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Superstition, witchcraft and HIV

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Superstition, witchcraft and HIV

prevention in sub-Saharan Africa: the
case of Ghana
a b
Eric Y. Tenkorang , Stephen O. Gyimah , Eleanor Maticka-
c b
Tyndale & Jones Adjei
a
Department of Sociology, Memorial University of Newfoundland,
St. John's, Canada
b
Department of Sociology, Queen's University, Kingston, Canada
c
Department of Sociology, Anthropology and Criminology,
University of Windsor, Windsor, Ontario

Available online: 30 Jun 2011

To cite this article: Eric Y. Tenkorang, Stephen O. Gyimah, Eleanor Maticka-Tyndale & Jones Adjei
(2011): Superstition, witchcraft and HIV prevention in sub-Saharan Africa: the case of Ghana,
Culture, Health & Sexuality, 13:9, 1001-1014

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 Culture, Health & Sexuality
Vol. 13, No. 9, October 2011, 1001–1014

Superstition, witchcraft and HIV prevention in sub-Saharan Africa:

the case of Ghana
Eric Y. Tenkoranga*, Stephen O. Gyimahb, Eleanor Maticka-Tyndalec and Jones Adjeib
a
Department of Sociology, Memorial University of Newfoundland, St. John’s, Canada;
b
Department of Sociology, Queen’s University, Kingston, Canada; cDepartment of Sociology,
Anthropology and Criminology, University of Windsor, Windsor, Ontario
Downloaded by [Memorial University of Newfoundland] at 12:51 28 August 2011

(Received 18 February 2011; final version received 25 May 2011)

Belief in superstition and witchcraft is central to many African conceptions of illness,

disease causation and etiology. While a number of anthropological studies have alluded
to a theoretical link between such beliefs and HIV prevention in particular, there is
limited empirical assessment of the association. Using data from the 2008 Ghana
Demographic and Health Survey and applying random-effects logit models, we
investigate whether the belief that AIDS can spread through witchcraft associates with
the sexual decision making of never-married men and women. The results show that
men who believed AIDS can spread through witchcraft and other supernatural means
were less likely to have used condoms at last sexual intercourse, controlling for other
socioeconomic and cultural variables. Women with similar beliefs were more likely to
have experienced sexual intercourse but less likely to have used condoms at last sex.
For women, however, the relationship between such superstitious beliefs and condom
use was somewhat attenuated after controlling for ethnicity and region of residence.
From a policy perspective, the findings suggest that local beliefs regarding AIDS
causation must be considered in designing HIV/AIDS programmes and interventions.
Keywords: Ghana; witchcraft; HIV/AIDS; disease causation; superstition; condom
use; demographic and health surveys

Introduction
Despite the recent decline in incidence, the global HIV epidemic remains a serious
concern. Generally, sub-Saharan Africa bears the brunt of the scourge given that it is home
to about 67% of the 33 million people infected with the virus globally (UNAIDS 2008).
While Ghana’s current prevalence of 2.3% is not as grievous as in other parts of Africa
(UNAIDS 2008; USAID 2008; Tenkorang and Owusu 2010; Gyimah et al. 2010),
behaviours putting people at risk of HIV infection remain widespread (Chatterji et al.
2004; Tenkorang, Adjei and Gyimah 2010; USAID 2008; Tenkorang and Owusu 2010).
To sustain and improve Ghana’s low prevalence, there have been calls for a
multifaceted approach that seeks to critically examine sociocultural factors that may be
contributing to HIV transmission (see Yamba 1997; Amuyunzu-Nyamongo et al. 1999;
Caldwell 2000; Crentsil 2007; Gyimah et al. 2010). Most HIV-prevention programmes
have been built on a paradigm of individual behaviour change rooted in a biomedical
understanding of disease causation. Prevention mostly relies on the awareness that
personal actions put one at risk and that behaviour change is required to reduce the risk of

*Corresponding author. Email: ytenko@yahoo.com

ISSN 1369-1058 print/ISSN 1464-5351 online

q 2011 Taylor & Francis
DOI: 10.1080/13691058.2011.592218
http://www.informaworld.com
 1002 E.Y. Tenkorang et al.

contracting the virus (Yamba 1997; Kalipeni, Oppong, and Assata 2007; Rotheram-Borus,
Swendeman, and Chovnick 2009). Thus, the focus is placed on increasing condom use,
reducing the number of sexual partners (especially concurrent partners), eliminating
needle-sharing, male circumcision and the administration of anti-retroviral drugs
(Rotheram-Borus, Swendeman, and Chovnick 2009).
While the biomedical paradigm has been widely used in understanding the spread of
HIV and in developing prevention initiatives, it has also been criticised for its failure to
accommodate cultural interpretations of disease (see Kalipeni, Oppong, and Assata 2007).
For instance, in settings where people believe AIDS is caused by an agent over which they
have no control, a model that focuses on individual actions may be ineffective. In fact,
Kalipeni, Oppong and Assata (2007) have attributed the failure of most HIV programmes
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in sub-Saharan Africa to their primary emphasis on risk groups and biomedical

explanations, while downplaying the role of cultural and economic factors. Also, the
‘ABC’ (Abstinence, Be Faithful, Condomise) approach to HIV prevention in sub-Saharan
Africa has for a very long time been grounded in, and dominated by rational scientific
discourse of the disease without recourse to non-scientific (spiritual) explanations, such as
belief in witchcraft, although capable of influencing sexual behaviours. Against this
backdrop, this paper examines how local understandings of HIV causation, in particular
beliefs that AIDS can be spread through witchcraft and other supernatural means (referred
to in the remainder of the paper as witchcraft), affect decisions to engage in sexual
intercourse and non-use of condoms among never-married men and women in Ghana.

