AIDS Risk Perception, and Sexual Behavior Change Among Young People in Ghana.

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research-article2015

QHRXXX10.1177/1049732315573204Qualitative Health ResearchGanle

Article

Hegemonic Masculinity, HIV/AIDS Risk Perception, and Sexual Behavior Change Among Young People in Ghana

Qualitative Health Research 1–19 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049732315573204 qhr.sagepub.com

John Kuumuori Ganle1

Abstract Among the youth in some parts of sub-Saharan Africa, a paradoxical mix of adequate knowledge of HIV/AIDS and high-risk behavior characterizes their daily lives. Based on original qualitative research in Ghana, I explore in this article the ways in which the social construction of masculinity influences youth’s responses to behavior change HIV/AIDS prevention interventions. Findings show that although awareness of the HIV/AIDS epidemic and the risks of infection is very high among the youth, a combination of hegemonic masculinity and perceptions of personal invulnerability acts to undermine the processes of young people’s HIV/AIDS risk construction and appropriate behavioral change. I argue that if HIV/AIDS prevention is to be effective and sustained, school- and community-based initiatives should be developed to provide supportive social spaces in which the construction of masculinity, the identity of young men and women as gendered persons, and perceptions of their vulnerability to HIV/AIDS infection are challenged. Keywords adolescents / youth, at-risk; Africa, sub-Saharan; behavior change; health behavior; HIV/AIDS prevention; masculinity; qualitative analysis HIV is one of the most challenging health threats to human well-being in many sub-Saharan African countries, including Ghana (Ganle, Tagoe-Darko, & Mensah, 2012). With a prevalence rate of 3.1%, Ghana is one of the countries in sub-Saharan Africa (SSA) where the development and well-being threats associated with the HIV/AIDS epidemic are currently being felt (Joint United Nations Programme on HIV and AIDS [UNAIDS], 2005). The pattern of the disease transmission shows that Ghana might soon exceed the 5% threshold seen as marking the beginning of an AIDS explosion. For instance, from a figure of 42 AIDS cases in 1986, the number rose to 2,148 in 1991, more than 5,000 in 1993, 15,980 in 1995, and 41,229 at the end of September 2000 (Ghana National AIDS Control Programme, 2000). According to a 2011 HIV sentinel surveillance report, Ghana had in excess of 212,000 adults and children living with HIV, majority (60%) of whom were women (Ghana AIDS Commission, 2012). The Ghana National AIDS Control Program’s projection is that Ghana’s national HIV prevalence rate will be 9.5% by 2014 (Oppong & Agyei-Mensah, 2004). Indeed, some regions in Ghana have already exceeded this threshold. For example, Cape Coast, the Central Regional capital, recorded Ghana’s highest HIV rate in 2011, leaping from a prevalence rate of 2.2% in 2010 to 9.6% in 2011 (Ghana AIDS Commission, 2012). The other regions

generally demonstrate an increasing trend: Eastern region recorded 3.6% in 2011 as against 3.4% in 2010, Greater Accra recorded 3.2% in 2011 as against 2.6% in 2010, Ashanti recorded 3.1% in 2011 as against 3% in 2010, while the Volta Region recorded 2.2% in 2011 as against 1.8% in 2010. Like most countries in SSA, an estimated 85% of all new HIV infections in Ghana occur through heterosexual relations (Agyei-Mensah, 2001). It is also estimated that 90% of all new HIV infections in Ghana occur among young people (Ghana AIDS Commission, 2012). This projection reflects a long-held statistic (in SSA and globally) that the youth remain one sub-population among whom the risk of HIV infection is high (UNAIDS–World Health Organization [WHO], 2007). Since the discovery of the disease, much progress has been made to increase awareness and knowledge of the disease, and to improve treatment and management as 1

Kwame Nkrumah University of Science and Technology, Kumasi, Ghana Corresponding Author: John Kuumuori Ganle, Population, Health and Gender Studies Group, Department of Geography and Rural Development, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana. Email: [email protected]

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Qualitative Health Research

well. In SSA where HIV/AIDS is predominantly transmitted through heterosexual intercourse, HIV/AIDS prevention campaigns have particularly focused on education to promote positive sexual behavior change (Oppong & Agyei-Mensah, 2004; Ragnarsson, Onya, Thorson, Ekstrom, & Aarǿ Edvard, 2008). The number of strategies designed to ameliorate the effects of infection, including antiretroviral drugs, nutrition supplementation, home care, and development of safety-net systems to accommodate AIDS orphans, has also increased (Skovdal et al., 2011). Important as many of these interventions are, they have not significantly eliminated the risk of HIV infection among the youth in SSA (Ganle et al., 2012). Although research shows that knowledge of HIV/AIDS risk factors is deeply penetrated and that most young people know a good deal about HIV/AIDS than other sexually transmitted diseases (Dilger, 2003; Eaton, Flisher, & Aarǿ Edvard, 2003), high-risk behavior continues to characterize the daily lives of the youth (Ganle et al., 2012). For example, most young people still initiate sex at a fairly early age (14.4–16.6 years), have multiple concurrent sexual partners, and rarely take protective measures, including condom use (Ragnarsson et al., 2008). In Ghana, where awareness of the disease among the youth is more than 95%, this has not translated into positive behavior change (Karim, Magnani, Morgan, & Bond, 2003). In the academic literature, attention has recently been drawn to the possibility of behavior change in HIV/AIDS prevention efforts being undermined by gender norms, particularly those related to hegemonic masculinity (Lindegger & Quayle, 2009; Skovdal et al., 2011). What is lacking, though, is empirical research on how the social construction of masculinity serves as a barrier to behavior change that undermines HIV prevention efforts among young people (Lindegger & Quayle, 2009). As youth continue to offer the best opportunities for HIV prevention efforts, a continued focus in research and policy on how ideas around hegemonic masculinity affect HIV/ AIDS risk construction and translation of knowledge of HIV/AIDS prevention strategies into safe health practices is critical. My aim in this article is to explore the ways in which the social construction of masculinity influences youth’s HIV/AIDS risk construction and responses to behavior change in HIV/AIDS prevention messages, and to highlight some of the pathways through which some young people manage to resist hegemonic masculinity and live out more positive HIV/AIDS riskreducing behaviors. The rest of the article proceeds as follows. The next section discusses the concept of hegemonic masculinity to outline a theoretical framework. The research methods employed are then described. Findings are presented and a discussion of the findings offered. The last section concludes.

Hegemonic Masculinity and HIV/AIDS The theoretical lens through which I explore the ways in which the social construction of masculinity in Ghana influences youth’s HIV/AIDS risk construction and responses to behavior change in HIV/AIDS prevention interventions is Connell’s (1995) theory of hegemonic masculinity. In Masculinities, Connell (1995) defined hegemonic masculinity as the enactment of an idealized form of masculinity—“being the real man”—in a particular time and place. Connell argues that male privilege and social power is produced and perpetuated through the construction of hegemonic masculinity, which describes the production and maintenance of a nexus of ideas, institutions, and behaviors that generate, normalize, and demand male dominance. Connell suggests that the power of hegemonic masculinity is deeply embedded in forms of social activity, giving it the appearance of inevitability and ensuring that it is naturally produced and reproduced in routine, mundane, social, and disciplinary practices. Although there can be variation in the specific forms of hegemonic masculinity depending on context and time, underpinning the concept are the elements of male dominance, risk-taking, competition, emotional toughness, physical strength that might be expressed violently, stoicism and aversion to expressions of weakness, exclusively heterosexual and frequent sex with multiple partners, and material success (Pattman, 2005). In SSA, these hegemonic masculinity norms are often viewed as norms unlikely to be experienced as identity choices, but as inviolable biological or cultural imperatives, to which even young adolescent boys strongly aspire (Thorpe, 2002). Hegemonic masculinity in SSA is also often seen as a process that is subordinating of women and other forms of masculinities including those exhibited by homosexuals (Skovdal et al., 2011). In this article however, I argue that hegemonic masculinity norms are identity choices that are subject to challenge and change, and that youth’s enactment of the social construction of hegemonic masculinity can also have a subordinating role for young men as well, by preventing them from living lifestyles that lower their risks of HIV/AIDS infection. For this reason, the interlinked concept of social representation theory (SRT; Moscovici, 1973) is used to frame the findings presented in this article. Social representations are forms of knowledge that are socially constructed, including values, ideas, and practices regarding local constructions of gender and gendered identities, which enable people to orientate themselves in their social world (Moscovici, 1973;


