UNIVERSITY OF GHANA SCHOOL OF NURSING COLLEGE OF HEALTH SCIENCES, LEGON EXPLORING THE ATTITUDE, KNOWLEDGE AND EXPERIENCES OF THE YOUTH TOWARDS HIV COUNSELING AND TESTING BY VINCENT KOJO TANYE ID. NO.10290516 THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MPHIL NURSING DEGREE. JULY, 2013 University of Ghana http://ugspace.ug.edu.gh i    DECLARATION I declare that except the information derived from published work of others that have been duly acknowledged in the text and list of references, this thesis is my own work that has not been submitted in any form for any degree or diploma at any University or other institution of tertiary education. Signature……………………………... Date……………........... APPROVAL The undersigned certify that the supervisors have read this research work and recommended to the School of Nursing for acceptance. ……………………………………………. …………………………………. Mr. Gladstone Fakor Agbakpe Date …………………………………………….. ……………………………….... Dr. Prudence Portia Mwinituo-Nyaledzigbor Date University of Ghana http://ugspace.ug.edu.gh ii    DEDICATION I dedicate this work to the almighty God who selflessly gave me the strength and wisdom to carry out this thesis right from the beginning to the end. I also dedicate this work to my late parents Mr. Joseph Tanye and Mrs. Rosina Nandong Tanye for nurturing me and making me what I am today and my wife Akosua Nyuor, my children, Nicholas Tanye and Nestor Tanye who inspired me to complete this work. University of Ghana http://ugspace.ug.edu.gh iii    ACKNOWLEDGEMENTS I first and foremost wish to acknowledge the almighty God for having given me the strength, wisdom, knowledge and understanding throughout the period of this study. I secondly wish to thank my wife for supporting the family whilst I was away for this study. I sincerely thank my supervisors Dr. Prudence Portia Mwinituo-Nyaledzigbor for her invaluable objective guidance and interventions without which this study would not have been possible. I also wish to thank Mr. Ameyaw Kwadwo Korsah for his timely constructive suggestions and corrections during the course of this study. I will not forget to thank the Dean, Dr. Ernestina Donkor and the other faculty members of the School of Nursing, University of Ghana for seeing me through this project work. My special thanks go to Miss Regina Ankrah for her job on correspondence and continuous reminders during the course of this study. I also offer special thanks to my principal Mr. Walter Mwinbo and the other staff members especially the late Boniface Tambaa the then accounts officer of Jirapa Nurses Training College for supporting me financially. My sincere thanks go to the Faculty members of Nursing, University of Alberta Canada, especially Dr. Judy Mill and Dr. Vera Caine who supervised me for my proposal development. I also thank my dear friend and mate David Baba for helping me to proof read some of the chapters of the thesis and not forgetting Mrs. Hannah Tanye who did the typing of the work to produce this thesis. I also thank the Ministry of Health, Human Resource Health Development Directorate, Ghana and the National Catholic Health Service for sponsoring me for the programme as well as the thesis. Finally, to the participants and the authors and publishers of the books and articles published in both Journals and electronic media that were sourced in this work I say a big thank you. University of Ghana http://ugspace.ug.edu.gh iv    ABSTRACT The study explored the attitudes, knowledge and experiences of the youth regarding HIV counseling and testing in the Jirapa district of the Upper West Region of Ghana. The study aimed at finding out the knowledge of the youth about HIV infection, transmission, the beliefs and attitudes toward undergoing HIV test and their experiences at the HIV counseling and testing centres. An exploratory qualitative design was used to explore the youth experiences. The sampling method employed was purposive and was based on data saturation- when no new information was forth coming. Saturation occurred at the 12th participant but four more interviews were conducted to cross check new emerging themes. The findings of the study showed that the youth had adequate knowledge of HIV counseling and testing but the participants indicated that there was lack of confidentiality at HIV counseling and testing centres, as counsellors easily spread the news to people about others who tested positive to HIV and the likely occurrences of stigma among the youth when HIV has been diagnosed. Findings from the study also indicated that there are some cultural and traditional practices as well as some parental influences on the utilization of HIV counseling and testing centres by the youth in the Jirapa district of Ghana. The study recommended that the health authorities in the district should re-strategize their HCT education programmes to include the youth in their own settings through the use of youth friendly services and the community Based Health Planning and Services (CHPS) in the district. University of Ghana http://ugspace.ug.edu.gh v    TABLE OF CONTENTS TITLE PAGE Declaration and Approval i Dedication ii Acknowledgements iii Abstract iv Table of Contents v List of figures and tables viii List of Abbreviations ix CHAPTER ONE 1 BACKGROUND OF THE STUDY 1 1.0 Introduction 1 1.1 The inception of HIV/AIDS 1 1.2 Statement of the Problem 4 1.3 Purpose of the Study 7 1.4 Objectives of the Study 7 1.5 Significance of the Study 7 1.6 Definition of Key Terms 8 CHAPTER TWO 9 LITERATURE REVIEW 9 2.0 Introduction 9 2.1 Knowledge of the Youth about HCT 10 University of Ghana http://ugspace.ug.edu.gh vi    2.2 Attitude towards HIV Counseling and Testing (HCT) 11 2.3 Socio cultural and sexual practices that influence attitude of the youth toward HCT 16 2.4 Barriers to HCT and Youth 21 2.5 Utilisation of HCT 25 2.6 Experiences of the youth on HCT 30 2.7 Summary 31 CHAPTER THREE 33 METHODS AND DESIGN 33 3.0 Introduction 33 3.1 The study Design 33 3.2 Research Setting 35 3.3 The Target Population and Sample 37 3.3.1 Sampling Technique 37 3.3.2 The eligibility Criteria of the sample 38 3.4 Data Gathering Procedure 39 3.5 Data Management 41 3.6 Data Analysis 41 3.7 Methodological Rigour of the study 42 3.8 Ethical Considerations 44 3.9 Summary 45 CHAPTER FOUR 46 FINDINGS OF THE STUDY 46 4.0 Introduction 46 University of Ghana http://ugspace.ug.edu.gh vii    4.1 Demographic Characteristics of the participants 47 4.2 Themes and categories 47 4.2.1 Knowledge of HIV Counseling and Testing 49 4.2.2 Reasons for utilization of HCT by individual youth 54 4.2.3 Reasons for non-utilisation of HCT centres by some youth 58 4.2.4 Sharing information about HCT among the youth 63 4.2.5 Cultural Practices and their influence on HCT 67 4.2.6 Parental influence on the youth and HCT 71 4.2.7 Youth Satisfaction with HCT services 72 4.2.8 Summary 75 CHAPTER FIVE 76 DISCUSSION 76 5.0 Introduction 76 5.1 Knowledge of HCT 78 5.2 Reasons for utilisation of HCT by the youth 79 5.3 Reasons for the non-utilisation of HCT by the youth 81 5.4 Sharing information about HCT among the youth 84 5.5 Cultural practices’ influence on HCT 85 5.6 Parental factors that hinder or enhance youth participation in HCT 86 5.7 Youth satisfaction with HCT services 88 5.8 Summary 89 University of Ghana http://ugspace.ug.edu.gh viii    CHAPTER SIX 90 SUMMARY, CONCLUSION, IMPLICATIONS AND RECOMMENDATIONS     90 6.0 Introduction 90 6.1 Summary and Conclusion 90 6.2 Field Experiences 92 6.3 Implications to nursing education 94 6.4 Implications to clinical Nursing 94 6.5 Implications to nursing administration 95 6.6 Implications to nursing research 95 6.7 Recommendations 95 REFERENCES 97 APPENDIX Appendix I Informed Consent Form 106 Appendix II Ethical clearance certificate 110 Appendix III Introductory letter for site approval 111 Appendix IV Interview Guide 112 Appendix V Participants profile 116 LIST OF TABLES Table 4.1 General characteristics of participants 116 Table 4.2 Themes and categories 48 University of Ghana http://ugspace.ug.edu.gh ix    LIST OF ABBREVIATIONS AIDS - Acquired Immune-Deficiency Syndrome ANC - Ante-Natal Clinic ARV - Antiretroviral CHPS - Community-Based Health Planning and Services DHS - Demographic and Health Survey FGD - Focus Group Discussions FGM - Female Genital Mutilation FHI - Family Health International FSW - Female Sex Workers GHS - Ghana Health Service HCT - HIV Counseling and Testing HIV - Human Immune-Deficiency Virus JDHS - Jirapa District Health Service KCMC - Kilimanjaro Christian Medical College MOH - Ministry of Health MTCT - Mother-To-Child Transmission OPD - Out Patient Department PLWHA - People Living With HIV/AIDS PMTCT - Prevention of Mother to Child Transmission TB -Tuberculosis UNAIDS - United Nations AIDS UNFPA - United Nations Population Fund University of Ghana http://ugspace.ug.edu.gh x    VCT- Voluntary Counseling and Testing WHO - World Health Organization University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    1    CHAPTER 1 BACKGROUND OF THE STUDY 1.0 Introduction This chapter provides the background to the study, the problem statement, purpose and objectives of the study as well as the significance and the definition of terms of the study. 