Superstition, witchcraft, and HIV/AIDS in Africa

Superstitious beliefs, including belief in witchcraft and sorcery, play a crucial role in
the social fabric of most African societies, and Ghana is no exception (Yankah 2004;
Heike 2007). Regarding witchcraft, Evans-Pritchard’s (1937) seminal work among the
Azande (who are mostly spread over the Congo, southwestern Sudan and the Central
African Republic) continues to inform intellectual debate and discourse around the subject
(see Farmer 1990; Yamba 1997; Outwater et al. 2001; Ashforth 2002; Yankah 2004;
Crentsil 2007; Heike 2007; Pearson and Makadzange 2008). Drawing on Durkheim’s idea
of societies having their own internal logic and mechanisms of explaining events in their
external world, Evans-Pritchard explains that although Africans may be aware of the
natural causes of events, those that are deemed unexplainable are attributed to the
supernatural. In this regard, witches, who are believed to be agents of the supernatural,
become easy explanations for people’s afflictions and misfortunes. Such beliefs, although
scientifically irrational, are deemed rational given the lack of alternate explanations in the
context or circumstances under which such misfortunes occur.
With increasing modernisation and the associated scientific breakthroughs in public
health and medicine, one would think that the African’s conception of disease causation
may change, but recent evidence suggests that traditional beliefs and superstitions persist
(see BBC News 2010). Among the Goba people of Chiawa in Zambia, witches are usually
thought of as malevolent forces who cause deaths and diseases to the extent that when a
person dies of common malaria, witches are blamed for it (Yamba 1997). Among several
ethnic groups in Ghana, diseases or illnesses are thought of simply as physical
manifestations of what has happened in the spiritual realm, most of which are believed to
be orchestrated by witches (Allotey and Reidpath 2001; Gyimah 2006; Yamba 1997).
Similar ideas exist in Soweto, South Africa, where afflictions and misfortunes are
interpreted as the work of evil people, who are loosely defined as witches (Ashforth 2001).
 Culture, Health & Sexuality 1003

The emergence of AIDS in Africa in the early- and mid-1980s was not only characterised
by fear and denial, but also confusion as to its cause. In South Africa, for instance, former
president Thabo Mbeki and his then health minister, Manto Tshabalala Msimang,
vehemently challenged the view of HIV as the causative agent of AIDS (see Fredland 1998;
Cohen 2000; Makgoba 2000; Butler 2005). Similarly, in an attempt to explain this ‘strange’
illness that has no cure, most Africans have resorted to a variety of paradigms, one of which
is the ‘witchcraft’ or ‘traditional’ paradigm (Yamba 1997; Kalichman and Simbayi 2004;
Crentsil 2007; Wreford 2009). This paradigm feeds into the idea that AIDS is a supernatural
disease caused by supernatural forces outside of individual control. As argued by others,
discourses such as these portray an effort by individuals to distance themselves from a
disease that attracts guilt, blame and contempt from society (Yankah 2004). In doing so,
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however, there is an attempt to shift the cause of the illness to an outward spiritual power
over which the victim has no control (Heike 2007). Clearly, such beliefs have implications
for HIV prevention in sub-Saharan Africa. For example, it becomes difficult to convince
people that behaviour change can keep them safe when they believe that infection is the
result of witchcraft and is beyond their power to control. The challenge here is that the
behaviour change discourse hinges on the ability of individuals to realise that they control
their fate through their own behaviours.
Using Demographic and Health Survey data, we explore whether the belief that AIDS
can spread through witchcraft affects sexual decision making, in particular, recent sexual
experience and condom use. We hypothesise that individuals who believe AIDS can
spread through witchcraft and supernatural means will be less likely to abstain from sexual
activity and use condoms.