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Ganle Skovdal et al., 2011). SRT views socially constructed knowledge systems and identities as dynamic, and subject to challenge and change (Lindegger & Quayle, 2009; Nzioka, 2001). This suggests that in the process of identifying themselves as men and others as non-men in the context of SRT, individual young men and women will have to situate themselves in relation to the norms and representations that define the dominant notions of masculinity in particular contexts and time. It also means that under the right conditions and provided with opportunities, young people can renegotiate and critically engage with social representation of hegemonic masculinity to produce outcomes that have positive benefits for HIV/ AIDS prevention. Although the pathways through which hegemonic masculinity affects HIV/AIDS risk perception and appropriate behavior change could be very complex and multifaceted, many studies in SSA have highlighted the relationship between elements of hegemonic masculinity and HIV risks. MacPhail (1998) found that social norms and practices that endorsed gender inequality and coercive sex placed young South African men and women at particular risk of HIV infection. In a number of countries across SSA, Buve, Bishikwabo-Nzarhaza, and Mutangadura (2002) found that the influence of peer norms among the youth in Africa—which involved the “proving” of masculinity through early sexual conquests and having multiple sexual partners—not only exposed them to HIV/AIDS infection but also lowered their willingness to adopt positive behavior change strategies. In South Africa, Lindegger and Maxwell (2007) also reported that late adolescent boys experienced extreme peer-based pressure to demonstrate their masculinity through claims of multiple sexual partners. In Zimbabwe, Skovdal et al. (2011) found traits of masculinity to be strongly linked to men’s unwillingness to use HIV prevention and treatment services. Jewkes (2009) also described how men’s denial of their vulnerability to HIV/ AIDS infection through the construction of masculinity around power, strength, and control led to increased HIV infection in South Africa. The social representation of hegemonic masculinity has also been found to undermine norms of health-protective behavior and help seeking among men in Africa (Hoosen & Collins, 2004). At the same time however, adherence to hegemonic masculinity norms was found to increase substance abuse and resistance to condom use among men because of issues of dominance, control, and fidelity (Hoosen & Collins, 2004). Hegemonic masculinity, and the social representation of hegemonic masculinity, therefore, offers a useful conceptual framework to investigate how the social construction of masculinity influences youth’s HIV/AIDS risk construction and responses to behavior change in HIV/AIDS prevention messages in Ghana.

Method Study Design This article forms part of a larger, original study that was conducted in Ghana between July 2009 and October 2009. The purpose of this larger study was to examine the gulf between HIV/AIDS risk awareness and motivation for behavioral change among Ghanaian youth. The study was designed as a multiple-method study and involved a survey of 1,200 young people and a qualitative research with 208 selected high school students. In this article, I focus on and report findings from the qualitative component of the study, which explored how the social construction of masculinity affected youth’s HIV/AIDS risk construction and responses to behavior change HIV/ AIDS prevention interventions. The inherently limited potential for structured surveys alone to contribute to the understanding of the gap between young people’s awareness of HIV/AIDS and behavior change is acknowledged in the literature (James, Reddy, Taylor, & Jinabhai, 2004). Qualitative research— which attempts to provide access to the opinions, aspirations, and power relationships—however, helps to explain how people, places, and events (e.g., HIV/AIDS risk) arise in identifiable local contexts that “privilege individual’s lived experiences” (Karnieli-Miller, Strier, & Pessach, 2009). The qualitative methods used in this research generated rich, contextually detailed process data that left the participants’ perspectives minimally altered and enabled an in-depth exploration of the topic.

Study Context Empirical research was conducted in one of Ghana’s 10 regions. The region is located in the northern part of Ghana and is one of the poorest in the country—88% of the population was estimated to be extremely poor at the time of this research (Ghana Statistical Service, 2007). Adult literacy rate was 25.4%, and this was below the 57.9% national average (Ghana Statistical Service, 2005). Youth constituted approximately 43.4% of the region’s 576,583 population (Ghana Statistical Service, 2005). The population was also predominantly rural (82.5%). Most families were organized around patrilineages and often subsisted on farming. The few people (usually men) in formal employment tended to work in towns. There was also large-scale seasonal out-migration of both young men and women to the southern part of the country. Although there were variations in HIV/AIDS prevalence rates, the study region had the second highest prevalence rate (4.7 %) in Ghana in 2004 (Oppong & Agyei-Mensah, 2004). Accessibility to health care services was very limited. For example, there were only 13 doctors in 2005, giving a doctor to population ratio of


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44,353, and 1,162 persons to a nurse (Ghana Statistical Service, 2005).

Ethics Ethical clearance was obtained from the University of Bristol, the Ghana Health Services Ethical Review Committee, the Parent-Teacher Associations of the study schools, and school heads. In addition, both informed written and verbal consents were obtained from all research participants. In all cases, consent was obtained after I had thoroughly explained to participants that their participation was entirely voluntary and that information obtained will be used for the purposes of this research only. To thank the research participants, I bought biscuits and soft drinks to refresh them.

Research Participants and Sampling Participants were youth drawn from five senior high schools in the study region. By “youth,” I mean young people between 12 and 24 years (Breinbauer & Maddaleno, 2005). I focused on this group because previous HIV/ AIDS research in Ghana has concentrated on “special populations” such as homeless street youth and commercial sex workers (Fobil & Soyiri, 2006). Consequently, very little is known about this group, particularly how hegemonic masculinity norms influence their HIV/AIDS risk construction and translation of knowledge of HIV/ AIDS prevention messages into positive behavior change. In all, 208 youth participated in the study, of which 49% were young women. The strategy for recruiting participants involved both probability and non-probability sampling procedures. The five schools were purposively selected: two consisted of young men only, another two were mixed, and the last comprised young women only. A simple random sampling technique was however used to select individual participants. Given that the emphasis of qualitative research is not always on representation or generalization, my initial strategy for sampling and recruitment was a combination of convenience and snowball sampling. However, the ethics review committee in Ghana raised concerns about such sampling procedures. In addition to arguing for the need to assure justice by using a fair and transparent sampling procedure, the committee was worried that using only convenience and snowball sampling techniques could produce participants whose experiences and accounts were far from representing that of the generality of the youth in the study region. In particular, a concern was raised about the potential for self-selection, whereby only participants with similar experiences, views, and behaviors are sampled into the study, thereby producing biased research findings. Within the methodological literature, the potential for convenience and snowball

sampling procedures to produce biased research samples is acknowledged (Bowling, 2009). The committee therefore recommended that I use a simple random sampling strategy with a relatively lager sample size. This, at least, would ensure that every student in the school had a fair chance of taking part in the research. It would also make the findings more representative. Of course, I could, in theory, have rejected this modification to the research. However, the recommendation was not merely a suggestion, but one that was to be fulfilled if I wanted the research to be approved. Therefore, the choice was really limited. Although the overall sampling procedure was laborious, it worked really well. For example, and with regard to the concerns that the ethics review committee raised, the selection process, particularly the idea of chance, helped to eliminate questions about why one student was included and another excluded from the study. Thus, as each of the students had a fair chance of participating in the research, the sampling procedure was deemed transparent and fair. The actual recruitment procedure involved three main steps. First, the names of all the students from the five schools were extracted from a central school registry. Second, the required number of participants was randomly chosen from the pool of names. The required number of participants was pre-determined (5% of the total population of each school), and this took into account the availability of time and resources at my disposal. Third, letters were then written to all the randomly selected persons, explaining the research purpose, how they were selected, and then inviting them to participate. Where any of the randomly selected participants declined participation (and there were only two cases), the selection process was repeated to get replacement.

