University of Ghana http://ugspace.ug.edu.gh ATTITUDES OF MOSLEMS ON HIV AND AIDS RELATED STIGMA AND DISCRIMINATION IN UPPER WEST REGION, GHANA BY ABUDU SAKARA (10097266) THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF P.HD IN ADULT EDUCATION DEGREE. JULY 2019 University of Ghana http://ugspace.ug.edu.gh DECLARATION Candidate’s Declaration I hereby declare that this thesis is the result of my own original research and that no part of it has been presented for another degree in this University or elsewhere. …………………………… …………………….. Abudu Sakara Date (Candidate) Supervisors’ Declaration We hereby declare that the preparation and presentation of the thesis were supervised in accordance with the guidelines on supervision of thesis laid down by the University of Ghana. …………………………… …………………….. Dr. Samuel Kofi Badu-Nyarko Date (Principal Supervisor) …………………………… …………………….. Dr. Clara O. Benneh Date (Co-Supervisor) i University of Ghana http://ugspace.ug.edu.gh DEDICATION I dedicate this work to my dear wife Niamatu Abdulai, and my lovely children, Nafisah Sakara, Hamdia Mwindingu Sakara, Abdul Hamid Tuurosung Sakara and Abdul Hamad Yelsung Sakara for their patience, understanding and prayers throughout my academic journey. ii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT I owe a lot of gratitude to the Almighty God for giving me life and sustained sound health which enabled me to go through successfully this academic journey. I am equally and particularly appreciative to my supervisors, Dr. Samuel Kofi Badu-Nyarko, Dr. Clara O. Benneh and Prof. Kate Adoo-Adeku of the Department of Adult Education and Human Resource Studies of University of Ghana for their patience, direction, advice and invaluable and constructive suggestions, which have contributed in no small measure to the completion of this work. Without their guidance and expertise knowledge, my efforts would have been in vain. To them I convey my utmost and deepest gratitude. My profound gratitude also goes to Ms. Valentine Gemegah, the Administrative Secretary and Ms. Zeidicurl Adjei, all of the Department of Adult Education and Human Resource Studies, Legon, Ms. Rebecca Abibata Larry, Administrative Assistant at the Kumasi Learning Centre for their secretarial work. My special appreciation also goes to Mr. Dayuo Augustine and family, Messrs. Mohammed Saani Seidu, Ilyas Yakubu Salifu and Adams Asuma for their continuous moral and material support during my academic journey. To my dear brother and colleague, Dr. Namoog Yinkorah Moses, I say accept my deepest regards and gratitude. Last but not the least, I express my gratitude to all staff of the Kumasi, Tamale and Wa Learning Centres of the School of Continuing and Distance Education, University of Ghana for providing me with the necessary conducive working environment to complete this work. iii University of Ghana http://ugspace.ug.edu.gh ABSTRACT HIV and AIDS is one of the most widespread and devastating epidemic with global public health implications in the 21st century and Ghana as a nation, is not an exception. Several studies in Ghana suggest that HIV and AIDS related stigma and discrimination has been the bane of fighting the reduction and elimination of HIV and AIDS. Such issues like nondisclosure, public outcry, and social exclusion constitute a basic problem so far as the disease is concerned. This study therefore tends to look into stigma and discrimination and for that matter, the influence of the beliefs and practices and socio-demographic characteristics of the Moslems on their attitudes towards PLWHAs within this catchment area. To achieve its objective, the study employed the cross sectional survey research design. With the aid of structured interview schedules as well as the multi stage, incidental and purposive sampling techniques, the primary data was gathered from 300 (178 males and 122 females) Moslem respondents from three sampled districts namely Wa Municipality, Wa West and Sissala East. Pearson correlation co efficient and the chi square test statistics as well as descriptive statistics (mean scores, standard deviation, frequency counts, percentages and cross tables) were also employed to check and analyse significance, the extent of relationship and or influence. The major findings of the study were that Moslems’ attitude towards PLWHAs was positive and to a large extent influenced by their beliefs and practices as enshrined in the Quran and Hadith. Among the four constructs of religious, social, economic and political, the most discriminatory was that of social engagement (x̅ = 3.60; sd= 1.13). iv University of Ghana http://ugspace.ug.edu.gh There was also a significant relationship between the socio-demographic or personal characteristics (sex, age and educational background) of the Moslems and their attitudes towards PLWHAs in relation to religious, social, economic and political engagement. The Moslems in the Upper West region will not disclose their HIV and AIDS status ( x̅ = 2.79; sd= 1.33) despite their religious beliefs and practices for fear of discrimination and stigma. To help minimise the negative impact of HIV and AIDS related stigma and discrimination, the study recommended that Moslem leaders’ teachings should be centered on what Islam espouses on attitudes towards the sick and vulnerable, especially PLWHAs. Another recommendation of the study was that adult education institutions (National Commission on Civic Education, Institute of Local Government Studies, Department of Adult Education of the University of Ghana and the District Assemblies) should organise training programmes to educate and sensitise religious leaders, tutors and students of Islamic educational institutions to enable them accept the sick, especially PLWHAs. It is also recommended by the study that Moslem leaders, National Commission on Civic Education and District assemblies should organise education and training programmes for Moslem communities to help reduce HIV and AIDS related stigma and discrimination. v University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS Content Page DECLARATION ................................................................................................................. i DEDICATION .................................................................................................................... ii ACKNOWLEDGEMENT ................................................................................................ iii ABSTRACT ...................................................................................................................... iv TABLE OF CONTENTS .................................................................................................. vi LIST OF TABLES .............................................................................................................. x 1.1 Background to the Study ........................................................................................... 1 1.2 Statement of the Problem .......................................................................................... 5 1:3 Purpose of the Study ................................................................................................. 7 1:4 Main Objective.......................................................................................................... 7 1.5 Research Questions ................................................................................................... 8 1.6 Significance of the Study .......................................................................................... 9 1.7 Scope and delimitation of the Study ....................................................................... 10 1.8 Definitions of Terms ............................................................................................... 10 1.9 Organisation of the Thesis ...................................................................................... 11 THEORETICAL FRAMEWORK AND REVIEW OF RELATED LITERATURE ....... 13 2.1 Introduction ............................................................................................................. 13 2.2 Attribution Theory .................................................................................................. 15 2.2.1 Attribution-Affect-Action Theory ........................................................................ 16 2.3 Review of Related Literature .................................................................................. 18 2.3.1 Concept of Stigma ................................................................................................ 18 2.3.2 Concept of Discrimination ................................................................................... 22 2.3.3 HIV and AIDS related- Stigma ............................................................................ 25 2 .3.4 Causes of HIV and AIDS related Stigma............................................................ 26 2.3.5 Effects of AIDS and HIV Stigma and Discrimination ......................................... 36 2.3.5 Attitudes towards Persons Living with HIV and AIDS ....................................... 37 2.3.7 The Islamic Religion: Beliefs and Practices ........................................................ 51 2.3.7 Islam and Economic Related Activities ............................................................... 54 2.3.8 Islam and HIV and AIDS related Stigma............................................................. 58 2.3.9 Policy Interventions on HIV and AIDS related Stigma and Discrimination ....... 64 vi University of Ghana http://ugspace.ug.edu.gh 2.3.10 HIV and AIDS Policy in Ghana ......................................................................... 68 3.1 Introduction ............................................................................................................. 73 3.2 Profile of the study Area ......................................................................................... 73 3.3 Research Design ...................................................................................................... 77 3.4 Population of the Study ........................................................................................... 78 3.5 Sampled Population of the Study ............................................................................ 79 3.6 Sampling Techniques .............................................................................................. 79 3.7 Sample Size ............................................................................................................. 82 3.8 Data Collection Instrument ..................................................................................... 82 3.9 Pre-Testing for validity and reliability of Data collection instrument .................... 84 3.10 Data collection ...................................................................................................... 85 3.11 Data Analysis Methods ......................................................................................... 87 3.12 Ethical Issues......................................................................................................... 87 PRESENTATION OF RESULTS .................................................................................... 89 4.1 Section A: HIV and AIDS related Stigma and Discrimination .............................. 90 4.1.1 Moslems’ Opinion on the Reality of HIV and AIDS related Stigma and Discrimination ............................................................................................................... 90 4.1.2 Moslems Beliefs and Practices: ........................................................................... 90 4.1.2 a. Faith (Belief) in Almighty Allah (God) ........................................................... 90 4.1.2 b. Reasons for Answer ......................................................................................... 90 4.1.2 c. Belief in Destiny............................................................................................... 91 4.1.2 d. Reasons for Answer ......................................................................................... 91 4.1.2 e. Fasting .............................................................................................................. 92 4.1.2 f. Reasons for No Answer .................................................................................. 92 4.1.2 g. Relating with PLWHAs ................................................................................... 94 4.1.2 h. Pilgrimage to Mecca ........................................................................................ 95 4.2.1 Moslem Respondents and Related Religious Engagement with PLWHAs ......... 96 4.2.2 Related Social Engagement with PLWHAs......................................................... 97 4.2.3. Related Economic Engagement with PLWHAs ................................................. 99 4.2.4 Related Political Engagement with PLWHAs ................................................... 100 4.4. a. Sex and Religious Relations with PLWHAs .................................................... 107 4.4.a. Correlation on Sex of Moslem Respondents and their Attitudes towards PLWHAs in Religious related Engagement ................................................................ 108 4.4.b: Age of Respondents and Religious Relations with PLWHAs ......................... 109 vii University of Ghana http://ugspace.ug.edu.gh 4.4. b: Correlation on Age of Moslem Respondents and their Attitude towards PLWHAs in Religious related Activities .................................................................... 110 4.4. c: Educational level and Religious Relations with PLWHAs .............................. 111 4.4. c: Correlation on Education level of Respondents and their Attitudes towards PLWHAs in Religious Related Relations ................................................................... 112 4.4.d: Sex and Social Relations with PLWHAs .......................................................... 113 4.4. d: Correlation on Sex of Moslem Respondents and their Attitudes towards PLWHAs in Social related Engagement ..................................................................... 114 4.4.e Age range of Respondents and Social Relations with PLWHAs ....................... 115 4.4. e: Correlation on Age of Moslem Respondents and their Attitude towards PLWHAs in Social related Engagements ................................................................... 117 4.4.f: Education level and Social Relations with PLWHAs ....................................... 118 4.4.f: Correlation on Educational level of Moslem Respondents and Attitudes towards Social related relations with PLWHAs ....................................................................... 119 4.4.g: Sex and Economic relations with PLWHAs ..................................................... 120 4.4.g: Correlation on Sex of Moslem Respondents and their Attitudes towards PLWHAs in Economic related relations ..................................................................... 121 4.4.h Age of Respondents and Economic relations with PLWHAs ............................ 122 4.4.h: Correlation on Age Moslem Respondents and their Attitudes towards PLWHAs in Economic related Engagements .............................................................................. 123 4.4.i: Education and Economic Related Relations with PLWHAs ............................. 125 4.4. i: Correlation on Moslem Respondents’ Educational level and their Attitudes towards Economic related activities with PLWHAs ................................................... 126 4.4. j: Sex of Respondents and Political Relations with PLWHAs ............................ 128 4.4. k: Age range of Respondents and Political Relations with PLWHAs (Yes) ....... 129 4.4.l:. Education and Attitude towards Political Relations with PLWHAs ................ 132 CHAPTER FIVE ............................................................................................................ 149 DISCUSSION OF RESEARCH FINDINGS ................................................................. 149 5.0 Introduction ........................................................................................................... 149 5.1 Moslems Beliefs and Practices on their Attitudes towards PLWHAs .................. 149 5.1.1 Attitudes towards PLWHAs in Religious relations ........................................... 158 5.1.2 Attitudes towards PLWHAs in Social relations ................................................. 160 5.1 Attitudes towards PLWHAs in Economic relations ............................................. 162 5.1.4 Attitudes towards PLWHAs in Political relations ............................................. 163 5.2. Socio Demographic Characteristics and Attitudes towards PLWHAs ................ 165 viii University of Ghana http://ugspace.ug.edu.gh 5.2.2. Sex of the Moslem Respondents and Attitude towards PLWHAs .................... 165 5.2.1 Education level of Moslem Respondents and Attitude towards PLWHAs in Religious ..................................................................................................................... 168 5.3. Identified teachings of Islam that support Moslems Non-Stigma and or Positive Attitudes towards PLWHAs........................................................................................ 180 CHAPTER SIX ............................................................................................................... 191 SUMMARY, CONCLUSION AND RECOMMENDATIONS..................................... 191 6.1 Introduction ........................................................................................................... 191 6.2 Summary of the Study........................................................................................... 191 6.3 Summary of the Study’s Findings ......................................................................... 193 6.3.3 Teaching of Islam that influence Moslems attitude towards PLWHAS ............ 193 6.3.4 Disclosure and its Effects on the individual, Family and Community .............. 193 6.3.5 Strategies for reducing HIV and AIDS related Stigma and Discrimination ...... 194 6.4 Conclusion ............................................................................................................ 194 6.5 Contribution to knowledge.................................................................................... 195 6.6 Recommendations ................................................................................................. 196 6.6.1 For Institutions ................................................................................................... 196 6.6.2 Development of knowledge ............................................................................... 197 6.6.3 For Further Research .......................................................................................... 197 REFERENCES ............................................................................................................... 198 APPENDICES ................................................................................................................ 203 Appendix A: Questionnaire ........................................................................................ 203 ix University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 4.1: Identified Religious related areas of Engagement with PLWHAs (Yes) ........ 97 Table 4 2: Identified Social related areas of Engagement with PLWHAs (Yes) ............. 98 Table 4.3: Identified Economic related areas of Engagement with PLWHAs (Yes) ....... 99 Table 4.4: Identified Political related areas of engagement with PLWHAs by the Moslems (Yes) ............................................................................................... 100 Table 4.5: Assessment of Moslem Respondents Attitudes and their Religious relations with PLWHAs ............................................................................................... 102 Table 4.6: Assessment of Moslem Respondents Attitudes and their Social relations with PLWHAs ........................................................................................................ 103 Table 4.7: Assessment of Moslem Respondents Attitudes and their Economic relations with PLWHAs ............................................................................................... 104 Table 4.8: Assessment of Moslem Respondents Attitudes and their Political relations with PLWHAs ............................................................................................... 105 Table 4.9: Overall Attitudes towards PLWHAs based on Religious Beliefs and Practices ........................................................................................................................................ 106 Table 4.10: Sex of Moslem respondents and related religious relations with PLWHAs (Yes) ........................................................................................................... 107 Table 4.11: Sex of Moslems respondents and related religious relations with PLWHAS ........................................................................................................................................ 108 Table 4.12: Age of Moslem Respondents and their Religious relations with PLWHAs (Yes) ............................................................................................................ 109 Table 4.13: Age of Moslem Respondents and their attitude towards Religious relations with PLWHAs (Yes) .................................................................................... 110 x University of Ghana http://ugspace.ug.edu.gh Table 4.14: Educational Level of Respondents and their Religious relations with PLWHAs (Yes) ........................................................................................... 111 Table 4.15: Educational level of Moslem Respondents and their Religious relations with PLWHAs (Yes) ........................................................................................... 112 Table 4.16: Sex of Moslem respondents and their social relations with PLWHAs (Yes) ........................................................................................................................................ 114 Table 4.17: Correlation between Sex of Moslem Respondents and their attitude towards Social relations with PLWHAs (Yes) .......................................................... 115 Table 4.18: Age of Moslems Respondents and their Social relations with PLWHAs (Yes) ........................................................................................................................................ 116 Table 4.19: Age of Moslem Respondents and their attitude towards Social relations with PLWHAs (Yes) ............................................................................................ 117 Table 4.20: Education and their Social relation with PLWHAs (Yes) ........................... 118 Table 4.21: Educational level of Moslems’ Respondents and their social relations with PLWHAs (Yes) ............................................................................................ 119 Table 4.22: Sex of Moslem Respondents and their Economic relations with PLWHAs (Yes) ........................................................................................................... 121 Table 4.23: Sex of Moslem Respondents and their attitude towards Economic relations with PLWHAs (Yes) .................................................................................... 122 Table 4.24: Age of Moslems’ Respondents and their Economic relations with PLWHAs (Yes) ............................................................................................................. 123 Table 4.25: Age of Moslems Respondents and attitude towards Economic relations with PLWHAs (Yes) ............................................................................................ 124 Table 4.26: Educational level of Respondents and their Economic relations with PLWHAs (Yes) ........................................................................................... 125 xi University of Ghana http://ugspace.ug.edu.gh Table 4.27: Educational level of Moslems Respondents and their Economic relations with PLWHAs (Yes) ........................................................................................ 126 Table 4.28: Sex of Moslem Respondents and their Political relations with PLWHAs (Yes) ............................................................................................................ 128 Table 4.29: Sex of Moslem Respondents and their attitude towards Political relations with PLWHAs (Yes) .................................................................................... 129 Table 4.30: Age of Moslems’ Respondents and their Political relations with PLWHAs (Yes) ............................................................................................................. 130 Table 4.31: Age of Moslem Respondents and attitude towards Political relations with PLWHAs (Yes) ........................................................................................... 131 Table 4.32: Educational level of Moslem Respondents and their Political relations with PLWHAs (Yes) ........................................................................................... 132 Table 4.33: Educational level of Moslems Respondents and their Political relations with PLWHAs (Yes) ........................................................................................... 133 Table 4.34: Islam and Stigmatisation and Discrimination against PLWHAs ................ 134 Table 4.35: Disclosure and Non-disclosure and Stigmatisation and Disclosure ............ 137 Table 4.36: Sex by Disclosure of HIV status variables .................................................. 139 Table 4.37: Age by Disclosure of HIV status variables ................................................. 140 Table 4.38: Educational level by Disclosure of HIV status variables ............................ 141 Table 4.39: Effects of Disclosure on stigma and discrimination on a PLWHA ............. 142 Table 4.40: Effects of stigma and discrimination on relatives of a PLWHA ................. 143 Table 4.41: Respondents Strategies for Reducing HIV and AIDS related Stigma and Discrimination ............................................................................................. 