Methods
We used data from the 2008 Ghana Demographic and Health Survey (GDHS). The GDHS
is a nationally representative dataset administered by the Ghana Statistical Service and
Macro. The 2008 GDHS employed a two-staged stratified sample frame where systematic
sampling with probability proportional to size was used to identify Enumerations Areas
from which households were selected. Face-to-face interviews were then conducted with
4568 and 4916 men and women aged 15– 59 and 15 –49, respectively. We limited
our sample to the never-married, leaving an analytic sample of 1940 men and 1546
women. The present study is limited to the never-married because of the reported high
sexual risk-taking behaviours among the single/never-married in Ghana (Mehryar
et al. 2003; Awusabo-Asare, Abane, and Kumi-Kyereme 2004) and condom-use is
considered more appropriate in these relationships than in marital unions (Maharaj and
Cleland 2005).
Two major dependent variables that underlie AIDS prevention messages across
Africa, namely abstinence from sexual activity and condom use, are employed in this
study. The first taps into whether respondents had recently engaged in sexual intercourse
(‘yes ¼ 1’ and ‘no ¼ 0’) and the second assesses whether condoms were used at last
sexual intercourse (‘yes ¼ 1’ and ‘no ¼ 0’). The focal predictor variable is whether the
respondent believes AIDS can spread through witchcraft (‘no ¼ 0’, ‘yes ¼ 1’, ‘don’t
know ¼ 2’). While acknowledging that beliefs about witchcraft are complex and that the
multidimensional nature of such beliefs is not easily captured by a single-item measure,
the study was constrained by the data available (the only witchcraft-related variable in the
data). In our analyses, we controlled for socioeconomic, sociocultural and demographic
variables such as religion, ethnicity, age, education, region of residence, rural-urban
 1004 E.Y. Tenkorang et al.

residence and the wealth status of respondents. Previous studies have identified socio-
psychological variables such as perceived risk of contracting HIV, knowledge about HIV,
knowing someone who has died of AIDS and belief in transmission myths as important
correlates of HIV-preventive behaviours (see Akwara, Madise, and Hinde 2003;
Macintyre et al. 2004; Tenkorang and Maticka-Tyndale 2008; Tenkorang, Fernando, and
Maticka-Tyndale 2009). We controlled for knowledge using a summative scale of
responses to three factual questions weighted by their factor scores: (1) risk of contracting
HIV can be reduced by using condoms, (2) abstaining from sex (3) and having a single
sexual partner (yes ¼ 1, no ¼ 0 on each). A measure of endorsement of transmission
myths was similarly created from three questions asking respondents if HIV can spread
through mosquito bites and sharing food with a person with AIDS and if a healthy looking
Downloaded by [Memorial University of Newfoundland] at 12:51 28 August 2011

person can have AIDS. Incorrect answers provided on these questions were coded ‘1’,
otherwise they are coded ‘0’. Principal Components Analysis was used to create both
measures. We are unable to include knowledge of someone who has died of AIDS and
perceived risk of contracting AIDS because the 2008 GDHS did not ask these questions.
We used binary logit models to analyse our dependent variables given that both
variables are dichotomous. The standard logit models are built on the assumption of
independence of observations but the GDHS has a hierarchical structure with respondents
nested within survey clusters which could potentially bias the standard errors (Raudenbush
and Bryk 2002). To control for this dependence, we employed random effects models that
enabled us to estimate both the magnitude and significance of clustering (see Guo and
Zhao 2000; Raudenbush and Bryk 2002). The extent of clustering in our models is
estimated using the intra-class correlations. For binary logit models, this is calculated as
the ratio of the variance at the cluster level to the sum of the variances at the individual and
2 2
cluster levels. That is: r ¼ s2u =s2u þ p3 where s2u is the cluster level variance and p3 the
variance at level 1 (individual level), which is that of the standard logistic regression
(Pebley, Goldman, and Rodriguez 1996; Gyimah 2009). The GLLAMM program
available in STATA is used to build all models.

Results
Descriptive results are provided in Table 1 for ‘never-married’ male (n ¼ 1940) and female
(n ¼ 1546) respondents and for respondents who had engaged in sex (Male ¼ 933;
Female ¼ 722). Almost half of never-married men and women had experienced sexual
intercourse and about 45% of men used condoms at last sexual intercourse compared with
only 29% of women. Men and women who experienced intercourse differed little in their
profile from the full sample. Sexually active men and women are older with mean ages 24
and 22 years, respectively. Although the majority does not believe AIDS can spread through
witchcraft, 31% of men and 38% of women of the sexually experienced hold this belief.
Table 2 provides odds ratios of the bivariate relationships for ‘recent sexual
intercourse’ and ‘condom use at last sex’, with selected independent variables. Women
who believe AIDS is spread through witchcraft were significantly more likely to have had
sex, compared to those who do not. Consistent with our expectations, both male and
female respondents who believed AIDS can spread through witchcraft were less likely to
have reported condom use at last sexual intercourse. Male respondents who did not know
if AIDS can spread through witches and superstition were also less likely to have used
condoms at last sexual intercourse.
The cross-classification analysis of our focal independent variable and other
socioeconomic and cultural variables in Table 3 showed that the belief that AIDS can
 Culture, Health & Sexuality 1005

Table 1. Univariate analyses of selected dependent and independent variables.