Data- Collection Methods Two methods of data collection were used, namely focus group discussions (FGDs) and in-depth interviews (IDIs). The FGDs. FGDs were the main data collection technique. Focus groups are a qualitative method of primary data collection in which the researcher uses pre-determined line of questioning to stimulate discussion among participants on a subject of inquiry with the primary aim of understanding perceptions, interpretations, and beliefs of a select population (Khan & Manderson, 1992). I adopted this data collection technique partly because of the context within which this research was being conducted. The northern part of Ghana where this research was conducted is characterized by ethnic, religious, and cultural diversity. This diversity suggests the need for a data collection method that can enable open exploration and understanding of the different beliefs and opinions of


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Ganle the various ethnic, religious, and cultural groups from whom the research participants were drawn. I believe the use of FGDs had the capability to reproduce young people’s representations of masculinity and gender roles, perceptions of their vulnerability to HIV/AIDS infection, and their responses to behavioral change HIV/AIDS prevention interventions in a normal peer-group exchange. But the choice of FGDs was also based on the methodological literature. FGDs are contextual (they avoid focusing on the individual) and non-hierarchical methods (they shift the balance of power away from the researcher toward the participants; Morgan & Krueger, 1993). For Morgan (1996), because FGDs have the ability to “give a voice” to the respondents, they should be used where there is the need to identify participants’ perspectives and frames of meaning. Green (2007) argued that a group setting often works well for generating talk about health, and that FGDs provide broader views about health and illness meanings. In fact, what made the outcome of FGDs relatively better than individual interviews was that, because FGDs were interactive, participants were able to query and challenge each other as well as explain themselves—hence offering validated data on the extent of consensus or diversity. Thus FGDs became a form of collective testimony. Rina Benmayor (1991, cited in Madriz, 2003) is one of the few to have pointed out the transformative experience of the collective testimony that FGDs generate. Benmayor argues that group testimonies empower people, either individually or collectively, and this empowerment enables people to speak, and speaking empowers. Even though I envisaged FGDs in this research to be only a method for generating data, the interactions that occurred within the groups accentuated and fostered self-disclosure and self-validation. Although the FGDs produced contextually rich and “thick descriptions” of youth’s perspectives, their use was not without challenges. Morgan (1996) observed that results from FGDs may be unduly influenced by “group thinking” or “group effect” in which respondents give socially desirable responses or simply endorse the views of dominant participants. In a few cases, this problem was encountered, especially when a school prefect spoke. A related challenge was that some participants were reluctant in disclosing some personal information such as whether one has ever had sex during FGDs. To minimize these limitations, all participants were constantly encouraged, especially the quieter ones, to speak, share their opinions as well as disagree with others where they felt the need to do so. Coupled with a mix of directed and non-directed facilitation, the effects of dominant participants on the rest of the other participants’ responses were also significantly minimized. In addition, themes and issues raised and discussed during FGDs were summarized and orally presented to participants to

confirm, alter, or reject at the end of the discussion. This was to make sure that the information I was collecting accurately represented participants’ perspectives. Five FGDs (involving 110 participants) were conducted. I believe the five FGDs yielded sufficient information that could enable in-depth exploration of the research topic. Four of the groups consisted of 8 to 15 participants while the fifth group had 22 participants. This difference was mainly due to differences in the sizes of the target populations. While a simple random sampling technique was used to select individual participants, I employed the segmentation or homogenization (Morgan, 1996) sampling strategy to guide the formation of groups based on sex. Segmentation proved extremely valuable as it created groups that could maintain an active and freeflowing discussion that generated information that typically reflected the participants’ relationship with the key topics of the research. It also built a comparative dimension into the study, allowing me to compare the responses of different groups. Moreover, group segmentation significantly reduced the impact of gender and power dynamics on participants’ responses. This was crucial because men in the study region usually wield far more power and authority relative to women. All discussions were held in the selected schools, usually at venues chosen by participants and on non-schooling days (Saturdays and Sundays). Each FGD lasted 1.30 to 2 hours, often ending when a point of saturation was reached (i.e., when no new ideas and issues seemed to arise). All discussions were conducted in English, the primary language of conversation in formal educational settings. In a few cases where some participants faced difficulty expressing their views in English, they were allowed to express themselves in Dagaare/Waale (the local dialects of the study region). My knowledge (spoken and written) of English and Dagaare/Waale is very good, hence I had no difficulty with the interview language. The IDIs. The need for multiple data collection techniques in the social aspects of disease and health research has been widely discussed (Østergaard & Samuelsen, 2004). It is argued that people may not necessarily tell the truth in any objective sense when it comes to sensitive issues such as health and disease within a group context (Oppermannt, 2000). In few cases as I have noted above, some participants felt uncomfortable disclosing information about themselves in focus groups. To complement the FGDs, I conducted IDIs with randomly selected young men and women in each of the five study schools. Marshall and Rossman (2006) have described in-depth interviewing as a conversation with a purpose that allows a researcher to explore a few more specific topics with an interviewee. The advantage of IDIs was their ability to address sensitive and private issues such as one’s sexual


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life and to probe deeply to elicit information, which participants might not have disclosed in the group setting. Also the dialogic nature of IDIs lessened the power differentials between the researcher and the researched, a phenomenon often encountered in one-way survey-type interviews (May, 2001). One shortfall of this approach was that the data produced were difficult to interpret due to their variegated and non-standardized nature (May, 2001). Nevertheless, in my analysis, I have endeavored to draw out areas of consensus and disagreement, while remaining committed to accurately portraying the meanings that interviewees attached to their responses as much as possible. In all, 98 IDIs were completed—20 each in three of the schools and 19 each in the remaining two schools. Interviews lasted 10 to 15 minutes. The set-up, timing, and interview language were however the same as those already described under the FGDs.

Research Instruments In all FGDs and IDIs, the research instrument used was an open-ended thematic topic guide. The instrument was designed to ensure that similar themes were covered in each discussion or interview. The instrument however had built-in flexibility that allowed questioning to flow naturally while permitting me to pick at random and probe more on any pertinent, but unexpected, issues that arose during the interview process. The instrument focused on exploring youth’s construction of masculinity, gender roles and sexuality, perceptions of HIV/AIDS risks, use of protective methods during sex, and responsiveness to HIV/AIDS prevention campaigns. Some specific questions that were explored included “Have you heard about HIV/AIDS and can you tell me what it is?” “Can you tell me how one can get the HIV infection?” “Who is at risk of HIV/AIDS infection?” “Do you think you are personally at risk?” “The young men and women in your community, which of the two groups do you think are most at risk of HIV infection?” “Are there any reasons why men/women are most at risk of HIV infection?” “How do you view men and women in your community?” “Do men and women play different roles, and if so why?” “Can you give me examples of roles men or women play?” “Do men and women have multiple current sexual partners in your community?” “Are there any reasons why men or women would want to have multiple sexual partners?” “Do you or some young men/women in your community also have more than one sexual partner?” “Is there a problem with having only one sexual partner?” “Would you personally prefer having not more than one sexual partner?” “Do you or other young people in your community know how HIV/AIDS could be prevented?” “Is it difficult for young people to avoid infection?” and

“What should be done to make young people more responsive to behavior change HIV/AIDS prevention messages?” To ensure that the instrument was reliable, a pre-test was done in three other schools (not included in the actual study). The pre-test enabled the reframing of questions and use of appropriate concepts. For example, during the pre-test, I discovered that most participants were reluctant to talk about youth sexuality in both FGDs and IDIs. This, I later learned, was because within the socio-cultural milieu of the study area, there is a cultural expectation of silence on sexual matters such that openly discussing youth sexuality was considered improper behavior. The association of HIV/AIDS with sexual behavior further brought stigma on sexual issues, thereby greatly limiting the open articulation of the dynamics of youth sexuality. In view of this, questions were appropriately modified. All discussions and interviews were taperecorded alongside hand-written field notes.

Data Analysis Following the completion of data collection, I analyzed the data using Attride-Stirling’s (2001) thematic network analysis framework. Several steps were followed before the analysis proceeded to an interpretative phase, in which the networks were connected into an explanatory framework consistent with the text. The first step involved transcription and reading of transcripts and field notes for overall understanding. During and after qualitative data collection, I transcribed all tape-recorded interviews. I then immersed myself in all transcripts and interview notes through reading and reviewing for overall understanding and comprehension of meaning. Reviewing data without coding in this first step helped me to identify emergent themes without losing the connections between concepts and their context. This first step was completed with a separate summary of each transcript outlining the key points participants made in response to the questions. Once the data were reviewed and a general understanding of the scope and contexts of key experiences was attained, the interview transcripts were exported to NVivo 9 qualitative data analysis software, where the data were both deductively and inductively coded. Codes, according to Miles and Huberman (1994) are labels, which are assigned to whole or segments of transcripts and interview notes to help catalog key concepts while preserving the context in which these concepts occur. Coding at this stage provided me with a formal system to organize the data, uncovering and documenting additional links within and between concepts and experiences in the data. The coding process involved the development of a code structure, finalization, and application of the


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Ganle code structure to develop themes for analysis. The development of the codes and code structure continued until theoretical saturation was reached. This is the point where no new concepts emerged from successive reviewing and coding of data (Bradley, Curry, & Devers, 2006). At this stage, the code structure was deemed complete and then applied to develop and report themes. Themes simply captured something important about the data in relation to the research question and represented some level of patterned response or meaning within the data set (Boyatzis, 1998). Finally, all the themes identified in the previous steps were assembled and a thematic chart was drawn to reflect basic themes, organizing themes, and global themes (see Table 1). To ensure that the thematic chart reflected and supported the data, I went through the data segments related to each basic, organizing, and global theme. Where necessary, refinements were made. In total, 51 codes were identified. These were grouped into 35 basic themes, which were further clustered into 12 organizing themes, and 3 global themes (Table 1). These global, organizing, and basic themes form the structure of the findings section. Where appropriate, I use verbatim quotations from interview transcripts to illustrate responses related to relevant themes and issues.