145 xii University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION 1.1 Background to the Study Stigma and Discrimination, in any form the world over is considered as one of the obstacles towards the reduction and elimination of some chronic health conditions or diseases, particularly HIV and AIDS. HIV and AIDS is one of the most widespread and devastating epidemic in the 21st century. The disease has not only brought untold hardships and its impact felt in all aspects of life but it has also affected different people of diverse status and background putting them at risk. It is, therefore, not surprising that it has emerged as a global public health concern that merits a multidimensional response. As it were, it has direct implications on the health of the economy, the social and political lives of affected countries. There is evidence to suggest that the overall level of new HIV infection is still high. Worldwide, 36.9 million persons were affected by the disease with two (2) million newly infected persons and 1.2 million deaths associated with the disease (UNICEF, 2014). The year 2015, however, recorded a decrease in the number of persons living with the disease, which stood at 36.7 million and AIDS related deaths at 1.1 million but unfortunately, there was an increase in the number of newly infected persons, which was 2.1 million (UNICEF, 2014; UNAIDS, 2016). Also, sub-Saharan Africa was not spared the scourge of the disease because it had 1.4 million newly infected persons with approximately 800,000 HIV and AIDS related deaths in 2014. For the year 2015, 25.6 million persons living with the disease were 1 University of Ghana http://ugspace.ug.edu.gh found in the region and that accounted for 2/3 of the global total of HIV infections (WHO, 2015). Ghana is not an exception as far as the HIV and AIDS epidemic is concerned. There has not been any remarkable improvement in terms of the reduction of the prevalence rate of infections and deaths despite numerous interventions by government and non- governmental organisations, agencies and bodies. Available data show that ever since the first case of the disease was detected in 1986, everybody has been at risk in Ghana. In 2012, the number of persons who were living with the disease was 235,982. Persons who were infected within that year totalled 7,991 and 11,655 as AIDS related deaths (UNAIDS 2013). The Ghana AIDS Commission (2013) stated that an estimated 224,488 people were living with the disease and that 7,812 had become infected in 2013. In the same year, the number of people who died due to AIDS related causes was 10,074. The 2014 National HIV and AIDS estimates showed that Ghana had 250,232 persons living with the disease and out of that number 229,009 were adults with 21,223 children. New HIV infections stood at 11,356 and AIDS related deaths recorded in 2014 were 9,248 (Ghana AIDS Commission 2014). Also, UNAIDS (2016) established that in 2015, 274,600 persons were living with the disease and that 13, 000 AIDS related deaths were also recorded in the same year. HIV prevalence rate in Ghana as at 2010 stood at 1.5% and remained same in 2011. There was a drop in 2012 to 1.4% and further dropped to 1.3% in 2013. However, the prevalence rate witnessed an increase to 1.5% in 2014 and a minimum decline in 2015 to 2 University of Ghana http://ugspace.ug.edu.gh 1.4. As at 2012, the rate had come down to 1.4% and further slowed down to 1.3 in 2013 (HIV Sentinel Survey Reports, 2013). This implies that the reduction or improvement in the prevalence rate is not steady. This could probably be due to certain factors that have not been effectively addressed by the many and different interventions by government and other related bodies. Some of these Government of Ghana interventions were the establishment of the National Advisory Commission on AIDS (NACA) in 1985, National AIDS/STI Control Programme (NACP) in 1987 and the Ghana AIDS Commission in 2000 to plan, co-ordinate, prevent, manage and control HIV in the country. Others included the Ministry of Education and Social Welfare and Employment respective introduction of School and workplace HIV and AIDS counseling services. The government’s commitment was also evidenced by being a signatory to many continental and international treaties, conventions and declarations on HIV and AIDS. The focus of all these instruments was on the rights and protection of persons living with HIV and AIDS, (PLWHA) from discrimination. Since 2001, about fifteen percent (15%) of the annual health budget of Ghana has been assigned for HIV and AIDS activities. Government Ministries were also required to have budget lines for HIV/AIDS related activities (Anarfi & Appiah, 2004). These interventions have created increased awareness and knowledge of the methods of acquiring the disease as well as the ‘hows’ to prevent and to treat it. According to the National HIV and AIDS Strategic Plan, Ghana: 2011-2015, issues of stigma and discrimination associated with the disease have been the greatest challenge to curtail the spread and new infections. 3 University of Ghana http://ugspace.ug.edu.gh Stigma and discrimination has been the biggest challenge or bane in the control and elimination of many health chronic conditions including leprosy, tuberculosis, (TB) epilepsy, mental illness and of course, HIV and AIDS, which seem to have common characteristics or attributes (Van Brakel, 2006). This is because they are considered and believed to be highly contagious, infectious and incurable, may cause disability to victims and disaffection to families and friends. HIV and AIDS is usually occasioned by fear, ignorance, lack of knowledge, misconceptions and rumors, as well as placing blame and accusation of moral wrong doing (ICRW, 2002; Ogden and Nyblade, 2005; Adoo- Adeku et al, 2010). In most instances, derogatory terms and jargons used to describe the disease such as ‘curse’, ‘demoniac’, ‘a form of mental illness or madness’, ‘a disease that can kill’ and ‘a walking skeleton’ contribute to the fears associated with the disease. Moreover, poverty further exacerbates the situation and thus makes it more difficult for the interventions to overcome the epidemic. All these contribute to PLWHAs’ relations and families’ negative social perception and image towards PLWHAs, which invariably re- inforce the latter’s denial and refusal to disclose their status; a situation that provides a fertile conduit for the spread of the disease. This assertion by the National HIV and AIDS Strategic Plan (2010) statement that HIV and AIDS related stigma and discrimination has been the most vibrant factor that promotes the continuous spread as well as the barrier for preventing and controlling the spread of HIV and AIDS cannot be overlooked. Some studies undertaken in Ghana revealed that addressing HIV and AIDS related stigma and discrimination were critical in addressing the planning management and control of the disease. For example, a study 4 University of Ghana http://ugspace.ug.edu.gh conducted by Mills (2003) revealed that most HIV-Sero women felt the need not to disclose their status based on perceived shame and disgrace surrounding the HIV infection. Similarly, Mwinituo and Mills (2006) found out that even caregivers experienced widespread stigma and discrimination from close neighbours, family members and health workers not to talk of the victims. Studies undertaken by Adoo- Adeku, Badu-Nyarko, Kwashie and Benneh (2010) on HIV /AIDS education on Stigmatization and Discrimination specifically in four regions including the Upper West Region concluded that tackling HIV and AIDS related stigma and discrimination were critical in the management and control of the spread of the disease in Ghana. 1.2 Statement of the Problem Several studies, Mwinituo & Mills (2006) Adoo-Adeku et al (2010) and Ayiworoh (2016) on HIV and AIDS related stigma and discrimination in Ghana have not done much on the extent to which the beliefs and practices of religious sects have influenced the attitudes of their members or individuals towards PLWHAs. In Ghana, religion plays a very important role in the lives of all Ghanaians. More than 90% are either Christians, Moslems or traditional believers. As regards the Upper West Region, which is the study area, over 95% of the population are adherents of the three major religions namely Christianity (44.2%), Islam (38.1%) and traditional religion (2010 Population and Housing Census). In this regard, one can confidently say that Ghanaians particularly are curiously religious and are not only seen to be peaceful, hospitable but also loving, caring and tolerant to fellow human beings, especially with respect to the sick and their fundamental human rights in the society. These are in fulfilment of the existing tenets and beliefs systems of 5 University of Ghana http://ugspace.ug.edu.gh their various religious sects including Islam, which in particular admonishes its followers to be loving and caring towards fellow human beings. As narrated by Abu Hurayra in Saheeh Bukhari, the Prophet (PBUH) said “There are five duties that the Moslem owes to his brother”, one of which is visiting the sick”. Another version states that “The rights of one Moslem over another are visiting the sick´’ and “Feed the hungry, visit the sick and free the captives”. God himself stressed the significance and reward of visiting the sick and afflicted as narrated by the Prophet: “On the day of Resurrection, God the Almighty and Majestic will say: “O child of Adam! I became sick and you did not visit me!’ The person will say, ‘O Lord, how can I visit you and you are the Lord of all that Exists! ‘’…Did you not know that if you visited him, you would have found me with him?’’ (Saheeh Muslim) Also, as captured in Saheeh Al Bukhari: 13, which states “None of you will have faith until he loves for his brother what he loves for himself”. The Holy Quran chapter 5:8 also states the following in relation to hatred and love “... And do not let the hatred of a people prevent you from being just. Be just; that is nearer to righteousness…’ “God does not forbid you to be kind and equitable to those who have never fought against your faith nor driven you out of your homes. In fact God loves the equitable’’ (Quran 60.8) 6 University of Ghana http://ugspace.ug.edu.gh ‘The parable of the believers in their affection, mercy and love for each other is that of a body. When any limb aches, the whole body reacts with sleeplessness and fever’ (Bukhari 5665). All these verses show the level of non-stigmatisation and non- discrimination based on religious beliefs and practices. This notwithstanding, little evidence exist on the extent of how the beliefs and practices of Islam have influenced the attitudes of practising adult Moslems towards PLWHAs in the Upper West region despite many and varied research and studies on HIV and AIDS related stigma and discrimination in Ghana. In the light of the above, this study therefore sought to find out: “To what extent do the beliefs and practices and socio-demographic characteristics of Moslems influence their attitudes towards persons living with HIV and AIDS in the Upper West Region in Ghana?” 1:3 Purpose of the Study The purpose of the study is to determine and assess how practising Moslems’ religious, social, economic and political relations with PLWHAs have been influenced by the beliefs and practices as well as their socio demographic characteristics such as age, sex and education in the Upper West Region have implications for adult education 1:4 Main Objective The study’s main objective is to establish the extent to which the beliefs and practices and socio-demographic characteristics in terms of sex, age and educational level of Moslems in the Upper West Region have influenced their attitudes towards people living with HIV and AIDS regarding their religious, social, economic and political engagement. 7 University of Ghana http://ugspace.ug.edu.gh 1.4.1 Specific Objectives of the Study In order to operationalise the main objective, the following specific objectives were formulated. 1 To find out the extent to which the attitudes of Moslems in the Upper West Region towards PLWHAs have been influenced by their beliefs and practices in religious, social, economic and political relations. 2 To assess the extent to which the socio-demographic characteristics ( sex, age and educational level) influence the attitudes of Moslems in the Upper West Region towards PLWHAs in religious, social, economic and political engagements. 3 To identify the teachings of Islam that influence the attitudes of Moslem respondents in the Upper West region towards PLWHAS 4 To determine how disclosure of HIV and AIDS status influences attitudes towards stigma and discrimination of PLWHAs 5 To find out the effects of stigma and discriminatory attitudes on PLWHAs and their relatives. 6. To determine Moslems’ views in reducing stigma and discrimination against PLWHAs 1.5 Research Questions To achieve the study objectives, the following research questions were addressed. 1. To what extent do Moslems beliefs and practices influence their attitudes towards PLWHAs in terms of religious, social, economic and political relations? 8 University of Ghana http://ugspace.ug.edu.gh 2 To what extent do the socio demographic characteristics (age, sex and educational level) of Moslems in the Upper West Region influence their attitudes towards PLWHAs in religious, social, economic and political engagements? 3 What teachings in Islam influence Moslem respondents’ attitudes towards PLWHAs? 4 In what ways does disclosure influence Moslems attitude towards stigma and discrimination of PLWHAs? 5 What are the effects of stigma and discriminatory attitudes on Moslems who are HIV positive? 6. In what ways can stigma and discrimination towards PLWHAs be reduced? 1.6 Significance of the Study It is a fact that stigma and discrimination has become an issue of national concern and both government and non-governmental institutions have initiated several policies and initiatives to focus on this phenomenon. Thus, the outcome of this study, which is the influence of religious beliefs and practices of Moslems on their attitudes towards PLWHAs, will serve as additional literature in the area of religion and health. Against the background of paucity of material or literature on Moslems beliefs and practices in relation to stigma and discrimination, this study is significant to adult education practice and theory as a guide for designing and planning management of effective education programmes as a tool to reducing HIV and AIDS related stigma. In this light, the study will fill in this void. There are several adult education institutions such as the Department Adult Education and Human Resource studies of the University of Ghana, Non-Formal Education 9 University of Ghana http://ugspace.ug.edu.gh Division of Ministry of Education, Institute of Local Government Studies (ILGS), District Assemblies and other Non-governmental organisations which are involved not only in the propagating and disseminating information on developmental issues but also in the training of communities. However, one important void is the incorporation of HIV and AIDS related stigma from the Islamic perspective in such training manuals. Thus, the findings of this study can therefore serve as a valuable resource in the teaching, learning and training manuals for such institutions. ` 1.7 Scope and delimitation of the Study The study is limited to only three districts of the Upper West Region where Islam is predominant and to 300 adult practising Moslems on their attitudes towards PLWHAs. The reliability of the study largely depends on how frank and candid the subjects of the study responded to the questions posed. Generalization of the findings may be limited to the study area because of regional disparities in the awareness level and beliefs. 1.8 Definitions of Terms Throughout the study, the under listed terms or words will have the meanings attached to them as stated below unless otherwise stated: Stigma: It is an attribute, characteristic or diagnosis, which is deeply discrediting and conveys a diminished social identity and reduced worth of the individual or group of individuals. People are therefore stigmatised as a result of their belonging to a particular group or possession of certain traits, which can lead to their exclusion from all the important aspects of life such as religious, social, economic and political. 10 University of Ghana http://ugspace.ug.edu.gh Discrimination: It refers to the unfair or unjustifiable behaviour or actions directed at individuals or group of persons due to their sexual orientation race, socio-economic or health status. Discrimination may lead not only to the exclusion or marginalization of people but also deprive them of their civil rights. Attitude: This refers to a relatively enduring organization of emotions, beliefs and behaviours, which result from experience, social roles or norms and learning towards a particular object, person, thing or event Practising Adult Moslem: This refers to the adherents of the Islamic faith who are eighteen (18) years and above. 1.9 Organisation of the Thesis The study is organized into six chapters as indicated. The Chapter One covers the introduction to the study. The major identified areas were the statement of the problem, the purpose of the study, the objectives and the research questions and finally the significance and delimitations of the study. Chapter Two is concerned with the attribution –affect –action theory of Bernard Weiner and a review of related literature on HIV and AIDS related stigma and discrimination, its causes and effects; religious beliefs and practices, and Islamic religious beliefs and practices vis a vis HIV and AIDS related stigma and discrimination. The Chapter Three deals with the research methodology, which includes the research design, the population and sampling techniques of the study; data collection and analysis. 11 University of Ghana http://ugspace.ug.edu.gh Chapter Four contains the presentation and analysis of primary data on the Moslems’ perception of HIV and AIDS related stigma and discrimination, the assessment of their opinions on the extent to which their beliefs and practices as well as their socio demographic characteristics influence their attitudes towards PLWHAs in religious, social, economic and political relation; the beliefs and teachings of Islam that support and influence Moslems attitudes towards PLWHAs, Moslems’ views on disclosure of HIV and AIDS status and the effects of stigma and discrimination on PLWHAs, their families and community. The chapter also presents Moslems views on reducing and possibly eliminating stigma and discrimination among PLWHAs in their communities. Chapter Five discusses the findings of the study while the last chapter concerns itself with the summary, the conclusion and the recommendations for institutional and knowledge development and other research areas for further studies. 12 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO THEORETICAL FRAMEWORK AND REVIEW OF RELATED LITERATURE 2.1 Introduction The chapter deals with Bernard Weiner’s theory of attribution, specifically the attribution-affect-action relating to stigma and discrimination against Persons Living with HIV and AIDS (PLWHAs) as the framework employed for the study. It also deals with a review of literature on the concepts of stigma and discrimination and reviewed empirical studies on the perceptions of society towards PLWHAs, HIV and AIDS related stigma and discrimination particularly religious beliefs and practices and in particular those of Islam and finally strategies for reducing HIV and AIDS related stigma and discrimination. Some theories on Stigma and Discrimination The labeling theory, which was propounded by Scheff (1996; cited in Corrigan, 2005) asserts that the label ‘ill’ results in society to treat the label-led person as abnormal. The label may be put by health professionals or through observation by noticing people who visit the hospital. Society’s response to the labeled may include fear and disgust, which results in a social distancing to avoid any contact with the ‘labeled person’. The resultant prejudice and discrimination cause the person labeled with mental illness to continue with the same behaviour and consequently fit the label of ‘illness’. In other words, negative social reactions ( negative stereotypes) are part of the etiology of the mental disorder, in this case, HIV/AIDS menace. The theory has been criticised on the basis that the abnormal behaviour, which is a product of the mental illness and not the label on it was the source of the prejudice. In this respect, the reason why people distance themselves from the mentally ill is not the ‘label of mental ill’ but the person with the 13 University of Ghana http://ugspace.ug.edu.gh illness who behaved in a bizarre way. Secondly, the effects of stereotypes on the mentally ill is only a temporary one, which also results to only a minor and short term problem for the affected person (Gove,1980). Modified Labelling Theory In view of the criticism leveled against the labelling theory, Link, Cullen, Struening, Shrout & Dohrenwend (1989) propounded a modified theory, referred to as Modified labelling theory, which states that labeled persons are not only rejected when they behave inappropriately but even when their behaviour is not abnormal. They also indicated that though negative labelling can worsen existing illness, it does not result in illness as shown in the labelling theory. Link et al (1989) as well showed how stigma exists notwithstanding mental health diagnosis and stigma variables acted as important predictors of social support network in patients. Psychiatric labels are linked to negative societal reactions that worsen the situation of the illness. This is not different from PLWHAs in our societies. Link and Phelan (2001) emphasise the importance of these labels in the stigmatising process, when the stigmatising group or person is in a more dominant social situation than the stigmatised group. Thus, according to this theory, the core ingredients of stigma are ‘labelling, stereotyping, separating, status loss and discrimination, which exist in a power situation that allows these ingredients of stigma to unfold’ (Link & Phelan, 2001, p367). It is in view of the shortcomings of the above theories in explaining HIV and AIDS related stigma and discrimination that the attribution theory is adopted. 14 University of Ghana http://ugspace.ug.edu.gh 2.2 Attribution Theory The Attribution theory has been one theoretical framework popularly employed for assessing societal reactions towards PLWHAs (Anderson, 1992; Cobb & De Charbert, 2002; Dooley, 1995, Greene & Rademan, 1997; Steins & Weiner, 1999; Weiner, Perry, & Magnusson 1998). The importance of this theory cannot be over-emphasised as far as understanding societal attitudes towards the sick and for that matter, PLWHAs is concerned. The theory has served as an explanatory tool for anticipating peoples’ immediate emotional and behavioural responses towards PLWHAs supported the specified interconnections between attribution types (internal versus external) and emotional and behavioural responses (anger versus sympathy and helping behaviour) as stated in Weiner’s Attribution. The theory also tested whether personal/environmental characteristics surrounding a target (person) illness (sexual orientation, seriousness of the illness, perceived personality) serve to influence perceivers’ emotional and behavioral responses towards the target (the sick). One factor that has been shown to moderate persons’ attitude towards the target is sexual orientation of the target with more negative emotional and behavioural responses toward homosexuals and PLWHAs. The attribution theory of Bernard Weiner (1974) simply states that when people assign the causes of an event to controllable internal factors other than to uncontrollable external factors, their pity and sympathy towards the affected person will be greatly minimised. On the other hand, if the causes are attributable to uncontrollable, external factors, people’s pity and sympathy towards the target person will increase. 15 University of Ghana http://ugspace.ug.edu.gh 2.2.1 Attribution-Affect-Action Theory The attribution-affect-action theory, which constitutes an aspect of the attribution theory, is a viewpoint that brings together causal attribution, emotion and behaviour and theorizes about their interconnections. The theory recognises three aspects of causality namely locus, which deals with whether the cause is attributable to internal or external factors, stability, which considers the cause as either stable or unstable and finally, controllability, whether the cause is something that is within the control of the person or beyond his control. One distinguishing feature of the theory is its differentiation between outcome-dependent affects and attribution-related affects. The outcome-dependent affects are general like happiness, which results from desirable outcomes and sadness due to negative outcomes. These are experienced independently notwithstanding the perceptions of the causes. The attribution-related affects on the other hand, are motivated by individuals, causal attribution. Thus, results, which are considered as unexpected, significant or undesirable influence, people to undertake a causal search to find out the reasons for the outcome. Varied emotions are exhibited based on the type of causal attribution one makes. The type of one’s behavior or attitude towards the target of attribution is, therefore, influenced by the emotions. Hence, one’s anger and sympathy determines the type of attitude whether in support or rejection of the target of attribution. This theory therefore propounds that if the cause of the ‘need’ is viewed as controllable or attributable to the person’s own responsibility, it is expected that more anger and less sympathy will be exhibited and by extension less support offered to the affected person. In contrast, when the cause is considered to be uncontrollable and not the responsibility 16 University of Ghana http://ugspace.ug.edu.gh of the person, sympathy will be experienced and for that matter, more support to the affected person. This study therefore employs this theory in view of the several studies on HIV and AIDS, (Weiner,1986; Reiserzein,1986; Eiser.C; Eiser,J.R; Lang 1989) which have revealed that PLWHAs who are seen as being responsible for their infection elicit anger and therefore receive no assistance and consequently negative reactions from the public; while those whose infections are not attributable to their responsibility, however elicit sympathy and support and, consequently positive response from the public. Several studies (Weiner, 1986; Reiserzein, 1986; Eiser.C; Eiser, J.R; Lang 1989) on HIV and AIDS related stigma and discrimination reveal that the degree and effects of stigma towards PLWHAs tend to change based on social factors. Prominent among them are the means of infection and social attribution, which significantly influence the assignment of blame and responsibility, and consequently attitude towards PLWHAs. As it relates to the present study, this theory has been employed to determine whether peoples’ attitudes towards PLWHAs are being influenced by their religious beliefs and practices, their demographic and personal characteristics or dependent on the causal attribution one makes as regards the infection. That is whether the infection is due to controllable internal factors such as immoral behaviours like prostitution, adultery, gay sex and drugs, which are condemned by the teachings of Islam and the society as a whole or attributable to uncontrollable external factors such as mother to child, blood transfusion or contaminated sharp objects. 17 University of Ghana http://ugspace.ug.edu.gh Apart from applying the theory to HIV and AIDS, Peters, de Boer, Kok & Schaalma (1994) also used it on other diseases like syphilis, lung cancer and tuberculosis. It is also important to add that the theory has been applied in the field of marketing (De Carlo, 2005; Fang, Evans & Landry, 2005). This study conceptualises that Moslems attitude towards PLWHAs will be modified on whether the cause of the infection was due to controllable internal factors or uncontrollable external factors. This is in view of the fact that stigma that arises from medical condition is very strong, when that condition is related to deviant behaviour or viewed as the responsibility of the individual. This becomes very strong if the illness is associated with religious beliefs and considered to be contracted through immorally unsanctionable behaviour. 2.3 Review of Related Literature This section of the chapter deals with reviewed literature on the concepts of stigma and discrimination, HIV and AIDS related stigma and discrimination as well as the causes and effects of HIV and AIDS related Stigma and discrimination. It also reviewed empirical studies on the perception of society towards PLWHAs, HIV and AIDS related stigma and discrimination. Again, religious beliefs and practices in particular those of Islam was addressed. 