1.1 The Inception of HIV/AIDS Human Immune-Deficiency Virus (HIV) and Acquired Immune-Deficiency Syndrome (AIDS) have become a global public health as well as a social problem. Three decades from when the first case of (AIDS) was first reported in 1981, the human race continues to suffer huge human, economic and social losses as a consequence of not finding a cure for the disease. Lamptey, Johnson and Khan, (2006) have referred to HIV/AIDS as the greatest catastrophic and most devastating health challenge in human history. The immensity of the consequences of HIV and AIDS is reflected in the death toll statistics as well as those living with the virus around the globe. Statistics indicate that about 39.5 million people were infected globally by the end of 2008 (UNAIDS, 2008). This figure includes the estimated 4.3 million adults and children who were newly infected with HIV in 2008, which were about 400,000 more than in 2004. Sub-Saharan Africa continues to bear the brunt of the global epidemic. Two thirds (63%) of all adults and children with HIV globally live in sub-Saharan Africa, with its epicentre in southern Africa (UNAIDS, 2008). One third (32%) of all people with HIV globally live in southern Africa and 34% of all deaths due to AIDS in 2008 occurring there (UNAIDS, 2008). More than 50% of all HIV infections world wide are among young people aged 15-24 years (Family Health International [FHI], 2006; University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    2    WHO, 2007). Again, more than 6000 youth are newly infected with HIV each day throughout the world. This rate of infection is due to the fact that the youth are more likely to engage in highly risky behaviours such as unprotected sexual intercourse that will lead them to contract HIV infection. Over half of the youth would have had sex at age 17 (Summerfield, 2008). Adolescents and the youth have much more power of sexual desire and are also more likely to engage in unprotected sexual intercourse, (GHS/UNFPA/MOH, 2005). Therefore, young people remain at the centre of the epidemic in terms of transmission, vulnerability, impact and also potential for behaviour change. This implies that young people will determine the course of the epidemic and therefore they are a critical focus for HIV prevention and behaviour change programmes (Mwandira, 2008). HIV counseling and testing provides an environment for teaching and learning about the virus and its transmission and the youth stand to benefit by their participation. According to Boswell and Baggaley (2002) Voluntary Counseling and Testing (VCT) for HIV which is now simply known as HIV counseling and testing (HCT) is the process whereby an individual or couple undergo counseling to enable him/her/them make an informed choice about being tested for HIV. This decision must be entirely the choice of the individual where trustworthiness and confidentiality at the HCT centre need to be ensured. HCT is much more than drawing and testing blood and offering counseling sessions. It is a vital point of entry to other HIV/AIDS services, including prevention and clinical management of HIV-related illnesses, tuberculosis (TB) identification for treatment and control, psychosocial and legal support, and prevention of mother-to-child transmission of HIV (MTCT). HCT offers benefits to those who test positive or negative. HCT alleviates anxiety, increases clients’ perception of their vulnerability to HIV, promotes behaviour change, facilitates early referral for University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    3    care and support including access to antiretroviral (ARV) therapy and more importantly, provides assistance for reducing stigma in the communities, (Mwinituo & Wright, 2010; Jeremi and Muula, 2008). Studies (Mwinituo & Wright, 2010) show that stigma is an issue in the study setting (Jirapa) and the Upper West Region as a whole. Persons infected or affected by HIV are often given names such as “muora” woman or “lean legs” or “lean buttocks” woman (Mwinituo & Wright, 2010). Jereni and Muula (2008) also indicated that HIV voluntary counseling and testing has been described as an important intervention for HIV prevention as it may serve as an early entry point for prevention and cure and support for those found infected. HIV counseling and testing (HCT) therefore remains the most widely accepted approach for promoting knowledge of serostatus especially for young people who constitute the future work force for any nation (Baiden, Akanlu, Hodgson, Alweongo, Debpuur & Binka, 2007). This is because it forms the gateway to HIV and AIDS prevention, care, treatment, and support interventions. High quality HCT enables and encourages people to patronise HCT services and these services are undoubtedly some of the most effective HIV prevention strategies. Hence, as a healthcare professional and a nurse educator in the Jirapa district, it is important to explore the perception of the youth regarding HCT and their views about its conduct. In Ghana, according to Abokyi (2008), HCT is also believed to offer strong motivation for those who test negative to remain so. HCT provides an opportunity for people to know their HIV status and consists of a package of services including pre-test counseling, the actual test for HIV and post-test counseling services. Irrespective of the results or outcome of a test, the client obtains information that could translate into behaviour change if the test result is negative so as to endeavour to always remain negative. On the other hand if test results turn out to be positive, University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    4    it offers the opportunity for early treatment and avenues to also live healthily for a longer time. With the advent of antiretroviral therapy, people living with HIV/AIDS (PLWHA) are able to live much more productive and healthy lives. HCT promotes a wider social acceptance of the HIV/AIDS epidemic. In fact a negative test result is believed to motivate behaviour change (Abokyi, 2008). This therefore underpins the importance for young people to take advantage of HCT services, as it will encourage them to develop acceptable behaviour practices for prevention of HIV infection. Unfortunately just 5% of people living with HIV and AIDS are estimated to be aware of their HIV status (WHO, 2004). It has also shown that, in Ghana, the patronage of HCT by the youth is low though they are aware of the existence of HCT services according to Abokyi (2008). Information from the Jirapa District Health Service annual reports indicate that between the years 2003 and 2007, the youth of the district constitute 24% of the general population of the district and only 13% of this group utilized the available HCT services in the district even though their behaviour and conduct make them the most vulnerable group to HIV infection. An anecdotal observation by the researcher show that some cultural/traditional practices such as festivals, funerals and intestate marriage (widow inheritance) in the district do involve the youth and increase their exposure to higher risk of HIV infection. It is therefore important to investigate the youths’ utilization of HCT services in the district by exploring their knowledge, attitudes and experiences of HCT. 1.2 Statement of the Problem Baiden et al (2007) in a research in HCT on Northern Ghana stated that access to HCT remains limited in most parts of Ghana with the rural population being the least served. This is University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    5    an indication that HCT patronage will equally be at a lower level because of the limited access. However, according to the health demographics in Ghana, there is an indication that almost every district in the country has at least one HCT centre. The Jirapa district in the Upper West Region of Ghana for instance, has two HCT centres one of which is located in the rural health centre in the Han community (Jirapa District Health Service [JDHS], 2007). It is expected that with the gradual availability of HCT service centres in the district, patronage of HCT by the youth will increase especially with the introduction of adolescent reproductive health services and youth friendly clinics by the Ghana Health Service in 2005. The adolescent reproductive health services do incorporate HCT services in Ghana. Abokyi (2008) confirmed an increase in the willingness for HCT by stating that, a survey conducted in Kintampo, Ghana, indicated that among 11604 respondents, 93% expressed willingness for HCT. An observation made by the researcher who is also a native of Jirapa shows that the majority of the youth in the Jirapa District are those that are usually involved in certain cultural practices such as engagement in liberal sexual practices at cultural festival grounds and funerals. More often than not the youth are those that are engaged in re-marriages of their late brother’s wives or a late husband’s brother without knowing the cause of death. This cultural and traditional practice of widow inheritance has been documented in the Upper West Region of Ghana by Mwinituo and Wright’s (2010) study among women diagnosed with HIV infection. In the midst of such unhealthy cultural practices that engage the youth to continue the lineage of families or clans, it is expedient to investigate youth participation in HCT to avert future explosion of HIV infection in the Jirapa district and also to educate the indigenes on the need for modification of their cultural and traditional practices. University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    6    The Jirapa District Health Service (JDHS, 2008) annual report indicate that for the period 2003-2007 a total of 1,754 people utilized the HCT services in the Jirapa district. Out of this number only 13% (235/1754) aged 15-24 years did utilize HCT out of a total youth population of 24%. This indicates a very low patronage of HCT by the youth in the district. A study conducted by Baiden et al. (2007) who used lay counselors to promote community-based voluntary counseling and HIV testing in rural northern Ghana reported a low patronage of HCT. If HCT is one of the powerful strategies that could be used to reduce the spread of HIV, and the youth in northern Ghana are aware of HCT services, why then are the youth not accessing the HCT services? The research questions that need answers include:  What is the knowledge and awareness of the youth on HCT?  What do the youth in Jirapa district know about the process of HCT?  How is privacy and confidentiality ensured at HCT centres?  What are the attitudes of the youth towards HCT?  What encourages or discourages youth participation in HCT?  What are the beliefs of the youth regarding HCT?  What are the experiences of youth who have utilized HCT services?  How do young people feel about undergoing HCT before and after?  What inform their decision to undergo HCT?  What are the reasons associated with the utilization and non utilization of HCT services by the youth in the Jirapa District? University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    7    1.3 Purpose of the Study The purpose of this study was to explore the attitudes, knowledge and experiences of the youth towards HIV counseling and testing and their reasons for utilization and non-utilization of HCT services in the Jirapa District. 1.4 Objectives of the Study The objectives of the study were to:  Determine the knowledge and awareness of the youth of HCT in the Jirapa District.  Investigate the reasons for the utilization and non-utilization of HCT services by youth in the Jirapa District.  Investigate the willingness of the youth to undergo HCT in the Jirapa District  Ascertain the experiences of the youth who have utilized HCT services in the District. 