Men Women
All men Sexually exp All women Sexually exp
Dependent variables n ¼ 1940 n ¼ 933 n ¼ 1546 n ¼ 722
Had sex % % % %
No 51.8 – 49.9 –
Yes 49.2 – 50.1 –
Condom use at last sex
No – 55.4 – 70.8
Yes – 44.6 – 29.2
Downloaded by [Memorial University of Newfoundland] at 12:51 28 August 2011

Independent variables
AIDS spread through witches
No 64.0 63.1 59.8 56.5
Yes 28.8 29.9 30.9 37.7
Don’t know 7.2 7.0 9.2 5.8
Knowledge about HIV (median) .568 .568 .733 .733
Transmission myths (median) 2 .793 2 .793 2 .737 2.737
Education
No education 7.8 8.1 6.1 5.8
Primary education 19.9 14.6 16.9 13.7
Secondary/higher education 72.3 77.3 77.0 80.7
Wealth index
Poorest 21.6 15.5 15.6 11.0
Poorer 17.9 15.8 15.2 15.8
Middle 17.3 17.5 18.8 20.5
Richer 23.3 27.5 23.4 25.8
Richest 19.9 23.7 27.0 26.9
Rural/Urban residence
Urban 45.7 52.1 54.4 58.8
Rural 54.3 47.9 45.6 41.2
Region of residence
Greater Accra 13.8 17.8 19.0 20.7
Central 6.2 6.2 6.7 7.5
Western 8.4 7.7 8.5 7.9
Volta 9.4 8.5 7.2 5.3
Eastern 10.0 11.0 11.4 14.1
Ashanti 15.3 17.3 18.4 21.1
Brong-Ahafo 7.3 10.2 6.1 6.1
Northern/upper west and east 29.7 21.3 22.6 17.2
Age of respondent (mean) 21.6 24.1 19.7 21.9
Ethnicity
Akan 40.3 44.4 46.5 51.2
Ga Adangbe 6.3 7.4 7.7 9.1
Ewe 14.2 14.7 11.6 10.9
Northern languages 34.9 27.9 29.6 24.1
Others 4.2 5.6 4.6 4.8
Religion
Christian 75.7 78.9 81.5 81.3
Muslim 18.8 16.6 15.9 15.2
Traditionalist 5.6 4.5 2.6 8.5

spread through witchcraft was surprisingly higher among men with secondary/higher
education but lower for women with similar educational background. The belief was also
higher among men and women with poorer to middle levels of wealth, residing in rural
 1006 E.Y. Tenkorang et al.

Table 2. Bivariate analyses of selected dependent and independent variables.

Had sex Condom use at last sex
Independent variables Male Female Male Female
AIDS spread through witches n ¼ 1940 n ¼ 1543 n ¼ 933 n ¼ 722
No 1.00 1.00 1.00 1.00
Yes 1.08 (.114) 1.79 (.126)*** .560 (.163)*** .616 (.197)***
Don’t Know 1.03 (.199) .483 (.209)*** .512 (.299)** .849 (.399)
Knowledge about HIV 1.16 (.053)*** 1.21 (.057)*** 1.15 (.080) .949 (.093)
Transmission myths .936 (.052) .859 (.057)*** .661 (.080)*** .790 (.102)**
Education
No Education 1.00 1.00 1.00 1.00
Downloaded by [Memorial University of Newfoundland] at 12:51 28 August 2011

Primary Education .485 (.216)*** .670 (.265) 1.57 (.379) 2.07 (.570)
Secondary/Higher Education .934 (.196) 1.10 (.237) 5.32 (.330)*** 4.15 (.518)***
Wealth Index
Poorest 1.00 1.00 1.00 1.00
Poorer 1.41 (.168)** 1.97 (.210)*** 1.81 (.266)** 1.14 (.401)
Middle 1.88 (.173)*** 2.25 (.204)*** 2.23 (.258)*** 1.65 (.383)
Richer 2.57 (.165)*** 2.28 (.196)*** 2.22 (.240)*** 2.46 (.367)***
Richest 2.60 (.172)*** 1.80 (.194)*** 4.42 (.251)*** 2.95 (.368)***
Rural/Urban residence
Urban 1.00 1.00 1.00 1.00
Rural .589 (.120)*** .663 (.129)*** .497 (.156)*** .583 (.209)***
Region of residence
Greater Accra 1.00 1.00 1.00 1.00
Central .535 (.263)** 1.06 (.272) .842 (.359) .466 (.345)**
Western .473 (.239)*** .693 (.252) .625 (.330) .400 (.345)***
Volta .433 (.235)*** .440 (.272)*** .795 (.318) .320 (.422)***
Eastern .674 (.229) 1.33 (.233) .636 (.297) .815 (.266)
Ashanti .685 (.206) 1.06 (.205) .472 (.270)*** .184 (.298)***
Brong-Ahafo 1.28 (.256) .764 (.276) .607 (.305) .297 (.402)***
Northern/upper west and east .293 (.186)*** .468 (.197)*** .665 (.249) .293 (.279)***
Age of respondent (mean) 1.41 (.016)*** 1.53 (.027)*** 1.01 (.013) .995 (.018)
Ethnicity
Akan 1.00 1.00 1.00 1.00
Ga Adangbe 1.17 (.225) 1.15 (.225) 1.28 (.352) 2.80 (.312)***
Ewe .896 (.163) .734 (.190) 1.54 (.224)** 2.22(.288)***
Northern languages .567 (.066)*** .550 (.140)*** .973 (.183) .942 (.238)
Others 1.51 (.263) .824 (.276) 1.15 (.328) 2.43 (.405)**
Religion
Christian 1.00 1.00 1.00 1.00
Muslim .764 (.147) .873 (.121) .785 (.203) 1.15 (.256)
Traditionalist .829 (.178) .588 (.367) .295 (.409)*** .773 (.522)