2.3.1 Concept of Stigma Stigma is multi-dimensional concept of which it significantly focuses on deviance or departure from an accepted standard or convention. It has gained a lot of attention especially in many health perspectives. The aftermath of Goffman’s (1963) definition as 18 University of Ghana http://ugspace.ug.edu.gh an undesirable or discrediting attribute, reducing an individual’s status in the eyes of society, the concept of stigma has been defined severally. According to Crawford (1996), the term stigma has its roots from the Greek language and refers to a tattoo mark branded on the skin of an individual as a result of some incriminating action, identifying the person as someone to be avoided. Generally, it has two meanings. One is derived from Christianity and denotes bodily marks which resemble those of the crucifixion of Jesus Christ; attributed to divine favour. The second meaning is secular, namely marks of disgrace, discredit, or infamy (Gilmore & Somerville, 1994). Today, the term “stigma” is applied more to social disgrace than to any bodily signs (Hardon, Boonmonkon& Streefland, et al, 1995). Goffman (1963) defined stigma as “an attribute that is deeply discrediting, which reduces the bearer from a whole and usual person to a tainted, discounted one”. Stigma can result from a particular characteristic, such as a physical deformity or from negative attitudes towards a group such as prostitutes or homosexuals. From this definition, society labels an individual or a group as different or deviant. It is for this reason that a respected person such as a wealthy person, a chief, an Imam, manageress or queen mother will immediately lose their status and become an object of ridicule immediately they have tested HIV positive. Stigma is also relational in nature and a process that is described by Link and Phelan (2001) as occurring in the context of power when four interrelated components – distinguishing and labeling differences; associating human differences with negative attributes; separating “us” from “them”; and status loss and discrimination-converge in the context of social, economic and political power. According to Link and Phelan 19 University of Ghana http://ugspace.ug.edu.gh (2006), stigma is a process that begins when a particular trait or characteristic of an individual or group is identified as being undesirable or disvalued. The stigmatized individual often internalizes this sense of disvalue and adopts a set of self-regarding attitudes about the marked characteristic including shame, disgust and guilt. These attitudes produce a set of behaviours that include hiding the stigmatized trait, withdrawing from interpersonal relationship or increasing risky behaviour (Smith, Rossetto & Peterson 2008).It is against this background that most PLWHAs, lepers, tuberculosis and epileptic patients respectively always strive to hide their conditions by avoiding the public such as staying indoors the whole day or moving to places where people might not know their status if the symptoms are not visible. In the view of Heijnders and Van DerMeij (2006) stigma, which is shaped and promulgated by institutional and community norms and interpersonal attitudes, is a social determinant of health. It is not coincidental that most of the conditions that elicit stigmatising attitudes from the community have to do with health conditions such as HIV and AIDS, tuberculosis, leprosy, epilepsy and mental illness. What is also important to note is that people exhibit such stigmatising attitudes based on what institutions and communities prescribe as acceptable and unacceptable actions and norms. Stigma generally refers to any attribute that marks the bearer as culturally unacceptable or inferior due to a physical condition or disfigurement, a moral blemish, membership in a despised social group or simply ‘different’. The affected person is cast out of the society and is made to feel of little value. As a result, people who are stigmatized, experience guilt, shame, rejection, feelings they may accept with fatalism that stops them seeking assistance or try to change things (Gillian Paterson.Undated) (https//scholar.sun.ac.za/bitstream/handle/100.19/) 20 University of Ghana http://ugspace.ug.edu.gh From this perspective, people with tuberculosis, leprosy, mental illness and HIV and AIDS are seen as sub-humans and valueless for the mere fact that they have some form of illness which conveys or elicits stigma. This creates some level of distancing between them and those who do not have these illnesses. It is equally important to state that stigmatization is not only the expression of individual attitudes but also involves social processes based on social, economic and political power. Power is required to be able to introduce stigma and to remove power from the stigmatized person (Link & Phelan, 2002). According to Parker et al (2002), stigmatization and discrimination as social processes, are employed to create and maintain social control and to produce and reproduce social inequality. Stigma contributes to the creation of social hierarchy in a community and then in turn legitimizes and perpetuates social inequality. Thus, stigma does not only mark the boundaries a society creates between ‘normals’ and ‘outsiders’, between ‘us’ and ‘those’ but it is also a social process in which people out of fear of the disease want to maintain social control by contrasting those who are normal with those who are different. The fact is that once someone is HIV positive, they are condemned in relation to HIV and AIDS related stigma and discrimination. The emphasis is that if one is HIV and AIDS positive, they are regarded as outcast and shunned by those who consider themselves as uninfected. The creation of a boundary is meant to protect those who consider themselves as not affected from those who are seen to be affected. In lending support to the above definitions, Bos, Reeder & Sutterheim (2013) stated that in modern times, stigma does not only refer to a physical mark but also an attribute that is characterized by widespread social disapproval- a discrediting social difference that 21 University of Ghana http://ugspace.ug.edu.gh yields a “spoiled social identity”(Goffmans,1963). Hebl and Dovidio (2005) also emphasise that stigma occurs in social interaction. In this regard, stigma is not considered to reside in the person but rather in the social context. It is however, important to also state that apart from social interactions, stigma is also manifested in religious, economic and political engagements. Thus, persons who are stigmatized due to their conditions especially HIV and AIDS are seen not as part of the community. Such persons are excluded from participating in social or communal activities by the larger community; those who see themselves as uninfected. They do not eat or share cooking or eating utensils or sleep with others in the same room, take part in family deliberations, and participate in religious activities and other activities. Persons affected by HIV and AIDS are stigmatized based on their physical condition, which is one of depreciation and leanness and on the basis of moral blemish (Kafuko, 2009). It is believed though erroneously that once affected by AIDS, it is either through promiscuity or immoral sexual activities or that the person belongs to a group of prostitutes, gay or drug injectors who are already stigmatized. 2.3.2 Concept of Discrimination Discrimination arises from stigma and occurs when a distinction is made of a person based on their real or perceived HIV and AIDS status and results in them being treated unfairly and unjustly. The Encarta Dictionary defines discrimination as: “…. Any situation in which a group or individual is treated differently based on something other than individual reason, usually their membership in a socially distinct group or category. Such categories would include ethnicity, sex, religion, age or disability. Discrimination can be viewed as favourable or unfavourable, 22 University of Ghana http://ugspace.ug.edu.gh depending on whether a person receives favours or opportunities, or is denied them. However, in modern usage, ‘discrimination’ is usually considered unfavourable (Microsoft ®Encarta Encyclopedia 2016). In this regard, discrimination can be defined as any action or measure that results in a person being treated unfairly because they belong or are perceived to belong to a particular group (National AIDS Trust, 2016). Thus, when persons, because of their HIV status are denied health care, employment, admission into educational institutions, residential accommodation because of their conditions, then a clear case of discrimination arises. Discrimination is a behavioural reaction, which in terms of stigma results from HIV and AIDS. It may include avoidance of associating with PLWHAs, which in turn reduces opportunities for employment, education and recreation. It may take the form of exclusion, segregation, withdrawal behaviours or withdrawal of assistance, which may be medical services. Another important aspect of discrimination is segregation or treatment of persons with HIV and AIDS in custodial or less restrictive health care facilities. Discrimination can be on the interpersonal or structural level (Link & Phelan, 2001). Interpersonal discrimination is excluding PLWHAs and cither persons suffering from terminal illness from social engagements while structural discrimination deals with excluding such people from public life through legal, economic, social and institutional methods. Apart from instances where supervisors blocked the promotion of staff and others losing their jobs or reassigned to lower positions within their organization due to their HIV positive status; HIV-positive are also excluded by family members from 23 University of Ghana http://ugspace.ug.edu.gh discussions and decision making due to the belief that PLWHAs were incapable of making any important contributions (Kafuko, 2009). Discrimination is a result of stigma. It consists of actions or omissions that derive from stigma and is directed towards those individuals who experience stigma. Discrimination is any form of arbitrary distinction, exclusion, or restriction affecting a person, usually but not only by virtue of an inherent personal characteristic or perceived to belong to a particular group (Mukasa, 2008). It includes actions that negatively impact the rights and entitlements of others based on prejudiced viewpoints or positions and ensue when a distinction is made against a person. The result is unfair or unjust treatment based on their HIV sero-status or risk status (UAC 2007). Discrimination may arise from social disapproval of the infection and its implied behaviours or from fears due to lack of knowledge about how HIV and AIDS can or cannot be transmitted. Because the HIV pandemic emerged so suddenly and progressed so quickly, in many countries discrimination could result from people’s belief “…that not enough time remains to weigh carefully the strengths and weaknesses of various alternative solutions to an AIDS-related problem” (Herek and Ghant, 1988:888) and the reaction is thus to err on the side of caution, even at the expense of individual rights. In this case, it refers to negative behaviour towards someone based on any grounds or qualities such as class, race, ethnicity, HIV and AIDS status, gender, sexual orientation and age. Discrimination, therefore, arises when people are treated with less respect or worth than they deserve due to any of the above mentioned characteristics. Thus, it can involve the distinction, exclusion, or preference of a person. In this regard, there are instances of 24 University of Ghana http://ugspace.ug.edu.gh PLWHA being allowed to work only for half of the required working hours, given light working schedule, assigned a separate examination room, and excluded from family discussion. Thus, persons living with HIV and AIDS, tuberculosis, leprosy and mental illness are discriminated against because they are seen by those who discriminate against them as belonging to particular or different groups and for that matter, such groups are treated in an unfair or unjustifiable manner. It is, therefore, common to see persons living with HIV or AIDS being ejected from their family homes, served with different and specific eating plates and drinking cups, sleeping in separate rooms, admitted in separate hospital wards called in some circles as isolation wards, wares and goods not being patronized at market and traders refusal to sell to them if they know their status to being refused employment or even sacked if such a person is already employed. From the discussion so far, one can therefore conclude that while stigma reflects an attitude, discrimination on the other hand as an act or behavior. 2.3.3 HIV and AIDS related- Stigma Stigma and discrimination, which is termed as the hidden burden of disease is not only to quantify but also added on to the burden of disease which can be measured (WHO fs218, 2001). Stigma and discrimination is a phenomenon associated with many chronic health conditions including HIV and AIDS, leprosy, tuberculosis and mental illness. Simply put, HIV and AIDS related stigma and discrimination refers to prejudice, negative attitudes and abuse directed at people living with HIV and AIDS. UNAIDS (2002) refers 25 University of Ghana http://ugspace.ug.edu.gh to HIV and AIDS related stigma as a process of devaluation of people either living with or associated with HIV due to sex and intravenous drug use. In associating with this view, Seale (2004) defines it as a real or perceived negative response to persons by individuals, communities or societies, which is characterized by rejection, denial, discrediting, disregarding; underrating as well as social distance. Badahdah (2010) considers HIV and AIDS related stigma as unfavourable evaluation, treatment and discrimination of people living with HIV and AIDS. Stigma may also affect the people associated with the person living with HIV and AIDS. According to AVERT (2015), a global online information and advice on HIV and AIDS cited in Ayiworoh (2015), HIV and AIDS related stigma includes negative attitudes and prejudice directed at people living with HIV and AIDS. 2 .3.4 Causes of HIV and AIDS related Stigma The International Centre for Research on Women (ICRW) (2002) states that the AIDS epidemic, since its early stages, has been characterized by fear, ignorance and denial leading to stigma and discrimination against PLWHA and their family members, which has accounted for the reasons why people do not want to find their sero-status, change their unsafe sexual lives and take care of PLWHA. Stigmatisation and discrimination associated with HIV and AIDS are underpinned by many factors including lack of understanding of the illness, treatment, irresponsible media reporting on the epidemic, the incurability of AIDS and prejudice and fears relating to a number of sexually sensitive issues including sexuality, disease and death, and drug use. Studies conducted by Tee and Huang (2009) and Herek (1999) have shown that HIV and AIDS related stigma and discrimination exist due to people’s limited knowledge about 26 University of Ghana http://ugspace.ug.edu.gh the causes of HIV and AIDS, in addition to existing treatment. In their view, Zeelen, Wijbenga, Vintges & de Jong (2010), assert that stigma exist because there is confusion about how the disease is contracted and how it can be prevented. In support of the above, Adoo-Adeku, Badu-Nyarko, Kwashie and Benneh (2010) study on HIV and AIDS Education on Stigmatization and Discrimination in Ghana, revealed that misconceptions about the causes, the myth and fear caused by earlier interventions regarding the disease constitute some of the main causes of stigma and discrimination. These are basically due to general perceptions that link the disease to immorality and socially unacceptable behaviours. The belief among many Ghanaians is that those infected lack good morals. It is important to remark here that against the background of wrong perceptions and erroneous beliefs of the disease, people have advocated for the urgent need for relevant programme implementors to promote and sustain their educational campaigns on the disease. Messages on HIV and AIDS Campaigns Fear-based messages, which portray negative attitudes about HIV and AIDS, have contributed significantly to people trying to avoid any situation that might pose a potential transmission risk. Fear-based messages about the disease and the messages in health campaigns, which focused heavily not only on death as the outcome of HIV but also on the depiction of a painful, disfiguring, and sometimes shameful death by linking HIV to socially unacceptable behaviours all play a role in stigmatization. These have negative implications that invariably increase stigmatisation on infected persons. 27 University of Ghana http://ugspace.ug.edu.gh Based on their experiences in Vietnam, Hong et al (2004) remarked: “Many posters use highly emotive symbols such as human skulls, bleeding syringes, and coffins, or they contrast images of sick and dying drug users with images of robust, healthy people”.( p.15 ). These kinds of messages heighten the anxiety and magnify the fear of contracting HIV. This fear then elicits stigmatizing behaviour such as isolation of people living with HIV and AIDS. A study in Ethiopia reveals that people do not want to associate with PLWHAs because of fear due to its horrible nature as captured by a female respondent “The reason people isolate a person living with HIV and AIDS is because they fear HIV and AIDS. The reason they fear HIV and AIDS is because they hear from different mass media, i.e. radio and TV, how horrible the disease is and how it is widespread in the country (Ogden and Nyblade 2005). The reference to the skull and crossed bones as a symbol of the disease, which by implication means that once an individual gets infected, the person will turn into skeletal bones as stated by Amankwaa (2008) make people avoid the company of infected people representing the idea of fear as one of the causes of stigma. Likewise, de Bryun as well as Mbonu, Van Den Borne & De Vries (2011) mentioned the life-threatening and contagious nature of the disease and assignment of guilt as a result of the assertion that PLWHAs are solely responsible for the disease due to their involvement in immoral and deviant behaviours such as promiscuity or deviant sex that deserves punishment. 28 University of Ghana http://ugspace.ug.edu.gh Fear, Ignorance, Social Judgement and Control: It might therefore be said that HIV and AIDS related stigma and discrimination arises from fear, ignorance, social judgement and control; and more importantly, the marginalization and exclusion of individuals from interaction has possibly originated as a defence mechanism to protect the community from infection. Visser, Makin, and Lehobye (2006), propound that apart from the fact that the disease is being stigmatised, it is also associated with fear and discrimination; and that it elicits stigma because people are not only afraid of contracting it but also due to negative assumptions about PLWHAs since HIV and AIDS is a life threatening disease. In lending support to this, Bollinger (2002) in Policy Project (2002) and Deacon et al (2005) state that PLWHA are stigmatized not only due to the perception that they have a fatal disease, which elicits fear of infection and often characterized by behaviour which is already stigmatized, but is also considered as the result of the individual’s own responsibility as well as punishment for deviant behaviours. In support of the above statements, Ogden and Nyblade (2005) in studies conducted in Ethiopia, Tanzania and Vietnam on stigma cited in Nkansa-Kyeremateng and Attua (2013) stated fear of infection from casual transmission of the disease due to inaccurate understanding and knowledge of how HIV is transmitted and the attribution of blame and accusation of moral wrongdoing on those infected as the causes of stigma. The fact that AIDS, as an illness is not only characterized by several attributes that elicit stigma but also seen as the outcome of immoral or deviant behaviour attributable to the person infected, makes people vulnerable. It is perceived as a threat to the community 29 University of Ghana http://ugspace.ug.edu.gh due to its contagious nature and viewed as a degenerative disease, whose outcome is death, are in the main, reasons PLWHAs are being discriminated against. . UNAIDS (2000), also, views HIV and AIDS as a life-threatening illness that people are afraid of contracting. They state that the various metaphors associated with AIDS have also contributed to the perception of HIV and AIDS as a disease that affects ’others’ especially those who are already stigmatized because of their sexual behaviour, gender, race, or socio-economic status and have enabled some people to deny that they personally could be at risk or affected. HIV and AIDS Similes Another area that has contributed to discrimination concerns the vocabulary used to describe the disease. For example, the early similes that were attached to AIDS such as ‘death’, ‘horror’,’punishment’,’guilt’, ‘shame’, and others have exacerbated these fears, reinforcing and legitimizing stigma and discrimination. It is therefore not surprising that people living with HIV and AIDS are considered variously as: “Living dead bodies”, “Dangerous people”, “People beset with misfortunes”, “People who should be isolated from society”, “People who would soon die because their days are numbered” (Amankwaa,2s08; Adoo-Adeku et al 2010; Appiah, Afrane and Price 2002). In support of the above, Campbell et al ( 2007) assert that in many societies, HIV and AIDS is associated with stigma against the backdrop that not only does it carry many symbolic association with danger but it also conveys attribution of contagiousness, incurability, immorality, and punishment for sinful acts. 30 University of Ghana http://ugspace.ug.edu.gh Some studies in Ghana have also indicated the association of HIV and AIDS with danger. Thus, a study by Mill in 1999 on the manner of informing Ghanaian women about their HIV and AIDS was done in a very indirect way as captured in the following statements: “You have acquired an illness which cannot be cured”, “You have the same ‘bad disease’ that killed your husband”. Similarly, Adoo-Adeku et al (2010) study revealed that persons living with HIV and AIDS are variously perceived as: “ghosts”, “People who are at the end of their lives”, “Patients who would die soon because their days are numbered and their lives are almost ended’ As regards its contagious nature, the story is not different in Ghana. In the same study by Adoo-Adeku et al (2010), the respondents stated fear of also being infected by persons living with HIV and AIDS as a reason to “avoid them”, ‘’shun their company”, and “do not go near them’. Respondents from the study adduced reasons for their actions not likely to take care of people living with HIV and AIDS such as: “Fear of transmission’, ‘Afraid of contracting the opportunistic and chronic diseases because the patient could intentionally infect me’, ‘It is very dangerous and does not have any cure’, ‘they should be kept in isolation’, ‘It is risky’. The respondents considered people living with HIV and AIDS as ‘dangerous people’ and a ‘threat to other people’s lives’, and as such, should be isolated from the society”. In view of the above, people will therefore go to every extent to ensure that such persons are avoided for fear of being infected. This brings into sharp focus the issue of lack of 31 University of Ghana http://ugspace.ug.edu.gh understanding or better still detailed information as regards the causes of HIV and AIDS. It is an acknowledged fact that the illness is not caused by casual contact but by other factors, which include contaminated blood, direct sexual contact with an infected person without protection among others. This, therefore, calls for intensified and comprehensive education by relevant institutions, both governmental and non-governmental organisations that are engaged in HIV and AIDS activities to correct these unfounded beliefs. The situation also calls for change of attitudes by the public. Also, Busza’s (2001) study in South East Asia on stigma shows that PLWHA were stigmatized through isolating both the infected and affected due to fear of casual contact, restrictions on participation in local events, refusal to allow infected children in local schools, lack of support for affected bereaved family members (including orphans), violation of confidentiality in the health sector and denial of religious rituals such as funeral practices. Immorality The linkage of HIV and morality might be explained by the reason that affliction or any suffering is an indication of moral transgression. This is not coincidental in view of the fact that in some African societies, certain specific illnesses or sets of symptoms are traceable to breaking one or more social prohibitions. In the same vein, Judeo-Christian societies believe that illness is a punishment for one’s sins. Thus, the tendency to associate illness with immoral impropriety is a significant contributory factor to HIV and AIDS related stigma. This stigma is exacerbated by the seriousness of the illness, its mysterious nature and its association with behaviours that are either illegal or socially sensitive. 