1.5 Significance of the Study The findings of this study will benefit the indigenes of Jirapa and the Upper West region as a whole. Health authorities will have an insight into some of the attitudes and experiences of the youth regarding HCT. It is envisaged that the current study will identify the gaps in HCT knowledge and barriers to utilization by the youth in Jirapa. Strategic plans for HCT utilization among the youth in the district could be made through documenting the factors that motivate others to utilize the available HCT services. Findings could also be used to guide, develop and implement appropriate youth educational programmes on HIV/AIDS. The study can also serve University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    8    as a knowledge base for future research into HIV/AIDS among the youth in the Jirapa district by non-governmental organizations and other researchers. 1.6 Definition of Terms Youth:- Any young adult aged 18 – 25 years and above regardless of marital or economic status and whether one has a child or not. Young people:- Any person age 18-24 years regardless of marital or economic status and whether one has a child or not Voluntary Counseling and Testing (VCT) for HIV:- A process whereby people willingly undergo an HIV counseling process and have an HIV test. HCT:- HIV counseling and testing, whether it is voluntary or provider initiated. Attitude: - Personal view, opinion or general feeling about something. Knowledge:-Awareness and availability of HCT. Uptake/utilization:- It means having gone through HIV counseling and testing and having had all the experiences. Culture:- the customs and traditional practices of the “Dagaaba” of the Upper West region such as their festivals, funeral rites and marriage systems, dance and way of life. University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    9    CHAPTER 2 LITERATURE REVIEW 2.0 Introduction In conducting the literature review, the various search engines including Pub Med, Jstor, EBSCOHOST, Sage Journals Online, Science Direct, Wiley Blackwell, Hinari, and google scholar were consulted. Search terms included HCT, HIV/AIDS in Africa, voluntary counselling and testing, youth behavior towards HIV/AIDS and so on. Literature was also obtained from annual reports of various organizations as well as books on HIV/AIDS, HCT and the youth. In compiling the literature, the under listed themes were employed:  Knowledge of the youth about HCT;  Attitudes towards HCT ;  Socio-cultural and sexual practices of the youth that influence their attitudes;  Barriers to HCT;  Utilization of HCT and  Experiences of youth on HCT. Finally the chapter ends with a summary of the review. University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    10    2.1 Knowledge of the Youth about HCT A qualitative study conducted by Sebudde and Nangendo (2009) in Rakai district of Uganda on the topic; HCT Services: Breaking resistance to access and utilization among the Youth, found that, there was adequate knowledge and awareness of HCT services available to youth in the district through various publicities. The main channel of publicity was the print media and radio communication as well as direct health education campaigns employed by HIV/AIDS counselors which were the main sources of information to most of the youth. Furthermore, the study identified certain limiting factors of individual, community and health care institutional structures that repel the youth from participating in HCT. Sobedde and Nangendo’s (2009) study concluded that mobile clinics and outreach programmes on HCT was more suitable to attracting youth participation than structural arrangements in health facilities. The current study set out to explore the attitudes, knowledge and experiences in a district dominated by illiteracy and lack of development in a deprived region (Upper West) of Ghana. There is only one radio station (Upper West Radio) and print media are available only once a week. Other channels of communication such as television constitute a luxurious choice for the few elite group stationed in the bigger towns. Thus, researching into the attitudes, knowledge and experiences of the youth in Jirapa district towards HCT is relevant. The reviewed study was also deemed relevant to the current study as it focused on the knowledge of the youth towards HCT. It discussed the need to increase the youths’ utilization of HCT. The study employed qualitative methodology to ascertain in-depth knowledge of the participants similar to the current study and the findings contribute to knowledge on youth and HIV. University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    11    In another study, Bayray (2010) researched into University students’ knowledge, attitude, and practice of voluntary counseling and testing (VCT) for HIV and increased uptake at Mekelle and Tigray in Northern Ethiopia, using a cross-sectional design and questionnaire. The study found that female respondents were more knowledgeable about HCT than male respondents. Furthermore Lemessa (2005) reported that females were more knowledgeable than males. Conversely, in a study conducted in North and South Gondar, Ethiopia, Mengesha (2006) found that with regards to issues of HCT, males and females did not differ in their knowledge and awareness about HCT. The current study employed a qualitative methodology which aimed at getting varied and rich information from youth participants through semi structured interviews. 2.2 Attitude towards HIV Counseling and Testing (HCT) In a qualitative study, Dennis (2010) examined the ways in which out-of school youth responded to a context of HIV/AIDS and how they themselves can be active participants in HIV/AIDS prevention. The title of the study was: “They should know where they stand”: attitudes to HIV Voluntary Counseling and Testing amongst a group of out-of-school youth. Four out-of-school youths, trained as fieldworkers, interviewed 32 other out-of-school youths in the Shongweni area of KwaZulu-Natal about their attitudes towards HCT. Interviews conducted in Zulu were translated into English by the four trained out-of-school youth researchers. Analysis of the data made use of both qualitative and quantitative methods to respond to the specific needs and observations that arose from the data collected. The study found a high general level of awareness of HIV/AIDS, certainly to the point that out-of-school youth could repeat many of the standard messages used in campaigns against HIV/AIDS. The study also reported that the out-of-school youth displayed positive attitude University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    12    towards HCT with 91% stating their intentions of getting tested and on the contrary, only nine (28%) actually testing due to high levels of fear of stigma surrounding HCT. Forty-three (43%) percent of the participants in the area indicated their preference for a HCT site or hospital to be far from home, or, if they could afford it, a private doctor, to minimize the likelihood of being seen by someone they knew. This factor made it more difficult and cost more for out-of- school youth to access HCT. For some, the fear of HIV infection has caught up with their existing social exclusion. In contrast, one reason for wanting to test amongst girls was their concern for the health of their future children. While out-of-school youth understood the role of HCT in maintaining a healthy lifestyle, the obstacles to acting on those intentions included the context of poverty, gender inequalities, stigma and the fear of gossip. Campaigns succeeded in raising awareness, but translating awareness into action remained a central problem. The study is significant to the present study as it employed a qualitative method. However the researcher did train people to do the interviews and not the researcher himself. The trained personnel may follow exactly the guiding questions and may not make further probing to obtain in-depth information that could enhance the findings of the study. In a similar study, Tenibiaje (2010) investigated the attitude of youths toward voluntary counseling and testing for HIV/AIDS in Nigeria with the aim to change the attitudes of youths in prevention of HIV infection. Using a descriptive quantitative survey through random sampling, 357 youths were selected from three states (Ondo, Kogi and Ekiti) in Nigeria. Data was gathered using an 18 item questionnaire. The data was analysed using percentages and multiple regression. The findings showed that the youth were aware of transmission and prevention of HIV/AIDS and knew the centre and importance of HCT HIV/AIDS. University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    13    The findings also showed that most of the youths (males and females) were sexually active, and that males had more sexual urge and more sexually curious. It was also found that male youth attached a sense of conquest to sexual activities than their female counterparts and also that, the youth were engaged in high risk sexual behaviour with about 65% of the youth experiencing sexual intercourse several times. Furthermore, (58%) of the youth had multiple partners. Despite the fact that the youths were aware of transmission and prevention of HIV, about 70.0% of the youth engaged severally in sexual activities without using condoms. The results again revealed that age, gender and religion have a significant partial correlation coefficient in the predictions of attitude of youths towards HCT. This study is relevant to the present study since it did investigate the attitude of youth towards HCT which the present study wished to emulate. However the findings could differ because the study employed a quantitative method whilst the current study used a qualitative approach. A study conducted by Abebe and Motikie (2009) entitled “Perception of High School Students towards Voluntary HIV Counseling and Testing, using a Health Belief Model (HBM) in Butajira”, sought to assess the perception and attitude of students towards HCT services. A cross sectional descriptive study was conducted in January 2006, among Butajira senior secondary school students where a multi stage sampling method was used. A probability sampling method was used to select 608 senior secondary school students and self administered questionnaires were used to gather data for the study. The study found that almost all the respondents indicated that they have heard of HIV/AIDS and HCT and that they heard it through the radio, television, friends and at school. About half of University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    14    the respondents also indicated that HCT was important. Fifty-two percent of the respondents stated that they preferred to be counseled by trained counselors, followed by physicians, HIV patients and religious leaders respectively. The majority 382 (60%) of the respondents showed preference to confidential testing, followed by anonymous way of testing 156 (24.4%). As a way of receiving HIV test result, the majority 365 (57.2%) preferred