by the fact that the respondents were more likely to report to siblings in case of trouble than to a parent and important decisions were often taken in consultation with peers rather than with siblings or a parent. It can thus be said that the tendency towards independence and peer influence appeared to have been conditioned by their social and physical environment and by some apparent loose family bonds that did not seem to have offered them meaningful social and economic support. As regards their sexual perception, the general opinion of the respondents was that sexual intercourse must begin at age 17 for boys and 16 years for girls. However, the female respondents had a perception that showed a tendency toward early sexual intercourse. In addition, 39 per cent of the respondents indicated that it was not possible for human beings to stay away from sex, citing biological necessity as the main reason. This view was further reinforced by participants in the focus group discussion. Further to the above, the greatest proportion of the respondents (43.6 per cent) (45.7 per cent males and 38.7 females) suggested that one must have sex 2-3 times a week. Among the females 13.3 per cent had suggested that sexual intercourse must be everyday, thus implying their possible involvement in commercial sex. The reported mean age at which they had their first sexual contact was 15.9 years for males and 16 years for females. However, the majority of them (52 per cent) had their first sexual intercourse between ages 15 and 19 (Table 1). Table 1: Distribution of Respondents by Sex and Age at First Sexual Experience
Regarding their current sexual practices the respondents were found to be very sexually active. The data showed that 83.2 per cent had ever had sex, 82 per cent had been active in the last year before the survey and 74.4 per cent in the last 3 months before the survey. In all, the respondents had had a mean of 5.4 sexual partners in their life time, 2.9 in the last year before the survey and 2.4 in the last 3 months before the survey (Table 2). The males had 5.9, 3.2 and 2.4 sexual partners over the specified periods whilst the females had 4.3, 2.3 and 2.3 sexual partners respectively. Table 2:Percentage Distribution of Respondents by Sex and Number of Sexual Partners Over Specified Periods
Sexual relations were maintained mainly as a source of pleasure as indicated by 48.8 per cent of the respondents (54.3 per cent for males and 36 per cent for females). However, 24 per cent of the females maintained sexual relations mainly for economic reasons as against 1.1 per cent of the males. This implies that a significant proportion of the females may have been engaged in commercial sex. The respondents largely engaged in sexual activity 1-3 times a week (42.8 per cent) but, for the females, the second largest proportion indicated that they were involved in sexual activity daily as reported by 36 per cent of their number against 16 per cent for the males (Table 3). This reinforces the earlier suggestion about their involvement in commercial sex. Sexual activities were to a large extent conducted in the market. Table 3: Percentage Distribution of Respondents by Sex and How Often They Met Their Sexual Partners
The sexual networking that characterized the group was sustained among members of the group and between the group and individuals from outside the group who came into contact with them (Figure 1). Within the group were boys whose sexual activities were motivated by desire for pleasure on the one hand, and girls who "did" it for pleasure and or for money on the other hand. Thus, a mutual sexual obligation existed within the group and this appeared to have turned their physical and social environment into a sex pool within which most of them were likely to bath. The harsh and vulnerable nature of their environment, which forged mutual co-operation and protection, further created the conditions for sexual involvement. Their occupations largely as porters and petty traders brought them into contact with others like traders, hawkers, truck drivers, etc. What started as economic relationships with these outsiders tended to develop into intimate relationships that fostered the economic activity and was further dictated by the environmental conditions within which they operated (Anarfi and Antwi, 1993). Given this background of vulnerability within a high-risk environment, the study examined the respondents' perception about sexually transmitted diseases including AIDS and their risk of acquiring such diseases. More than 90 per cent of the respondents showed a high knowledge and awareness of AIDS and its mode of transmission as largely through sexual contact (Table 4). However, virtually all of them qualified such sexual contact to be one with a commercial sex worker, thus introducing some level of misconception into their knowledge. Another sign of misconception was shown in their belief that AIDs could be caused by witches, supernatural powers, and through kissing. Females were more likely than males to hold such misconceptions. About one-fifth of them actually reported having been treated for STDs before, the male proportion being almost twice that of females. Further, about 67 per cent of them had good knowledge about the early symptoms of STDs which largely centred on discharge and pain in genital organs and pains in the lower abdomen. Table 4: Percentage Distribution of Respondents by Sex and Knowledge about AIDS Transmission
Self-medication was the initial effort at treating STD usually with penicillin powder in either "akpeteshie" (a local gin) or palm wine. In addition to this and the misconceptions earlier mentioned, the respondents did not appear to regard STDs in particular as serious ailments as some of them confessed that they still had sex even when they knew they had STD. On their risk reduction behaviour, although the majority of them knew of condoms, less than one-fifth used them. For instance, in the last three months before the survey, only 6 per cent of the respondents reported using condom, the same period in which 76 per cent reported being sexually active. The main reason offered for non-use of condom was that they just did not like it. However, this might be associated with their general belief that STDs/AIDS could mainly be contracted through sexual contact with commercial sex workers. Logically then, if one's partner is not seen as a prostitute there would be no need for one to use condom. The specific changes in sexual behaviour resulting from the AIDS scare seemed to centre on avoiding sexual contact with persons engaged in commercial sex. Implications for infection and spread of HIV/AIDs The socio-demographic background of the respondents pointed to their low socio-economic status, appalling residential arrangements and independence from parental control, with peers as source of emotional support and information. They were therefore vulnerable to social forces that operated in their environment. Such vulnerability was strengthened by the unprotected nature of their sleeping arrangements and the necessity of satisfying natural