Note: ***p , .01; **p , .05;*p , .1.

areas, speaking the Akan language and residing in the Akan-speaking areas such as the
Central, Western, Ashanti, Eastern and Brong Ahafo Regions. In all these, the percentages
were higher for women compared to men.
Multivariate models are presented in Table 4 for recent sexual activity and condom
use. In all models, we estimated the magnitude and significance of clustering. Even after
controlling for other theoretically relevant covariates, the belief that AIDS can spread
through witchcraft was significantly related to engaging in sex for women and condom use
at last sex for men. Compared with those who did not believe AIDS can spread through
witchcraft, women with such beliefs were about 55% more likely to have recently engaged
in sexual intercourse. Consistent with the bivariate results, the multivariate models show
 Culture, Health & Sexuality 1007

Table 3. A cross-classification analyses of selected independent variables and belief in witchcraft

as a means of spreading AIDS.
Male Female
Selected variables Yes No Don’t know Yes No Don’t know
Education*
No Education 26.0 49.3 24.7 36.6 43.9 19.5
Primary Education 41.2 49.3 9.6 43.7 46.6 9.7
Secondary/Higher Education 67.2 28.0 4.7 36.8 59.0 4.2
Wealth Index*
Poorest 29.2 58.3 12.5 31.7 52.4 15.9
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Poorer 34.9 56.2 8.9 42.0 50.4 7.6

Middle 30.2 62.3 7.4 41.4 53.5 5.1
Richer 29.2 66.9 3.9 37.4 57.6 5.1
Richest 27.6 67.0 5.4 35.1 63.0 1.9
Rural/Urban residence***
Urban 26.3 67.5 6.2 36.6 59.8 3.5
Rural 33.8 58.3 7.9 39.2 51.8 9.0
Region of residence*
Greater Accra 24.7 69.3 6.0 29.6 69.8 0.6
Central 48.3 46.6 5.2 49.1 47.4 3.5
Western 47.2 45.8 6.9 30.5 55.9 13.6
Volta 21.8 62.8 15.4 17.1 75.6 7.3
Eastern 33.0 61.2 5.8 38.5 55.0 6.4
Ashanti 34.2 64.6 1.2 58.0 39.5 2.5
Brong-Ahafo 38.9 53.7 7.4 40.4 55.3 4.3
Northern/upper west and east 16.2 73.6 10.2 25.4 61.5 13.1
Ethnicity*
Akan 37.9 58.0 4.1 47.7 48.0 4.3
Ga Adangbe 37.7 55.1 7.2 27.5 71.0 1.4
Ewe 25.7 68.4 5.9 26.2 69.0 4.8
Northern languages 20.1 67.6 12.4 26.9 61.5 11.5
Others 15.7 78.4 5.9 29.7 67.6 2.7
Religion*
Christian 32.3 61.7 6.0 39.3 54.9 5.8
Muslim 20.9 68.0 11.0 28.4 66.4 5.2
Traditionalist 21.4 69.0 9.5 40.0 52.0 8.0
Note: *p , .001 for males and females. No significant differences were found for females regarding religion.

that men who believe AIDS can spread through witchcraft were less likely to have used
condoms at last sex. Similar results are observed for women but, the coefficient lost
significance once ethnicity and region of residence were controlled (model not shown).
Correct knowledge increased the odds of recent sexual intercourse for both men and
women, but was not significant for condom use. Endorsement of transmission myths,
significant at the bivariate level, lost significance as other variables were controlled.
Ghanaian men with secondary/higher education were more likely to use condoms at last
sex. Similarly, those in the richer and richest wealth quintiles were more likely to have
recently engaged in sexual intercourse and to have used condoms at last sex. However,
women in the richest quintile were less likely to have sex, compared to those in the poorest
quintile.
Unlike the bivariate analysis, the effects of wealth on condom use vanished in the
multivariate models for women. Age was significantly related to having experienced
sexual intercourse but not condom use at last sex for both genders. There were also gender
 1008 E.Y. Tenkorang et al.