Results The research participants’ accounts, which explored issues such as youth’s awareness and knowledge of HIV/ AIDS, youth’s construction and/or social representation of masculinity, gender roles and sexuality, perceptions of HIV/AIDS risks, use of protective methods during sex, and responsiveness to HIV/AIDS prevention campaigns, converged on a number of common themes, which I explore in detail below.

Youth’s Awareness and Knowledge of HIV/ AIDS A useful entry point into the presentation of the findings is to examine the level of HIV/AIDS awareness among the youth. To achieve this, participants were first asked whether they have ever heard about HIV/AIDS, how they heard it, what HIV/AIDS was, what caused it, what its symptoms were, and how it was transmitted. Apart from two young women, all participants had heard or read about HIV/AIDS, and knew, among many things, that HIV could be transmitted through unprotected sexual intercourse with an infected person as well as through HIV-contaminated blood products. The majority of participants first heard or learnt about the disease through classroom education, HIV/AIDS prevention campaigns, and the media (radio and television). One participant

described how she first learnt of the disease in a particularly graphic way: I remember very well how I first heard about this disease [HIV/AIDS]. One day, I came back from school and saw my father, mother, and my siblings sitting together. They were all quiet and looking very sad . . . my mother was even crying. So I asked why and they said our eldest sister who has travelled to Sunyani has returned home very sick. They said the sickness has no cure and that she was going to die. So I asked what kind of sickness it was, and my father said it was called AIDS. That is how I got to know it. (Young Woman, FGD)

Generally, awareness and knowledge of HIV/AIDS among participants seemed to be very high. However, as I show below, participants’ awareness and knowledge of HIV/AIDS has yet to translate into attitudes and behaviors that do not expose them to the risk of HIV/AIDS infection.

Social Representation of Masculinity Representations of masculinity, and in some instances femininity, were pervasive in youth’s accounts of their social reality, their discussions on HIV/AIDS risk, their responses to behavioral change HIV prevention campaigns, and why young people did not take advantage of HIV/AIDS prevention interventions and services. These accounts were centered on the idea of the “real man,” the social expectations to be a real man, and sexuality and manhood. Although not all the youth subscribed to this characterization of hegemonic masculinity—and others had managed to resist it by, for example, avoiding risky sexual behaviors or making the decision to be tested for HIV/AIDS—participants related to it as a yardstick against which they measured themselves. Social representation of the real man/woman. Young people’s experiences of self and others were constructed around those “manly” or “womanly” traits that distinguished them. Most young men perceived themselves as “superior” to their “weaker” female counterpart. Many young men also perceived themselves as physically strong, emotionally tough and resilient and capable of withstanding pain and disease, domineering, especially over women, less risk averse, highly competitive, problem solvers, and highly sexual. “You see, as young men we are physically strong and fearless, and we have the capacity as problem solvers” (Young Man, FGD). For these young men, while it is all right for women to show signs of fear and weakness, “a real man” must do the opposite. This is because showing that they do not fear or that they are not weak is a central feature of the definition and identity of men.


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Table 1. Thematic Network Analysis Framework: From Codes to Global Themes. Codes •• HIV is sexually transmitted •• Youth have heard about HIV •• Media campaigns and classroom education are sources of information about HIV •• Men are strong •• Pride •• Men feel superior •• Men can’t show fear •• Risk-taking is part of being a man

•• Men are leaders •• Men are household heads •• Men are providers •• Changes in gender roles •• Men do difficult tasks •• Young men have many girlfriends •• Women not allowed to have more than one man •• Virginity is a virtue •• Sex is an eye opener •• Having HIV exposes their promiscuity •• Fear being alone •• Fear being stigmatized •• Fear to know HIV status •• Taking sexual risk •• Youth’s behaviors conflict with HIV/AIDS prevention •• Make excuses to avoid testing for HIV •• Denying it can happen to them •• Fatalism and risk-taking •• Avoid thinking/talking about HIV •• Counseling is essential •• School and community are reflections of the identities of young men and women

Basic Themes Identified

Organizing Themes

Global Themes

•• Youth know about HIV/AIDS •• Youth are aware of the HIV/ AIDS epidemic

Knowledge of HIV/AIDS

HIV/AIDS Awareness

•• Unlike women, men are physically strong and capable of withstanding pain and disease •• Men should not fear but it’s alright for women to show signs of fear

Characteristics of a real man/woman

Social representation of masculinity

•• Men should take risks •• Men should be emotionally tough •• Men are perceived as breadwinners •• Women should take care of the home •• Men should carry out all heavy duties •• Gender roles become fluids as households get affected by disease or economic difficulties •• Unlike women, it is a virtue for men to have multiple concurrent sexual partners •• Women should be faithful •• Young people fear losing their dignity to HIV/AIDS

•• Young people hate to feel at risk of HIV/AIDS infection

•• Taking sexual risks is part of the definition of manhood •• Elements of HIV/AIDS prevention conflict with behaviors that define manhood/womanhood •• Few young people acknowledge the seriousness of HIV/AIDS in their lives •• Young people do not believe it can happen to them, but take risks as accidents are unavoidable •• Provide safe social spaces for young men and women to reflect on their identities as gendered persons

Men’s and women’s role/ responsibilities

Sexuality and manhood/ womanhood

Fear of acknowledging HIV/AIDS

Barriers to behavior change

Masculinity conflicts with responsible therapeutic citizen persona

Delusion, denial, and diversion Gender-sensitive HIV/ AIDS communication

Facilitators of behavior change

(continued)


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Ganle Table 1. (Continued) Codes

Basic Themes Identified

•• Self-efficacy training

•• Enable young people to resist gender-based stereotypes •• Promote gender equality in schools and communities •• Sexual control and behavior change is a mark of responsible manhood/womanhood •• Use popular opinion leaders/ role models to communicate and promote behavior change messages •• Use mass and social media to promote HIV awareness and behavior change •• Encourage youth to protect their health

•• Men and women are equal •• Real men are in control •• Sexual risk-taking is irresponsibility •• Mass and social media attract youth •• Youth look up to role models •• Popular opinion leaders can influence young people •• •• •• •• ••

Attitudinal change Self-reflection Challenge stigma Voluntary counseling & testing Live precautionary life

Organizing Themes

Global Themes

Constructing responsible masculinities

Promote popular opinion leader model

Promote responsible therapeutic citizenship

•• Encourage young people to seek HIV/AIDS testing •• Encourage sexual behavior change among the youth

A few young men however held views that were different from the above characterization. According to this group, men are not necessarily superior to women. Rather, it is society that has socialized men and women into different roles. “I do not think that we men are necessarily better than women. I think the society we live in has made us men to believe we are the strongest or the best” (Young Man, IDI). Most of the participants who shared this view did not also support perceptions that being a man means taking unnecessary risks, including sexual risk, or being dominant over women. Rather, real men should be more responsible and be able to exercise control over their life choices. “Well, I do not see any benefit in saying that a man should not fear taking risks. I think a good man should be more careful and responsible in terms of how he leads his life” (Young Man, FGD). In accounting for why they did not support the characterization of real men as superior or fearless, these young men often described and/or saw themselves as different from other men. The majority of young women in this study also spoke of men and themselves in ways that were similar to what majority of the young men said. As one of them points out “men are not supposed to show their fear and emotions or anxiety about their own welfare. They should also be able to exercise control and authority in the household” (Young Woman, FGD). Many young women however emphasized the kind of pressures young men go through to be seen as “real men.”

