Factors Associated with Negative Attitudes towards Albinism and People with Albinism: A Case of Households Living with Persons with Albinism in Lake Zone, Tanzania

Assessment on factors associated with negative attitudes towards people with Albinism was conducted in northern part of Tanzania specifically in regions where higher incidences of albinos’ killings were recently observed. A total of 156 respondents from households living with persons with albinism were involved in this study. Qualitative responses describing attitudes on albinism and people with albinism were transformed into numerical values (using a five points Likert Scales) to allow statistical computation. Measures of association and effect between several independent variables and the dependent variable were done using multiple linear regression analysis. Higher proportion of those interviewed (80%) had negative attitudes towards albinism and people with albinism (PWA). In this study, education level determined attitudes of respondents whereby unfavorable attitudes were highly associated with education level and occupation of respondents (p < 0.001). Relationships between education, attitudes and awareness on albinism confirm the liberalizing effect of education on attitudes and general awareness. Widening the understanding on albinism will help on abandoning cultural beliefs related to albinism and its cause.


Introduction
Attitudes that persons hold about albinism and persons with albinism (PWA) How to cite this paper: Masanja

Methodology
This study involved respondents from households living with persons with albinism in regions where attacks and killings of people with albinism were reported most. Four regions where most of the attacks and killings were reported were included in this study. Four districts (one district from each of the selected regions) were randomly selected. Households with persons with albinism were randomly selected from a list of households with persons with albinism in each of the selected district making a total of 156 respondents. A set of structured questionnaire was used for data collection from heads of households with PWA, people with albinism, and their relatives. The set of questionnaire was used to assess albinism awareness, attitudes towards albinism and PWA. The questions in the questionnaire included albinism awareness and attitudinal tests (for which a five points Likert scales was used).
To ensure validity, the study applied the triangulation technique by using interviews, focus group discussion in which the researcher was used checklist of questions so as to achieve data consistency and completeness and this was done through piloting of the data collection instruments used to collect data. Also in order to ensure reliability the researcher was selected the sample randomly with the help of the local people in the study area.
Data were edited, coded and analyzed using the Statistical Package for Social Sciences (SPSS) for Windows computer software. Descriptive statistics were computed including means, frequencies, percentages, cross-tabulations, and minimum and maximum values of various variables. Levels of albinism awareness among categories of respondents.
Qualitative responses descriptions of attitudes were transformed into numerical values (using a five points Likert scales) to allow statistical computation.
Measures of association and effect between several independent (predictor) variables and the dependent variable were done using multiple linear regression analysis.

Albinism Awareness
The levels of awareness on albinism among PWA, PWA's relatives and Heads of households were determined by administering awareness test to all 156 respondents who fell under different categories. Awareness scores categories were set, in which poorly aware was scores between 0 to 30 scores, while moderately aware was between 31 and 50 scores, aware was scores between 51 and 80 scores and highly aware was scores between 81 and 100 scores. The maximum score on the awareness test was 95 scores and the minimum score was 10 scores. The mean of the scores was 45.2. Table 1 shows that, 50% of those who were poorly aware were Persons with Albinism and 50% were relatives of PWA. Only 12% of those who were highly aware were PWA. Several variables associated with levels of albinism awareness were tested. All the variables, except marital status and number of children with albinism were significantly associated with level of albinism awareness as seen in Table 2.

Level of Albinism Awareness across Various Age Categories
From the results in Table 2, there was significant association between categories of awareness in various age categories (p = 0.004). Among respondents aged below 16 years, 42.9% had poor knowledge and the rest (57.1%) had moderate knowledge on albinism, while those with age above 60 years (33.3% of them) were highly aware and none of them (0.0%) performed poorly in albinism awareness test. Braathen (2005) in a study in Malawi, revealed that in general the community lacks proper information and knowledge about albinism. It was found that albinism was seen as a condition immersed in myths and superstition. According to Lund (2001), lack of knowledge about albinism leads to many superstitions which when combined with poverty magnifies problems related to skin and eyesight. This lack of correct knowledge on albinism, results in myths about albinos being spread which has horrifying effects on the albinos in Tanzania (Stensson, 2008).
According to Allen (2010), the ambiguity and general ignorance surrounding     Lund (2005) as quoted by Moe (2011), it is obvious then that, due to lack of awareness of albinism in general society then it means that teachers and classmates are likely unaware of problems with eyesight and as a result maintain the belief that people with albinism have lower-than-average intelligence. Nzagi (2009) insists that lack of awareness of the condition is not only among those in rural areas, but also trained medical professionals. Thus, PWA's quality of life is severely affected and worsened by the lack of community awareness (Kiprono et al., 2012).

