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Program Brief

A Collaborative HIV Prevention and Education Initiative in a Faith-based Setting

Aaron, Erika, MSN1; Yates, Lucy, EdD2; Criniti, Shannon, MPH3

Author Information
Journal of the Association of Nurses in AIDS Care: March-April 2011 - Volume 22 - Issue 2 - p 150-157
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Faith-based organizations can play a critical role in reaching out to African American communities to deliver HIV prevention programs. These organizations can be an important partner in HIV prevention efforts and in decreasing stigma so as to prevent the spread of HIV through HIV testing services, education, and awareness activities in their communities (Wells, Ford, McClure, Holt, & Ward, 2007). Faith-based organizations have multiple strengths that can augment the success of an HIV prevention initiative: they often have an active congregation of members who are willing to participate in church-based programs; they are respected within their communities and have social capital and credibility among members; They can influence their members and help to decrease stigma within the community; and they play an important role in the lives of youth members and have the potential to reach out to the youth outside of their communities (Francis & Liverpool, 2009). However, collaborations between faith-based organizations and public health and HIV medical institutions have been underused in HIV prevention programs.

In 2006, the U.S. Office of Minority Health awarded a grant to a partnership of three organizations based in Philadelphia to develop and implement a Minority Community Health Partnership HIV/AIDS Demonstration Project in Southwest Philadelphia and Eastern Delaware County. The three organizations (referred to collectively throughout those article as the “Partnership”) consisted of a faith-based organization affiliated with a 1,200-member historic African American Baptist church, a community-based maternal health organization, and an HIV medical clinic affiliated with a university. The Partnership was created in part because of the long working history of the community-based maternal health organization with the HIV medical clinic through client referrals, and through the provision of services in the neighborhood of the congregation. The maternal health organization was aware of the interest of the faith-based organization in working to increase awareness and decrease stigma of HIV in the community.

The primary goal of the program was to increase the capacity of all three organizations to address the HIV epidemic by providing education, increasing awareness, and decreasing the stigma of HIV. This article focuses on the efforts of the Partnership to expand the faith-based organization’s capacity to decrease the stigma of HIV and increase HIV education and awareness in the community through a series of educational workshops and events.

Background

Historically, African American churches have had wide-reaching institutional power within their communities and have acted as a locus of community organization for African Americans (Lincoln, 1990). These churches have been an agent for social reform, responding to different circumstances and problems confronting their communities (Billingsly, 1999). The African American church has historically taken the lead in addressing important health issues affecting African Americans, such as heart disease and breast cancer awareness (Francis & Liverpool, 2009).

More recently, faith-based institutions have recognized a need to combat the stigma related to HIV that has been prevalent in many African American spiritual communities (Beckley & Koch, 2002). Historically, religious communities have associated HIV-infected people with sin and shameful lifestyles (Dixon, 1994). Because HIV disease has become a worldwide crisis disproportionately affecting minorities, many African American churches have abandoned this attitude and have worked to bring messages of education, prevention, treatment, and hope to their constituents (Francis & Liverpool, 2009). The National Coalition of Pastors’ Spouses (NCPS) reported that in the past, some churches and other faith centers ignored the issue of HIV. Recognizing that silence by faith-based leaders has not stopped HIV from spreading, this organization has encouraged congregations to address the behaviors that put people at risk for getting HIV. This organization recognizes that African American leaders of faith have consistently been at the forefront of major social movements in the United States, and that they can play an integral role in shaping and directing the issue of HIV in the African American community (NCPS, 2007).

Although considerable progress has been made in reducing the effect of the HIV epidemic, racial and ethnic minorities continue to bear a disproportionate burden (Centers for Disease Control and Prevention [CDC], 2006). In the United States, African Americans account for 50% of newly diagnosed cases of HIV, with case rates among African American men and women seven and 21 times higher as compared with that for White men and women, respectively (CDC, 2007). Within Philadelphia, the concentration of AIDS cases in the minority population is striking: among the reported AIDS cases, 65.4% are African American, 23.1% are Caucasian, and 10.1% are Latino (Ross-Russell, Agha, Law, & Getahun, 2009).