This expectation that men must be tough or less risk adverse makes it particularly harder for some young men, to the extent that they can jeopardize their lives and those of others in order to show that they too are real men.” (Young Woman, FGD)

Thus although young women’s social representation of men as gendered persons largely reinforced men’s own perceptions of themselves, they also recognized the inherent problems that are associated with men’s attempt to enact and demonstrate their masculinity. Representations of men’s and women’s roles. Participants’ accounts and representation of men/women in their communities were also directly related to the different roles men and women play and the responsibilities they carry out on a daily basis. For example, both young men and women perceived men not only as household providers but also as having responsibilities for performing tasks that required physical strength. On the contrary, women were perceived as being responsible for taking care of the home, including childcare, as well as supporting their men. In our communities, men and women play different roles . . . Men are supposed to do all the difficult tasks like farming, looking after livestock, and working hard to provide for their family including paying school fees and buying clothes for


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their women. As for the women, they are supposed to concentrate on taking care of the home . . . like cooking for the family. These are the roles men and women play, and these roles basically define who they really are. (Young Man, FGD)

Most discussants acknowledged that it was precisely these social expectations, particularly those related to the roles and responsibilities of men that added to the stress of manhood by making it harder for them to behave or act in ways that are counter stereotypical. Such social expectations also enormously pressure young men into believing that those who are unable to fulfill their expected roles and responsibilities either as family breadwinners or household heads are not real men. But as reported earlier, some young men who had held different views about who a real man was also gave more reflective and non-hegemonic accounts of their own masculine identities. For example, one young man pointed out during an IDI, I do not see anything wrong with a man cooking for his family. My sister used to be the one doing all the cooking, but when she fell ill, I had to do all the house chores . . . I see nothing wrong with it.

Another young man reported, For me the whole question about what roles and responsibilities men and women should play in the society is not important. Nowadays, some women are employed in the formal sector and they even work more and earn more than their men. So I do not see why such women should not provide the money while the men who probably are less busy should take care of the home and the kids. For me I do not mind at all. (Young Man, IDI)

Indeed, a few of the young women interviewed reported that family and economic exigencies have encouraged some men to adopt more fluid gender roles, including playing roles hitherto considered to women’s, such as cooking for the family. Social representation of sexuality and manhood/womanhood. One other issue that my interviews and discussions with participants focused on was the social representation of sexuality among young men and women. While a few participants, particularly young men gave accounts that suggested that they are actively renegotiating and/or resisting the dominant conceptions of masculinity in their communities, the majority of them portrayed men and women as engaging in activities that demonstrated their sexuality. Most of the young men interviewed believed that men were sexually untamable. Unlike women, it was reported that men should have sex, both frequently and

with multiple concurrent partners, because infrequent sex could cause penile weaknesses and the loss of male virility. Well, the issue is that, as men, it is in our nature to perform sex. That is how we were created or should I say that is what we are taught. That is why men have many girl friends or even marry many women but a woman cannot do the same. (Young Man, FGD)

The representation that men are sexually unstoppable appears to justify men’s ideas and practices regarding sexual conquest. Crucially, whereas almost all the young men argued that men generally were sexually unstoppable, hence premarital sex and multiple concurrent sexual partners among men was normal, they did not believe the same applied to women. Most of the young women who participated in this study endorsed this view, often arguing that young women should remain virgins, and when they are married, they must be faithful to their husbands because virginity and fidelity is a pride that their husbands and society will respect them for. I think that it is in the nature of men to have more sex with several girls . . . That is how they are. But we the women cannot do the same thing as the men because people will say you are a prostitute. Nobody will even respect you and you may not even get a husband to marry if you are a young girl like me and you go out with several men. (Young Woman, IDI)

In this way, there appears to be an intrinsic acceptance of local social constructions and representations of men’s sexuality and the need to assert it, as a matter of fact. A few participants (both young men and women) however reported that these local representations of men’s sexuality were problematic, particularly to young men, because such constructions tend to place enormous pressure on young men to perform and demonstrate their sexuality in ways that could be detrimental to their well-being. As one young woman revealed during an IDI session, “in order to maintain and control a large network of sexual relationships, many men especially the young ones always expend high levels of resources.” For married men, it was reported that to maintain their extra-marital relationships, much needed money and resources are often taken away from their homes. One young man even reported that, “this pressure seemed to have increased young men’s sexual exploits in our society, and has also greatly diminished their fear of HIV/AIDS infection as well.” At this point, I asked participants in FGDs and IDIs to discuss young people’s sexual behaviors within the context of HIV/AIDS: whether young people engaged in premarital and/or multiple sexual relations and the reasons for such behaviors.


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Ganle Except three dissenting views, there was consensus that sex was for people in a marriage relationship and that sex after marriage was the ideal thing. Despite this, participants reported that premarital sex, particularly among young people, was a common practice, and that the age of first sexual debut was as low as 12 years. One issue that attracted the interests of most participants was the question of the moral acceptability or otherwise of having premarital sex or multiple concurrent sexual partners. Generally, there was agreement that unlike women who should be faithful and abstain from premarital and multiple sexual relationships, it was a virtue for men to have multiple concurrent sexual partners. Ironically, while men are expected to be in control when asserting their sexuality, it was reported that in an era of HIV/AIDS, this was precisely one area that men often got out of control and became susceptible to HIV infection, a weakness that undermines their identity as men. Some participants reported that men’s roles, responsibilities, and sexuality were now under threat by HIV/AIDS, and this is leading to alternative conceptions of masculinity. This threat, as few young men argued, should form the basis on which men and women must begin to rethink their identities as gendered and sexual beings. For me, one reason why I do not see any sense in having many girlfriends is the fact that I can get infected with diseases like AIDS and die. So I think that we men especially need to change the way we think about ourselves and also change our sexual behavior. (Young Man, FGD)

Youth’s Response to HIV/AIDS Prevention Campaigns and Barriers to Behavior Change As noted earlier in this article, heterosexual intercourse remains the dominant medium by which HIV/AIDS is transmitted in most parts of SSA, including Ghana. Efforts to prevent infections in the sub-region have therefore included a significant focus on sexual behavioral change interventions. My FGDs and IDIs with young people explored how ideas from the social representation of masculinity intermingled with youth’s personal experiences to influence their perceptions of risk, risk-taking, risk of HIV/AIDS infection as well as their responses to behavior change interventions. Findings—which are presented below—largely suggest that youth’s perceptions of their vulnerability to HIV/AIDS and their responses to sexual behavioral change HIV/AIDS prevention messages are deeply intertwined with, and dictated to by, social representations and expectations of men and women as gendered and sexual persons. Youth’s perceptions of risk and HIV/AIDS risk-taking. Within many HIV/AIDS prevention campaigns, young people

are seen as one of the high-risk groups. In my FGDs and IDIs with young people, I explored the concept of risk, particularly the ways in which the social representation of hegemonic masculinity influences thinking about risk and risk-taking, and how this manifests differently for young men and women. I also sought to understand how the youth construct their vulnerability to HIV/AIDS infection, and the barriers to behavior change. My findings from these explorations are detailed below. While few young people appeared to be renegotiating how they have been socially represented in their communities in ways that enabled them to think differently about risk and risk-taking, most accounts given in relation to risk, risk-taking, and perceptions of personable vulnerability to HIV/AIDS were still largely framed by macho and fatalistic ideas and practices. Many of the young men interviewed reported that risk and risk-taking were an important part of a man’s life and that not to take risks, including sexual risk, means that one is not man enough. Whether I have sex and get infected with HIV/AIDS or not, I will die one day. So what is the point about not having sex with many women? For me being a young man, I feel like I am not man enough if I say ok, HIV has come, I will have no sex or I will not have sex with many women. I should not be afraid of any disease, after all life itself is a risk. (Young Man, IDI)

One young woman also related, It is true that HIV/AIDS has come but what can we do? Should you say because there is AIDS then no sex? Well, that does not seem possible. Even as a lady, if I say I will not have sex till I marry, how sure am I that the guy I will marry has not been having sex with other women? So when you think about all this, you just ask yourself why be careful at all? You just have to take the risks because life itself is full of risks. (Young Woman, FGD)

The idea that risk and risk-taking is an inseparable part of life appears to be exerting considerable influence on youth’s perceptions of their vulnerability to HIV/AIDS infection, despite the fact that many appreciate the danger of HIV/AIDS infection. For the young women, a combination of powerlessness and uncertainty largely framed many of their accounts in relation to representations of risk and risktaking in the context of HIV/AIDS, and this appears to be leading many of them to systematically underestimate their personal vulnerability. The reason why I am not concerned about my personal vulnerability to HIV infection is because even if I do not enter into any sexual relationship now but in the future I decide to marry a guy, I cannot know whether he has had sex


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and probably gotten HIV, neither can I tell him not to have sex with any other person, because being a man, he will do it one day because it is in the nature of men to do that. (Young Woman, IDI)

Fear, denial, and diversion. Only a few of the young people interviewed in my study acknowledged the seriousness of HIV/AIDS in their lives. In fact, while almost all participants did not doubt the existence of HIV/AIDS, many did not believe they could personally get infected. “For me, I do not really feel I am at risk” (Young Man, IDI). Others simply made excuses to avoid thinking, talking, or testing for HIV by telling themselves that HIV/AIDS is a disease that only exceptionally promiscuous people can contract. I say I do not feel at risk because I do not behave improperly. AIDS will come to you if you have an improper behavior . . . like sleeping with many girls. But me, I do not do these things and my girlfriend too does not do them. (Young Man, FGD)