Level of Albinism Awareness among Respondents of Various Status
The results in Table 2 show that there was strong association between albinism awareness and social status of respondents (p < 0.001). Since some household members (PWA's relatives) were also community leaders, they had been purposely capacitated by being given the correct information about albinism as a means of dealing with the problem at community level, and it is obvious that community leaders had either primary school education or secondary education.
Community leaders were involved in intervention to save PWA's lives through community engagement not only in Tanzania but also in other African counties (PHPAFRICA, 2012). UNICEF lauded such measures and it is called on the judiciary, the media, religious leaders, politicians and communities to bolster the response and weed out deeply-rooted superstitious beliefs that incite the murders (UN, 2008). It was critically important to engage communities through community leaders in which albinos lived if stigmatization and discrimination that negatively affect PWA's lives were to be mitigated. This is because murders of PWA are, to a large extent, fuelled by spiritual, cultural and or religious beliefs as well as lack of understanding of the causes of albinism (PHPAFRICA, 2012).

Level of Albinism Awareness among Males and Females
Level of awareness was significantly associated with sex of respondents in which males were slightly more aware of albinism than females (p = 0.017). Relatively poor awareness among females can be explained in the light of gender inequality in African cultural family settings in which women have unequal access to information compared to men (McLin-Bronson et al., 2009). Traditions which ignore women's wellbeing are deeply rooted in African communities which place women at a disadvantage in many aspects. Like in many African traditions, women in rural Sukumaland where traditions still dominate are required to remain silent and besides being unable to demand their rights they rarely have the chance to speak freely and express themselves. While insufficient information and communication network being an obstacle to improving women status, men's attitudes are unsupportive of women's efforts (Rwebangira, 1996

Level of Albinism Awareness and Respondents' Occupation
Respondents who were government employees and religious leaders were more aware than peasants and traditional leaders (p = 0.001). This reflects how they are deeply rooted traditions in the study area among peasants and traditional leaders who are mainly indigenous in the study area. Ignorance, prejudice, traditional beliefs and poverty are what drive people to kill albinos under the influence of witchdoctors and the belief in traditional magic which are still strong in many remote villages (Hogan, 2012). The killings indicate that there are some primitive, superstitious beliefs attached to people in the study area that make some wicked men to continue hunting PWA (Good & Bad Culture, 2012). In general people in this area don't look at the PWA as part of the community but still stand firmly in their traditional beliefs (Aljazeera, 2009).

Level of Albinism Awareness and Respondents' Education Levels
Albinism awareness was highest among those with secondary school education (100%) and those with education beyond secondary school (100%). Two thirds (60%) of those with primary education and those with no formal education (56.6%) had moderate awareness. The association between awareness among groups and different education level was significant (p < 0.001). As a result, many rural areas where most of the killings have been taking place were poor and not able to afford to fulfill their basic things like accessing high and quality education. In these areas, primary level of education was the highest level the majority had reached. Since education plays major role in one's life like creating awareness and knowledge, which helps one to make critical decisions in life, then because of lack of education people become ignorant and involve themselves in inhumane acts (Mtholyoke, 2009). It is obvious then that Tanzania and the international community as a whole need to make serious commitments to raise awareness about albinism. Tanzanians in rural areas where the killings have been taking place mostly need to be educated so that discrimination against and the murder of PWA can stop. Lund (2001) suggests further that, since an understanding of the pattern of inheritance where affected babies are born to two carrier parents would help to counter stories of albinism being a curse placed on a family or evidence of the mother's infidelity then genetic education is sorely needed to improve social integration of this group. Furthermore, Lubus (2010) insists that it is important to educate the entire society which is illiterate and unaware that albinism is a genetic defect that causes a lack of pigmentation in skin, eyes and hair and not the ghost sent to kill community or family members or that PWA contain magic power which can make someone rich.