Table 4. Odds ratios of recent sexual intercourse and condom use at last sex among Ghanaian men
and women.
Had sex Condoms at last sex

Independent variables Male Female Male Female

AIDS spread n ¼ 1940 n ¼ 1543 n ¼ 933 n ¼ 722
through witches Model 1 Model 2 Model 1 Model 2

No 1.00 1.00 1.00 1.00

Yes 1.14 (.142) 1.55 (.157)*** .696 (.176)** .821 (.207)
Don’t Know 1.05 (.252) .602 (.251)** .670 (.323) 1.42 (.411)
Knowledge about HIV 1.16 (.063)*** 1.17 (.070)** 1.14 (.085) .927 (.095)
Transmission myths 1.13 (.069) 1.03 (.074) .874 (.087) .932 (.111)
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Education
No Education 1.00 1.00 1.00 1.00
Primary Education 1.12 (.295) .906 (.347) 1.74 (.406) 1.19 (.591)
Secondary/ 1.17 (.295) .932 (.332) 4.44 (.384)*** 2.44 (.543)
Higher Education
Wealth Index
Poorest 1.00 1.00 1.00 1.00
Poorer 1.37 (.220) 1.42 (.263) 1.41 (.303) 1.16 (.413)
Middle 1.53 (.243) 1.18 (.287) 1.46 (.320) 1.56 (.428)
Richer 1.72 (.265)** .828 (.298) 1.25 (.339) 2.24 (.436)*
Richest 1.48 (.297) .450 (.327)*** 2.49 (.370)*** 2.17 (.468)
Rural/
Urban residence
Urban 1.00 1.00 1.00 1.00
Rural 1.16 (.175) .958 (.202) .671 (.203)** 1.03 (.265)
Region of residence
Greater Accra 1.00 1.00 1.00 1.00
Central .651 (.334) 1.91 (.352) 1.48 (.371) .655 (.413)
Western .767 (.306) 1.07 (.328) 1.41 (.352) .609 (.407)
Volta .719 (.330) .588 (.382) 1.80 (.370) .262 (.519)***
Eastern 1.04 (.290) 1.76 (.297) 1.29 (.307) 1.04 (.324)
Ashanti 1.04 (.266) 1.23 (.276) .757 (.277) .270 (.347)***
Brong-Ahafo 2.67 (.330)*** 1.14 (.361) 1.54 (.334) .443 (.473)*
Northern/ .516 (.332)** .987 (.361) 2.30 (.354)** .333 (.475)**
upper west and east
Age of respondent (mean) 1.40 (.019)*** 1.52 (.027)*** 1.01 (.014) .971 (.020)
Ethnicity
Akan 1.00 1.00 1.00 1.00
Ga Adangbe 1.10 (.287) 1.19 (.299) 1.31 (.310) 1.72 (.343)
Ewe 1.06 (.242) 1.27 (.288) 1.37 (.264) 2.28 (.344)***
Northern languages 1.07 (.251) .786 (.276) 1.45 (.294) 1.51 (.388)
Others 1.70 (.360) .705 (.366) 1.46 (.396) 2.00 (.486)
Religion
Christian 1.00 1.00 1.00 1.00
Muslim .680 (.213) 1.29 (.230) .656 (.269) 1.21 (.320)
Traditionalist 1.05 (.234) .652 (.488) .443 (.454) 1.24 (.565)
Constant .7.44 (.602)*** 2 7.98 (.693)*** 22.14 (.637)*** 21.27 (.848)
Random effects
Variance at level 2 .250 (.120)* .295 (.151) .061 (.150) .189 (.240)
Intra-class correlation .071 .082 .018 .054
Log likelihood 2931.8781 2753.772 2546.669 2400.734

Note: ***p , .01; **p , .05;*p , .1

differences in the various regions and among the different ethnic groups regarding sexual
experience and condom use. While men in the Brong Ahafo Region were more likely to
have recently experienced sexual intercourse, those in the Northern Regions were less
likely, compared to respondents in the Greater Accra Region. For condom use, men from
 Culture, Health & Sexuality 1009

the Northern Region were more likely to have used condoms at last sex compared to those
from Greater Accra. For women, however, respondents from the Volta, Ashanti, Northern
and Brong Ahafo Regions were all less likely to have used condoms at last sex, compared
with those in the Greater Accra Region. Never-married Ewe women were twice as likely to
have used condoms at last sex, compared to the Akans. While the null models (not shown)
showed that clustering was significant, the loss of effects after controlling for all individual-
level variables means they sufficiently explained heterogeneity in the dependent variable.