face-to-face while by 197 (30.9%) preferred it to be done secretly in an envelope. Regarding their attitude towards HCT and its practice, 118 (18.5%) had used HCT service. When students’ willingness to undergo HCT was assessed, five hundred and twenty six (82.5%) of the respondents explained they were willing to undergo HCT. Those who were not willing to undergo HCT and gave the reason as fear of anxiety following possible positive result was 50 (45.5%) and those due to fear of stigma and discrimination by the society was 22 (19.6%). The results also indicated that less than half of them had low perception of acquiring the infection. The most frequently cited reasons by those with low perception were having had no sexual contact (41.6%), being faithful to their partners (37.3%) and using condom consistently (18.7%). Half of the respondents had high perception towards severity of HIV/AIDS. Also majority of the students had high level of perception on barrier for HCT. Furthermore the majority of the respondents had high confidence in using HCT. The study concluded that the majority of students have heard about HCT and revealed willingness to undergo HCT. Willingness for HCT was affected by age, education and previous sexual experience. High perceived susceptibility and high perceived barriers were associated with low willingness to undergo HCT. On the other hand, students with high perceived benefits revealed better willingness to undergo HCT. University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    15    This study is relevant to the present study as the author evaluated the knowledge level of HIV counseling and testing as well as the students’ willingness to test for HIV. Respondents of the questionnaire were students who were within youthful ages similar to the participants that were sampled for the present study. The only difference was that the researcher employed a quantitative methodology as against a qualitative methodology that was employed in the present study. A qualitative study conducted by Adekeye (2011) on the attitude of HIV/AIDS counselors towards undergoing HIV voluntary counseling and testing themselves in Ado-Odo/Ota, Nigeria revealed that participants had high knowledge of HIV/AIDS but they refused to go for the test themselves due to the fear they habour that they may be positive and that their acquaintances may blame them for the positive results. Other reasons for the refusal to test were the belief that if they tested positive, they would have problems disclosing their HIV status. They also had fears about the lack of confidentiality in testing centres. Other reasons included fear of death. This study is relevant to the present study since it employed a qualitative methodology with the intention of getting in-depth knowledge and attitudes of participants for HIV testing. Findings of the study could be similar to the present study since the present study also employed a qualitative approach for data collection. However the study cannot be generalized to cover all counselors for HIV counseling and testing because the researcher who was using HIV counselors as participants could not actually tell whether all the participants had not actually been tested for HIV. Mphaya (2006) used an exploratory descriptive design in a study to explore factors that motivate young people to access HCT services in Malawi. Both male and female youth who were sexually active felt that they had been exposed to HIV and hence the need to seek HCT University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    16    services. The study indicated that females in urban and semi-urban areas were more likely to access HCT services than their counterparts in rural areas. Friends, radio and school health education were found to be the main sources of information about HCT. Mphaya (2006) again found that other young people reported that they were not willing to have HCT because of fear of testing positive. They preferred seeking HCT services at government health facilities, to ensure confidentiality and conducive conditions for testing. Conducive conditions included having a youth friendly health facility and young people providing the services in a clean environment with privacy. This is comparable to the findings of Mwandira (2008) that “youth to youth” counseling sessions were the best motivation factors for young people seeking HCT services. 2.3 Socio-cultural and Sexual Practices that influence attitude of the youth toward HCT A non-governmental organisation, Action Aid Ghana (2007) conducted a survey entitled “violence against women and HIV in northern Ghana” with a sample of 222 participants recruited for interviews and focus group discussions. It was found that women in their fertile age comprising of mostly young women and widows according to culture, were forced into marriage with their late husbands’ brothers. When such widows are inherited without knowing the cause of the husband’s death and in cases where the husband died of AIDS, and she being positive herself, she will end up infecting the new man who will also infect his other wives. Such widows may be confused as to whether to go in for HIV test or not. The study further found that women as widows were not allowed to remarry outside the clan but to continue staying in their deceased husband’s homes, remaining single or having several secret lovers. The study reported that such women were willing to do the HIV test because they were free from extended family intrusion and could decide for themselves. University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    17    These studies are relevant to the current study and informed the researcher to explore the issues of cultural practices relative to youth experiences of HCT in the Jirapa district. The difference from the present study was that the survey concentrated on violence as a cause of HIV/AIDS transmission and not HCT to diagnose HIV infection. A study in Ghana by Mwini-Nyaledzigbor and Wright (2011) also found that in sub-Saharan Africa and Ghana in particular, women reported having no right to either refuse sex with their husbands or boyfriends or suggest the use of condoms. The risk of women becoming infected with HIV is disproportionately high to the men being infected. The study also reported that in Ghana young women between the ages of 15 and 19 years were three times more likely to be infected than their male counterparts, whilst women aged 20-24 years old were 10 times more likely to be living with HIV than men in their age cohort (Mwini-Nyaledzigbor & Wright, 2011). Additionally it has been reported that women who were divorced, separated or widowed tend to have significantly higher HIV prevalence than those who were single, married or cohabitating. Often, divorce or widowhood of women stems from the woman’s HIV status since many women diagnosed with HIV are usually divorced or driven out of their marital homes or lose their spouses to AIDS related illnesses (UNAIDS, 2009). In a related study, on the misconception about HIV infection faced by diagnosed Ghanaian women (Mwini-Nyaledzigbor & Wright, 2011) found that widow inheritance was a sociocultural practice among the people in Northern, Upper East and Upper West regions of Ghana where young ladies were often obliged to their late husband’s senior or junior brothers from the same clan to enable the family to continue with the lineage as a way of pacifying the ancestors and also ensuring peace for the souls of the late or departed husbands. In that study most of the women who were diagnosed with HIV had lost their husbands to AIDS in mining University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    18    and urban centres and towns of Ghana, but could not break the news for fear of being ostracized from society. Such women may not want to know their status if not already known for fear of being positive to HIV and facing the consequences of ostracism. Socio-culturally, a woman diagnosed with HIV in the northern part of Ghana has brought ‘muora’ (a contagious disease associated with HIV/AIDS) to her husband who will suffer bloating of his abdomen and swelling of his feet before dying. (Mwini-Nyaledzigbor & Wright, 2011). The word ‘muora’ was used on the diagnosed woman to mean spoiled woman who slept with other men apart from her husband. The socio-cultural beliefs and practices in some societies in sub-Saharan Africa and Ghana contribute to the sustained presence of the virus in Africa and the sub region. This can be explained by the fact that there have been dearth of literature on the socio-cultural beliefs and practices to bring a change in people’s behaviour regarding the prevention of HIV transmission and other practices. These therefore have an influence on the people’s attitude towards HCT (Mwini-Nyaledzigbor & Wright, 2011). Other modes of transmission of HIV such as scarification, tribal marking and female circumcision favour the spread of HIV. Awusabo-Asare, Biddlecom, Kumi-Kyereme and Patterson (2006) in their survey observed that some initiation rites like female genital mutilation (FGM) that ushered young people into adulthood as well as tribal marking for social identification is commonly practised among tribes in the Northern parts of Ghana. The indigenous ‘surgeons’ of FGM mostly do not know much about the germ theory and could easily transmit HIV through their practices among young people. Once young persons who have undergone FGM and have also become aware of the mode of HIV transmission, they may not utilise HCT for fear of positive results and stigmatization. University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    19    Several authors (Mavhu, Langhaug, Manyonga, Power and Cowan, 2008; Debrah, 2007) did suggest that culture and societal norms and economic factors have a strong influence on adolescent sexuality. Mavhu et al (2008) for instance reported that culture and societal norms have a major role to play in obtaining sexual information from the youth. Mavhu et al (2008) also argued that socio-cultural and economic factors have an influence on adolescent sexual activities. In the Jirapa district, it is a common practice for parents to give out their youth daughters (e.g. drop outs from school and those that have never been in formal education) to other families as betrothal for marriage and elopement. Younger male siblings get married to the wives of their late elder male siblings without knowing the cause of death. This is an issue of great concern (IPPF, 2008). Debrah (2007) suggested that sex and sexuality are some of the major elements of contemporary Ghanaian youth culture. The researcher did observe that the youth in the Jirapa district are