Level of Albinism Awareness and Respondents' Religious
Affiliation About a half of Christians (48.8%), all Muslims (100%) and more than a half of traditional believers (56.5%) were moderately aware of albinism. However, 26.1% of traditional believers were poorly informed, and 20% of Christians were highly aware of albinism. Statistically, the association between albinism awareness and religion affiliation was significant (p < 0.001). Traditional believers in the study area agreed that use of human body parts in preparations of charms is commonly practised in the area. Albino parts are believed to be the best parts especially the males and females private parts (Lubus, 2010). According to UTSS (2012), the Sukuma (the dominant ethnic group in the study area) traditionally killed their babies with albinism as soon as they were born and baby's remains were used for witchcraft rituals. Therefore, poor awareness among those who believe in traditions reflects what dominates in their mind. According to Tanner (2010), due to beliefs rooted in traditions, PWA used to be killed by groups of Sukuma so that parts of their bodies could be used in the preparation of supposedly protective magic medicines. The medicines could be used to relieve a range of suspected and real misfortunes, ranging from witchcraft to the prevention of rain and the spread of AIDS as well as to increase the possibilities of success. Being largely religious but still adhering to traditions, people are still very rooted in superstitions, that is why Dave-Odigie (2010) observed that public enlightenment strategies to deal with the issue and sensitizing the populace should be strengthened but there is no denying the fact that it will take more than awareness and education to stop superstitions discrimination and stigma against PWA in this area. Table 2 show that there was significant association between respondents of different ethnic groups and albinism (p = 0.025). The Sukuma ethnic group was less aware compared to other ethnic groups in the study area. More than a half (54%) of Sukuma people were moderately aware, being slightly lower than Nyamwezi (50%) who were also moderately aware. Eight percent (8.0%) of the respondents from the Sukuma ethnic group were poorly aware while other ethnic groups had no respondents who were under this category. All (100%) other ethnic groups (i.e. neither Sukuma nor Nyamwezi) were aware compared to Nyamwezi (50%) and other ethnic groups (18.2%). About one-fifth (20.5%) of the respondents from the Sukuma ethnic group were highly aware while none were highly aware from the respondents from other ethnic groups. The association between awareness and different ethnic groups was statistically significant (p = 0.025). This reflects cultural beliefs which may have been an obstacle to the clear understanding of albinism. According to Tanner (2010) the Sukuma ethnic group members were most reported being responsible for the persecution of PWA. Their witchdoctors teach that PWA's body parts, skin, hair and blood, when combined with other ingredients and rituals performed by the witchdoctors and made into potions bring power and wealth to people. One of prominent Tanzanian newspapers, The Guardians on Sunday (IPPMEDIA, 2012) reported as follows:

Level of Albinism Awareness and Respondents' Ethnic Groups
"Dozens of Albinos are killed mainly in Sukumaland, in north-west Tanzania because of the belief that parts of their bodies could be used in the preparation of supposedly protective 'magic' medicines which could be used to relieve a range of suspected and real misfortunes, ranging from witchcraft to the prevention of rain and the spread of AIDS as well as increasing the possibilities of success …" The killings are said to be due to witchdoctors in this area who require PWA's body parts which are believed to provide the potent ingredient for magic charms, which many local people use believing to prosper (BBC, 2008). The beliefs, being held by the majority in the study area, affect clear understanding of the scientific facts of albinism.

Assessment of Attitudes towards Albinism and PWA
In determining level of attitudes among interviewee, a five points Likert scale including strongly disagree, disagree, undecided, agree and strongly agree was used to measure attitudes towards albinism and PWA.