32 University of Ghana http://ugspace.ug.edu.gh Assumptions are made about the moral integrity of PLWHA; hence blame is apportioned as being morally improper and “guilty’’ of transgressions, resulting in shame felt by PLWHA. The perception is that HIV infection is the product of one’s personal choice of engaging in social evils, and thus it is a punishment for disobedience to God’s laws. When dealing with a PLWHA, the emphasis is on “guilty” versus “innocence” with regard to how the person became infected, and this informs the degree of stigmatization the person will experience. It is also significant to state that AIDS stigma is often targeted at individuals and groups in society who are already stigmatized. In North America, the groups that are stigmatised are gay men and intravenous drug users whereas in Ghana, AIDS stigmatization is compounded by its association with prostitution (Mill 2001). Thus, an individual who is already marginalized and suffers from HIV illness may experience a double burden or layering of stigma. In supporting these views, Herek, Capitanio and Widaman (2002) affirm that people tend to reject PLWHAs because they feel they have been sexually immoral and therefore deserve ‘to die’. The said rejection extends to the social groups to which PLWHAs belong as well as to their care givers (Van Dyk, 2008). In confirmation to this statement, Patterson (2005) states that HIV infection is viewed as a deserved punishment or retribution for violating the community norms. As such, the stigmatized person is held accountable for any real or imagined ills that affect the community, which can only be cleansed by the expulsion or isolation of the polluting influence. Their continued presence can become a threat to the survival of the whole group. It is thus against this that exclusion, victimization and ‘scapegoating’ follow. Further justification is 33 University of Ghana http://ugspace.ug.edu.gh established by the belief that those who are ‘different’ are sub-human, and do not feel things like ‘normal people do’. This is applicable not only to people living with HIV and AIDS but other stigmatized persons such as tuberculosis patients and lepers. In Ghana, the description of TB wards as ‘isolation wards’ and’ “cured lepers” home, which are often separated from the mainstream community all confirm the issue of exclusion and stigmatization. There are also cases of landlords and even family members who eject their tenants or family members based on their HIV and AIDS status. These actions are undertaken to protect the alleged normal people from being contaminated by the “not normal people”. Similarly, Abraham’s (2006) study on perceptions of HIV /AIDS related stigma among Moslems in a Cape Town community in South Africa reveals that Moslems do not associate with people living with HIV and AIDS (PLWHAs) based on their belief that the creator could punish all of them though it might be one person who commits the sin. From this perspective, they regard PLWHA as ‘sinners’ and therefore would want to avoid doing anything with them for fear of their creator’s anticipated wrath against the entire family. Closely linked up with this is the shame associated with pre-marital and extra-marital sexual relations which would result in a family being ostracized by the community because of its association with a sinner. Definitions, Representations and Metaphors: The definitions, representations and metaphors associated with HIV and AIDS have also been responsible for people disassociating with PLWHAs. The early definitions, which associated it with sexually transmitted disease and not a viral communicable disease has 34 University of Ghana http://ugspace.ug.edu.gh had an implication on the social definition of AIDS (Altman, 1994; Gilman, 1988). The sexual transmission of this disease denotes, for many, a manner of infection that is self- induced (Sontag, 1989). Women have been particularly vulnerable to AIDS stigma by being positioned as ‘dirty’, ‘diseased’ and ‘undeserving’ (Lawless, Kippax & Crawford, 1996).These issues become critical when viewed against the backdrop that this study is targeting Moslem, and will therefore be interested in determining whether the issues raised are also applicable to them. Witchcraft and Supernatural Forces: As far as witchcraft or supernatural forces are concerned, Shisana and Simbayi (2002) assert that there is a belief in many traditional cultures that witchcraft or supernatural forces can cause HIV and AIDS and hence, the reason why people in South Africa shun the company of PLWHAs. Similarly, Kalichman and Simbayi (2004) study in South Africa on the traditional beliefs and causes of stigma indicates a high level of stigma among those who believe that AIDS was caused by supernatural forces and spirits than those who did not hold the same belief. Again, Senah (1997) and Wyllie (1983) studies on the traditional healing system in Ghana reveal that diseases, which lead to deformity or is contagious, whose source the victim is unaware of and characterized by seriousness and stress attributable to the violation of a cultural norm, qualifies such a disease to be the result of supernatural forces or spirits. From these characteristics, there is the tendency for HIV illness to be regarded as supernatural and in reality assigned a supernatural explanation by Ghanaians (Awusabo-Asare & Anarfi, 1997). Thus, the linkage of HIV illness with supernatural forces contributes to its stigmatization. 35 University of Ghana http://ugspace.ug.edu.gh 2.3.5 Effects of AIDS and HIV Stigma and Discrimination The effects of HIV and AIDS related stigma and discrimination do not only lead to isolation, deprivation of human rights but also worsens the impact of infection as stated by Van Dyk (2008). It is also instructive to state that in view of stigma and discrimination, PLWHAs do not disclose their status, fail to attend voluntary counseling and testing (VCT) and also do not seek treatment. More importantly is the fact that there is no open discussion about the disease in view of stigma and discrimination as noted by Herek, 1999; Ogunjigbe, Adeyime & Obiya (2005). The net effect of all these contribute in no small measure to creating barriers in HIV and AIDS prevention programmes. The effects of HIV and AIDS related stigma and discrimination are felt in every aspect of life of PLWHAs, their families and associates as well as the society as a whole. The non-disclosure of their HIV positive status to their partners, family members and health providers as a result of fear of stigmatisation does not only contribute in no small measure to the spread of the disease but also the quality of health care PLWHAs receive. It also leads to social isolation of PLWHAs where they are denied participation in family and community events, which lead to their loss of power and respect. Due to this, some PLWHAs are left on their own with no care and support, which eventually leads to their death. Another significant consequence of stigma and discrimination is the shame and guilt, which most PLWHAs face with its consequential effects of adverse psychosocial disorders such as distress, depression and in extreme cases, suicidal tendencies and death. Stigma and discrimination also affects the human capital development of the region in view of the fact that PLWHAs are denied the space to make available their 36 University of Ghana http://ugspace.ug.edu.gh talents and skills in the economic, political and social arenas. The views and concerns of PLWHAs are therefore not being represented at the appropriate decision making and implementation agencies or departments. From the discussions on the causes of HIV and AIDS related stigma, it is evident that the fear of contagion, the linkage of the disease with life-threatening conditions associated with death, its association with behaviours that people disapprove may explain why people exhibit stigmatic attitudes towards PLWHA. Also, people show unfavourable attitudes to HIV and AIDS infected persons as a result of the misconception that HIV is transmitted through only sex, which borders on immorality and the issue of personal irresponsibility. The notion that once infected with HIV, it is due to moral fault which deserves to be punished. Furthermore, inaccurate information as regards how the disease is transmitted, creating irrational behaviour and misperceptions of personal risk, all constitute in the main, factors that fuel stigma and discrimination. 2.3.5 Attitudes towards Persons Living with HIV and AIDS In as much as the HIV and AID is not only about sociological but biological and medical issue, it is also a disease that has elicited both negative and positive responses from society. Globally, just as the AIDS pandemic has not only generated responses of compassion, love, solidarity and support from people, families and communities, it has also nevertheless witnessed behaviours associated with stigma, ostracism, maltreatment and discrimination since PLWHAs or persons believed to be affected by HIV have been rejected by their families, their loved ones and their communities in both the developed and developing countries (Kwashie, 2014). 37 University of Ghana http://ugspace.ug.edu.gh Phiri’s (2012) study on HIV /AIDS knowledge levels and attitudes towards PLWHAs in South Africa by members of the Pretoria South LIONS Club shows high levels of knowledge of HIV and AIDS and positive attitudes towards PLWHAs by the members. Another study by Tee and Huang (2009|) on the knowledge of HIV and AIDS and attitudes towards PLWHAs among the general staff of a public university reveals a positive attitude towards PLWHAs, though some felt uncomfortable relating with the latter. Similarly, Visser’s (2007) study on stigmatising attitudes towards PLWHAs shows that most of the respondents (80%) felt uncomfortable relating with PLWHAs though they also believe that their human rights should be protected. The results also indicate that notwithstanding the sound knowledge of HIV and AIDS by the respondents, they are still uneasy about physical contact with them such as buying food or sharing utensils with PLWHAs. Al-Owaish, Moussa, Anvar, Al-Shoumer & Sharma (1999) study in Kuwait to assess the attitudes of the people towards PLWHA, also reveals that while 80 per cent of them believed that PLWHA should not be left freely in the community, 34 percent of them stated that those infected should be ostracized to prevent the HIV chain of transmission. The study also found that females, younger ages and single respondents were more likely to express negative attitudes towards PLWHA. Thus, indicating that socio-demographic characteristics of an individual may affect their attitude towards PLWHA. The argument may be that these categories of the population, namely females, the youth and unmarried expression of negative attitudes borders on insufficient or lack of relevant information on HIV and AIDS. This suggests the urgent need for the appropriate institutions both government and non-governmental as well as religious organisations to undertake 38 University of Ghana http://ugspace.ug.edu.gh sensitization and educational programmes for these categories of the population to equip them with the relevant knowledge and positive attitudes. Another study in India by Sudha, Vijay & Lakshmi (2005) reveals that there is a high level of stigma and discrimination among the people towards PLWHAs. While 18 per cent of the participants were willing to take care of HIV- positive family members, 41 percent were against HIV infected students attending schools and buying things from a PLWHA retailer respectively. The degree of the negative attitude towards PLWHA in this community was exemplified by the fact that 51 per cent of the participants wanted a public list of people infected with the disease so as to avoid them. The study further indicated that illiterates and the poor were more likely to show discriminatory attitudes, which is also an indication of the role socio-demographic characteristics play in determining one’s attitude towards PLWHA. Findings from a study by Mahdi, Nnedu, Ogunowo and Jolly (2004) in rural Jamaica found that persons below 30 years were less tolerant to PLWHA as against those 30 and above years. Furthermore, the study establishes that women in the same study were more tolerant than men to PLWHAs. This is an indication that socio-demographic characteristics of people may influence their attitudes towards PLWHA. An epidemiological study in Turkey on HIV knowledge, attitude and misconception by Ayaranci (2005) showed that women, married participants, people living in cities, well- educated and rich participants showed positive attitudes towards PLWHAs. This suggests that socio-demographic characteristics of a person may determine their attitude towards PLWHA. Another significant finding was that misconception about HIV and 39 University of Ghana http://ugspace.ug.edu.gh AIDS also influences stigmatising attitudes resulting in the need for education programmes to focus on accurate and detailed knowledge about the disease. Telephone surveys conducted by Herek, Capitanio and Widaman (2002) in United States on the prevalence of negative feelings and attitudes towards PLWHAs indicate that while 20 per cent of the respondents support a quarantine action for PLWHA and 30 per cent will avoid shopping in a PLWHA grocery shop, one-fourth of them attributed the PLWHAs situation to what they deserve. This, however, contrasts with Adeku et al (2010) findings in Ghana where respondents from both rural and urban communities were divided on whether or not to purchase cooked food from PLWHAs while about 80% supported institutional confinement of PLWHAs, their negative attitudes could be attributed to the misconceptions held about the disease by the respondents. Besides, EKOS Research Associates (2006) in Canada on HIV and AIDS Attitudinal Tracking Survey revealed some patterns of stigmatisation towards PLWHA in the general population. In the said study, about 25 per cent of the respondents believed that PLWHA should not be allowed to be hairstylists, dentists and food vendors. The result also indicated that Canadian women were more likely to show positive attitudes, while senior citizens were less likely to support the rights of PLWHA, thus suggesting a relationship between socio-demographic characteristics of a person and his/her attitude towards a PLWHA. Research by Genberg et al (2009) on the impact of HIV and AIDS related stigma and discrimination in four countries namely Tanzania, Zimbabwe, South Africa and Thailand indicated more negative attitudes and higher perceived discrimination towards PLWHA 40 University of Ghana http://ugspace.ug.edu.gh especially in areas which lack support system and educational programmes. What is significant is the relationship between HIV knowledge and attitudes towards PLWHA. Letamo (2003) in an AIDS Impact Survey in 2001 in Botswana to assess stigmatising attitudes of respondents towards PLWHA found women to be more tolerant than men possibly due to the fact that women were the main caregivers in households in developing countries. The findings also showed that most of the respondents who expressed discriminating attitudes were young people and hence, the need for targeted educational programmes. The study findings may also give credence to the belief that one’s socio-demographic characteristics influence their attitude towards PLWHA. In another study by Letamo (2004) in Botswana, the results showed that sex, age and education were positively associated with attitudes towards PLWHA. Respondents who were young and those who were of low educational level were more likely to stigmatise PLWHA than older and those with higher educational level emphasizing that one’s demographic characteristics also has an influencing role to play when it comes to attitudes towards PLWHA. Furthermore, Ogunjuyigbe, Adeyime and Obiyan (2009) in Nigeria assessed the attitudes of citizens of Lagos towards PLWHA. It was revealed that more than half HIV negative participants would not shake hands (55%) and eat together (66.5%) with PLWHA. Again, 71.5% of the participants believed that PLWHAs should not hold public offices. The results invariably reflect a high degree of stigmatisation towards PLWHA. It must also be emphasized that in relation to Ghana, the issue of negative attitudes towards PLWHAs is not different from what is found in other places. For instance, 41 University of Ghana http://ugspace.ug.edu.gh Awusabo-Asare and Marfo (1997) studies in Cape Coast on HIV and AIDS stigma established that there was general fear of infection .and hence stigmatising attitudes among health workers towards PLWHA. Mills (2003) reporting on the experiences of HIV sero- positive women in Accra and Agomanya showed that many of the women, for fear of shame and disgrace, which ultimately will lead to stigmatisation did not reveal their status. As cited in Nkansa-Kyeremateng and Attua (2013), Ghana Statistical Service, GHS, IFC Macro, 2009, all found stigma and discrimination of PLWHA as relatively high as evidenced in the 2008 Ghana Demographic and Health Survey where only 11 percent of adult females and 19 percent of adult males exhibit accepting attitude towards PLWHA. Such attitudes found expression at all levels, which include individuals, homes, workplaces, institutions and the communities. A study conducted by Kwashie (2014) on determining people’s attitudes towards PLWHA in Ghana concluded that major explanatory factors such as sex, education, marital status and comprehensive knowledge contributed to attitudes towards PLWHA. It also revealed that age, religious affiliation, occupation, and place of residence constituted important factors in understanding the people’s attitude towards PLWHAs. Ayiworoh’s (2016) study on stigma in Wa in the Upper West Region of Ghana reveals widespread stigma among the respondents towards PLWHAs. In this study, people who are uninfected with the AIDS virus and have family members living with the disease employ efforts to distance themselves from PLWHAs. The results of the study also stated impending death and physical deterioration of PLWHA, HIV as a product of 42 University of Ghana http://ugspace.ug.edu.gh punishment and sin, outcome of prostitution, infidelity and above all misinformation as the causes of stigma. 2.3.6 HIV and AIDS related Stigma and Discrimination and Religious Beliefs and Practices Based on one’s religious affiliation, a person’s response to HIV and AIDS is likely to change due to their underlying religious belief system. It is as a result of this that certain people hold the opinion that the religious response to AIDS has often been ambiguous and contradictory. A victim-blaming orientation is likely to stem from what Pargament, McCarthy, Shah, Ano, Tarakeshwar, Wachholtz, et al (2004) refer to as ’negative religious coping’, which involves seeing God as punitive. This is in contrast to ‘positive religious coping’ which views God as loving and caring to probably lead to a more tolerant orientation. In this way, religion has the potential to mould followers’ attitudes about the illness. It can influence thinking around what causes illness, what treatment is indicated and how society should view and support sufferers. Otolok-Tanga, Atuyambe, Murphy, Ringheim and Woldehanna (2007) study in Uganda reveals that faith-based organisations in the past were seen as those that promoted HIV and AIDS related stigma due to inadequate knowledge, morality and fear associated with sensitive issues in relation to sexuality and death. However, due to increased awareness about HIV status among the clergy and congregants and the leadership of PLWHA, their stance has now changed to a more positive one. This stance will definitely have an impact on the beliefs system of the congregants in relation to their attitudes towards PLWHAs. This is because Africans are so religious that they will readily accept whatever their religious leaders say as regards the religion. The implication is that once 43 University of Ghana http://ugspace.ug.edu.gh the people have adequate information and knowledge about HIV and AIDS, they will surely exhibit positive attitudes towards PLWHAs. In South Africa, Keikelame, Murphy, Ringheim and Woldehanna (2010) established that notwithstanding the perceptions that faith-based organisations are committed to tackling the issue of stigma and discrimination, on the contrary, they are seen as promoting them in view of their association of sexuality issues, morality with HIV and AIDS with sin. This is attributed to lack of information and self -stigmatisation which prevents PLWHA from revealing their status. Li, Lee, Thammawijaya, Jiraphongsa and Rotheram-Borus (2009) work on stigma, social support, and depression among people living with HIV in Thailand, revealed that HIV related stigma has a negative impact on the psychological wellbeing of PLWHA in Thailand since depression was significantly associated with stigma. Thus, there is the need for emotional and social support to be provided as a protective effect for the mental health of PLWHA. According to Okunna and Dunu (2006) cited in Oluduru (2010), the linkage of HIV and AIDS epidemic with punishment from God for sexual transgression or divine curse due to an immoral act has made some religious leaders to believe erroneously that any association with PLWHAs is an endorsement of the affected person’s act or supporting the afflicted person’s acts. The fact that religious leaders view PLWHAs as ‘sinners’ or equate the epidemic with a ‘curse’ instead of showing compassion and care contributes significantly to the stigma, discrimination, guilt and shame suffered by PLWHA. This is unfortunate when one comes to realize the fact that people become infected through other means such as mothers getting infected through caring of their children, 44 University of Ghana http://ugspace.ug.edu.gh contaminated blood transfusions to innocent persons, faithful partners infected through unfaithful partners and innocent females infected through rape and others. Studies abound which support the importance of religious beliefs and practices in dealing with HIV and AIDS, particularly in reducing HIV symptoms and improving quality of life of PLWHAs and their families (Coleman &Holzemer,1999; Green, 2003; Woodard & Sowell, 2001). Green (2003) found that in regions with high HIV prevalence, faith- based organisations (FBOs) have contributed in no small measure to stigma especially towards PLWHAs. In support of this, Parry (2003| asserts that religious entities have become avenues of exclusion for PLWHAs rather than places of shelter and comfort. A study conducted by Muturi and Soontae (2010) on HIV /AIDS stigma and religiosity among African American women reveals that persons who display high religiosity significantly exhibit high level of stigma towards PLWHA associating the disease with a curse or punishment from God. This view is supported by Madru (2003) who also observe that HIV infection is as a result of sinful acts and immorality and AIDS as an outcome of such behaviour. UNAIDS (2002) on the same issue, asserts that religious and moral values account for some people to conclude that AIDS is due to moral fault like promiscuity or ‘deviant sex’ and hence deserved punishment. These perceptions are further given credence by the Biblical teachings captured in the following verses: ‘Wages of sin is death’ (Romans, 6:23) ‘Likewise, Sodom and Gomorrah…committed sexual sins and engage in homosexual activities, serve as an example of the punishment of eternal fire’ (Jude, 1:7) and “for all have sinned and come short of the glory of God” (Romans 3:23). These teachings to a great extent, have accounted for the stigmatisation against PLWHAs by most people especially, the religious. 45 University of Ghana http://ugspace.ug.edu.gh Religious beliefs and practices influence the behaviours and attitudes of people towards PLWHAs. Dilger (2007) in a study in Dar.Es Salaam established the role of religious organisations in both spiritual matters and material needs. Apart from the fact that they can give PLWHAs spiritual counseling, prayers for healing, hope for spiritual salvation, social and material support, they can also provide care and assurance of burial after death. Likewise in Tanzania, Zou, Yamanaka, John, Watt, Ostermann and Thielman (2009 found that most of the respondents believed that PLWHAs have disobeyed the word of God and are therefore being punished accordingly. They however, believe that they could be cured through prayers. The study also revealed that people who hold such beliefs exhibit high level of stigma towards PLWHAs. Another study by Varas-Diaz, Neilands, Malave-Riveral and Betancourt on religion and HIV and AIDS stigma in Puerto Rico establishes that Nursing students who were greatly involved in religious activities exhibit higher levels of HIV and AIDS related stigma. Also, Andrewin and Chien (2007) studying stigmatisation of patients among doctors and nurses in Belize stated that health care professionals who identified themselves as religious exhibited high level of stigma as compared to those not considered religious. Again, Rader and Campbell (2002) asserted that religious groups are noted for responding to issues of HIV and AIDS in negative terms, which breeds stigma and discrimination. They stated that judgmental comments from religious leaders and debate about condoms have been responsible for such a situation. This is attributable to the unwillingness of the religious sector to engage in any way that could imply dilution of moral standards, hence PLWHAs experience of rejection by religious people. 46 University of Ghana http://ugspace.ug.edu.gh It is important to state that this is not a good practice since religion is expected to assuage human suffering, show love, care and compassion and above all provide a supportive environment for the excluded and rejected. The essence of religion will be lost to its adherents if religious leaders engage in activities that suggest rejection, isolation and above all stigma for the mere fact that such persons have contracted a disease, HIV and AIDS. Religious leaders should rather lead their lost flock to salvation instead of condemning them. Nyblade et al (2003) in Mukasa (2008) declared that in Ethiopia and Zambia, there is a strong linkage among sex, religion and stigma in view of the belief that HIV is a deserved punishment from God for sexual sins committed by individuals and communities. Religious institutions are reported to play a contradictory role towards people living with HIV and AIDS. Mukasa (2008) reports that a number of studies show religious leaders as active proponents of stigma towards PLWHAs. As noted by Braithwaite & Genrich (2005), there is the possibility of the church to be turned into a stigmatizing environment for PLWHAs in view of the association of sexual and moral connotations with HIV transmission. The perceived stigma towards PLWHAs may be traceable to their perceptions that the disease was contracted through such immoral ways like pre-marital sex, infidelity and prostitution, which are all considered as sinful. Thus, the actions of the religious leaders and congregations are therefore meant to protect them from the sinners. This, however, should not be the situation because the church and mosque are supposed to be havens for those who might have committed sins and need redemption or salvation. It is also important to state that people may get infected through other ways other than immoral ways, which may not be their fault. They also emphasise that religious beliefs significantly shape individuals’ outlooks on living 47 University of Ghana http://ugspace.ug.edu.gh with HIV since faith practices and beliefs do not only provide a sense of peace and hope but also assist people to prepare for and accept death. It is against this background that people often turn to religion to make sense and come to terms with being HIV-infected. The employment of prayers, meditation and faith in God and other forms provide solace to the infected. This is evidenced in studies in Tanzania and other African countries (Makoe, Greef, Phetlhu, Uys, Naidoo, Kohi, Dlamini, Chirwa Holzemer, 2008). It is significant to mention that as part of its contradictory role, just as religious faith and beliefs are seen as an avenue for providing solace and hope for PLWHA, they on the contrary promote fatalistic attitudes and passive resignations, which obstruct participation in treatment. This is supported by McKinney & Hess (2007) study in Mali, where those who believed that AIDS was a punishment from God had fatalistic attitudes than those who did not. In the same vein, there is the tendency for PLWHA to discontinue their treatment because of their belief that their pastors’ prayers can cure them of HIV. The implication of the statement is that once God is the source of the disease, no matter what treatment the PLWHAs engages in will not yield any positive results. Such a person will surely die and there will not be the need to waste time and resources in undergoing any treatment. It is important to state that such a stance will affect the uptake of antiretroviral drugs and possibly lead to the spread of the disease and for that matter, the fight against stigmatisation towards PLWHAs. In a study conducted by Abraham (2006) on perceptions of HIV and AIDS related stigma among Moslems in a Cape Town community, the majority of the participants perceived HIV and AIDS as a curse or punishment from God. This might have resulted from the understanding that Moslems were compelled by God to follow his rules and he 48 University of Ghana http://ugspace.ug.edu.gh punished them when they chose not to do so. Islam prohibits Moslems from having pre- marital and extra-marital sexual relations and based on that, any member who did so was regarded as having committed sin, and hence was punished by God through HIV and AIDS. They reported that a participant lamented as follows: “In all religions ………. HIV ……….we talk about it as punishment from God. If you look at the prostitutes, right, she or he knows that HIV/AIDS is right outside. You can pick it up anytime now why you still go out and do your thing outside and at the end of the day you get the disease. So if you decide that I wanna go that direction of HIV /AIDS that is a punishment”. Thus, such persons were seen as guilty, bad and shameful based on the belief that they chose behaviours that put them at risk of HIV infection. The underlying belief was that if you have HIV and AIDS, then you are guilty of a transgression against God through illegitimate behaviours such as sexual promiscuity, homosexual relationships and drug/needle abuse; and therefore you chose to be bad and sinful and accordingly, you were deserving of punishment. The teachings of religious leaders, which link HIV illness to immoral behaviour, according to Anane (1999) account for their reluctance to address the issue of HIV illness in Ghana. In support of this assertion, Judy (1999) also indicated the unwillingness of PLWHAs to disclose their status to church communities due to stigma. This was confirmed when a participant, who is a church secretary stated that churches in Ghana played a significant role in the propagation of AIDS stigma. 