Discussion
The behaviour change paradigm has dominated AIDS prevention approaches (Rotheram-
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Borus, Swendeman, and Chovnick 2009). At the heart of this paradigm is the concept of
risk-reduction through personal action. The success stories of Uganda and Zimbabwe,
credited to the behaviour change model, have made this paradigm more popular in the
region (UNAIDS 2008; Rotheram-Borus, Swendeman, and Chovnick 2009). Despite these
successes, the model has been criticised not only for its emphasis on risk groups, but also
its focus on individual agency to the neglect of the broader socioeconomic and cultural
environment (see Maticka-Tyndale and Tenkorang 2010; Tenkorang, Maticka-Tyndale,
and Fernando 2011).
We have argued in this paper that the belief that AIDS can spread through witchcraft
constitutes a major cultural feature that can undermine HIV prevention. Using the
recently collected GDHS, this study investigated how the belief that AIDS can spread
through witchcraft affects engaging in sexual intercourse and condom use. This is
particularly important given that a number of studies have established a theoretical link
between sorcery (Yamba 1997; Ashforth, 2002; Yankah, 2004; Crentsil, 2007),
witchcraft and AIDS prevention in Africa but very few, if any, have established
empirical connections between the two. Among never-married Ghanaian men and
women, we found that the belief that AIDS can be spread through witchcraft is
associated with risky sexual behaviours. Female respondents who believed AIDS can
spread through witches had higher odds of recent sexual intercourse and male
respondents with such beliefs had lower odds of using condoms at last sexual
intercourse. High knowledge about AIDS transmission and prevention however did not
necessarily deter sexual intercourse or contribute to condom use which is somewhat
consistent with findings from other studies (Zellner 2003; Lidell, Barrett, and Bydawell
2006).
The findings raise questions about the efficacy of a prevention model that requires
individuals to consider their fate to be under their own control in settings where such belief
is absent. Generally, they suggest that believing witches spread AIDS may detract from the
sense that one can influence their own fate through behaviour choices, making actions to
reduce risk less likely (Yamba 1997; Heike 2007; Yankah 2004; Liddell, Barrett, and
Bydawell 2006; Hess and McKinney 2007; Wreford 2009). As it stands, never-married
Ghanaian men who believe AIDS is spread through witchcraft may not even know why
they should protect themselves against HIV by using condoms, since it is the malicious
witches who transmit the disease. To this extent, in designing future HIV-prevention
programmes in Africa, policy makers need to consider ideas of disease causation and
aetiology peculiar to the local context (see Awusabo-Asare and Anarfi 1997; Yamba 1997;
Mshana et al. 2006). The findings suggest that it is not enough for policy makers to just
teach the ABC of AIDS prevention but to also deal with the myths that counter such
teachings.
 1010 E.Y. Tenkorang et al.

Ethnic and regional differences related to beliefs that AIDS spreads through witchcraft
are worth noting. In this sample, the belief is higher among female respondents with a
primary level of education, poorer to middle levels of wealth and residing in rural areas.
The belief is more concentrated in the Akan-speaking regions (Central, Western, Eastern,
Ashanti and Brong Ahafo) and is higher among the Akan, followed by ‘other’ ethnic
groups, the Ga Adangbe, those speaking Northern languages and the Ewe, respectively.
The Akan follow the matrilineal kinship system and entrench witchcraft in the ‘dark side
of kinship’ since witches can only cause illnesses such as AIDS to members of their own
kin groups with whom they are bound by common blood ties (Crentsil 2007).
Support for the importance of considering local beliefs and their influence on
prevention behaviours is evidenced in the consistency of the results reported here and rates
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of HIV infection in different regions of Ghana. The Northern, Upper East and Upper West
Regions have consistently recorded the lowest HIV prevalence in the country (see Akwara
et al. 2005; USAID 2008). This is consistent with our finding that men from these regions
are less likely to have experienced sexual intercourse and more likely to have used
condoms at last sex, compared to the Greater Accra Region, which has relatively higher
levels of HIV prevalence. We contrast this with the Brong Ahafo Region where HIV
prevalence is relatively high and our finding that men in this region are more likely to have
had sex. These regional differences in sexual activity may broadly reflect not merely
individual choices, but the cultural norms and values that govern sexual behaviour in
different ethnic groups. The anthropological literature (see Meekers 1992; Addai 1999;
Djamba 2003) notes that societies that are matrilineally structured such as the Akans of the
Central, Brong Ahafo and Ashanti regions tend to report higher sexual activity and lower
condom use compared with their patrilineal counterparts from the Volta, Northern and
Greater Accra Regions. Premarital sexual behaviour tends to be more permitted in
matrilineal societies since lineage formation is considered to be more important than
conjugal ties. Here, children are often considered automatic members of a woman’s
lineage regardless of her marital status (Meekers 1992; Djamba 2003). On the other hand,
the desire to establish paternity in patrilineal societies, leads to proscription of pregnancy
outside of marriage (Caldwell, Orubuloye, and Caldwell 1991).
It is also important to mention that the Northern Region of Ghana has benefitted
immensely from the works of non-governmental organizations (NGOs), some of which
have emphasised issues of sexuality, sex education and HIV prevention. Thus, our findings
of safer sexual behaviours among men in this region compared to those from the South
may be due to the possible influence of programmes rolled out by NGOs in the area of HIV
prevention in the North (Nimo and Wood 2005; Fobil and Soyiri 2006).
This study corroborates others in sub-Saharan Africa that report socioeconomic
influences on safer sex behaviours (Ukwuani, Tsui, and Suchindran 2003; Kongnyuy et al.
2006; Gillepsie, Kadiyala, and Greener 2007; Kongnyuy and Wiysonge 2007; De Walque
2009; Mishra and Bignam-Van Assche 2009; Tenkorang, Fernando, and Maticka-Tyndale
2009). Never-married men in the richer and richest wealth quintiles were more likely to
have sex and use condoms at last sexual intercourse and those with secondary/higher
education were more likely to use condoms. Never-married women in the richest wealth
quintile were less likely to have sex, but more likely to use condoms at last sex, albeit the
coefficient was not significant. With higher education and more resources, men may have
more access to sexual activity and condoms are more within the economic and social reach
of wealthy than poor men and women. For never-married Ghanaian women, being wealthy
and well educated may contribute to empowerment in sexual and condom use decisions.
Thus, from a policy perspective, increasing formal education and creating wealth among
 Culture, Health & Sexuality 1011