sexual gratification which in turn could be stepped up by their easy accessibility. Within this context, sex could be conducted in a very reckless and frequent manner without much protection due to a probable combination of such factors as financial inadequacy, ignorance and environmental conditions. For instance, if one had to engage in sexual intercourse in a corner or under a stall, it would be environmentally inexpedient to have to slip on a condom. One might always be in a hurry to finish the "act" before someone emerged. Besides, respondents might not even have the money to purchase the condom. It is suggested that when micro and macro conditions occasion such phenomena, the arena for heterosexual behaviour and possible spread of the HIV would have been unintentionally created. In such circumstances, the likelihood of infection and spread of the AIDS virus among the youth cannot be ruled out. The danger is that this happens to be a group that may hardly readily come to mind in AIDS intervention programmes probably because they appear to be "unreachable". The respondents had a forward motivated perception of sex which made them see sexual intercourse as an unavoidable biological and pleasurable necessity. This perception was translated into very active sexual behaviour. Within the study group itself sex appears to be conducted in a massive and reckless manner and involved partner swapping. The inherent implications of these for the infection and spread of the disease are very obvious. The risk is even made higher by the fact that common STDs known to be important co-factors of the spread of HIV are rife among the youth. The argument here is that if a few of them contract the disease, there is the dangerous potential that it can spread fast within the group due to their unrestrained sexual practices. As Lewis and others (1989) point out, the basic reproduction rate of AIDS, that is, the number of other people that the typical HIV-infected person goes on to infect will determine the severity of the spread of the disease. It was also noted that members of the group interacted with others who came into their environment for economic activities. Such contact could result in sexual intimacy. An infected outsider could pass on the virus to the youth. The reverse is also true. The two persons involved in the drama then "freely distributed" the virus within their own respective environments depending on their general sexual conduct. The implication here was that the environment of the out-of-school youth could serve as the pool from which the HIV could spread to the general population via the others who came there. It is generally suggested that the vulnerability of the youth conditioned by poor economic background latently makes them least resistant to the spread of the infection. As Sabatier (1987) puts it, "when the AIDS virus is introduced into a society it tends towards the path of least resistance". This is often the path trodden by the poorest, most disadvantaged, least-powerful, or most stigmatized (Muir, 1991). Almost all the adjectives adequately describe the study group. These then become the escape routes for infection and spread of the disease into the general population. The worrisome side is that such groups of people are usually cut off from AIDS campaign programmes since their activities do not become apparent. Secondly, they do not operate in an organized form, to make them accessible to intervention efforts. Thirdly, the environment within which they operate (as work place and sleeping place) will generally not expose them to general public campaign programmes through the electronic and print media. The respondents showed a high knowledge and awareness of STDs and their mode of transmission. The same high level of awareness was reported in the specific case of AIDS. Almost all the respondents readily mentioned sexual contact as the main mode of transmission of STDs and AIDS. However, virtually all of them qualified such sexual contact as one with a prostitute, thus introducing some level of misconception into their knowledge. It was also thought that one could get infected through supernatural manipulations. The impression here appears to be that a respondent is likely to perceive himself/herself safe if he/she did not engage in these "risky" habits or is not bewitched. Under the circumstances, a respondent may unknowingly be spreading an infection he/she may have contracted from a perceptibly safe habit. As regards their risk reduction behaviour, although the majority of them knew of condoms, just about 6 per cent used them in the last three months preceding the study. This might be attributed to their general belief that STDs and AIDS could be contracted through sexual contact but only from those engaged in commercial sex. Logically then, if one's partner is not seen as belonging to that category there would be no need for one to use condom. Subsequently, in the absence of any meaningful risk reduction behaviour the youth may be spreading the disease possibly at a rate no one imagines and may thus constitute one of the potential HIV distributors in the country. Recommendations Given that most of the behaviours of the "street-involved" children help them cope and survive in their adverse environment, AIDS intervention programmes must be innovative in adopting an integrated approach addressing their situation as well. In addition to mass awareness campaigns, an office must be set up preferably in the environment in which they operate to cater specifically for their needs. This will make certain medical and educational services more accessible to this category of people who feel cut off from the main society. The youths can enter this office for advice and counselling, or even for treatment without fear of being tagged. Social marketing could be put to use in such an office. The treatment of sexually transmitted diseases (STD) should be made a priority. There was evidence that, among the study group, STDs were not sufficiently treated and it is now known that untreated STDs greatly facilitate the spread of HIV. Such treatment must therefore be free or heavily subsidized. Efforts must be made to improve the social and economic conditions of the youth and thus reduce their dependence on practices such as peddling, drug abuse and prostitution. Those who require training in certain skills should be given the opportunity to upgrade themselves. It has been observed that, with increased knowledge and behavioural skills in particular, individuals can give up certain behaviours and negotiate lower-risk sexual activity. It has also been observed that educational programmes which make use of "insiders" as role models prove particularly successful. Campaign programmes must therefore have components of peer support and peer education. Above all, the integrated approach requires that the AIDS campaign programme must be run by a team of dedicated experts with varied backgrounds. They should include a social scientist, a medical practitioner, a psychologist and a social worker. References
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