49 University of Ghana http://ugspace.ug.edu.gh In yet another study by Adoo-Adeku et al (2010) in Ghana, the relationship between immoral behaviour, or for that matter, sexual sins and HIV were given expressions as reflected by the respondents concerning their perceptions about PLWHAs. In this study, respondents considered people living with HIV and AIDS variously as: “Sinners who are being punished and therefore need no sympathy”, “Not God-fearing people”, “People with no values and worthless”, “Immoral people” and “They are people paying for their bad deeds”. What is significant from these statements is that some people still do not know the causes of the illness due to lack of relevant information and knowledge. It may, therefore, be argued that in view of the insufficient or lack of relevant knowledge on the causes of HIV and AIDS, more intensive sensitization and education on the illness targeted at religious groups and their leaders is very paramount. This will promote a more compassionate and caring environment for PLWHAs. Ever since the outbreak of HIV and AIDS disease around 1985, Islamic ethical literature has considered the illness as something that pertains to only Europeans and American homosexuals. With the recognition now being held that HIV and AIDS are spread mainly by multiple partners and heterosexual activity, Moslem leaders have done all they could to avoid having any discussion on the topic due to the strong religious taboos in relation to sex. Rademakers, Mouthaan and de Neef (2005) stated that Islam stresses sexual abstinence before marriage for both males and females. Al-Islam (2001) held the opinion that in the Islamic view, HIV and AIDS are as a result of behaviour that displeases and disobeys God and therefore merits punishment. On the other hand, Francesca (2002) reiterated 50 University of Ghana http://ugspace.ug.edu.gh that some Moslem religious groups, however, stress the great tolerance of Islam, which should include people living with HIV and AIDS. The issue of HIV and AIDS has therefore created a sense of dilemma for Moslem religious leaders. As highlighted by Amod (2004), Muslim religious leaders in South Africa, a country with one of the highest prevalence rates for HIV and AIDS, are torn between avoiding any discussion of HIV and AIDS and considering it as an admonition from God to avoid illicit conduct, denying the threat of the pandemic to their societies (Hassan, 2004; Kelley & Eberstadt, 2005), or promoting tolerance or favourable attitudes towards PLWHAs (Francesca, 2002). Thus, the dilemma of Moslems is how to reconcile compassion for PLWHAs with the issue of punishment as deserved divine retribution. HIV2 infection, which is characterized by promiscuous behaviour, has divided Islamic religious opinion as to whether persons living with HIV and AIDS (PLWHA) should be punished or stigmatized for their sinful behaviour or embraced or accepted based on religious tolerance. Notwithstanding inconsistent and confusing messages from religious and political leaders, a study conducted in South Africa targeting Moslem students’ attitudes to people living with HIV and AIDS, did not only show their high levels of religiosity but also displayed an unexpectedly tolerant attitude towards people living with HIV. 2.3.7 The Islamic Religion: Beliefs and Practices The Islamic religion constitutes the second largest religious group worldwide and according to gordonconwell.edu, it has a population of 1.7 billion as at 2015. Moslems, according to Rassool (2000) are linked by their common Islamic faith, heritage and 51 University of Ghana http://ugspace.ug.edu.gh belief in: one God; angels; God’s revealed books; prophets through whom God’s revelations were brought to mankind; a day of judgement; individual accountability for actions; God’s complete authority over human destiny; and life after death. The holy Qur’an is considered by Moslems as a record of the exact words, revealed by God through the Angel Gabriel, to the Prophet Mohammed and then to the people. The Qur’an thus, serves as the main basis of every Moslem’s faith and life practices (A study in 2015/16). The religion also encompasses ritual practices and guidelines for a complete way of life, and is shown in Moslem cultural beliefs and their practices. The five pillars of Islam, which constitute the foundation of the religion, are faith (Sahadad), prayer (Salat), concerns for the needy (zakat), self- purification (fasting) and pilgrimage by those who are able, to Mecca (Abdul-Wahid, 2016). As far as the Moslems’ world is concerned, Hasnain (2005) remarks that Islam defines culture, and culture gives meaning to every aspect of an individual’s life including behaviours, perceptions, emotions, language, family structure, diet, dress, body image, concepts of space and time, and attitudes towards health and illness. According to Athar (2007), each aspect of a Moslem’s life has implications for the delivery of health care. Moslems view health, illness, suffering and dying as part of life and as a test from Allah. Thus, they are encouraged to receive illness, suffering and death with patience, meditation and prayers. Also, Moslems believe they are to consider illness and suffering as atonements for sins, and death as a part of their journey to meet God. The idea of seeking appropriate treatment and care for a person is strongly encouraged in Islam. It is also stated that health, illness and caring are considered part of the human experience of performing worship activities while on earth (Athar 2007). 52 University of Ghana http://ugspace.ug.edu.gh Moslems’ view about caring, according to Rassool (2000) is embedded in the theological framework of Islam. The concept of caring in the religion is founded in the belief that providing care to others is a service to God, which should be given freely and without ties to commercialism. Caring is viewed as a natural outcome of having love for Allah and the prophet Mohammed, and refers to having the will to be responsible, sensitive, concerned, motivated and committed to acting the right way in order to achieve perfection in life. It is also important to note that the religion advocates its adherents to follow the guidelines delineated in the Qur’an and the Sunnah (the prophetic traditions of Mohammed). Moslems believe that the prophet was sent to provide mankind examples of how to live, including matters of health and personal hygiene. There exist several Islamic traditions that relate to health care practices which coincide with specific traditions that take place along the human life span. Homosexuality is condemned, and considered sinful and punishable by Allah. Moslem couples are encouraged to have children and sex outside marriage is discouraged while contraception and family planning are allowed (Akhtar 2002).Abortion is not permissible in Islam except if the pregnancy threatens the life of the mother, since children are seen as a gift from Allah. Boys born into the Moslem family are circumcised to enable them to maintain cleanliness through washing (wudlu) and to prevent urine from collecting in the foreskin. Moslems prefer to be cared for by a member of the same gender. In addition, the Islamic faith emphasized cleanliness, which includes eating with the right hand, consuming only permissible (halal) food. The forbidden or non-permissible (haram) foods and items include pork, non-halal meat, alcoholic beverages, gelatin products and illegal drugs (Islamic Council of Queensland 1996). 53 University of Ghana http://ugspace.ug.edu.gh In Islam, human life is considered precious and the will of Allah should be allowed to prevail. In that regard, the taking of a life through suicide or euthanasia is considered a major sin. Moslems also believe in life after death and the Day of Judgment. The religion also enjoins its adherents to treat terminally ill patients with sympathy and compassion and also take care of their spiritual needs. 2.3.7 Islam and Economic Related Activities The history of Islam in most West African countries, and for that matter Ghana cannot be written without mentioning the role of the trans-Sahara trade between Africa and the Mediterrean. The North African traders were the main players in bringing Islam into West Africa. This is because their main aim was to trade. They nevertheless transported their religion, Islam since some of them were scholars interested in propagating their religion by teaching the natives the Arabic language, which was more of a secular education than the formal type. This probably might be the reason why most of the Moslems had only secular education making it difficult for them to gain formal sector employment due to lack of formal education particularly in Ghana. It has also affected HIV and AIDS stigma and discrimination messages which are mostly in the English language. Islam as a religion is not only about spirituality but deals with every aspect of human life. It gives directions in social life, political life, marital as well as economic or business transactions (Azmi 2015). According to Al-Ghazali and Mohammed (2001) striving for the sustenance is required. It is part of human nature to earn the livelihood for himself as well as for the dependants. As stated by Al-Maududi and AbulAala (2009), an individual can get nothing unless he puts his efforts. 54 University of Ghana http://ugspace.ug.edu.gh As a religion, Islam is very particular with encouraging economic activity and exhorting its followers to hard work, which is productive and profitable as opposed to unemployment, dependency and idleness. This is meant to fight poverty, a phenomenon considered social illness, which effects do not affect only the poor but the society as a whole (Azimi, 2015). The view of Islam is that society cannot be established on a firm solid foundation when a section of its population suffers from the effects of poverty. It is on these that economic activities or business transactions are considered very vital in Islamic communities. According to Shafi (2002) business simply refers to trading, buying, selling and transactions which deal with things and services of physical and spiritual value. Business transactions in the Islamic religion must be based on the Quran, traditions and practices of the Prophet and his companions as specified in the books of Jurisprudence. Economic related activities or business transactions are considered as the foundation of any society and growing business or economic related activities play a significant role in raising the social status of the individual and the community as it consequently contributes to the development of the economy. In this regard, the role of all those persons engaged in this enterprise cannot be over-emphasised once they all contribute to the development of the community. Thus, there should not be any reason why certain categories of persons due to their conditions, should be excluded from this enterprise or stigmatised against when it comes to business transactions .This is important when viewed from the position of Islam as a religion which does not discriminate based on one’s tribe, colour, sex, social or health status as exemplified in its religious practices and rituals such as prayers and the Hajj performance. 55 University of Ghana http://ugspace.ug.edu.gh From the perspective of Islam, economic related activities and business transactions are conducted for the purpose of distribution of wealth and not for the control of resources. This is captured in the Quran, Surah Al Nisa (4), Ayat 29 and 30: 29. ‘O ye who believe! Eat not your property among yourselves in vanities; but let there be among you traffic and trade by mutual good-will: nor kill (or destroy) yourselves: for verily God hath been to you. 30. ‘if any do that in rancor and injustice, soon shall We cast them into Fire: and easy it is for God’. As in other aspects of life, business transactions should also be governed by the main concept of Islam. According to At-Tirmidhi and Mohammed IbnIsa, ’how the man earns the wealth and where he spends it “will be questioned one day. One of the important verses in the Quran as regards business transactions is quoted below: “What Allah has bestowed on His Messenger (and taken away) from the people of the townships,-belongs to Allah,-to his Messenger and to kindred and orphans, the needy and the wayfarer; In order that it may not (merely) make a circuit between the wealthy among you. So take what the Messenger assigns to you, and deny yourselves that which He withholds from you. and fear Allah. for Allah is strict in punishment’’. The import of this verse is that in Islam wealth should not be confined in the hands of the rich alone. It must spread in the society for every individual whether rich, poor, sick, healthy, black or white to have equal benefits of it. It is important to state that the flow of wealth should not be from the poor to the rich to make the latter richer and the poor poorer. It should rather be from the rich to the poor and the needy in the society not only 56 University of Ghana http://ugspace.ug.edu.gh to empower them but also raise them to the level where they could be in the position to contribute their quota to the welfare of the larger community and strengthen the economy. In the light of this, it is against the tenets of Islam for people not to engage in business transactions or patronize the goods and services provided by the sick especially PLWHA because of their situation, since they constitute the vulnerable, needy and disadvantaged in the society. They must survive and not be dependent on others. Rather, zakat was made mandatory and voluntary charities were recommended and generosity appreciated. A great proportion of the revenue was fixed to cooperate the socially and occasionally deprived people and to assist them come out of their debt burdens if ant accrue as indicated by Abdullah and IbnAnas (2015). It is also important to state that as far as businesses are concerned, there is no fixed list of permissible businesses in Islam. Originally, all kind of business transactions were allowed. However, business transactions should not involve forbidden things such as gambling, wine and pork. Also, Moslems are not allowed to engage in business transactions that cause harm or reciprocates harm. Any business transaction that has clear uncertainty or speculation is not permissible in Islam because it leads to problems or disputes between the parties involved. It is important to emphasise that these principles governing business transactions in Islam have been put in place to ensure the sustainability of the economy and above all spread the profit to benefit majority of the people who are less privileged, vulnerable, needy and the sick in the society. 57 University of Ghana http://ugspace.ug.edu.gh 2.3.8 Islam and HIV and AIDS related Stigma As far as Islam is concerned, the issue of stigmatisation in general and HIV and AIDS related stigma is not encouraged at all. Reference is made to the time when the Holy Prophet came with the divine message and proclaimed that no Arab was superior over a non-Arab and no white was superior over black and that superiority was by righteousness and God-fearing alone as captured in Surat Al-Hujurat 49:13. Thus, the problem of racial or colour discrimination was eradicated and that one’s superiority should not be based on birth or colour or blood but by God-fearing and righteousness, suggesting that discrimination of any type does not have a place in the religion. It is also significant to mention the Prophet’s address to the people during the last Hajj (pilgrimage), which is also known as the last sermon, saying: ‘O People! Your God is one; your father is one; no preference of an Arab neither over non-Arab nor of a non- Arab over an Arab or red over black or black over red except for the most righteous .Verily the most honored of you is the most righteous” (Al-Bukhari, Hadith 1623, 1626, 6361). Islam emphasizes the fact that all people are equal and belong to one race and therefore there is no need for segregation or discrimination based on one’s situation which could be poverty, sickness or any unfortunate circumstances. It is reported by Abu Hurayrah that the Messenger of Allah (Mohammed) said: ‘Do not envy one another; do not outbid one another, do not hate one another, do not shun one another…It is a serious evil for a Moslem that he should look down upon his brother Moslem. All things of a Moslem are inviolable for his brother in faith; his blood, his wealth and his honour.’(Hadith 35) 58 University of Ghana http://ugspace.ug.edu.gh Another important illustration, according to Moustapha 2005; Yaqut; 2007 is the daily and Friday prayers in the mosque where equality is practically demonstrated with no signs of discrimination and differences. Whoever went to the mosque first took his place in front rows notwithstanding his financial or social status and whoever went late will find himself in the back or last rows. Thus, the rich and poor, the knowledgeable and non-knowledgeable, the short and tall, the black and white, the stout and lean all find themselves in the same row. This is even manifested clearly during the Hajj and Umrah pilgrimage where everyone is expected to wear simple white clothes, which equates the rich and poor, the ruler and ruled all walking around the Holy Kaaba asking one lord. All these are suggestive to the fact that as far as the religion is concerned, there is no discrimination and all Moslems are equal before the lord (Moustapha, 2005). Reference is also made to the Holy Prophet who once refused to pray against the people of At-Ta’if for once stigmatising and injuring him, though Allah gave him the opportunity to take revenge for their injustices against him. The prophet declared ‘No, I shall beseech Allah to make from among their progeny a generation of true believers!’(Hadith of Mercy, Sahih-al-Bukhari 3059 & Sahih Muslim 1759). The prophet went ahead to pray for them to be guided and their unjust acts forgiven. Islam also enjoins all Moslems to always visit and show love to the sick and that explains why it is not Islamic to stigmatise PLWHA. Gloating over others’ misfortune is the manner of the unbelievers and hypocrites. Allah Almighty says, “If a lucky chance befalls you, it is evil unto them, and if disaster strikes you they rejoice thereat. But if ye persevere and keep from evil their guile will never harm you. Lo! Allah is surrounding what they do” (Aal- ‘Imran 3:120). 59 University of Ghana http://ugspace.ug.edu.gh It is important to remark that equally significant Islamic religious leaders’ responses to HIV and AIDS, and for that matter, stigmatisation are worthy of consideration since they are supportive of positive attitudes towards PLWHAs: “...We also acknowledge that people living with HIV/AIDS need unconditional love and support and are not to stigmatise and discriminated’ (International Pre-conference Muslim Workshop on HIV/AIDS, Bangkok, Thailand, 9 July 2004). Islamic Relief (2008) wrote that ‘there is no ‘us’ and ‘them’ and that all attempts to split society into ‘us’ and ‘them’ are counterproductive-whether manifested in a reluctance to use toilets and shake hands, in exclusion from the labour market or in condemnation and exclusion. In that context, infection patterns need to be identified to enhance the effectiveness of HIV and AIDS –related programming but, once a person is infected, the single priority is how the person and their community are affected’. Subsequently, research has revealed that: “Instead of gloating over the misfortune of those who are afflicted by AIDS, we should help them get proper care and treatment .Instead of stigmatising them for carrying or having a disease for which they may not be responsible, why don’t we make du’aa for them? Why don’t we earnestly ask Allah to shower them with His mercy? (Moustapha 2005) Islam places a high premium on life and discourages one from having a sense of hopelessness or abuse regarding life. It is against this stance that when Moslems become HIV positive or develop AIDS, other Moslems are supposed to care for them since they are still part of the Moslem fraternity. It is important to state that Moslems are not supposed to avoid or neglect those living with HIV or AIDS due to the disease (www.positivemuslims.org.za/hivaidsis.htm; retrieved 20/10/18). 60 University of Ghana http://ugspace.ug.edu.gh Instead, Moslems believe that there is the need to give considerable attention; care, love and affection to PLWHA so as to enable them lead dignified lives (Moustapha, 2005). Moreover, it is their conviction that no Moslem has the right to judge or condemn PLWHA since the right to forgive or punish is in the bosom of Almighty Allah. Love and compassion are considered the qualities of a good Moslem and PLWHA cannot be denied this powerful emotion. The Holy Prophet recommended that Moslems should give much attention to visiting and caring for the sick and that since PLWHA need compassion, love, support and affection, Moslems should feel comfortable embracing them (Yaqut, 2007). It is important to stress that the Islamic tradition and ethics stress empathy for the sick, no matter the type of illness. As reported by Abu Hurayra cited in Al-Nawawi (1997) the prophet of Islam stated that one of the five rights a Moslem has over another Moslem is to visit the sick. This is evidenced in the quotation: “The Messenger of Allah, may Allah bless him and grant him peace, said ‘Allah, the Mighty and Exalted, will say on the Day of Rising, ‘Son of Adam I was ill and you did not visit me”. The man will say,”O Lord how could I visit You when You are the Lord of the worlds? He will say, ‘Do you not know My slave was ill and you did not visit him? Do you know that if you had visited him, you would have found Me with him? Based on the above statement, it is clear that it is not permissible in Islam to treat persons who are sick, especially PLWHA differently or show negative attitudes towards them just because they have AIDS. What is required of Moslems is kindness, care and love and above all assist such people to get medical treatment. 61 University of Ghana http://ugspace.ug.edu.gh It is however important to point out that notwithstanding these, which are pointers to the fact that Islam has positive attitudes towards PLWHAs, Lake and Wood (2005) stated that some Moslems are of the belief that HIV and AIDS is a punishment from God for bad behaviour and /or sins committed’ and that the only way persons are infected is through illicit drug use, male-to-male intercourse and /or extra-marital sexual activity. It is therefore not coincidental that Hasnain (2005) remarked that such incorrect beliefs contribute to stigmatization and discrimination towards persons living with HIV and AIDS, which appears to be more widespread among Moslem communities than in other populations. Studies conducted by Lohrmann et al (2000) and Williams et al (2006) indicate that among non-Moslem populations, people’s knowledge and attitude towards persons living with HIV and AIDS are strong determinants in relation to one’s willingness to care for PLWHA. On the contrary, however, in Moslem communities, whether one does or does not willingly care for PLWHA appears inconsistent and dependent upon the community. While negative attitudes towards PLWHA have been found to exist among Tunisians, it is rather the opposite as far as Turkey and Iran are concerned where the people exhibit positive attitudes towards PLWHA in view of their adequate knowledge about HIV and AIDS (Ayranci, 2005; Montazeri, 2005). Though there is limited information as regards caring practices for PLWHA in Moslem communities, knowledge generated from earlier studies on the same issue among non- HIV and AIDS populations, studies within the context of the Islamic faith, can be used to better understand how Moslems care for those with chronic illness. Islamic religious practices and cultural norms are factors that have been shown to influence individuals providing care to family members with schizophrenia. The said family caregivers have 62 University of Ghana http://ugspace.ug.edu.gh been found to interpret caring as love and concern, obligation of family members, acceptance as prescribed by Allah and a test of patience set by Allah (Vanaleesin, 2007). It is however regrettable to state that as Martin (2004) stated, in some areas of Asia, Moslem practices continue to be influenced by local cultural beliefs traceable to previous traditions. Issues in relation to spirituality respect for ancestors, beliefs in spirits and mystics, and gender relations are some of the beliefs that are derived from pre-Islamic beliefs. What is significant to note is that Asian cultures stress maintenance of social and religious harmony with the universe, which influences one’s attitude toward health and disease (Martin, 2004). In this regard, since HIV and AIDS has been viewed as an immoral disease, seeking health care for the illness or disclosing the presence of a sero-positive status can bring a lot of shame to one’s family and the community. In order to avoid such an embarrassing situation, PLWHA often become isolated or are totally rejected by the Moslem community (Ibrahim and Songwathana 2010). What is significant to note is that Islamic beliefs and traditions determine the culture and the Moslems way of life as well as directly influence their health care practices. It is, however, the misperceptions and lack of knowledge about HIV and AIDS that continue to exist among many Moslems thereby fueling stigmatisation, discrimination and neglect of PLWHA (Ibrahim and Songwathana 2010). 