never-married Ghanaian women may help empower and improve upon their sexual
bargaining power and self protection.
The need for prevention initiatives tailored towards separate socioeconomic groups is
evidenced in the differences in beliefs about HIV transmission related to levels of
education, wealth and region of residence. This is further supported by the influence of
socioeconomic characteristics on the association between beliefs and prevention
behaviours. The finding that traditionalists are less likely to use condoms at last sex
compared to Christians may also be a reflection of socioeconomic influences since
members of these groups differ in socioeconomic profile (Gyimah et al. 2010).
The study has some limitations worth noting. Questions have been raised about the
reliability of self-report data especially when they are related to HIV/AIDS and sexual
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behaviours in Africa (Cleland et al. 2004; Hewett, Mensch, and Erulkar 2004; Plummer
et al. 2008). This notwithstanding, demographic and health surveys are a valuable source
of information on issues of sexuality, HIV/AIDS and sexual behaviours (Johnson 1991;
Curtis and Sutherland 2004; Obermeyer 2005; Zaba et al. 2009). We also take cognizance
of the fact that beliefs about witchcraft are complex and that the study would have
benefited from using multiple items to measure the complexity surrounding such beliefs.
We worked within the limitations of the DHS data given that a single question was asked
regarding witchcraft and recommend that future surveys incorporate different dimensions
of the construct.
The cross-sectional nature of the data does not allow us to make causal connections
between our independent and dependent variables. Also, guidelines for HIV prevention
stress consistent and regular use of condoms across all sexual encounters. We must be
cautious therefore not to equate condom use at last sex with consistent or regular use of
condoms.

Acknowledgements
We acknowledge the Social Science and Humanities Research Council of Canada and the Canada
Research Chairs programme for providing support for this study.

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Résumé
Les superstitions et la croyance en la sorcellerie sont au centre de nombreuses représentations
africaines sur la maladie et ses causes. Alors que certaines études anthropologiques ont évoqué un
lien théorique entre les croyances et la prévention du VIH en particulier, la possibilité d’une
évaluation empirique de cette association est limitée. En utilisant des données d’une Enquête
Démographique et de Santé conduite au Ghana en 2008, et en nous appuyant sur des modèles logit à
effets aléatoires, nous tentons de vérifier si les croyances selon lesquelles le sida peut se propager par
le biais de la sorcellerie, sont associées aux prises de décision concernant les rapports sexuels, chez
des hommes et des femmes n’ayant jamais été mariés. Les résultats montrent, après contrôle des
autres variables socio-économiques et culturelles, que les hommes qui croyaient que le sida peut se
propager par le biais de la sorcellerie et d’autres moyens surnaturels étaient les moins susceptibles
d’avoir utilisé des préservatifs lors de leur dernier rapport sexuel. Les femmes partageant ces
croyances étaient les plus susceptibles d’avoir eu des rapports sexuels, mais les moins susceptibles
d’avoir utilisé le préservatif lors de leur dernier rapport sexuel. Cependant en ce qui les concerne,
après contrôle de l’appartenance ethnique et de la région de résidence, le lien entre les croyances et
l’usage du préservatif s’est un peu atténué. Les résultats suggèrent que les croyances locales sur les
causes du sida doivent être prises en compte pour l’élaboration des programmes et des interventions
de lutte contre le sida.

Resumen
Creer en la superstición y la brujerı́a es indispensable para muchos conceptos africanos de las
enfermedades, sus causas y su etiologı́a. Si bien en numerosos estudios antropológicos se hace
referencia a un enlace teórico entre tales creencias y, en particular, la prevención del sida, existen
escasas evaluaciones empı́ricas de esta asociación. Con ayuda de datos de la encuesta demográfica y
de salud de 2008 en Ghana y aplicando modelos logit con efectos aleatorios, analizamos si la
creencia de que el sida puede contraerse a través de la brujerı́a está relacionada con las decisiones
sexuales de hombres y mujeres que nunca han contraı́do matrimonio. Aun teniendo en cuenta otras
variables socioeconómicas y culturales, los resultados muestran que los hombres que creı́an que el
sida se podı́a contraer a través de la brujerı́a y otros medios supernaturales eran menos proclives a
utilizar preservativos en la última relación sexual. Entre las mujeres con creencias similares habı́a
más con relaciones sexuales, pero menos que habı́an utilizado preservativos en sus últimas
relaciones. Sin embargo, para algunas mujeres la relación entre tales creencias supersticiosas y el uso
de preservativos era menos pronunciada al tener en cuenta la etnia y la región de residencia. Desde
una perspectiva polı́tica, los resultados indican que, a la hora de elaborar programas e intervenciones
sobre el VIH/sida, deben tenerse en cuenta las creencias locales sobre la causa del sida.

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