more aware of their sexuality than previously; they express their sexuality more than before and sex is gradually becoming a normal component in the lives of most Ghanaian youth (Debrah, 2007). Hence, sex education has of late become a component part of the educational curriculla in Ghana. According to Debrah (2007), the youth have different beliefs concerning sexuality. For some young people, sexuality is a question of morality based on religion and faith. But for the majority of the youth, it is simply a choice to satisfy an innate human desire. Furthermore, Debrah (2007) showed that young people of all ages are sexually active and increasingly parents are losing their ability to control the sexuality of their children resulting in most parents blaming the problem on peer pressure and the social implications of their fast growing communities. Parents often complained about the influence of the media and western cultures for instance (indecent dressing that exposes the private parts of females) to their young peer counterparts. University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    20    According to the author, there exists a gap of mistrust between parents and youth on issues of sexuality due to a generation gap between them. This perception of the Ghanaian parent could stem from their belief that sex matters should not be discussed among children/youth as a way of preventing children from becoming sexually active. Also, Awusabo-Asare et al. (2007), observed that the spread of HIV/AIDS and other sexually transmitted infections (STIs) are still highly topical issues in Ghana and the youth form the biggest risk group for the spread of HIV/AIDS. Studies by (Awusabo-Asare, 2007; Anochie & Ikpeme, 2001) have shown that youth in Ghana engage in premarital sex and that the majority of those who do so start at an early age. In a Ghana Demographic Health Survey (DHS) report (2006) more than 90% of Ghanaian youth are aware of HIV/AIDS and yet the majority do not use condoms when engaging in sex. These studies conducted by Awusabo-Asare (2006) and others are relevant to the present day attitude of youth in the Jirapa district of the Upper West Region. The traditional area have certain cultural traditional festivals obverved at the beginning of the new crop harvest and end of year celebrations for good rain and bumper harvest each year known as the ‘Bogri’ and ‘Bongo’. Such festivals require the participation of all and sundry most especially the youth. On such occasions, vulgar music/dance carry the day where youth display their skills in many ways including sexual randez vous amidst much displays. The question the researcher puzzles on is what is the knowledge, attitude and practices/experiences regarding HCT? Do the youth ever feel such exposures could render them liable to become victims of the virus that causes AIDS? Whose responsibility is it to draw the attention of the traditional people of Jirapa about the vulnerability of the youth to HIV infection? The purpose of the current study was to explore the knowledge, attitude and experriences of the University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    21    Jirapa youth towards HIV counseling and testing (HCT) with considerations of their socio- cultural practices which can serve as deterrant to participation in HCT. 2.4 Barriers to HCT and Youth Meiberg, Bos, Onya and Schaalma (2008), conducted a qualitative study on “Fear of Stigmatization as Barrier to Voluntary HIV Counseling and Testing in South Africa”. Their aim was to identify psychosocial correlates of HIV counseling and testing (HCT), with an emphasis on the association between fear of AIDS-related stigma and willingness to have an HIV test. The study was conducted among students of the University of Limpopo (UL), Polokwane, South Africa. The group was a sexually active target population and was relatively easy to reach. Ten focus group discussions were held among students to explore correlates of HCT and fear of stigma and discrimination. A total of 72 black students comprising 35 men and 37 women of the UL participated. They were undergraduate (62) and postgraduate (10) students, varying in different grades. All students, except one who was married, were single and they were between 18-36 years of age, and belonged to different ethnic groups, but most of whom were “Sotho” or “Tsonga”. The students were asked about their HIV/ AIDS knowledge and the underlying factors (transmission, ways of protection, and consequences of being HIV positive / negative). Also, their HCT knowledge was asked including benefits and barriers associated with going for testing. To stimulate group discussion, the facilitators told ‘stories’ to which students could react. The stories were used so that the students could replace themselves in the person in the story, to give an accurate opinion. In the stories the themes of stigmatization and HCT were cited. Participants were recruited by means of posters, announcements on the University radio station by research assistants and peer educators. University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    22    Results from the study indicated that there was still a strong HIV/AIDS-related stigma in South Africa. Most participants agreed that people living with AIDS (PLWA) were neglected, ignored and isolated. For instance, participants frequently mentioned that it would be very difficult to get a job when you are HIV positive, that many men leave their women when they are HIV positive, that even family members frequently blame their relatives for contracting HIV/AIDS, and that many PLWA are rejected by friends because people do not want to be associated with someone with HIV/AIDS. The FGD also revealed that the participants were struggling with HIV/AIDS-related stigma themselves. Many acknowledged that PLWA should not be stigmatized and discriminated against; they recognized that they themselves were also not free of stigmatizing reactions. The results of the study by Meiberg et al (2008) also revealed that although HCT becomes increasingly available nowadays in South Africa, at the time of the study, antiretroviral drugs were still unavailable in Limpopo province and participants in all FGD still strongly associated HIV/AIDS with ‘dying’ and ‘death’. During the discussions HIV/AIDS was frequently described as ‘the disease that cannot be cured’ or ‘another international death sentence’. Many participants expected that HIV infection would end all their future plans, and some thought that they might commit suicide when tested HIV positive. Only a few participants believed that HIV is not immediately causing death and that it can be possible for PLWA to live a rather normal life. The FGD further revealed that participants were seriously concerned about contracting HIV/AIDS. Although they recognized that their beliefs about HIV prevalence at the University campus were based upon rumours, they assumed that about half of the students might be HIV positive. University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    23    According to Mwinituo and Wright (2010) at the beginning of the AIDS epidemic in the early 1980s when there were no known drugs and prophylaxis; fears gripped many people to undertake HCT. The general attitude was not to be told about one’s infection but to remain unaware until the AIDS set in. Many claimed such attitude gave them false hope and boosted their psychological morale. Once diagnosed, worries and sleeplessness set in that deteriorate the individual psychologically. The psychological and emotional distress stemmed from the way society views the diagnosed individual (Mwinituo & Wright, 2010). In a psycho-education intervention study to teach HIV infected women on positive living and avoidance of self-stigmatization, in a non-governmental organization setting, (Mwinituo & Wright, 2010) reported that the stigma and discrimination attitudes of people including friends, family members and significant others resulted in the development of various negative impression and feelings leading to suicidal ideation, social isolation, low self esteem and sleeplessness among the sample studied. The participants were sad, shy and embarrassed because they had contracted a disease that society label as “bad” (Mwinituo & Wright, 2010). The worries experienced by most participants in the Mwinituo and Wright (2010) study stemmed from the women always thinking about the disease, its outcome, and the shuttered future plans and hopes for their children. Hence availing oneself to HCT when one was not sure of negative test results was sufficient to sign for a death warrant. Sukari (2008) also conducted a study on Barriers and attitudes towards HIV voluntary counseling and testing (HCT) among secondary school pupils of Sengerema in Mwanza. A cross-sectional design was used for the study. A total of 400 secondary school students from two schools in Sengerema district, Mwanza were included in the study. By using simple random University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    24    sampling technique, the two secondary schools (Sima and Tuitange) were selected and enrolled in the study. After a verbal consent from each interviewee as well as observing confidentiality, data were collected using a pre tested Swahili questionnaire. Data analysis was done using Epi Info 2002. The findings of the study were that only a small number (4.2%) of the students thought that HCT was not necessary with 47.8% saying it was against their religious teachings. While a large proportion (65.8%) of the students knew HCT sites in Sengerema district, only a few (24.3%) of them ever used the available HCT services. Of those who ever used HCT services, 32.7% were just interested in knowing their HIV status and to get HIV education while only a small number (6.2%) of students used HCT services because they were pressurized by their spouses. For those who never used HCT services, (41.8%) said they feared being labeled as HIV positive and 34.9% said these services were not meant for students. It was also observed in this study that HCT services were more accepted among female students than male students. From the findings it was concluded that a large number of students knew that HCT use was necessary and the acceptance of HCT among the students was influenced by age where younger students were more willing to use HCT services than older students. Similarly, Yahaya, Jimoh and Balogun (2010) conducted a study that aimed to examine the factors hindering the acceptance of HCT by the youth in Kwara state of Nigeria. A descriptive quantitative methodology was employed using 600 youths as respondents to a questionnaire. Findings