63 University of Ghana http://ugspace.ug.edu.gh 2.3.9 Policy Interventions on HIV and AIDS related Stigma and Discrimination The Cambridge English Dictionary (2019) defines a policy as a set of ideas or a plan of what to do in a particular situation that has been agreed to officially by a group of people, a business Organisation, a government or a political party. A policy is therefore a law, procedure, administrative action, incentive or voluntary practice of governments and other institutions. A policy is a deliberate system of principles, set of ideas or plans meant to serve as a basis for making organisational decisions, which may include the identification of diverse alternatives such as programme or spending priorities in order to achieve rational outcomes. From these definitions, one may conclude that a policy is a legality, which implies that it is founded on law and anyone who flouts it is likely to face the necessary punishment as may be prescribed for offenders. HIV and AIDS related stigma has been considered as one of the greatest obstacles in any effective fight against the epidemic. Apart from the fact that its devastating effects are felt at the individual, social and national levels, it has also been singled out as the main hindrance to accessing prevention, care and treatment services. That notwithstanding, the varied negative treatment meted out to PLWHA by individuals, society and its institutions, various efforts by the community, national and international actors have yielded minimal results in reducing the negative effects of HIV and AIDS stigma. It is in the same vein that the belief is commonly held that any interventions in the area of stigma will definitely lead to reduction in HIV and AIDS related stigma and not its total elimination. 64 University of Ghana http://ugspace.ug.edu.gh In a review of research studies and future directions for prevention strategies on HIV /AIDS –related stigma and discrimination in Nigeria, Monjok,Smesny and Essien (2009) suggested that the news media, home videos, radio jingles should be employed to produce de-stigmatisation programmes in schools, hospitals and religious centres. Apart from stressing that the introduction of AIDS education should be integrated into the curriculum of teaching in the country from the primary to university level, they also mentioned the empowerment of the stigmatized groups such as PLWHA, sex workers, drug users as well as their involvement in the design and implementation of prevention programmes in the country as ways of addressing stigma. Another important intervention has to do with focusing more prevention activities in the rural and remote areas than in urban centres since majority of the population in most developing countries reside in such areas where they lack access to modern day mass media. In their study on Stigma in the HIV/AIDS epidemic: A review of the literature and recommendations for the way forward, Mahajan, Sayles, Patel, Remien, Ortiz, Szekeres and Coates (2008) noted some of the stigma reduction strategies as those designed to reduce stigma at the community level by increasing the tolerance of the general population towards PLWHA. The strategy employed was education through provision of factual information about HIV and AIDS. Another strategy was the mass-media campaigns relating to HIV and AIDS knowledge, attitudes and behaviours. Such campaigns include broadcast such as the radio and television which target national audiences or small media in the form of posters, pamphlets and drama aimed at localities which disseminate messages about HIV and AIDS with the aim of potentially reducing HIV and AIDS related stigma. 65 University of Ghana http://ugspace.ug.edu.gh In the view of Mahajan et al, the above and several other existing stigma reduction strategies are focused on cognitive-behavioural and social-cognitive models engaging activities such as information dissemination, empathy induction, counseling, and cognitive behavioural therapy at the individual level. They rather propose a more comprehensive conceptualization of HIV and AIDS stigma and discrimination, development of stigma reduction programmes at the institutional and structural levels, whose designs must be influenced by the prevailing social and cultural forces that provide the dominant groups the power to create stigmatising and discriminatory conditions. The need for community level mobilization with the sole aim of re-awakening the power of resistance of the PLWHA in collaboration with the support of important structural targets such as religious leaders, the judiciary and the legislative bodies can effectively respond to stigma. Also, the importance of appropriate reporting and enforcement mechanisms like legal aid services and hotlines to report discrimination cannot be over- emphasised when it comes to socially endorsed rights based approach (Parker and Aggelton 2005). Derived from the principles of community organizing and community building requested the need for new models for advocacy and social change in response to HIV and AIDS related stigma. The principle of GIPA (Greater Involvement of People Living with HIV and AIDS) is vital for effective social programme response to HIV and AIDS stigma. According to UNAIDS Policy brief (2007), GIPA aims to realize the rights and responsibilities of PLWHA, including the right to self-determination and participation in decision making process that affect their lives. The Public participation of PLWHA at both community and social levels would not only promote individual level responses to 66 University of Ghana http://ugspace.ug.edu.gh internalized stigma on the part of PLWHA but could also prove a powerful deterrent to stigmatising impulses of the general population. In his study on the role of religious leaders in curbing the spread of HIV /AIDS in Nigeria, Oluduru (2010) recommended constant and regular training of religious leaders on HIV and AIDS prevention, as well as counseling since equipping them with accurate information on the disease will enable them to disseminate such accurate information to their congregation thereby eliminating misconceptions which fertilizes stigma and discrimination. Religious organisations role in assisting prevention and care through the dissemination of information in the local FM stations using the local languages are essential. Trained religious leaders can either through press statements or interviews in the media discuss the factors that fuel the epidemic and its impact on the individual, families and societies (UNICEF, 2003). Another important intervention worthy of mention is the need for religious leaders to employ their spiritual or religious teachings to emphasise compassion and support for PLWHA. According to UNICEF(2003), they must also ‘work with other religious leaders, faith-based coalitions and community leaders to find common beliefs, spiritual teachings and moral, legal and social standards that can help prevent HIV and alleviate the sufferings of those affected by AIDS. One other equally important intervention is to channel valuable resources at the disposal of religious organisations such as schools, clinics, hospitals and orphanages for HIV work. These could be used for creating awareness about the disease and its related effects 67 University of Ghana http://ugspace.ug.edu.gh and providing the necessary care and support for PLWHA (Afrol News http://bit.ly/ha8D69; UNAIDS Partnership with Faith-based organisations). According to Ulasi et al (2009), educational interventions should take into consideration the prevailing sociocultural, religious and economic environment, and address areas such as the harm of cultural and religious judgments of PLWHAs, benefits of testing and knowing one’s HIV status, inability to contract the disease through mere social contact. To them, PLWHA and their families are to be provided with factual information about the disease including information on home management and psychological aspects of the disease. Also, PLWHAs need training to assist them improve their self-esteem and self - efficacy and positive coping skills. Such educational intervention should erase the minds of the community people that they can be physically, socially, and morally be tainted by interacting with PLWHAs (Ulasi et al, 2009). 2.3.10 HIV and AIDS Policy in Ghana The current policy, known as the National HIV and AIDS, STI policy is a revision of the 2004 policy, anchored on the dictates of the 1992 Fourth Republican Constitution and other government’s policies, international conventions and protocols, which include the Millennium Development Goals. The policy is meant to address the very serious health and developmental challenges occasioned by HIV and AIDS. The eleven strategic thrusts of the policy are : (1) human rights, legal and ethical issue,(2) prevention of HIV and STIs infections,(3)treatment, care and support,(4) mitigation of social and economic effects of HIV and AIDS,(5) health systems strengthening,(6) community systems strengthening, (7) public sector policy, roles and responsibilities, (8) private sector 68 University of Ghana http://ugspace.ug.edu.gh policies, roles and responsibility, (9) national HIV and AIDS, STIs workplace policy (10) research, monitoring and evaluation (11) funding mechanisms. It must be stated that as far as HIV and AIDS related activities in Ghana are concerned, it is the Ghana AIDS Commission, (GAC), a multi sectoral institution, which co- ordinates them. The Commission provides support, guidance and leadership for the national response to HIV by formulating national policies, coordinating the national response to HIV, and managing and monitoring the utilization of resources (GBSN, 2006). It must however be pointed out that GAC is not directly involved in service provision for PLWHAs and key populations. Rather, it co-ordinates and develops policy. Goals and Objectives: The main goal of the objective is to create a favourable environment for every aspect of HIV and AIDS, STI prevention, care and support. Some of the main objectives, which are relevant to the study are:  Identify components that ensure that the basic rights of each person in Ghana, especially persons infected and affected by HIV are respected, protected and upheld.  Alleviate the social, cultural and economic effects of HIV and AIDS at individual, household and community levels by reducing HIV- related stigma by providing information, basic needs and legal and community safety nets for PLWHAs, orphans and vulnerable children (OVC) and key and vulnerable populations  Ensure that access to social and economic opportunities remains open to PLWHAs and key and vulnerable populations. 69 University of Ghana http://ugspace.ug.edu.gh Under human rights, legal and ethical issues, the policy calls for an HIV and AIDS prevention law and information to the public about their health rights in the Patients charter of the Public Health Act 2012 (Act 851). The policy establishes that discrimination against a person infected or affected by HIV or AIDS is prohibited. Thus, a person who dies of an AIDS –related condition, or is perceived to be HIV positive, is not to be denied burial services on grounds of HIV status. This also applies to the workplace. All workplaces, whether public or private are to have HIV and AIDS policies. Legal proceedings may be instituted for discrimination by CHRAJ, Legal Aid scheme and public interest groups. The right to privacy and confidentiality is safeguarded in the policy, subject however to certain exceptions. The policy also advocates against any mandatory medical exams as part of the pre-employment or pre-enrolment to an educational institution. However, where a person is charged with a criminal offence mandatory testing is to be conducted. This also applies to procedures for the transfer of body parts or fluid. Cultural practices that serve as obstacles to HIV prevention should be proscribed by law, supported with educational campaigns to encourage the people to stop the practice. The policy also states that the Criminal Offences Act 1960 (Act 29) should be used to prosecute the offenders of willful infection. Guidance is also give as regards HIV prevention, treatment, care and support and STIs in the policy in view of the importance of prevention to the reversal of the devastating effects of epidemic. 70 University of Ghana http://ugspace.ug.edu.gh The policy also identifies areas, which deal with the mitigation of social and economic effects of HIV and AIDS, STIs and addresses issues of HIV and AIDS related stigma and discrimination, sexuality, gender, differences in cultural practices and the socio- economic status of the infected and affected. The main aim of mitigation is to reduce HIV and AIDS related stigma and discrimination towards persons infected and affected by HIV and AIDS and above all draw attention to the compelling public health rational to overcome stigma and discrimination at the individual, household and community levels. The policy also identifies a role for government, non-governmental and private sectors and outlines specific responsibilities. The public sector has the responsibility to provide an enabling environment to achieve the nation’s development goals and objectives. Key line ministries have been singled out as critical in successfully mainstreaming HIV and AIDS in the public sector and are required to incorporate issues of HIV and AIDS into the main core business. They include Ministries, Departments and Agencies (MDAs), coordinating bodies, GAC, National Development Planning Commission (NDPC) and National Population Council (NPC). The private sector organisations and enterprises are required to develop and implement workplace policies and programmes for HIV and AIDS, STIs in consonance with the National Workplace HIV and AIDS policy. They include HIV and AIDS, STIs prevention, education for workers, condoms distribution and protection of PLWHAs. Under the private sector policies, roles and responsibilities, provision is made for faith- based organisations. Among others, faith-based organisations are not required to demand HIV testing as a prerequisite for marriage, though couples could be encouraged to 71 University of Ghana http://ugspace.ug.edu.gh undertake confidential testing before marriage. The policy also advocates faith-based organisations not to perpetuate stigmatising messages against PLWHAs and vulnerable populations. It is remarkable to state that research, monitoring and evaluation are key to effective planning and co-ordination of the national HIV and AIDS, STI policy. In view of the importance of funding to the successful implementation of any policy or programme, the policy also contains funding mechanisms for internal and external funds. In this regard, it stresses the need for adequate and sustainable funding for HIV and AIDS programme as paramount to the national response. The policy advocates the establishment of an HIV and AIDS fund with legal support. 72 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE RESEARCH METHODOLOGY 3.1 Introduction This chapter presents information on the research design, the population and sampled population, the sampling techniques used and the sample size, the data collection instrument, pre-testing of the data collection instrument (pilot study), data collection and data analysis methods as well as ethical issues. 3.2 Profile of the study Area a. Location and Position The Upper West Region is located in the North-Western quadrant of Ghana. It is bordered on the north by Burkina Faso, the south by the Northern Region, the west by Cote d’ Ivoire and on the east by the Upper East Region. The region covers a geographical area of 18,476 sq.km, which constitutes 12.7 percent of the total land area of Ghana. It is the seventh largest among the regions in terms of land size though, also the least populated region. The capital and largest town is Wa with other towns such as Lawra, Tumu, Jirapa and Nadowli. b. Population Composition and Distribution The total population of the region is 702,110 made up of 341,182 males (48.6%) and 360,928 females (51.4%), which represents 2.8% of the national population. The sex population favours females and it has a sex ratio of 94.5 males per 100 females (2010 Population and Housing Census).The age structure of the region indicates that the proportion of the population aged 0-14(under 15years) is 41.7%, and those aged 15-64 and 65+ are 52.3% and 6.0% respectively. The region experiences more outflows of people to other parts of the country than people migrating into the region. This therefore 73 University of Ghana http://ugspace.ug.edu.gh gave the region a negative net migration value of -209,144. The total fertility rate is 5.0 and contraceptive prevalence rate that is the use of modern contraceptives among currently married women was 24.8% in 2014.The HIV prevalence rate in the region was 0.8% which was lower than the national HIV prevalence of 1.3 % (National Population Council, Upper West Secretariat, 2015). c. Ethnicity The region is ethnically heterogeneous .The different ethnic groups that are found in the region form part of the over 100 groups in Ghana, which are distinguishable by language and cultural differences. The two major ethnic groupings in the region fall under the broad generic categories of the Mole-Dagbani and Grusi. The main ethnic groups are the Dagaaba, Sissala, Waala, Chakalei and Lobi, though there are other smaller groups such as the Hausa, Fulani and the Moshie, who are settlers from the neighbouring countries. d. Religious Affiliation The 2010 Population and Housing Census indicated that in terms of religious affiliation, there are three major religious groupings in the region namely Christianity (44.2%), Islam (38.1%) and Traditional (13.9%), those who do not practise any religion (3.5%) and others (0.3%), (2010 Population and Housing Census). There are very marked differences among the districts in relation to religious affiliation. Christians make up the largest religious group in Nadowli/Kaleo, Lawra, and Nandom and with strong presence in Jirapa and Wa municipality. A very large number of adherents of the traditional religion are also found in Jirapa, Karni-Lambussie with fairly good presence in Wa West and Daffiama/Bussie/Issa districts respectively. The Islamic religion has most of its 74 University of Ghana http://ugspace.ug.edu.gh adherents in Sissala East and Sissala West respectively, Wa Municipality, Wa East and Wa West respectively. e. Local Economy The major economic activity of the region is agriculture. This is supported by the fact that 72.2 per cent of the economically active group is engaged in agriculture or related activities. Food production is poor with resultant seasonal food insecurity. Crops grown include corn, guinea corn, millet, rice, yam, groundnuts and beans. The region is a leading producer of cotton and Shea nuts which are two main cash crops. Livestock rearing is buoyant with cattle, sheep, goats, pigs and poultry dominating. Due to the fact that the region’s dry season is long, which extends roughly from October to May, many people leave the region to work in the southern part of Ghana from November to April of the year. Other economic activities include production and transport equipment, sales, service and professional, technical and related work respectively. f. Socio-cultural Practices. The notable festivals in the region include the Dumba, Kobine, Kakube, Zumbeti, Willa, Bagre, Paragbiele, Kala, Bongngo and Singma. The Zumbeti festival is celebrated in the Dagaare speaking traditional areas such as Nadowli/Kaleo and Chakalei speaking areas, Kobine and Kakube in the Lawra and Nandom traditional areas respectively. While the Zumbeti festival is celebrated to usher in the New Year, those of the Kobine and Kakube are meant to offer thanks to God through the ancestors for blessing them with bumper harvest. It is however, instructive to note that the Dumba festival, which means the birth and naming ceremony of the Holy Prophet, is celebrated by the chiefs and people of the Wala Paramountcy who are mostly Moslems. Apart from serving as an occasion to foster 75 University of Ghana http://ugspace.ug.edu.gh unity among the people of the area, it also commemorates the birthday of the Holy Prophet Mohammed and more significantly, renews the people commitment to Islam. Another important institution in the region is that of chieftaincy. It is not only a respected but a major medium for community mobilization. Among the Waalas and Dagaaba, the title Naa is used such as Wa Naa or Nandom Naa. The Sissalas and Chakalei also use the title Kuoro. For example, Tumu Kuoro and Gwollu Kuoro. The Imams (Islamic religious leaders) and Tendaambas (landowners) also play important roles as far as the traditional administration of the region is concerned. g. Education and Literacy As regards education, the region can boast of educational institutions at all levels with tertiary institutions such as Colleges of Education, a polytechnic and university. Thus, there is at least a secondary school in every district capital. Wa Polytechnic and University for Development Studies campuses are hosted in the regional capital. According to the 2010 Population and Housing Census, the adult literacy rate in the region is 40.5 percent. The low literacy rate will definitely affect health and HIV and AIDS education since studies have shown a high positive correlation between literacy and HIV and AIDS awareness. UNESCO (2007) asserted that non-literacy and low level of education often contribute to lack of awareness and low level of adoption of HIV and AIDS prevention and management measures. This implies that the level of literacy determines the level of HIV and AIDS awareness. According to Kickbuschi (2005), people’s inability to read and write makes them vulnerable to getting the virus. Literacy education, as noted by Oyedeji 76 University of Ghana http://ugspace.ug.edu.gh (1985) is needed to empower the recipient and acquire indispensable knowledge and skills that will enable them perform more effectively in every societal activity like family planning and HIV and AIDS prevention and management. The level of literacy determines how well a person will be able to protect and manage themselves in the contact of HIV and AIDS. The more literate a person is, the more that person will be able to make meaningful decisions about them and the society. It is important to state that a literate person would more readily accept and practise HIV and AIDS preventive measures and would be more able to manage the disease. h. Health Facilities The region has a number of health facilities, which include a regional hospital located at Wa, eleven (11) district hospitals, four (4) polyclinics, fifteen (15)clinics, seventy(70) health centres, two hundred and forty four (244) Community-based Health Planning and Services (CHPS) compounds and five (5) maternity homes. Most of these facilities are government- owned with the few being Mission and privately owned facilities. More than half of the available manpower in the health sector is supporting staff while the auxiliary nurses make up about 38.8%. The situation with medical doctors has improved considerably with 46 of them being at post since at a point in time the whole region could only boast of fifteen (15) medical doctors (Upper West Regional Health Directorate). 3.3 Research Design The research is largely quantitative and the design employed by this study was the cross sectional survey to collect data on Moslems for the study. The cross sectional survey research design was adopted for the study based on its inherent advantages and 77 University of Ghana http://ugspace.ug.edu.gh appropriateness. It enabled the researcher to replicate the data and generalise the findings to the whole Upper West region, though the study was undertaken in three districts in view of the fact that numerical data was less opened to ambiguities of interpretations. In addition to that, the said approach also afforded the researcher the opportunity to collect, analyse and interpret the data within a relatively short time. Thus, it ensured rapid analysis (Antonius, 2003). Significantly, the issue of addressing the core question of interest of the thesis, which is ‘how and to what extent’, was realized through this approach. Furthermore, against the backdrop of its objective nature, the said approach also ensured that the conventional standards of reliability and validity were achieved. The survey research design was chosen because it enabled the researcher to gather data from a wide spectrum of Moslems of diverse backgrounds at a single point in time. In addition, it afforded the researcher the opportunity to sample the varied opinions, knowledge, expressions and views of Moslems about the extent to which religious beliefs and practices, how their socio–demographic or personal characteristics have influenced their religious, social, economic and political relations with PLWHAs. Furthermore, it was also considered because it allowed the researcher to sample the population, use descriptive statistics to present and analyse primary data collected from Moslems from three sampled districts of the study area about the population to make generalization (Fowler, 1998; Badu-Nyarko, 2012). 3.4 Population of the Study The population of the study comprised all practising Moslems in the Upper West region aged 18 years and above who are deemed to be actively observing the tenets and beliefs of the religion, Islam. 78 University of Ghana http://ugspace.ug.edu.gh 3.5 Sampled Population of the Study The sampled population of the study was Moslems in three districts of the Upper West region-(Wa Municipality, the Sissala East, Wa West) selected randomly in the study area out of the eleven districts of the region. 3.6 Sampling Techniques The sampling techniques used by the study included multi stage sampling technique, convenience and purposive sampling methods. First, the multi- stage sampling technique was used to select three districts out of the eleven districts of the Upper West region. The multi stage technique was seen by the study as suitable and appropriate because it allowed the researcher to sample large and dispersed population such as the selection of districts in the region and villages in the districts.((Badu- Nyarko, 2012; Atindanbila, 2013). Also, in view of the absence of a sampling frame and for that matter a complete list of all practising Moslems in the region coupled with the high cost of data collection involved in travelling to a widely dispersed sample of villages to undertake the in-person interview survey, the choice of this technique was seen as very appropriate (Battaglia, 2011). The three districts were selected by writing all the names of the eleven districts on pieces of paper, folded and placed in an empty packet. This was reshuffled several times to mix. Three districts namely (Wa Municipal, Wa West and Sissala East) were then selected randomly out of the eleven districts for the study. Secondly, out of each of the three districts selected, five villages were selected making a total of fifteen villages selected using the simple random sampling method for the study. The total number of villages in the Wa Municipality was 19 but because Wa Township was large enough, it was subdivided into six communities and for the purpose of this 79 University of Ghana http://ugspace.ug.edu.gh study termed villages thus giving a total number of villages as 25. There were 19 villages in the Sissala East District and 20 villages in the Wa West District. The three (3) sampled districts and the five (5) selected villages in each of the sampled districts was occasioned by financial challenges and limited time at the disposal of the researcher to go round all the eleven (11) districts and sixty four (64) villages. Lastly, twenty respondents were selected from each of the fifteen villages using the convenience and purposive sampling methods. The convenience sampling was employed to interview who ever were at the mosque and willing to be interviewed whilst the purposive was used or assisted to select 18 and above years Moslems at the mosque. The purposive allowed the researcher to select and interview the target population for rich information on the study topic. The convenience and purposive sampling techniques used afforded the researcher to interview 178 Moslem males and 122 Moslem females for the study using structured interview instruments. In total, three hundred (300) respondents were selected from the 15 selected villages for the study. In each village, 20 respondents were selected using the convenient and purposive sampling methods at the central mosque of each village. Depending on the availability and willingness of respondents, in some villages more men than women were interviewed while in others it was the same numbers. This may be due to engagement of the women in the household chores, which therefore makes it difficult for them to pray at the mosque. However, what was significant was the required number of twenty respondents for each selected community. The issue here was that it was difficult to get the exact population of Moslems, especially those who were 18 years and above in each village which makes up the district, thus giving each district an equal percentage of respondents. In this case, no 80 University of Ghana http://ugspace.ug.edu.gh required formula was applied. The other reason was that it was somewhat a homogeneous group (Moslems) and adults above 18 years and living in the selected village. Depending on the respondent, they were interviewed in any place they feel is convenient to them, which was either in or outside the mosque or any shady area with the premises of the mosque The fact that the simple random technique is both efficient and easy to apply when it comes to issues of eliminating personal bias and subjectivity in the selection of subjects for a study, especially from a homogenous population such as Moslems, or for that matter districts of the Upper West region, accounted for its employment in the study. More importantly, it afforded all the individual districts the same chance of being selected from the population of the study to be in the sample (Badu- Nyarko, 2012; Atindanbila, 2013). 