Respondents' Attitudes towards Albinism and PWA
The five point scales were summarized to make three scales. Half of the statements in the Likert scale had negative connotations while the other half had positive connotation. The most negative attitude was represented by 20, the neutral attitude was represented by 60 and the most positive attitude was represented by 100. The range of points for negative attitude was 20 to 59; and that of points for positive attitude was 61 to 100.
The results showed that, over four-fifth (80%) of respondent had negative attitudes towards albinism and PWA, 9% had positive attitudes and 11% were undecided. Like in other communities across the world, albinism is hardly understood in this area too. Due to negative attitudes towards albinism and PWA, many women have been divorced by their husbands and shunned by families after giving birth to children with albinism (Kiprono et al., 2012). They have been accused of sleeping with men of other races, of being cursed and unclean, and of being witches thus abandoned by spouses and isolated in their communities (Wilkinson, 1998). Children with albinism have also been hidden from the public, forbidden from socializing with others and treated as outcasts (Thuku, 2011).
During data collection, it was obviously observed that, due to negative attitudes towards PWA, they seemed not to trust anybody (including neighbors and community leaders), not confident and felt inferior beings. One respondent (a person with albinism) dared to tell us that: "I don't believe that I could sit and talk to any educated people. We are normally mistreated by our brothers and sisters who see us as useless and inferior beings …" Due to negative attitudes towards PWA, derogatory names for persons with albinism were commonly used in the study area. It is obvious that such names lead to prejudice and stereotypes which lead communities to condemn PWA basing on their condition rather than appreciating their humanity. Due to negative attitudes, PWA suffers rejection by the community, denial of the right to found families and killings done for a purpose of getting their body parts. These pose serious impacts on their psychological and economic status. Negative attitudes in these regions may be due to what historically happened in the past among the Sukuma in response to albinism. Children with albinism were instantly killed at birth for fear of shame attached to the condition or beliefs that they carry bad luck, in some cases birth of a child with albinism resulted into marital discord, leaving children without proper parental care (Rohwerder, 2018;UN, 2016).
Due to such attitudes towards albinism, then it seems that in the study regions, murders went on unreported for a long time and thus there is no reason to believe that it has ended (Jozen, 2012). Since the killings are due to witchcraft beliefs which has been a potent force in African life for a long time and goes far back into prehistoric times it thus continues today, not only among primitive people, but also among the civilized (Nemec, 1974). It is then obvious that it is difficult to detach Africans still committed to their traditional religions from cultures that existed before the coming of Christianity and Islam (The Citizen, 2011).
Five variables were tested using chi-square statistical test to determine their association with attitudes towards albinism and PWA. The results are summarized in Table 3. Education and type of work showed significant association with attitudes towards Albinism and PWA. However, attitude had no significant association with age, type of respondent, religion and sex. The result confirms the relationship between education and attitudes in which there is liberalizing effect of education on attitudes (Ohlander et al., 2005). This shows that, education can help in changing people's attitudes.

Association between Respondents' Education Level and Attitudes
towards Albinism From the results in Table 3, all who had not gone to school and 88.7% of those with primary school education had negative attitudes towards albinism and PWA. More than two-thirds (68.8%) of those with secondary education and 50% of those with education above secondary education had positive attitudes towards albinism and PWA while 50% of those with education level above secondary education, 31.25% of those with primary education and few (9.57%) of those with no formal education could not express their attitudes. Attitudes towards albinism and PWA were highly associated with education level of respondents in which those with no formal education had negative attitudes which decreased with the increase in education level (i.e. 100% with no education, 88.7% with primary school education and 0.0% among those with higher education levels). The association of attitudes with education levels was statistically significant (p < 0.001).
Ignorance makes people to discriminate against each other, thus awareness and education are the keys to overcoming discrimination (BBC, 2006). Ohlander et al. (2005 insist that the relationship of education and attitudes is not a spurious one but there is obvious liberalizing effect of education on attitudes. This  suggests that negative attitude of the community is to change as people know more about albinism and PWA. Then widespread dissemination of accurate information about the genetics and health management of albinism is relevant measure to counter the many myths and misconceptions surrounding albinism and PWA (Lund, 2001). Murders of albinos are, to a large extent, fuelled by spiritual, cultural and or religious beliefs as well as lack of understanding of the causes of albinism. Stigmatization and discrimination obvious affect lives of PWA and their families. Behavior like the killing of PWA and old women regarded as witches can be traced from the way socialization processes take place and might have been in favor of many cultural backgrounds which lead to illusory correlations (Tanner, 2010). In this case Sukuma beliefs that magic "medicines" containing human body parts are correlated to relief of serious personal misfortunes will be possible to be declared scientifically impossible and socially irrelevant.