from the study indicated that the main factors hindering acceptance of HIV/AIDS testing was ignorance, fear of being positive, high cost of HCT, inadequate HCT centres, stigmatization, discrimination, religious beliefs, cultural beliefs, parental pressure and inadequate motivation. Though HCT is a health promotion strategy that monitors individuals and their University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    25    health, most people especially the youth may view it as doing the health care provider some good. Whereas HCT is known for just diagnosing HIV infection, the process of HCT accrues several benefits to clients other than just testing for HIV. The HCT affords individuals with knowledge about the virus, detection of other diseases such as STIs for early treatment and above all, early detection of HIV infection for management and prevention of AIDS. It is therefore important for population groups such as the youth to undertake HCT. 2.5 Utilization of HCT Many studies conducted on HCT utilization report that the utilization of HCT was related to a number of factors. In one of these studies in Eastern Cape, South Africa conducted among 3,374 adults aged 15 years and older, Hutchinson and Mahlalela (2006) reported that HCT utilization generally was low and identified less educated men and women who were more likely to utilize HCT than highly educated individuals. Women in particular were less likely than men to utilize HCT due to stigma. The study also found that availability of HCT services were more likely to have a greater impact on HCT utilization by men. In a related study on “Factors Associated with Utilization of a Free HIV HCT Clinic by Female Sex Workers in Jinan City, Northern China,” Wang, Li, Pan, Sengupta, Emrick, Cohen and Henderson (2011) employed a quantitative methodology with 1059 female sex workers (FSW). The FSW were sampled for the interviews at entertainment centres in Jinan Township. The study revealed that the majority of the subjects had the willingness to be tested for HIV, though only few (11%) got tested. The results from the study also indicated that the low level of the actual testing was due to the fear of stigma and identification as sex workers by their acquaintances at the testing clinic. University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    26    Tefera (2006) conducted a study to determine the demographic characteristics and factors that affect HCT acceptance as well as HIV prevalence among youth in Addis Ababa. Both quantitative and qualitative data collection methods were employed. A total of 3220 youth aged 15-24 accessed HCT and were used for the interviews. The findings from the study revealed that there were high utilization rates of HCT among youth, and particularly females in Addis Ababa, Ethiopia and the reason for this high uptake was that, they wanted to know their status and they also suspected they were infected and wanted to go abroad. Hutchinson and Mahlalela (2006), who conducted a study with 3,374 adults aged 15 years and over in South Africa sought to examine attitudes towards voluntary counseling and testing (HCT) services, patterns of utilization of HCT services and the relationships between HIV/AIDS-related stigma, HCT service availability and quality and the use of HCT. A quantitative methodology was employed. The study revealed that HCT utilization was poor. A similar study by Fabiani, Cathrone, Nattabi, Ayella, Ogwang and Declichs (2007) investigated the factors associated with HCT uptake among women attending the ante-natal clinic (ANC) of the St. Mary’s Hospital Lacor in Uganda and found that uptake of HCT among ANC women was generally low. Utilization rates were associated with age, marital status, level of education, recent change of residence and having a partner with a government occupation. The study did not take into account certain variables such as: the accessibility of the clinic; the woman’s relationship with the staff; the confidentiality of HIV testing; and the women’s willingness to be informed of positive HIV test results. The study also did not consider several factors that may have been barriers to HCT: the stigma attached to being HIV positive, self perceived HIV risk, the woman’s fear of her partner, and the knowledge of and attitude towards University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    27    testing. These factors contributed to the generally low utilization of the HCT services by the women. Also a study in Northern Ghana by Baiden et al. (2005) found that the participants’ spousal involvement in HCT had a strong positive influence on the utilization of HCT. Van Dyke and Van Dyke (2003) also agreed with the other authors on barriers to HCT that people may refuse to utilize HCT because of fear of rejection if found to be positive, fear of a breach of confidentiality, fear of people knowing them and shunning them if found to be positive after testing, and lack of trust of the HCT personnel and services. Again Mwandira (2008) evaluated the effectiveness of youth HCT counselors in promoting HCT uptake among fellow youth, using client satisfaction data from exit surveys. The findings indicated that older adolescents were more likely than younger adolescents to access HCT services from youth friendly sites or centres. Marital status was found to significantly affect the choices of an HCT site by youth; single sexually active young people were more responsive to HCT motivation messages and perceived HCT services as being very vital for decision making in their lives especially before marriage. Despite this finding, there was generally low demand for services by the youth. The author reported that a high proportion of youth in youth centres and health facilities preferred peer counselors to adult counselors. Furthermore, Regassa and Kedir (2011) aimed at assessing students’ attitude and practice on preventive measures against HIV/AIDS. Six hundred and six (606) participants were drawn from Addis Ababa University through multistage sampling. Data were collected using quantitative survey (questionnaire) and qualitative methods (FGDs) and subsequent analysis was made through the use of descriptive statistics. The results of the study revealed that half of the respondents adopted abstinence as a top preventive measure. The results also showed that almost University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    28    all the participants were willing to take HIV test and half of the participants had already taken the test. Similarly Mgosha et al. (2009) conducted a study on the evaluation of uptake and attitude of HCT among health care professional students in Kilimanjaro Region, Tanzania whereby the main objective was to assess the acceptability of HCT and its actual uptake among health professional students at Kilimanjaro Christian Medical College (KCMC). The study was a cross sectional survey that employed structured questionnaires delivered to health care professional students aged between 18-25 years enrolled for degree, diploma and certificate programmes at KCMC. A total of 309 students were recruited through a convenience sampling method. That is, only students who were available during the class sessions were selected and the questionnaires administered to them. The results indicated that female students were more likely to be at high risk of contracting HIV/AIDS than males. Knowledge about the availability of HCT services and programmes was also high. However, the uptake of HCT among the students was very low. The majority of the students had a positive attitude towards HCT and was willing to do the test. Almost all the students agreed that HCT should be free of charge and preferred being tested at the school. This was as a result of the majority of the students perceiving themselves to have low risk of HIV contraction. The mass media played a role in the education of the students on HCT. But students had a lower level of knowledge on the benefits of HCT. Hence the study concluded that efforts be put in place to educate the students more on the benefits of HCT. In another study, Ma, Wu, Qin, Detel, Shen, Li, Lui and Chen (2008) compared the knowledge, attitudes and uptake of HCT in one county in China that had an HIV/AIDS testing and care, China CARES (CC) programme with a county that did not have the programme. A University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    29    cross sectional study with two-stage cluster sampling was employed and the data analyzed quantitatively after administration of questionnaire to respondents. Results from the study revealed that, participants in the CC County had better knowledge and uptake of HCT but a more negative attitude towards persons living with HIV. For any HCT centre to provide the needed services on HIV care, counseling and care is paramount as it affords the health care provider to have closer relationships with the clients and their needs. Hutchinson and Mahlalela (2006) sought to examine attitudes towards voluntary counseling and testing (HCT) services, patterns of utilization of HCT services and the relationships between HIV/AIDS-related stigma, HCT service availability and quality and the use of HCT. They used household survey data linked with clinic-level data to assess the impact of expanded HCT services and access to rapid testing on the likelihood of being tested in rural areas and on /AIDS stigma. Analysis of the study findings revealed that HCT utilization generally was low. However, less educated men and women were more likely to utilize HCT than highly educated ones. Men were more likely to utilize HCT than women because of stigma. Non- availability of HCT services was more likely to have an impact on HCT utilization by men. In a related study, Madebwe et al. (2012) conducted a study entitled “Taking the test: voluntary counseling and testing among midlands state University students.” Probability in the study, sampling was used to select the 173 students that took part in the questionnaire survey. The students were selected from each department in the faculties of Arts. The majority of students (81.1%) were aged below 25 years and predominantly single. The study showed that most of the students had heard about HCT but only 28% and 27% of male and female students respectively had taken the HIV/AIDS test before the survey. Among those who had not undergone HCT, 87% of male and 91% of female students expressed a willingness to be tested University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    30    for HIV/AIDS. More male (54%) than female students (43%) would choose to take the test on campus. Fifty-seven percent of male students and 68% of female students who had sex in the 6 months preceding the survey did not use a condom at last sex suggesting a low HIV/AIDS risk perception among the students. 