Many young people therefore appeared to be in denial regarding the seriousness of HIV/AIDS and their personal vulnerability to infection. For a few young women, however, denial arose from fear. “AIDS for me is hopelessness, pain, stigma, and death. I just feel terrified and sick any time I hear it mentioned” (Young Woman, FGD). According to this account, the fact that AIDS is incurable evokes dramatic images of fear, pain, and death. The difficulty of coping with all the emotional distress therefore makes HIV/ AIDS an unmentionably fearful disease. Unfortunately, this fear appears to have rather led these young women into resignation, such that they continue to systematically underestimate their own risk and vulnerability. The fact is that I fear HIV and I hate to think about it. Many times, I do not think about it. I just want to live my life the way I want to . . . if I get it one day fine, if I do not contract it too fine. I am just getting tired of being very fearful of HIV/AIDS. (Young Woman, IDI)

Masculinity conflicts with responsible therapeutic citizen persona. Many of my informants’ accounts also suggested that the way in which young men and women perceived and represented themselves and their roles and sexuality conflicted with what Nguyen, Ako, Niamba, Sylla, and Tiendrebeogo (2007) have termed responsible therapeutic citizenship. That is, the identities and associated practices that one needs to adopt to avoid HIV/AIDS infection or to gain access to HIV/AIDS services. For instance, although complete sexual abstinence—which is one trait of responsible therapeutic citizenship—is often promoted as an effective means of protection against infection in many HIV/AIDS prevention programs (Setswe, 2007), my interviews and discussions with young people found

that less than a quarter (5 young men and 11 young women) have never had penetrative sex. Two main reasons were given to account for why complete sexual abstinence among the youth was difficult. First, and for the young men, is the idea that “sex is an eye opener” and until a young man has had penetrative sex, he is not “a real man.” The truth is that in our communities, a young man or woman is considered naïve if he/she has not had sex before. As a young man we believe that it is only when you know a woman . . . I mean when you have had sex with one or two or three women, that people will regard you as a man. That is why we the young people cannot stay away from the women because nobody wants to be stereotyped. (Young Man, FGD)

One discussant also said, My friends used to tease at me because I had a girl friend, but we had not had sex yet. They said I was not a man and that I was afraid. I felt bad, and decided that I did not want my friends to tease me again . . . so I convinced my girl friend to have sex with me. (Young Man, FGD)

A few participants however disagreed: I do not really agree that having sex is what makes you a man. Sometimes, many of us young men are simply irresponsible! How can sex at my age make me feel like a man? I think real men should rather be responsible by abstaining and controlling their libido. (Young Man, FGD)

The second reason, which most young women reported, is the pressure they often faced from young men. You see, as a young lady, I really wanted to abstain and protect my virginity. But it was my boy friend . . . every day he kept on saying his friends were making fun of him because our relationship did not involve sex. So he started complaining that I did not love him. In order to make him happy, I said fine let us do it. (Young Woman, IDI)

One discussant also reported, For us young ladies, we always want to abstain, but the guys are always forcing us. Some older men will even promise you heaven just to have sex with you. That is why we are unable to abstain. (Young Woman, FGD)

But it is not only abstinence that young people in this study had difficulty with. Many of their accounts also illustrated potential conflict between their identities as gendered and sexual persons and the need to abide by HIV/AIDS prevention messages that urged them to be


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Ganle faithful in their relationships. Although the majority of them agreed that staying faithful in a relationship was the ideal thing to do, in practice, they reported that it was problematic. For example, several discussants reported during FGDs that young men and women often “celebrated sex” as well as “competed on the number of women or men they were able to conquer.” “To me, this faithfulness thing sounds good, but how do you expect me as a young guy to have only one woman . . . I need to get more girls to show that I am a capable young man” (Young Man, FGD). Another participant said, “Personally, I don’t think it is a good idea to be with only one girl. Look, the thing is that having more than one girl makes others respect you. It means you are a champion” (Young Man, IDI). One young woman also added, Me, I really will want to have one boyfriend, but you see, these days, guys want to use girls and dump them. So, if I have two or three boyfriends at the same time and if one of them decides to dump me today, there will be no problem because I will still have two. (Young Woman, FGD)

Crucially, a lively discussion was observed in most FGDs regarding which of the sexes should adhere to HIV/AIDS prevention messages that promote faithfulness. More than two thirds of the young men interviewed were of the view that men should have more sexual partners while women should be obedient to men, behave properly, and have as few partners as possible. I believe it is not bad if a guy has more girls as sexual partners . . . but it is bad for a girl, because even in our communities, a woman cannot marry more than one husband but a man can marry many women. (Young Man, IDI)

The responses of the majority of young women on the issue of faithfulness were however ambiguous. Many were not necessarily opposed to the view held by the young men but rather wondered why they [women] were the ones who were expected to be faithful. This notwithstanding, there were few young men who did not believe it was proper for both men and women to have multiple concurrent sexual partners. I believe having one girl/woman at a time is the right thing to do because the more women you have as sexual partners, the more your risk of getting AIDS. Even the church [referring to the Catholic Church] says one man, one wife, so why two or three girl friends? (Young Man, FGD)

Apart from suggesting to the reader that not all young men in the study region subscribed to dominant social representations of manhood and men’s sexuality, the quote above also points to the potential role of religion, especially Catholicism, in shaping both youth’s

conceptions of masculinity/femininity and their responses to behavior change HIV/AIDS interventions. Although my research did not explore this issue in detail, it is possible that the high level of religiosity in the study region, coupled with the fact that two of the three dominant religions—Islam and Traditional African Religion—support polygyny, does exert some influence on young people’s framing and acceptance of HIV/AIDS prevention messages, which preach abstinence and faithfulness. One other area where the social representation of sexuality and manhood/womanhood appeared to conflict with the responsible therapeutic citizen persona was condom use. Consistent condom use during penetrative sexual intercourse is one of the important strategies in current HIV/AIDS prevention campaigns. In my research with the youth in Ghana however, condom use was found to be unpopular among young people. Of the number who reported ever having sex, only 12 reported using a condom, albeit not consistently. FGDs and IDIs data revealed a number of negative attitudes that not only discredited condom use promotion programs but actually diminished condom usage. Participants, majority of whom were young women, reported that condom use was unnatural and sinful, a partner would be offended by the introduction of condoms in a relationship, condom use compromised the pleasure of sexual intercourse, and that condom users were often stigmatized as promiscuous or morally questionable people. For most of the young men interviewed however, condom use conflicted with their masculine identity. According to this account, “a man is a man because of his ability to venture into the unknown and take risk.” Therefore, condom use during sex was linked to being afraid, and not being man enough to take risks. On the contrary, non-use of condom during sex was seen as a manly virtue—a demonstration of male prowess. As one participant reported, “it seems funny that because of AIDS, every now and then we are being asked to use condoms. For me, using a condom is like saying as a man, I am afraid” (Young man, IDI). Another participant said, Personally, I do not like the idea of condoms. I used a condom when I first had sex but later when I told my friends about it, they all laughed at me . . . they said real guys do not use condoms. Since then, I have stopped using condoms. (Young Man, FGD)

In relation to this so-called “not man enough” argument, many young men likened sexual intercourse to work or performance and noted that using a condom during sexual intercourse was similar to “doing an unpaid job.” “Are you asking me whether I use condoms any time I have sex? Actually, no I do not, because using a condom, for me, is like I am working for no pay (Male,


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IDI). For these participants, the essence of sex is to ejaculate into the woman, and because condoms prevent the direct release of semen into the woman, the effort is unpaid for.