81 University of Ghana http://ugspace.ug.edu.gh 3.7 Sample Size The total respondents of the study were three hundred (300), made up of 178 males and 122 females. The breakdown is in table 3.1 Table 3.1: Sample Size of the Study No District Village No of Respondents Women (f) Men ( f ) 1 Wa Municipality (25 Bamahu 9 11 villages) Charia 6 14 Dondoli 10 10 Kabanye 10 10 Tampaalipaani 8 12 2 Wa West (20 villages) Dorimon 7 13 Polee 7 13 Ponyentanga 8 12 Tanina 8 12 Wechiau 8 12 3 Sissala East (19 Bugubelle 8 12 villages) Bichenbelle 6 14 Kong 7 13 Tumu Zongo 10 10 Wellembelle 8 12 Total 122 178 Source: Field survey, 2018 3.8 Data Collection Instrument The study employed semi-structured interview schedules to gather data from the wide spectrum of respondents. This instrument is suitable and appropriate for this study because the study anticipate that there will be literates and highly non- literates or semi- literates that could hardly read nor write to comprehend and respond to the research questions posed (Borg, Gall & Gall, 1992). It also enabled the researcher to have a personal and direct contact with the participants and also eliminated non- response rate. Finally, it had an added advantage of the fact that the respondents were in a compact geographical area. 82 University of Ghana http://ugspace.ug.edu.gh The data collection instrument, semi-structured interview schedule, which covered sixty five (65) items, was organized into (five) sections. Section A sought information on the socio- demographic and personal characteristics of Moslem respondents such as age, sex, and educational background as a way to determine the profile of Moslem respondents using close-ended questions. Section B, which employed the close-ended and open-ended questions sought to confirm from the Moslem respondents the basic Islamic beliefs and practices as they relate to their attitudes towards PLWHAs, their opinion on the reality of HIV and AIDS related stigma and discrimination as well as the identified areas of their engagement with PLWHAs such as religious, social, economic and political relations. The section C also sought information on the Moslems assessment of their respective opinions on the extent to which their beliefs and practices as Moslems have influenced their attitudes towards PLWHAs in relation to religious, social, economic and political activities by using a five (5) point Likert scale measure such as (i) Very large extent, (ii) Large extent, (iii) Uncertain, (iv) Very small extent, (v) Small extent. Section D of the data collection instrument sought responses on the opinions of Moslem respondents as regards whether it is Islamic to stigmatise and discriminate against PLWHAs with beliefs and teachings of Islam to support their stance. These were sought with both open-ended and close-ended questions. The section, also using a five (5) point Likert scale measure such as (i) Strongly Agree, (11) Agree, (iii) Neutral, (iv) Disagree, (v) Strongly Disagree as well as open-ended questions sought information on the Moslems assessment of their views on disclosure of HIV and AIDS status, the effects of stigma and discrimination on PLWHAs, their families and community as a whole. 83 University of Ghana http://ugspace.ug.edu.gh The final section, E sought from the Moslem respondents’ strategies to reduce and possibly eliminate stigma and discrimination among PLWHAs in their communities by the use of open-ended questions. 3.9 Pre-Testing for validity and reliability of Data collection instrument Reliability of the data collection instruments: A pre-testing was done with a sample size of thirty Moslem respondents who were randomly selected in Nadowli-Kaleo District that was not part of the study. The purpose was to establish the consistency (reliability) of the instrument (interview schedules) and the extent to which the instrument measure what it supposed to measure and perform what it designed to perform as regard the set objectives of the study. The selection of Nadowli- Kaleo for the pilot study was because of the belief that it has similar and relevant characteristics like that of the Districts under study such as education, economic, political and geo-socio-cultural conditions. Also, the said district was very close to the regional capital. After the pre-test, some of the items on the instrument, which were ambiguous or not understood for consistency were modified to be in tune and consistent with the research questions and more importantly, the objectives of the study. Validity of the data collection Instruments As a way of ensuring the instrument (interview schedules) measure what it supposed to measure and perform what it designed to perform (validity), the said instruments were given out for experts (knowledge and professionalism) such as the supervisors and other senior faculty research fellows as well as by peers-other PH.D students both within and outside the University of Ghana for assessment and corrections. 84 University of Ghana http://ugspace.ug.edu.gh 3.10 Data collection The study employed both secondary and primary data. The secondary data were generated from journals, books, research and conference reports and papers as well as internet sources, which included UNICEF, UNAIDS, Ghana AIDS Commission, National HIV prevalence and AIDS Estimates as well as HIV Sentinel Survey reports. The primary data were gathered by the researcher and three research assistants using the semi-structured interview schedules. The personal interviews were conducted in the local languages spoken in the selected districts. The questions on the interview schedules were interpreted or read to the hearing of the respondents in the respective local language that they understood and the corresponding answers written appropriately to the questions. In order to ensure that whatever responses they gave were correctly captured, a tape recorder was used, however, with permission sought from the respondents. The said responses were then read back to the respondents in their local languages for them to confirm. That was done to ensure credibility and validity. These are Waali in the Wa municipality and Wa West district and Sissala in the Sissala East district. The researcher and research assistants were found to be conversant with the popular languages spoken in the study area –Waali, Dagaare and Sissali that were coincidentally relevant for the data collection task. Little training was needed since they were all graduates already in the business of data collection for quite a good number of years as field workers. They also had the advantage of being natives of the respective study districts. Prior to the data collection especially in Wa Municipal and Wa West district, the researcher and his research assistants were able to contact the local Imam or other opinion leaders depending on who was available and explained to them and permission sought to conduct the said interviews. The time, which was after night prayers (Isha) 85 University of Ghana http://ugspace.ug.edu.gh every day and after Friday prayers (Jummat) was agreed to be convenient to the community members and the researcher. As regards the Sissala East, where one of the research assistants, who also happens to be the researcher’s former student is a native and understands and speaks the language, the arrangements of meeting the relevant opinion leaders was handled by him due to the language barrier. At the said meetings however, the researcher was always present. On the appointed dates whoever happened to be at the mosque and was 18 years and above and willing and ready was interviewed. The researcher was always on the field with the research assistants not only to assist with the data collection but to ensure the speedy and prompt resolution of any challenges that might crop up. Five (5) questionnaires were always completed if it was only one research assistant in the field but on a day if two persons went the number always doubled. The researcher actively participated in the Kabanye, Dondoli, Tampaalipaani, Charia, Tanina, Polee, Ponyentanga and Tumu Zongo communities in the administration of the questionnaire. Depending on which ever community the researcher found himself, there was always a daily briefing of activities to strategize for the next day data collection. It took approximately three months for the data collection to be completed (2nd October to 26th December, 2018). The data collection process was however not without challenges. The researcher faced the challenge of perpetual postponement of interviews. At other times, the researcher or research assistant will get to the community and would not get anyone willing to be interviewed because they were tired after spending the whole day working on their farms and would not be in the right mind frame to provide the right answers. There was also the difficulty of funding research assistants to conduct the interviews and also meeting 86 University of Ghana http://ugspace.ug.edu.gh the financial demands of some of the respondents for refreshment/entertainment after the interviews. The community, and in particular the participants, were very accommodating and co- operative especially because they believed that such a study would go a long way in assisting to get ways that would reduce the level of stigmatisation and discrimination, which they claimed was a source of worry to most known PLWHAs and their families. 3.11 Data Analysis Methods The primary data were organized and presented with the assistance of computer package, SPSS (Statistical Package for Social Sciences) and Excel. The primary data gathered from the respondents were coded, imputed and then analyzed using descriptive and nonparametric statistics as well as using narratives to describe the open-ended questions. The closed-ended questions which yielded quantitative data were analysed using mean scores, standard deviations, and the chi square test statistic to explain the extent of independence of the variables. The open-ended questions were analysed quantitative and qualitatively. The research adopted the Cross-case approach where same or similar answers or responses from the various Moslem respondents to the same question asked were organised together under common themes for purposes of easy classification, presentation and analysis. The qualitative responses were narrated and supported by statements made directly by the respondents from the field (anecdotes). 3.12 Ethical Issues The researcher, before engaging the respondents to collect the data sought and obtained informal permission from the Imams (religious leaders) and chiefs of the various mosques and villages respectively where the study was conducted. The researcher also 87 University of Ghana http://ugspace.ug.edu.gh allayed the fears of the respondents by disclosing the goal and purpose of the research, which is for purely academic reason, that is, thesis for the awards of PH.D degree at the University of Ghana. Also, they were assured of the confidentiality of the information they provide and their anonymity before commencing the interview that is references were not made to the respondents by way of their names but in terms of socio- demographic characteristics when appropriate. 88 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR PRESENTATION OF RESULTS In this chapter, the analyses of the primary data gathered from the field based on the research questions of the study are presented. These were largely opinions of Moslems in the three districts of the Upper West Region. In this case, their beliefs and practices as well as how their socio-demographic and personal characteristics such as sex, age and educational background influence their religious, social, economic and political relationships with PLWHAs, i.e. discrimination and stigmatisation were analysed. To achieve this, the chapter was therefore divided into four (4) sections. Section A presented data on the Moslems’ perception on the existence of HIV and AIDS related stigma and discrimination and the extent to which their beliefs and practices have influenced their attitudes towards PLWHAs in their identified areas of engagements such as in religious, social, economic and political relations. Section B dealt with the assessment of the extent to which the Moslem respondents’ attitudes towards PLWHAs are associated with selected socio-demographic characteristics. The third section covered data on the Moslems respondents’ opinions on the beliefs and teachings of Islam that support and influence their attitudes based on religious, social, economic and political relations with PLWHAs. It also includes the Moslems views on disclosure of HIV and AIDS status, effects of disclosure on stigmatisation and discrimination on PLWHAs, their families and the community as a whole. Finally, section D dealt with the Moslem respondents’ suggestions with regards to the strategies in reducing HIV and AIDS stigma and discrimination. 89 University of Ghana http://ugspace.ug.edu.gh 4.1 Section A: HIV and AIDS related Stigma and Discrimination This section analyses data on responses of the Moslems and their perception of the existence of HIV and AIDS related stigma and discrimination, and the extent to which their beliefs and practices have influenced their attitudes towards PLWHAs in their identified areas of engagements such as in religious, social, economic and political relationships. 4.1.1 Moslems’ Opinion on the Reality of HIV and AIDS related Stigma and Discrimination Responses sought from the Moslem respondents on their opinions on whether HIV and AIDS related stigma and discrimination in reality existed. This revealed that almost all the respondents 297 or 99% confirmed that HIV and AIDS related stigma and discrimination is real among the Moslem respondents. 4.1.2 Moslems Beliefs and Practices: 4.1.2 a. Faith (Belief) in Almighty Allah (God) In response to the question whether PLWHAs should continue to have faith in Almighty Allah or in spiritual powers, all the respondents, 300 or 100% stated that they should have faith in Almighty Allah. 4.1.2 b. Reasons for Answer Their reasons are that Allah is the creator of everything in the universe including one’s health and all sicknesses, and has the power to cure such sicknesses. Thus, if one puts your trust in Allah, he will be able to cure all sicknesses. They also mentioned that Allah is the master of all things and all powers in heaven and earth are under his control. 90 University of Ghana http://ugspace.ug.edu.gh Sickness, according to the respondents, is to test one’s faith and therefore PLWHAs should continue to have faith in Allah. Some of the above responses are captured below: ‘Whatever bestowed on you, the first thing is to have faith and trust in Almighty Allah ((Q: 2:155; 9:23); (Male Mallam, 56 above years, Wa Municipality). ‘In order to get (Janna) from Almighty God, we have to go through a lot of challenges and test from Almighty Allah’ (Q 29: 2); (Male Arabic teacher, 31-55 years, Sissala East). ‘Almighty Allah can use such phenomenon to test a person’s faith to see how the person will react to it but it shouldn’t prevent the person from taking his /her faith from Allah to other spiritual powers (Female, 18-30 years, Wa West). 4.1.2 c. Belief in Destiny As to the question whether in their opinion, a PLWHA should attribute his/her condition to destiny or supernatural forces, all the respondents (300) mentioned that they should attribute it to destiny. 4.1.2 d. Reasons for Answer The reasons they advanced were that Allah has already destined what will happen to every person including sickness and therefore PLWHAs should consider their situation as part of their destiny. Thus, whatever happens to everyone on this earth, whether good or bad is the will of God, and there is nothing that one can do about it. According to them, God does everything for everybody and knows what is best for each and every one, and hence HIV and AIDS. 91 University of Ghana http://ugspace.ug.edu.gh This stance is expressed by the following statements: ‘Allah created mankind and knows the future of everyone, where we were born, where we will die, how we will die and the day we will die. So destiny is part of every mankind life and we should accept it as such whether good or bad’ (An Imam, 56above, Wa West). ‘Nothing happens to believers except what God ordains for them, so whether you are sick or healthy, rich or poor, male or female, white or black, God has already destined that before you are born into this world and nothing can change it unless the will of God’ (Female, 31-55 years, Sissala East) ‘Only Allah has the power to decide for his slaves and everything happens to humans in Allah’s permission. No spiritual force has any authority over Allah’s slaves’ (Male, 31-55 years, Wa Municipality). 4.1.2 e. Fasting In response to the question, whether in their opinion, a PLWHA should fast during the month of Ramadan, 198 (66%) of the respondents opined that they should not fast during the month of Ramadan while 102 (34%) hold the contrary opinion. 4.1.2 f. Reasons for No Answer One of the reasons they adduced was that fasting, as one of the rites prescribed by the religion in both the Quran and Hadith, is only for those who are fit and healthy and not the sick such as PLWHAs. They also mentioned that PLWHAs will not be able to follow their medication routine and that may seriously affect their health and possibly lead to their death. Finally, they mentioned that it is stated in the Quran that those who are 92 University of Ghana http://ugspace.ug.edu.gh unable to fast will fulfil that rite by giving zakat (charity) to the poor. Some of their responses include the following: ‘ The prophet said it in the Hadith that every Moslem should fast in the month of Ramadan except Muslims who are very sick to the extent that they cannot fast such as women who are menstruating and people suffering from severe sicknesses’ (Female, 31-55 years, Wa Municipality). ‘A PLWHA cannot fast during the month of Ramadan if the virus would harm him/her and cause additional health risk to him/her ‘(Male, 18- 30years, Wa West) ‘PLWHAs cannot abstain from food and drugs because of their health condition and because of that they should be excluded from fasting (Female, 18-30 years, Sissala East). For those respondents who said they should fast, they mentioned that once it is not mentioned anywhere in the teachings of the religion that Moslems should not perform their religious rites, which include fasting because of sickness and in particular, HIV and AIDS, they should therefore fast. Furthermore, the respondents also stated that PLWHAs should fast in order to seek forgiveness from God and be healed. Their stance is supported with the following statement: ‘PLWHAs should fast because HIV does not prevent the person from doing any work imposed by his/her creator if he/she has the faith in the creator. In this way, once the creator has asked that all Moslems should fast, it is therefore necessary for PLWHAs to also fast’ (Female, 56 above years, Wa West) ‘It is Allah who gives all sicknesses including HIV and AIDS and he never said his followers should not worship him because of their sicknesses. In this regard, 93 University of Ghana http://ugspace.ug.edu.gh PLWHAs can worship him including fasting during the period ‘(Male, 31-55 years, Wa Municipality). 4.1.2 g. Relating with PLWHAs As to how respondents will relate with PLWHAs who stay in the same house 287 (95.6 %) said they will relate well and warmly with them by respecting their feelings and emotions. They claimed that they will do things in common such as sharing same toilet, household facilities, cooking as well as eating with them. They will also attend other social events such as funerals, weddings, and outdoorings with them. Some of their responses are depicted below: ‘I will relate very well with PLWHAs by giving them the encouragement to cope up with life, shake hands and eat together, assist them in their household activities without showing any discrimination’ (Female, 31- 55 years, Wa Municipality) ‘I will associate with them as fellow human beings because the disease is not contagious. Moreover, we should not leave them alone as they can harm themselves when they start to think about the illness or the diseases’ (Male English Arabic teacher, 31-55 years, Sissala East). ‘I will relate with such a person in a friendly and kindly manner to make him feel that he is still part of the society by playing, chatting and being close to him in order to prolong his lifespan’ (Female 18-33 years, Wa West) The minority, (4.3%) however said they distance themselves by being cautious not to eat or share other household items for fear of infection as revealed by the following statements: 94 University of Ghana http://ugspace.ug.edu.gh ‘I will make sure that I don’t get very closer to them and will not share same toilets, dishes, cutlery sets, razor blades, needles and toothbrush with them since I can easily get the disease.’ (Female, 56 above years, Wa Municipality) 4.1.2 h. Pilgrimage to Mecca On their opinion about a PLWHA undertaking a pilgrimage to Mecca, 268 (89.3%) of the respondents are of the opinion that a PLWHA can undertake a pilgrimage to Mecca. The reasons they gave were that it is a religious duty upon every Moslem once he /she has the resources to undertake it. Secondly, the respondents stated that there was no verse in the Quran or Hadith which excludes PLWHAs from performing the pilgrimage once the disease was not contagious and moreover, such a pilgrimage will offer them the opportunity to seek forgiveness and mercy in the next life. The below statements support their position: ‘PLWHAs should undertake the pilgrimage if they have the wealth to do so because HIV/AIDS is not a fluid contagious air borne disease where the virus can transfer easily from one person to another’ (Female 18-30 years, Sissala East). ‘The yearly pilgrimage to the holy place (Mecca) is a religious duty for every Moslem to be there once in his/her lifetime and there is no verse in the Quran or Hadith that I know of that prevent (PLWHA) from undertaking pilgrimage to Mecca (Hajj), hence they shouldn’t be hindered to Mecca’ (Male, 41 years, Wa West). ‘It is the privilege of the person to undertake the pilgrimage to Mecca in order to seek forgiveness from his creator so that she/he may have his mercy on the next life (Male, 31-55years, Wa Municipality) ‘ Those minority Moslems who are of the view that PLWHAs should not undertake the Hajj mentioned the issue of their health status, considering the energy sapping activities they will go through as part of the performance of the pilgrimage, which will have dire 95 University of Ghana http://ugspace.ug.edu.gh consequences for them as one main reason. Thus, some of their statements are captured below: ‘PLWHAs may encounter challenges regarding their anti-retroviral therapy, the use of drugs, forgetfulness of drug intake during the pilgrimage (Female, 31- 55years, Wa Municipality,) ‘Some of the rituals will be very difficult for them because of the strength and energy that will be involved in undertaking them and since they are not very healthy, it may be difficult for them’ (Male, 31-55years, Wa West) 4.2.1 Moslem Respondents and Related Religious Engagement with PLWHAs The study sought to group the areas of engagement into religious, social, economic and political for easy analysis and interpretation. One of the greatest challenges in the fight against stigmatisation and discrimination towards PLWHAs, especially in Africa is the linkage of HIV and AIDS with certain religious beliefs and practices. Studies by Abraham (2006), Shisana & Simbayi (2002); Duffy (2005) among others, indicated that some Moslems believe PLWHAs are persons who committed sexual sins and are being punished by God, or the ancestors or they might have had the disease through witchcraft, supernatural forces, and a curse as in the case of some traditional African communities. In the light of these religious beliefs, most persons are therefore compelled not to associate with PLWHAs for fear of also being punished. It is therefore against this background that the study elicited responses from the Moslem respondents to ascertain their religious engagement with PLWHAs to enable the researcher make informed analysis and conclusions. The responses gathered to that effect are presented in Table 4.1 96 University of Ghana http://ugspace.ug.edu.gh Table 4.1: Identified Religious related areas of Engagement with PLWHAs (Yes) Religious related activities with PLWHAS Yes (f) Yes (%) Perform Prayers 300 100 Give alms 300 100 Accept alms 45 15 Accept as an Imam 5 1.6 Source: Field Survey, 2018 The results in Table 4.1 suggests all the Moslem respondents confirmed performing together with them prayers and offer alms to PLWHAs whilst 15% and 1.6% respectively indicated either accepting alms from PLWHAs or accepting or recognizing them as their Imam or religious leader . This implies that religiously some level of discrimination exist regarding PLWHAs in leadership and charity from such persons but rather offer them alms and perform prayers together. 