2.6 Experiences of the youth with HCT Yoder and Matinga (2004) conducted a study on VCT for HIV in Malawi on Public Perspective and recent VCT Experiences”. The aim of the study was to document experiences of HCT clients at the testing facilities which included the way clients were welcomed, how they gave blood for the test, and how they were counseled and advised. A qualitative approach was used whereby 12 people were trained to collect data through in-depth interviews on participants’ interactions with counselors at the testing facilities. The interviews were tape recorded, translated and transcribed by the trained personnel. A total of 245 participants were interviewed in four districts most of whom were youth or young people. The participants’ experiences at the testing facilities showed that clients were warmly received at the testing centres. Results from the studies also indicated that clients who came to the testing facilities were counseled and told everything about HCT. Almost all participants indicated that the counselors asked about their feeling before and after the test. It was also revealed that participants came in for the test for several reasons which included:  Wanting to know their status of HIV.  Response to signs of illness.  When individuals feel at risk or vulnerable to HIV infection. University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    31     When they are planning an event in their lives, such as having a child, getting married, or getting a new job.  Fear of having been exposed to HIV by one’s own actions and  Fear of having been exposed to HIV by the actions of one’s spouse or partner(s). Denison et al. (2008) also explored the HIV testing experiences of Zambian adolescents and the involvement of families, friends and sexual partners in decisions about HCT and the disclosure of HIV status. The study was based on 40 qualitative in-depth interviews with 16 to 19 year olds who knew their HIV status in Ndola, Zambia. The findings from the study demonstrated that: (a) almost half of the youth turned to family members for advice or approval prior to seeking HCT; (b) a disapproving reaction from family members or friends often discouraged youth from having HCT (c) participants often attended HCT alone or with a friend, but rarely with a family member; and (d) disclosure was common to family and friends, but infrequent to sex partners. Disclosure was not linked to accessing care and support services. It was concluded that family members need access to information on VCT so they can support young peoples’ decisions to test for HIV and to disclose their HIV status. These results reinforced the need to provide confidential VCT services for adolescents and the need to develop and test innovative strategies to reach adolescents, their families and sex partners with VCT information and services. 2.7 Summary Thus far, there seemed to be a dearth of literature from the study setting, Jirapa and in Ghana as a whole concerning the attitudes, knowledge and experiences of the youth towards HIV counseling and testing. There is therefore the need to bridge the gap regarding HCT among the youth. Literature from six thematic areas were reviewed. These were knowledge of the youth University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    32    about HCT, attitudes towards HCT, socio-cultural and sexual practices that influence attitudes toward HCT, barriers to HCT, utilization of HCT, and experiences of youth with HCT. When examined, the literature supports a number of important issues such as the youth’s knowledge of HCT, the attitudes, socio-cultural and sexual practices that influence attitude which may enhance or prevent HCT utilization. Barriers to and experiences of the youth with HCT were also reviewed to support the study. This information as documented in the literature provided the basis upon which the research on exploring the attitudes, knowledge and experiences of the youth was undertaken in the Jirapa district. University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    33    CHAPTER 3 METHODS AND DESIGN 3.0 Introduction This section describes the research methods and design employed in the study, the study setting/context, the population for the study, the sampling techniques and procedures for data gathering, data management and data analysis. It also includes the pretesting of the interview guide and tape recording instrument and finally, the rigour regarding to the qualitative study as well as the ethical consideration for the study. 3.1 The Study Design An exploratory descriptive qualitative design was employed for the study. A qualitative study is an inquiry of understanding a social or human phenomenon based on building a complex, holistic picture, formed with words, reporting detailed views of informants, and conducted in a natural setting (Creswell, 2009). Qualitative research is therefore the method of inquiry in which phenomena are explored in their natural environment (Mayan, 2009). A qualitative methodology brings out the hope to the discovery of extremely covert, subtle and subjective realities and truths about the meaning and expressions of participants (Mayan, 2009). A descriptive qualitative research primarily seeks to explore and understand phenomenon of interest under study (Creswell, 2009). For example, the attitude of the youth towards HIV counseling and testing is such a phenomenon that needs to be explored using a qualitative design. Hence, the reasons for such an attitude and behaviour by the youth were described in the context of the culture of the youth (Morse & Field, 1999). The approach focused on finding answers to questions and explanations centred on the attitudes of youth toward HIV Counseling and Testing University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    34    (HCT). The approach also gave the researcher the opportunity to develop in-depth understanding of the attitude and experiences of the youth rather than the researcher’s own perspectives. Knowing the reality of the youth having built an attitude toward HCT was an important assumption. A descriptive qualitative method was therefore the best approach to answer a research question that had implications for human subjectivity and interpretation (Streubert & Carpenter, 2001). The researcher’s commitment to the views of the participants is also an important aspect of qualitative research because it draws the attention of the “emic view” (Streubert & Carpenter, 2001), that is the inner perspective of the participant. A descriptive qualitative method was preferred because it is also unique to nursing as it involves description and interpretation of a shared health or illness phenomenon from the perspectives of those who live it (Thorne, Kirkham & MacDonald-Emes, 1997). Some research problems that are best explored using qualitative method include: behaviours, feelings, thoughts, actions and experiences (Mayan, 2001; Burns & Groove, 1993; Polit & Hungler, 1993). Qualitative research reflects for knowledge about aggregates in a manner that does not render the individual case invisible and recognizes that there are multiple realities, which are subjective and mentally constructed by individuals (Polit & Hungler, 1995). Until the feelings and experiences of the youth concerning HCT is investigated, there exists no other way of knowing about youth attitude toward HCT. Hence this method will facilitate the development or enhancement of HCT services in the district. A qualitative methodology was used by the researcher because individual attitudes and experiences differ and one needs to explore and understand in detail the participants’ thinking and feelings about HCT unlike quantitative method that will direct these thoughts and feeling on specified issues on HCT. A qualitative method will unearth the attitudes and experiences as lived University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    35    by the youth in terms of HCT so that the true picture of the phenomenon being studied will be understood. Literature reviewed indicated that research work on youth and HCT have been extensively done worldwide especially in sub-Saharan Africa mostly using the quantitative approach and a few qualitative studies. In Ghana a few, studies have been done on youth and HCT. The quantitative approach was employed. There was no evidence of use of qualitative methods, especially in the Jirapa district. This therefore provided the basis for which this research study was embarked upon. Even though the researcher is a Registered Nurse Educationist and an HIV/AIDS counselor, he did not go into the research with any biases and prejudices which was necessary to ensure that the realities on the ground were described as true reportage from the participants. Also setting aside any biases and prejudices during the research data collection, analysis and writing of the report did allow for identification of the attitudes and experiences of the youth toward HIV counseling and testing. 