Facilitators of Behavior Change The results presented above indicate that the youth in Ghana, particularly young men, face very special challenges with regard to taking advantage of HIV/AIDS prevention programs and services. However, some of the accounts young people gave suggest that they have been able to, or are beginning to, overcome these obstacles by constructing new identities in ways that align with the demands of responsible therapeutic citizenship, and which are more likely to be associated with reductions in HIV risk behavior. In this section, I highlight some of the pathways through which HIV/ AIDS prevention efforts can be modified to better appeal to the youth living in this cultural milieu. Constructing responsible masculinities to promote responsible therapeutic citizens. A significant number of the youth in this study indicated that in order for young men and women to accept their personal vulnerability to HIV/ AIDS and respond positively to behavior change messages, there is a need for them to undergo transformation to break free from socialized norms of what it means to be a real man or woman. I think that for we the youth to avoid contracting HIV, we must change the way we think about ourselves. We the young men will have to accept that men and women are equal, and that a real man is one who takes charge of his sexuality. (Young Man, FGD)

Other participants suggested that young people must be encouraged to lead precautionary lives by voluntarily patronizing HIV/AIDS counseling and testing services as well as protecting themselves against HIV/AIDS infection. Some participants further proposed that risktaking must be made less attractive to the youth, particularly young men. “I think HIV/AIDS prevention campaigns must also stress that sexual risk-taking is irresponsibility” (Young Man, FGD). One young woman also suggested, Well for there to be a change, I think in our communities and schools, society must begin to tell us, the young people, that sexual control as well as less sexual risk-taking are marks of responsible manhood/womanhood. That way, I believe young people will change for the better. (Young Woman, IDI)

Gender-sensitive HIV/AIDS prevention communication. A significant part of the discussion in this article has thus

far highlighted the way in which gender-based stereotypes can hamper the youth’s understanding of risk, risktaking, their personal vulnerability to HIV/AIDS infection, and their responses to preventive interventions. This suggests the need for more gender-sensitive HIV/ AIDS prevention communication. A number of participants in this study provided pointers as to how HIV/AIDS prevention campaigns can be modified to help young men and women overcome gender-related barriers to behavior change. Few of the participants suggested that behavior change HIV/AIDS prevention campaigns must emphasize the provision of safe social spaces for young men and women to both reflect on their identities as gendered persons, and the obstacles that prevent them from taking advantage of HIV/AIDS prevention services. You see, part of the problem is that gender and sexuality issues are not normally discussed in our homes and communities. Most times, we the young ones learn these things from our peers, which might not be right. So I believe the way out is for people, especially those who want to prevent HIV infection among the youth, to find a way of bringing young people together in a conducive environment so that we can talk about some of these issues. (Young Woman, IDI)

Some participants also suggested that young people needed counseling that could enable them to challenge dominant social representations of themselves and their sexuality and to resist gender-based stereotypes. I think young people also need to be counseled more. Last year, I went for voluntary HIV counseling and testing . . . and it was really good. It changed my perception of people I thought were the only ones who could get infected. I also learnt a lot about how to resist peer-pressure as well as control myself sexually. (Young Man, IDI)

Accordingly, gender-sensitive HIV/AIDS prevention communication, including counseling and self-efficacy training, could help the youth to resist derogatory gender stereotypes from their peers and to become self-efficacious in taking some kind of control over their sexuality while still being able to fulfill some of the key traits of being a real man/woman. Promote popular opinion leader model through mass and social media. Many of the youth interviewed also proposed the use of popular opinion leaders/role models via mass and social media to communicate and promote behavior change messages. They suggested a number of practical ways to achieve this, including the endorsement of community leaders who openly advocate the deconstruction and/or rejection of health-damaging masculinities and


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Ganle femininities, mobilization of peer-based groups within safe social spaces, use of role models, and use of visual and social media and fun activities such as football to engage young people. Participants advocated the use of popular opinion leaders and role models because they believe these are people who the youth usually look up to, and therefore such people can easily influence young people’s behavior in ways that make them [young people] less susceptible to HIV infection. I think one solution is to identify public opinion leaders such as politicians and traditional chiefs, and role models such as musicians and sport personalities, and use them to propagate the message of AIDS. These are people that most young people would likely listen to and believe what they say. (Young Man, FGD)

The use of social media was also particularly emphasized because of its capacity to attract the youth. I believe social media provides the best medium to engage the youth on the issue of HIV. I say this because, these days most young people like Facebook or Twitter or WhatsApp. So it will be easier to attract their attention if messages about HIV/AIDS prevention were disseminated through social media. (Young Woman, FGD)

Discussion This article responds to calls for greater attention to how the social construction of masculinity serves as a barrier to behavioral change toward HIV/AIDS prevention efforts among young people (Lindegger & Quayle, 2009). Although previous research has drawn attention to the possibility that hegemonic masculinity norms may be undermining youth’s perceptions of personal vulnerability to HIV infection and the need for appropriate sexual behavior change in SSA, this article is one of the few indepth empirical investigations that explicitly examines the role of hegemonic masculinity in influencing young African men and women’s risk perceptions of HIV/AIDS and their response to behavioral change HIV/AIDS prevention campaigns. Findings reveal that although awareness of the HIV/ AIDS epidemic and the risks of infection is very high among the youth in Ghana, and despite being exposed to HIV/AIDS preventive programs, there is little by way of changes in attitudes, beliefs, and behavior to prevent transmission of the disease, giving credence to Cornwall and Wellbourn’s (2002) assertion that changing what people know may have little or no impact on what they do. Rather, a mix of hegemonic masculinity and perceptions of personal invulnerability appears to mediate (rather negatively) both the processes of young people’s HIV/AIDS

risk construction and appropriate behavior change. The majority responses in both FGDs and IDIs demonstrate young men defining and asserting their identity in terms of the “real man” persona, which requires them to be and act in control, be emotionally and physically tough, be fearless, take risks, be highly sexual, have multiple concurrent sexual partners, and be in competition with their peers. These demands, my findings suggest, appear not only to conflict with the requirement of responsible therapeutic citizenship but also make it difficult for the youth to acknowledge personal vulnerability to HIV/AIDS and to avoid high-risk behaviors. Coupled with the maintenance of an irrationally positive macho outlook on their lives, many young people continue to perceive themselves as invulnerable to HIV/AIDS infection, thereby systematically underestimating their personal risk of infection. Yet, many of the elements of the social representation of masculinity—which I documented in this article, such as control over women, particularly control over sexual decisions, risk-taking, frequent and multiple concurrent sexual partners, and unprotected sex—are closely related to the typical high-risk behaviors associated with HIV transmission. Crucially, my findings also suggest that young girls and women profoundly aid the appraisal and maintenance of these hegemonic masculinity behaviors, despite the fact that they (women) are often subordinated under these norms. This suggests that although the values of stereotype masculinity could be ubiquitous within the society, without women’s promotion of these ideals, they will perhaps not be sustainable. HIV/AIDS prevention programs could potentially benefit from the institutionalization of community-based strategies that empower women to challenge and resist the social construction and enactment of masculinity norms. But young people are not only underestimating their vulnerability to HIV/AIDS infection through the active construction of a cordon sanitaire around themselves, which never includes themselves as potentially infectious agents. In the process of enacting the so-called real man persona, many young men also construct themselves as being dominant and in control of sexual relationships, objectifying women and using sexual performance as a benchmark for proving manhood. Thus, many young men viewed sex as performance of a manly duty, exerted enormous pressure on young women, and in many instances, proceeded to aggressively resist HIV/AIDS prevention campaigns that require sexual behavioral change such as abstinence, faithfulness, and condom use. This was often exacerbated by the enactment and circulation of a gendered double standard discourse whereby men are encouraged to actively pursue sexuality and take multiple partners, while women may be punished for being sexually active and are constructed as loose and promiscuous. Such gendered double standards are clearly symptomatic of


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gender-based discrimination, a phenomenon that often characterizes societies where hegemonic masculinity reigns (Lindegger & Quayle, 2009). In the context of an emerging materialist youth culture and a dominant patriarchal system, continuous enactment and circulation of such gendered double standards can make young women more vulnerable to the development of social identities, which render them susceptible to being maneuvered or coerced into having unprotected sexual relationships. The findings here therefore highlight the fact that although HIV/AIDS is increasingly being recognized as a gendered disease, impacting disproportionately on young women, it is critical that the role of men and the social construction and performance of masculinity in driving the epidemic are properly analyzed and taken into account when planning preventive programs. My research however documented few responses that both challenge these dominant notions of masculinity and offer suggestions on how to promote behavior change. Present in these narratives were some young men’s desires to have an alternative experience of being a man. For these young men, the costs of hegemonic masculinity outweighed the benefits. Coupled with the increasing equality of women in the labor market and high levels of unemployment in the region, the ability of many men to adequately satisfy the requirement of hegemonic masculinity is increasingly undermined. Indeed, it seems the HIV pandemic itself has also begun to play a role in escalating or facilitating these changes by forcing acknowledgment of the dangers of misogynistic masculinity in public and private life and facilitating public conversation about sex and sexual practice. Such findings, although in the minority, are significant because they suggest that masculinity norms are not as fixed and static entities as some scholars have suggested (see Thorpe, 2002). Rather, they are both sites of intense contestation and fluid social resources that are exploited to produce or police particular instantiations of identity. I believe the findings here are hopeful signs of the transformation of masculinity, although the young people in this study did not find the process of change to be an easy one. What is required is for individual young men and women to be appropriately schooled to develop the skills to evaluate the social construction and enactment of masculinity and to contest efforts that seek to police them into particular masculine behaviors. Also, while previous research indicates that the social construction of hegemonic masculinity generally produces “patriarchal dividend that privileges men over women” (Lindegger & Quayle, 2009), findings presented in this article suggest that the pressure on young men to live up to the demands of hegemonic masculinity can be rather detrimental to some of them by exposing them to several unnecessary risk-taking as well as preventing