4.2.2 Related Social Engagement with PLWHAs One of the significant features of every social life is social interactions or social activities or the manner in which people act with other people. Against the backdrop of John Done’s statement that ‘No one is an Island’ society can only grow and survive if there are interactions among the people. It is also important to state that social order, which is a necessity for any society can only be possible if there is effective social interactions or social related activities. Social-related activities provide a platform for people to socialize and interact with one another. Such activities could be occasions of happiness or sorrow such as marriage, 97 University of Ghana http://ugspace.ug.edu.gh outdoorings, festivals, funerals and others that may involve some level of communality like eating, sleeping, shaking of hands or embracing. These activities constitute an important component of every society or community in view of the fact that they are the vehicle through which people learn and educate others about the society’s norms, values, practices and beliefs. More importantly, they also provide an opportunity for people not only to share in the joy and sorrow but more fundamentally, to form attitudes, opinions and behaviours based on the interactions among the various people assembled. Thus, the question on the related social relations the Moslem respondents had with PLWHAs was to gather information to establish their areas of their social engagement with PLWHAs. The information gathered is presented in Table 4.2. Table 4 2: Identified Social related areas of Engagement with PLWHAs (Yes) Social related Activities with PLWHAS Yes (f) Yes (%) Attend social events (weddings, funerals etc.) 258 86.0 Marry 4 1.3 Embrace 260 86.7 Shake hands 261 87.0 Share same utensils 30 10 Sleep in same room 278 92.7 Children attend same school with theirs 291 97.0 Visit them when sick 295 98.3 Source: Field Survey, 2018 The results in Table 4.2 show that among the areas of social engagement, discrimination was identified in marriage and sharing items relating to food. However, they were willing to participate in social events, shake hands, embrace and allow their children to attend same school with such children and visit PLWHAs when they are sick. 98 University of Ghana http://ugspace.ug.edu.gh 4.2.3. Related Economic Engagement with PLWHAs It is important to mention that apart from farming which is the major pre-occupation, trading or engaging in buying and selling is another main activity found in most Moslem communities and especially the study area. The activity is engaged in by both males and females depending on the items involved as a way of economic venture to provide income for the individuals to satisfy their basic as well as other important financial obligation Information on what economic areas the Moslem respondents were engaged in with PLWHAs was to determine the economic related areas they have generally found themselves engaged in to enable the study make informed analysis. Responses gathered are presented in Table 4.3. Table 4.3: Identified Economic related areas of Engagement with PLWHAs (Yes) Economic related activities with PLWHAS Yes(f) Yes (%) Offer employment 275 90.7 Accept employment 294 97.0 Trade 283 93.3 Consumption of their products 15 3 Source: Field Survey, 2018 The data in Table 4.3 suggest that over 90% of the Moslem respondents agreed to engage in the economic related activities with PLWHAs except consuming their products (1.3%). This also implies that the Moslems may not drink or eat items prepared by PLWHAs for fear of being infected. 99 University of Ghana http://ugspace.ug.edu.gh 4.2.4 Related Political Engagement with PLWHAs Participation is an important component of every society whether small or big and hence political participation, which is a critical part of any democracy, is the process that affords the individual the opportunity to take part in the political process by making his or her opinion, beliefs and interest known. The most important ingredient in political participation is voting for someone or persons to represent your interests and equally making yourself available to be voted for into any political office. Participation ensures that the society or community benefits from the talents and skills of those who are voted to represent the larger society, no matter their disability or state of health. It is therefore important to state that those who fail to participate, due to neglect or exclusion are likely to be denied certain benefits which include their ability to influence policies which will inure to their benefits. Information was sought on which of the political related activities or engagement were the Moslem respondents engaged in with PLWHAs to establish their attitudes politically towards PLWHAs. The responses are presented in Table 4.4. Table 4.4: Identified Political related areas of engagement with PLWHAs by the Moslems (Yes) Political related activities with PLWHAS Yes(f) Yes (%) Elect as an Imam 11 3.7 Vote as an Assembly Member 120 40 Vote as Member of Parliament 97 32 Vote as a chairperson of an event 9 3 Source: Field Survey, 2018 The data in Table 4.4 suggest that less than 50% of the Moslem respondents actually favour any of the identified related political activities. Interestingly but not surprising, over 96% of the moslem respondents would not engage in or favour the election of PLWHAs as an Imam (3.7%) or as a chairperson for any event be it political or social 100 University of Ghana http://ugspace.ug.edu.gh (3%). This implies that the Moslems’ attitude towards PLWHAs in political related issues is negative or low. 4.3 Assessment of Attitude towards PLWHAs and Moslems’ Beliefs and Practices Beliefs and practices of individuals or group of persons that form their value systems most often than not is a function of their lives and for that matter, define their attitudes and culture. In view of this, the study sought to assess the extent to which the Moslem respondents’ beliefs and practices influence their attitudes towards PLWHAs in terms of their religious, social, economic and political relations or engagements using a five- point Likert scale measure. A. Influence of Moslem Respondents beliefs and practices and their Attitudes towards PLWHAs - Religious relations The opinions of the respondents were sought to assess the extent to which their beliefs and practices have influenced their attitudes towards PLWHAs in terms of their religious relationship or engagements so as to make an informed assessment as it were. 101 University of Ghana http://ugspace.ug.edu.gh The respective weighted mean scores of the responses and the associated standard deviations are shown in Table 4.5 Table 4.5: Assessment of Moslem Respondents Attitudes and their Religious relations with PLWHAs Attitude towards Very Large Uncertain Very Small Sd Religious Relations large extent (4) (3) Small extent x̅ extent extent(2) (1) with PLWHAs (5) % % % % % 4.20 1.00 Perform Prayers 48.6 30.8 5.8 2.2 6.5 34.1 34.4 12.3 6.9 6.9 3.86 1.19 Give alms 19.2 39.9 14.1 2.2 20.3 3.37 1.10 Accept alms Accept as an Imam 3.79 1.33 38.0 19.9 14.5 8.3 8.3 General Opinion (A) 3.80 1.15 Source: Field Survey, 2018 The results in Table 4.5 reveal that Moslems’ attitude towards PLWHAs in terms of religious relations as revealed by the weighted mean scores and standard deviation was to a large extent (x̅=3.80) influenced by their beliefs and practices. This means that Moslems have a positive attitude towards PLWHAs in religious related activities. B. Influence of Moslem Respondents beliefs and practices and their Attitudes towards PLWHAs - Social relations The data on the opinions of the Moslem respondents on the extent to which their beliefs and practices have influenced their attitudes towards PLWHAs that were sought on their social relations or engagements so as to make an informed analysis are presented in Table 4.6 102 University of Ghana http://ugspace.ug.edu.gh Table 4.6: Assessment of Moslem Respondents Attitudes and their Social relations with PLWHAs Attitude towards Very Large Uncertain Very Small Small x̅ Sd Social Relations with large extent (3) extent(2) extent PLWHAs extent (4) (1) (5) % % % % % Attend Social events 3.77 1.28 42.0 29.0 8.7 8.3 8.3 (i.e,weddings, funerals etc) Marry 15.2 28.6 13.8 12.7 14.5 2.71 1.33 26.8 43.5 12.0 4.3 4.7 Embrace 3.57 0.53 Shake hands 42.8 29.0 18.8 2.2 7.2 3.98 1.05 Share same utensils 16.7 23.2 16.7 13.8 21.4 2.80 1.34 Sleep in same room 25.0 27.2 22.8 8.3 8.0 3.34 1.23 Children attend same 62.0 18.4 15.6 4.0 4.38 1.18 school with theirs Visit them when sick 57.6 22.4 12 8.0 4.29 1.14 General Opinion (B) 3.60 1.13 Source: Field Survey, 2018 Data in Table 4.6 show that to a large extent, Moslems’ attitude towards PLWHAs in terms of social relations or engagements was influenced by their beliefs and practices. Though the data also show Moslems will discriminate in marrying and sharing the same cooking utensils with PLWHAs, the weighted mean scores and standard deviation (x̅=3.60, sd= 1.1) however revealed a positive and unanimous attitude towards PLWHAs in social interactions. They will willingly allow their wards to attend same school with children of PLWHAs (x̅=4.38) or visit them while sick (x̅=4.29) respectively. 103 University of Ghana http://ugspace.ug.edu.gh C. Influence of Moslem Respondents beliefs and practices and their Attitudes towards PLWHAs – Economic relations The opinions of the respondents were sought to assess the extent to which their beliefs and practices have influenced their attitudes towards PLWHAs in terms of their economic relationship or engagements so as to make an informed assessment are shown in Table 4.7 Table 4.7: Assessment of Moslem Respondents Attitudes and their Economic relations with PLWHAs Attitude towards Very large Large Uncertain Very Small Small Sd extent (5) extent (3) extent(2) extent x̅ Economic Relations with (4) (1) PLWHAs % % % % % Offer employment 57.6 18.6 19.6 4.0 4.29 1.14 Accept employment 45.6 11.2 11.6 31.6 3.94 0.94 Trade 73.2 14.8 8.0 4.0 4.57 1.27 Consumption of the their 12.0 11.2 15.6 46.4 14.8 2.59 0.87 Products General Opinion (C) 3.84 1.01. Source: Field Survey, 2018 The data in Table 4.7 show that Moslems attitude towards PLWHAs in terms of economic interactions or engagement was positive or non-discriminatory ( x̅ =3.84; sd= 1.01) .However in terms of consumption of products, they showed discriminatory tendencies (x̅ =2.59; sd= 0.87).The data also show that even though in terms of individual economic activities such as consumption of products of PLWHAs, Moslems will discriminate, the weighted mean scores and standard deviations reveal that their relationship with PLWHAs in economic engagement on the whole were largely positive and may be influenced by the Moslems’ beliefs and practices (x̅=3.84) 104 University of Ghana http://ugspace.ug.edu.gh D. Influence of Moslem Respondents beliefs and practices and their Attitudes towards PLWHAs - Political relations The opinions of the respondents were elicited on the extent to which their beliefs and practices have influenced their attitudes towards PLWHAs in terms of their political relations or engagements as a means of their civic responsibilities and rights of PLWHAs. The data gathered and the related computed weighted mean scores and standard deviations using the five point Likert scale measure are shown in Table 4.8 Table 4.8: Assessment of Moslem Respondents Attitudes and their Political relations with PLWHAs Attitudes towards Very large Large Uncertain Very Small Small x̅ Sd Political relations with extent (5) extent (3) extent(2) extent PLWHAs (4) (1) % % % % % Elect as am Imam 25.0 27.2 22.8 8.3 8.0 3.26 1.23 Vote as an Assembly 3.57 0.53 26.8 43.5 12.0 4.3 4.7 Member Vote as a Member of 42.8 29.0 18.8 2.2 7.2 3.98 1.05 Parliament Vote as a Chairperson of an event 42.0 29.0 8.7 8.3 8.3 3.77 1.28 General Opinion (D) 3.64 1.02 Source: Field Survey, 2018 Data in Table 4.8 shows that Moslems’ attitude towards PLWHAs in terms of political relations was to a large extent influenced by their beliefs and practices as shown by the weighted mean scores and standard deviation ( x̅ = 3.64; sd= 1.02) Their relations is therefore positive. In fact they will highly elect PLWHA as an MP and chairperson of an event than as an Imam. 105 University of Ghana http://ugspace.ug.edu.gh Putting all these attitudes .religious, social, economic and political together, it produced the data in Table 4.9 Table 4.9: Overall Attitudes towards PLWHAs based on Religious Beliefs and Practices Area of Attitude x̅ Sd Religious Related Activities 3.80 1.15 Social Related Activities 3.60 1.13 Economic Related Activities 3.84 1.01 Political Related Activities 3.64 1.02 General Opinion 3.72 1.07 Source: Field Survey, 2018 The common or general opinion on the Moslems’ attitude towards PLWHA in terms of religious, social, economic and political relations based on their beliefs and practices was high showing positive relations. Yet, social relations recorded the lowest level of attitude among the four variables studied. 4.4. Assessment of Attitudes towards PLWHAs and Moslems Socio-Demographic and Personal Characteristics Studies by Rosabelle (2011); Dahlui, Azahar, Bulgiba, Zaki, Oche , Adekunji & Chinna (2015); Ulasi, Preko, Baidoo, Bayard, Ehiri, M.Jolly E.Jolly (2009 ) and Kwashie (2010) have shown that there is a relationship between socio-demographic characteristics such as age, sex, education, socio-economic status, place of residence and among others of respondents and their attitudes towards PLWHAs. These have been found to inform people’s attitudes towards PLWHAs just as in other influence (Kwashie, 2014). It is in view of this, the study sought data on the Moslem respondents’ demographic characteristics (age, sex and educational level) and their attitudes towards PLWHAs in 106 University of Ghana http://ugspace.ug.edu.gh related religious, social, economic and political engagement to establish whether there is a significant relationship between the two variables. 4.4. a. Sex and Religious Relations with PLWHAs The relationship between the sex of Moslem respondents and their attitudes towards PLWHAs in religious related engagements were sought to establish whether there exists any relationship between them and to determine the extent of influence sex had on their attitudes towards their respective religious relations PLWHAs. Data gathered to that effect is presented in Table 4.15. Table 4.10: Sex of Moslem respondents and related religious relations with PLWHAs (Yes) Sex of Religious relation Respondent Perform Give alms Accept alms Accept as an Total Prayers Imam Responses f % f % f % f % f % Male 178 46.9 178 46.9 21 5.5 2 0.5 379 100 Female 122 45 122 45 24 8.8 3 1.1 271 100 Totals 300 46.1 300 46.1 45 6.9 5 0.7 650 100 Source: Field Survey, 2018 *Multiple responses Responses in Table 4.10 show that Moslems of both sexes are willing to perform prayers and offer charity to PLWHAs as part of their religious duties. On the contrary, they may not, either male or female try to accept alms from PLWHAs (6.9%) and accept them as their Imam or religious leader (0.7%) respectively. This implies that there is limited differential level of engagement with PLWHAs by the two categories of sex of the Moslem respondents. In order to confirm the above statistics, a correlation analysis was performed as in Table 4.11 107 University of Ghana http://ugspace.ug.edu.gh 4.4.a. Correlation on Sex of Moslem Respondents and their Attitudes towards PLWHAs in Religious related Engagement The computed correlation coefficients in Table 4.11 on Moslems responses on the influence of sex on their attitude towards PLWHAs in religious relations or engagement was to determine the extent of influence sex had on their attitude towards PLWHAs in religious related activities by establishing the respective significance of their relationships, degree or strength of relationship and their co-efficient of determination. Table 4.11: Sex of Moslems respondents and related religious relations with PLWHAS Attitude towards PLWHAs N R r2 r2% Sig. @ 0.05 Perform Prayers 300 1 1 100 1 Give alms 300 1 1 100 1 Accept alms 300 0.081 0.162 16.2 0.161 Accept as an Imam 300 0.234 0.468 46.8 0.000 Source: Field survey, 2018. The results in Table 4.11 reveal that at 0.05 level of significance there is a positive relationship or correlation between sex of the respondents and their attitude towards PLWHAs in all the four related religious activities. The relationship between the influence of sex of the Moslems and their attitude in terms of accepting a PLWHA as an Imam was positive and significant but weak (r=0.234; 0.000) while that of their attitude towards the issue of prayers ( r=1; 1), and alms giving (r= 1; 1) was highly positive. The issue of accepting alms (r=0.081; 0.161) was nil and insignificant. This shows that they will not in any way differentiate when accepting alms from PLWHAs. As regards the relative degree or strength of the relationships, the issue of performing prayers and giving of alms (r=1) were very strong (r >0.7) while that of accepting alms and accepting PLWHA as an Imam were weak (r< 0.3). 108 University of Ghana http://ugspace.ug.edu.gh With regards to the extent to which the sex of the Moslems’ respondents has influenced or is associated with the Moslems attitudes towards PLWHAs, the computed co-efficient of determination showed that less than 48% of their attitude of accepting PLWHAs by religious engagements was by sex. This implies that other factors are associated with their attitudes other than sex. 4.4.b: Age of Respondents and Religious Relations with PLWHAs Responses on the Moslem respondents’ age and their attitude towards PLWHAS in their respective religious engagements or relations were sought to determine the relationship and the extent to which the Moslem respondents’ age is associated with their respective related religious engagement with PLWHAS. The result is presented in Table 4.12 Table 4.12: Age of Moslem Respondents and their Religious relations with PLWHAs (Yes) Age range Religious relation of Perform Give alms Accept alms Accept as an Total respondents Prayers Imam responses f % f % f % f % F % 18-30 111 48 111 48 8 3.4 1 0.4 231 100 31-55 180 46.2 180 46.2 28 7.1 1 0.2 389 100 56 above 9 30 9 30 9 30 3 10 30 100 Totals 300 46.1 300 46.1 45 6.9 5 0.7 650 100 Source: Field Survey, 2018 *Multiple responses Data in Table 4.12 showed that Moslems, no matter their age, will engage in prayers and give alms to PLWHAs. The young and middle (matured) adults however will discriminate more against PLWHAs by rejecting their charity and acceptance as well as recognizing them as Imams than those who are older. This implies that at least there is some differential level of engagement with PLWHAs by all the age categories of the Moslem respondents. As a way of confirming the above statistics, a correlation analysis was performed as shown in Table 4.13. 109 University of Ghana http://ugspace.ug.edu.gh 4.4. b: Correlation on Age of Moslem Respondents and their Attitude towards PLWHAs in Religious related Activities Correlation results at 0.05 significance levels in Table 4.13 on the age of the Moslem respondents and their religious relations or engagement with PLWHAs also produced the respective significance, degree or relative strengths as well as the coefficients of determination to measure the strengths of relationships and the extent to which the respondents’ age ranges are associated with their attitude towards PLWHAs in religious related relations. Table 4.13: Age of Moslem Respondents and their attitude towards Religious relations with PLWHAs (Yes) Attitude towards PLWHAs N R r2 r2% Sig. @ 0.05 Perform Prayers 300 1 1 100 1 Give alms 300 1 1 100 1 Accept alms 300 0.050 0.1 10 0.390 Accept as an Imam 300 0.213 0.426 42.6 0.000 Source: Field survey, 2018. The correlation results in Table 4.13 show that there is a very strong positive relationship between the ages of the Moslem respondents and their attitudes towards PLWHAs in religious related activity of accepting them as Imam which was positive and significant. However, their attitude towards other religious activities such as prayers, alms giving and accepting alms were positive but not significant. This shows that both the aged and young will discriminate religiously. Significantly the old would not likely accept PLWHA as their Imam. On the relative degree or strength of the relationship, the Moslems’ attitude towards PLWHAs in the areas of prayers and alms giving were very strong while those of accepting alms and accepting them as Imam were weak. As captured in the Table 4.13, the computed co-efficient of determination also showed that 110 University of Ghana http://ugspace.ug.edu.gh less than 45% of their attitude towards PLWHAs was associated with other factors than age. 4.4. c: Educational level and Religious Relations with PLWHAs A cross tabulation of responses on the educational level of Moslem respondents and their attitudes towards PLWHAs in religious- related engagement were sought to establish whether there exists any significant relationship between the two variables. Data gathered is presented in Table 4.14 Table 4.14: Educational Level of Respondents and their Religious relations with PLWHAs (Yes) Educational level of Religious Relations Moslems Respondents Perform Give Accept Accept as Total Prayers alms alms an Imam Responses f % f % f % f % f % No Formal Education 65 48.1 65 48.1 5 3.7 - - 135 100 Basic Education 48.9 48.9 2.1 - 92 100 45 45 2 - (Primary-JHS) Secondary Education 40 25 40 25 - - - - 160 100 Post-Secondary (Nursing, 49.3 49.3 3.7 - 79 100 39 39 3 - Agric.ext, Teacher etc.) Tertiary Education 42.2 42.2 13.3 1.9 262 100 111 111 35 5 (Polytechnic, University) Total 300 41.2 300 41.2 45 6.1 5 0.6 728 100 Source: Field Survey, 2018 *Multiple responses Responses in Table 4.14 showed that none of the Moslems with limited education is ready or likely to accept PLWHAs as an Imam and only 5.8% of them are ready to accept alms from PLWHAs in the identified related religious relations. The Moslems, notwithstanding their level of education will however not discriminate on the basis of performing prayers with PLWHAs and offering charity to them. This shows that irrespective of the level of education, Moslems share similar sentiments religiously on the basis of charity and common group prayers (congregational). 111 University of Ghana http://ugspace.ug.edu.gh This further suggests that when it comes to perhaps certain critical related religious areas the Moslem respondents seem to have different attitudes towards PLWHAs, hence the need to determine the extent of influence of their education levels on their attitude towards PLWHAs in terms of related religious relations. A correlation analysis was performed in order to confirm the above statistics as depicted in Table 4.15 4.4. c: Correlation on Education level of Respondents and their Attitudes towards PLWHAs in Religious Related Relations The correlation results at 0.05 significance levels in Table 4.15 on the educational level of the Moslem respondents and their religious relations or engagement with PLWHAs also produced the respective significance, degree or relative strengths as well as the coefficients of determination to measure the strengths of relationships and the extent to which the respondents’ educational levels are associated with their attitude towards PLWHAs in religious related matters. Table 4.15: Educational level of Moslem Respondents and their Religious relations with PLWHAs (Yes) Attitude towards PLWHAs N R r2 r2% Sig@ 0.05 Perform Prayers 300 1 1 100 1 Give alms 300 1 1 100 1 Accept alms 300 0.341 0.682 68.2 0.000 Accept as an Imam 300 0.101 0.202 20.2 0.081 Source: Field survey, 2018. The results in Table 4.15 showed that there is a highly positive but insignificant relationship between the Moslem respondents’ level of education and performing congregational prayers with the PLWHAs (r=1; p=1.00) and giving alms to PLWHAs (r=1; p=1.00) as well as accepting PLWHAS as their Imams (r=0.101; p=0.081) while that of accepting alms from them (r=0.341; p=0.000) was lowly positive but significant. 112 University of Ghana http://ugspace.ug.edu.gh The respective computed coefficients of determination in Table 4.15 showed that over 68% of their attitudes in terms of giving alms (100%), doing prayers (100%) and accepting alms from PLWHAs (68.2%) were associated with their level of education. However, their attitude towards PLWHAs in terms of accepting them as Imam was minimally associated (r2% =20.2) with their level of education. This implies that, generally, there is a strong relationship or influence of their level of education on their attitude towards their religious engagements with PLWHAs. It can therefore be inferred that, the higher the formal educational attainment of adult Moslems of a community, the more likely their attitude will be positive towards their religious engagement with PLWHAs. Social Relations and Personal Characteristics of Practising Moslems Social relations refers to a dynamic changing sequence of social activities between individuals or group who modify their actions and reactions as a result of the actions or behaviour of those they relate with .It is thus a relationship between two, three or more individuals. Social relations or engagement is very important and necessary for social order and its growth .It also provides a platform on communal occasions such as marriages, outdoorings, festivals funerals for people not only to socialize and interact with one another but to learn and educate others about the society’s norms, values ,beliefs and practices. It is therefore important that all members of the society are part of these social relations. 4.4.d: Sex and Social Relations with PLWHAs A cross tabulation of responses on the sex of Moslem respondents and their attitudes towards PLWHAs in socially related engagements were sought to establish whether 113 University of Ghana http://ugspace.ug.edu.gh there exists any significant relationship between the two variables. Data gathered is presented in Table 4.16 Table 4.16: Sex of Moslem respondents and their social relations with PLWHAs (Yes) Respondents Social Relations with SEX OF RESPONDENTS TOTAL PLWHAs Male Female F % f % f % Attend social events 152 58.9 106 41.0 258 100 Marry 1 25 3 75 4 100 Embrace 153 58.8. 107 41.1 260 100 Shake Hands 161 61.6 100 38..3 261 100 Share same Utensils 5 16.6 25 83.3 30 100 Sleep in same room 156 56.1 122 43.8 278 100 Visit them when sick 173 58.6 122 41.3 295 100 Children attend same school with 70 36.6 121 63.3 191 100 theirs TOTAL RESPONSES 871 55.2 706 44.7 1577 100 Source: Field Survey, 2018 *Multiple responses Data in Table 4.16 showed that in terms of sex, Moslems will discriminate against PLWHAs depending on the particular social activity they relate with them. Moslem men will have positive social engagement or relations with PLWHAs except in the area of marriage (25%) and in the sharing of utensils (16.6%). The women will also discriminate in a similar way. 4.4. d: Correlation on Sex of Moslem Respondents and their Attitudes towards PLWHAs in Social related Engagement Correlation results at 0.05 level of significance on the sex of the respondents and their attitude towards PLWHAs in social related activities in Table 4.17 shows the respective relationships and the extent to which sex of the respondents has influenced or associated with their respective attitudes towards PLWHAs in social related activities. 114 University of Ghana http://ugspace.ug.edu.gh Table 4.17: Correlation between Sex of Moslem Respondents and their attitude towards Social relations with PLWHAs (Yes) Attitude towards PLWHAs N R r2 r2% Sig. @ 0.05 Attend social events 266 0.143 0.286 28.6 0.019 Marry 295 0.112 0.224 22.4 0.055 Embrace 295 0.083 0.166 16.6 0.154 Shake hands 295 0.076 0.152 15.2 0.191 Share same utensils 290 0.106 0.212 21.2 0.072 Sleep in same room 300 0.103 0.206 20.6 0.076 Children attend same school with theirs 300 0.146 0.292 29.2 0.012 Visit them when sick 300 0.157 0.314 31.4 0.006 Source: Field survey, 2018. The correlation results in Table 4.17 showed a weak positive relationship between the sex of the Moslems’ respondents and their social relations with PLWHAs (r