3.2 Research Setting The research was conducted in Jirapa, the capital of the Jirapa district in the Upper West region of Northern Ghana. The district has a total population of 110,894 with 24% of this population comprising of the youth (Ghana Statistical Service, 2010). The Jirapa town itself has a population of 8000 people and 1,900 of them are youth. Eighty-five per cent of these youthful population are students in the senior high schools and training colleges located in the Jirapa district. The district has one referral hospital which is located in the town, six clinics in sub- districts and four Community-Based Health Planning Services (CHPS) zones in surrounding villages. The district also has established HIV Counseling and Testing centres (HCT) located in each health service institution within the district and in the main hospital within Jirapa township. University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    36    There are other ones in Han Health Centre; a rural community located 35 kilometres east of the Jirapa Town. The district shares boundaries with the Lawra district to the north, Sissala West district to the east, Nadowli district to the south and the Black Volta River to the west. Geographically, the district is a savanna land and has two main seasons, the rainy and dry seasons. The study was conducted at two HCT service centres within the district, namely Han and the Jirapa Town HCT. The HCT centre at Jirapa is managed by two trained counselors one of whom is a public health nurse and the other counselor a nurse midwife all trained in HIV pretest and post-test counseling and testing. The Jirapa centre is located at the western end of the Jirapa hospital administrative block. It has three rooms, the first to reach is a room where the counselors of the centre usually sit and receive visitors to the centre. The second or middle room is an inner room of the first one and it is reached through a door from the first room. This is where the counseling and testing usually take place. Privacy and confidentiality are ensured in this room through the provision of partitions. Only the counselor and the client stay in this room during the counseling. Third persons are kept away until counseling and testing are over. There is a door that leads to the outside of the building. The last room is a big room with adequate furniture, in-door games with assorted books, journals and posters for visitors to the centre. People living with HIV/AIDS (PLWHA) usually receive their counseling, anti-retro viral treatment and support in this room since the centre is one of the treatment centres for PLWHA in the Upper West Region of Ghana. The centre at Han is also managed by a resident midwife and a resident community health nurse who are both trained in HIV testing, pre and posttest counseling (JDHS Annual Reports, 2008). The centre at Han has only two rooms, one for the counselor to receive visitors and the other for counseling and testing. For the purpose of confidentiality, the HCT room has University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    37    two doors to its entry, one door is connected to it through the visitors’ room whilst the other door is at the back of the room. People living with HIV/AIDS in this area are usually referred to the Jirapa centre for treatment and support. The Jirapa district also has three senior high schools and three nurses’ training schools. The people of the district are mainly subsistence farmers who rear small herds of animals for sale and domestic use. Most of the youth with no formal education and those that are out of school migrate to the Brong Ahafo Region especially Techiman and its environs in search of jobs to earn a living. These migrants occasionally return home to participate in traditional festivals and funeral rites. While away from the influence of parents and elders in the strange lands, the youth are liable to social influence regarding friendship and dating. This attitude is exhibited as the researcher observed that the youth often date and engage in sexual relationships during festival celebrations constituting a culture of vulnerability amongst youngsters in the region. The common language spoken in the region is Dagaare. The researcher is an indigene of this region and understands the culture and traditional practices of the Dagaaba people as a whole which may be divergent from the perceptions of the contemporary youth of today’s Ghana. 3.3 The Target Population and Sample The target population for the study is the youth aged 18-24 years both literate and non- literate, in school and out of school in the Jirapa district, and youth who have utilized or not utilized HCT services. 3.3.1 Sampling Technique Nothing highlights the difference between quantitative and qualitative methods explicitly than the logic that underlie sampling. The aim of quantitative sampling is about generalization to University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    38    the larger population based on random sampling and statistical probability theory (Mayan, 2009) for control of sampling bias. Where as in this qualitative exploratory study, the researcher aims at understanding the phenomenon of interest in-depth and in its totality i.e. understanding the knowledge, attitude and experiences of the youth in the Jirapa district concerning HCT through the use of purposive selection of the participants as a way of increasing the sampling strength to reduce threats to rigour. The researcher selected individuals and contexts based on their characteristics and ability to give the most and best information about the topic in a most conducive context. The HCT centre in the Jirapa Township and the one at the Han community were the selected sites respectively. These two HCT centres were well known for their provision of privacy and confidentiality among people who visited the facilities. There also existed a good interpersonal relationship between the health care professionals and their clients. Consequently, the researcher planned to interview participants each by purposively selecting from these two HCT centres in the district. The final sampling frame (16) was however based on data saturation, when no new data emerged, when all leads were followed and negative cases were checked and the story came to a close (Mayan, 2009). 3.3.2 The Eligibility Criteria of the sample Eligibility criteria for the sample included:  Youth within the ages of 18-24 years.  Youth residing in Jirapa district for more than one year  Youth who could express themselves in English or “Dagaare”. University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    39     Youth who have ever migrated to other regions outside Upper West Region  The youth who were either literate or non-literate  Youth in school and out of school  Youth who had utilized or not utilized HIV Counseling and Testing services, and most importantly,  Youth who indicated their willingness to participate in the study 3.4 Data Gathering Procedure The Nurses in-charge of the clinics at both Jirapa and Han were briefed about the study and on how to recruit participants to the study. A participant information leaflet (see Appendix I) containing the study objectives, purpose and recruitment formalities was used and explained to the HCT counselors at the Health centres. The counselors further explained the aims and objectives of the study to any youth that visited their clinic for services and obtained their mobile phone numbers for the researcher to contact. Notices about the study objectives, the inclusion criteria were put up in the clinic premises, schools and college campuses and also in the Jirapa Township with the researcher’s contact number for prospective participants to contact the researcher if they wished to participate in the study. Before the commencement of data collection, ethical clearance was sought from the Noguchi Memorial Institute for Medical Research (Appendix II: Ref. No: DF 22). Permission for site approval from the School of Nursing was written to the Director of Health Services in the region and to the District Health Directorate and the Health facilities involved (see Appendix III). The purpose of the research was outlined in an information leaflet for the participants and University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    40    Head Nurses (Appendix III). Informed consent was also sought from every participant verbally and written form by thumb printing or signature (Appendix I). An office space was allocated to the researcher for conduction of interviews in each of the HCT centres. The researcher assigned days when he was always present at each of the centres to conduct the interviews. The data were gathered over a period of nine months commencing from September, 2009 to May, 2010 after the guiding questions and the audio recording equipment were pretested on two youth 18 years old in a senior high school in the district. Each participant was identified by the HCT counselors and asked for his or her participation in the research and any of them who agreed was then referred to the researcher. The researcher further explained the objectives and purpose of the study to prospective participants using the information leaflet. Any participant that indicated willingness was then made to sign a consent form. The interview guide (Appendix IV) had two sections. The first, section A was made up of questions on personal information while the second section, B was made up of guiding questions on knowledge, attitudes and experiences. The guiding questions were supplemented with probing questions. Once a participant was recruited, interviews were carried out. The researcher anticipated to interview each participant between forty-five minutes to one hour. However some of the interviews went beyond this period as the researcher being a nurse and an HIV counselor in the district had to spend time creating rapport with each of the participants. Usually after the interview, the researcher obtained the mobile phone numbers of each participant and physical address locations for the purpose of follow-up interviews. After each interview the participant was informed that he/she could be contacted for another interview after transcribing and reading the first interview. In all, four participants needed to be traced for a follow-up interview to clarify some themes that emerged from the initial interview. The follow-up interviews were conducted under University of Ghana http://ugspace.ug.edu.gh                                                                                                                                                              HCT and Youth    41    sheds and shady trees away from public scene. The participant was usually contacted on phone and informed about the need for a second interview. Participants’ views were sought concerning the venue of the interview. During the interview process, the researcher maintained a cordial and friendly environment to relax the participants to enable the participants to talk. Permission was obtained from each participant to tape record the conversation. Some of the participants exhibited non- verbal cues in their responses which were recorded in the field notes. A Journal of all activities that took place was also kept including the objective of each interview, the venue, the environment. The incidents that were heard, seen, expressed and thought about during the process of data collection were recorded by writing in order to comprehend and interpret the content of the interviews better. 3.5 Data Management Data that were gathered from each interview were immediately transcribed and typed out on Microsoft word and stored in identifiable files in a personal computer by the researcher and a password given to the transcribed data. Print out transcriptions and the tape recorder used for the study were kept in a cupboard under lock. The transcripts will be kept for a period of five years after which (in the absence of any untoward occurrences from the study) these recordings and transcribed data would be destroyed according to the University of Ghana and School of Nursing policy. Only the researcher and his supervisors had access to the tr