them from leading precautionary lifestyles against HIV/ AIDS infection. At the same time, few of the young women interviewed appear to be appropriating men’s enactment of these traditional masculine ideals to their benefit, including self-esteem and financial rewards arising from their involvement in multiple sexual relationships with men. This suggests that men and women might unequally benefit from the enactment of hegemonic masculinity. This also suggests that problematizing the positive or negative features of hegemonic masculinity alone is not enough; the benefits and vulnerabilities that individual young men and women face from the social construction and performance of masculinity in the context of HIV/AIDS must also be explored. As Seidler (2006) suggested, over-commitment to the structural aspects of gender relations can overshadow the personal struggles of individual young men and women, and especially struggles with personal emotion, sexuality, and the capacity to relate. Therefore critical engagement with, and reflections on the vulnerabilities, as well as the skills for managing them, are clearly essential for young people to live out more positive masculinities that aid in the reduction of HIV/AIDS infection and transmission. This calls for continuous and systematic discussion on masculinity at the family, community, national, and global levels to understand the ways in which hegemonic masculinity norms might favor or disfavor men and women particularly in the context of HIV/AIDS. In the context where this study took place, and with particular reference to the youth, my findings not only suggest the urgent need to modify prevention efforts to better appeal to the youth but also provide useful pointers to how progress can be achieved in practice, particularly through the provision of supportive social environments in which young men and women can renegotiate more health-enhancing gender identities. These include the development and implementation of gender-sensitive HIV/AIDS prevention programs, and the use of mass and social media and popular opinions of leaders and role models to encourage and disseminate behavior change HIV/AIDS campaign messages. To modify the behaviors associated with masculinity, my findings suggest that gender issues must become part of the mainstream of HIV intervention, which would require creating spaces for young people to critically reflect on the social construction of gender and consider alternate patterns of masculinity, challenging beliefs and assumptions about masculinity based on biology and culture, the psychological empowerment of women to resist control by men and to play an active role in sexual decision-making, and the economic empowerment of women to reduce their dependency on men. In this regard, it is particularly important that a competency enhancement approach to HIV prevention, which promotes resiliency through


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Ganle strengthening the protective factors in the face of risk and adversity, be adopted. HIV prevention educators could also provide counter narratives to challenge a hegemonic masculinity that positions females as submissive and sex providers, and male sexual behavior as biologically driven. Also, as adolescence is an experimental phase and young people are likely to be open to reflections on issues such as gender, identity, relationships, health, and sexuality, I strongly believe that school and community-based initiatives that bring together diverse groups of young people, educators, teachers, parents, and opinion leaders, offer opportunities for reflection, learning, and change. Similarly, families provide the most proximal social system for influencing positive family relations, communication about sexuality and safer sexual behaviors, as well as the monitoring of peer activities. I therefore support Pattman’s (2005) suggestion that HIV/AIDS prevention and educational initiatives must involve training trainers to be gender sensitive, with HIV education focusing not on sex per se but more generally on the lives, cultures, and identities of young people. Such an approach may provide opportunities to interrogate young people’s definitions of their identity and sexuality and thereby encourage them to protect themselves through fuller sexual expression and safer sexual practices. Of course educational programs alone cannot address these issues. Therefore individual-level programs should pay attention to personal factors such as depression, impulsivity, and rebelliousness, which mediate self-efficacy and have been found to be associated indirectly with youth’s highrisk sexual behavior (Brook, Morojele, Zhang, & Brook, 2006). Similarly, campaigns focusing on abstinence must avoid treating sex as an event (in this case to be avoided), while condom use and faithfulness promotion programs must also be accompanied by knowledge regarding prevailing power relationships, sexual patterns, and the context within which sexual and reproductive decisions are made. In this regard also, I recommend the provision of a supportive environment where men and women have opportunities to dialogue on issues such as self-confidence, intimacy, respect, and mutual fidelity. Finally, given the fluidity of masculinity constructs, and their importance in producing individual and group identity and determining young peoples’ responses to HIV/AIDS, leaders in groups that are important to young people and those with influence over media such as advertising, sports, and entertainment also have a responsibility to reinvent the social construction of masculinity to incorporate gender equity, reduce HIV risk, and give young people a platform to engage in satisfying egalitarian relationships. As Gibbs and Jobson (2011) have found, the media is a central space in which narratives of masculinity are produced and reproduced. Bertrand and

Anhang’s (2006) and Bertrand, O’Reilly, Denison, Anhang, and Sweat’s (2006) review of 24 mass media studies on changing HIV-related knowledge, attitudes, and behaviors in developing countries have indeed demonstrated the ability of mass media campaigns to reduce risky sexual behavior. Mathews, Guttmacher, Hani, Antonetti, and Flisher (2001) have also explored the potential of using the “popular opinion leader” model in high schools, as a mechanism for facilitating a change in social norms, with promising outcomes. The potential for using such strategies to promote the development of health-enhancing group social identities among young people in Ghana could therefore be enormous. The findings and recommendations in this article however should be read against the backdrop of certain limitations. The study had a limited coverage, focusing on a relatively homogeneous population within a specific environmental set-up. But as the results demonstrate, although young people are complicit with, subject to, or resistant to the social construction of hegemonic masculinity, they can subscribe to different versions of hegemonic masculinity depending on the place, time, and audience. Therefore, the effect of hegemonic masculinity on youth’s HIV/AIDS risk perceptions or their responses to behavior change messages could vary depending on context, time, social class, ethnicity, or educational attainment. Despite this, the findings could have important lessons and policy implications for HIV/AIDS prevention among young people not only in the study region but also other regions in Ghana and SSA.

Conclusion The findings and discussion in this article significantly improve understanding of how the social construction of masculinity serves as a barrier to behavior change that undermines HIV prevention efforts among young people in SSA. Across FGDs and IDIs, a clear and explicit version of masculinity emerged, in which young people viewed the “real man” as physically strong, fearless, highly sexual, and the breadwinner of the family, while his counterpart woman is seen as weak and submissive. Young men and women do not only aspire to live their lives according to the dictates of such representations, but they also engage actively in constructing, appraising, and sustaining them. Such demonstrations of masculinity sharply conflict with the demands of responsible therapeutic citizenship, which requires young people to take steps to avoid HIV/AIDS infection and to protect their health. Although not all young people subscribed to the above versions of masculinity, this conflict provides potentially competent explanation for both the gap between HIV/AIDS risk awareness and lack of behavior change among the youth, and why increased


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policy attention and resource mobilization to HIV/AIDS prevention among young people might not yield the desired positive behavior change and progress in the reduction of new infections. In conclusion, the study I reported in this article demonstrates that youth’s perceptions of their personal vulnerability to HIV/AIDS infection as well as their capacity to adopt appropriate sexual behavior changes are deeply intertwined with (a) the social construction of hegemonic masculinity that characterizes a particular context, (b) the ability of the said context to promote open discussion on hegemonic masculinity, and (c) the ability of young people, particularly young men, to negotiate the conflict between the so-called “real man” persona embedded in the social construction of masculinity and the need to lead precautionary lifestyles that protect against HIV/AIDS infection. This clearly presents opportunities for designing and/or modifying prevention efforts to better appeal to the youth in Ghana. If HIV/AIDS prevention among the youth is to be effective and sustained, it must go beyond information transmission and technological solutions such as condom use to creating and providing safe and supportive social spaces in which the construction of hegemonic masculinity, the identity of young men and women as gendered persons, and the proclivity of young people to hold rational reasoning about their personal vulnerabilities to HIV/AIDS infection hostage are challenged. In particular, the individual and collective vulnerabilities inherent in the social representation and enactment of hegemonic masculinity need to be acknowledged and appropriate skills developed to enable young people manage and live out more positive masculinities needed for reducing the risk of HIV/AIDS infection and transmission. Declaration of Conflicting Interests The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author disclosed receipt of the following financial support for the research, authorship, and or publication of this article: This study was supported by The Commonwealth Shared Scholarship Scheme, 2008/2009 Academic Year.

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Author Biography John Kuumuori Ganle, PhD, is a lecturer and researcher in population/demography, health and development, and gender and development at the Department of Geography and Rural Development, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.


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