Association between Respondents' Occupation and Attitudes towards Albinism
The findings show that, while all (100%) traditional leaders had negative attitudes towards albinism, 87.69% of peasants had negative attitudes too (Table 3). Only Government employees had a slightly higher proportion of respondents (42.11%) who had positive attitudes towards albinism and PWA. Traditional leaders were equally divided in which 33.33% of them had negative attitude and the same had positive attitudes and 33.33% remained undecided. This shows a high proportion of traditional leaders and peasants having negative attitudes while Government staff having positive attitudes towards albinism and PWA. Such findings are very painful experience for PWA who actually would need physical expressions of love, care, interaction and acceptance from the whole community. Lund & Gaigher (2002) explain the negative attitudes towards PWA as unhappy consequence for PWA being labeled as socially unacceptable and that people's stigma can come to dominate the perceptions that others have.
Negative attitudes among traditional leaders and peasant confirm the fact that negative attitudes toward albinism reflect a general lack of information and a degree of negativism in a respective community (Estrada-Hernández & Harper, 2007). Though traditional healers are mostly blamed to be behind the killings, traditional leaders are also said to be behind the killing of children with albinism secretly as far as the killings are related to culture and traditions which traditional leaders are custodians of. Sukuma traditions demanded killing of babies with albinism as soon as they were born and baby's remains were used for witchcraft rituals (UTSS, 2012). Traditional leaders were keen enough to see that people adhere to traditional norms so as to keep the community safe from angry gods. During data collection, a person with albinism was thankful for her late mother for refusing to kill her once she was born in their rural village in 1977.
The mother was several times instructed by her neighbors and traditional leaders to fulfill the requirement of Sukuma culture by burying her child alive or throwing her in a river since she was an unwanted child in the community. Being a devoted Christian she refused to commit the offence. Such practices are said to be practiced in rural areas of Tanzania as the Daily News (2011) wrote: "In rural Tanzania, in the past, newborn albinos were sometimes killed right after birth. Although the practice is less common in most parts of Africa today, it is still practised in some rural areas, according to the Tanzanian Albino Society (TAS)." Though those who were government employees showed some degree of positive attitudes, they are not capacitated enough to change their attitudes. With expectation that government employee might be knowledgeable enough and thus have positive attitudes, The Daily Mail (2011) reports that: "Teachers, nurses and our government leaders don't know enough about albinism. We need education campaigns …" According to Dave-Odigie (2010), greater accessibility to education in the nation's rural areas could play a crucial role of moving people away from various forms of irrational beliefs that help drive the ritual practice of killing albinos for their body parts. However, it will take more than awareness and education to stop superstitious discrimination and stigma because such beliefs are deep-seated in African traditional culture and religion and may be held to some degree even by more highly educated individuals (Anderson, 2004).

Conclusions
Awareness (knowledge) on albinism among family members is moderate. Categorically, awareness is poor among those with lower or with no formal education while awareness increases with increase in age categories and formal education level. Males seem to be slightly more aware than females. The study shows that, awareness is highly associated with religious affiliation and ethnic groups of respondents. Attitude towards albinism and PWA is poor, the problem is highly associated with high level of illiteracy. Relationships between education, attitudes and awareness confirm the liberalizing effect of education on attitudes and general awareness on community related issues.

Recommendations
Since illiteracy is the main force behind the beliefs and attitudes towards albinism and PWA. A policy for a long time solution should be formulated to insist on awareness of pupils on albinism from lower schools levels. This will comparatively increase understanding on albinism condition which is lacking among people with low level of education. Awareness on albinism should be accompanied with socialization of children with positive attitudes towards PWA. This will ensure having a nation with positive attitudes towards PWA as well as to other people with other forms of disabilities. This will widen the understanding of albinism and will help young people not to hold on cultural beliefs on the cause of the condition.