On the basis of these devastating statistics and the high rate of HIV in their community, the leadership and members of the African American Baptist church and it{L-End} 's affiliated faith based organization, Neighbors to Neighbors Community Development Corporation, recognized the need to place the church in a leadership position to promote HIV awareness and prevention, and to help decrease the stigma of HIV in the community. The health ministry of the congregation, whose membership consisted of nurses, social workers, health care providers, and educators, had consistently expressed an interest in promoting HIV awareness in the community. The leader of the faith-based organization, a member of the governing body of deacons in the church, strategically selected two key members from the church’s health ministry, whose experience and dedication were invaluable to the success of the Partnership. They included a nurse with a doctoral degree in education and a health care worker with experience as an HIV testing counselor. These representatives both had extensive experience working in health care programs, substantial social and leadership recognition within the community of their faith, and a history of leadership positions in the church-based health ministries. The Partnership presented the opportunity to expand the capacity and build upon the strengths of the church and the faith-based organization to address the issue of HIV in their community and attempt to reduce the disproportionate effect of HIV.

Program Description

The National Black Nurses Association community collaboration model was used to gain participant support. This model proposes that nurses—in collaboration with individual and organizational partners—can influence healthy behaviors among individuals and communities (Bolton & Georges, 1996). This model postulates that individuals are more likely to accept preventive health strategies if they receive support from community stakeholders and health professionals.

The demographic area of the project was a high-risk neighborhood in Pennsylvania. This region has the sixth highest number of AIDS cases in the United States, with 35,489 cumulative AIDS cases reported through 2007 (Kaiser Family Foundation, 2007). In Philadelphia, the 2006 estimate was 1,400 new HIV infections for a case rate of 114 new HIV infections per 100,000, which is five times the national rate and 1.6 times the rate in New York City (Ross-Russell et al., 2009). Of the four counties making up the Philadelphia Eligible Metropolitan Area, Delaware County—where the church was located—represented the highest number of cumulative AIDS cases.

Each organization had appointed representative members with expertise in various complimentary programmatic areas to collaborate on the design, execution, and evaluation of the HIV prevention programs. A nurse with a doctoral degree in education and a long history of working with church members on various health issues and a nurse practitioner specializing in the care of adults with HIV infection, including pregnant women, were included in this group of representatives. Other members included program administrators, researchers, community outreach specialists, and public health experts. The Partnership developed and implemented HIV education interventions targeted to minority adults and adolescents in the community. In addition, an HIV testing event in the church and special Sunday sermons that focused on decreasing the stigma of HIV, attempted to decrease stigma and increase awareness in the church and the community.

In recognition of the importance of securing buy-in and assistance of several key stakeholders in the church community, the Partnership requested and obtained full support from the pastor. The pastor granted permission for and promotion of educational sessions on HIV geared toward adults and adolescents in the congregation. He delegated selected ministry leaders, including the chair of the board of deacons, to place emphasis on HIV awareness events during the church’s Sunday services. He invited a Partnership representative to speak to the congregation directly from the pulpit during a Sunday service to describe the goals and objectives of the Partnership. This message emphasized the importance of addressing the issue of HIV in the church, decreasing stigma, and promoting acceptance of those with HIV within the community. The Partnership also submitted an article to the church bulletin and posted flyers around the neighborhood to solicit community interest in the events and activities. These efforts helped to gain congregational support of the Partnership’s activities in the church.

Through formal and informal interviews with congregants and key leaders, and through several focus groups, the congregation identified the following two areas of need: (a) targeting adolescents and parents as specific sub-groups of the congregation that they believed could benefit from increased education efforts, and (b) holding an HIV testing event to promote increased knowledge of community members’ HIV status, to show support for individuals and families affected by HIV, and to decrease the stigma of HIV-infected individuals within the congregation.

In response to the congregation’s request, the Partnership provided several basic educational workshops on HIV to adults. The main objective of the workshops was to increase knowledge about HIV, including an understanding of HIV transmission and prevention, as well as information about disease progression and treatments. The guidebook, HIV/ AIDS: A Manual for Faith Communities, written and published by the NCPS in collaboration with the U.S. Department of Health and Human Services, was adapted into lessons to meet the needs of the constituents of the congregation. A facilitator with a background in HIV education was hired to lead the workshops. The curriculum was developed with input from nurses and health educators from each of the organizations in the Partnership, the facilitator, ministry leaders from the congregation, and from focus groups and interviews. The curriculum outline was reviewed by the pastor and his advisors to get full approval from the leadership and to ensure cultural and ethnic sensitivity.

A total of 42 adults participated in six separate workshops. The workshops included didactic education sessions through lectures, powerpoint presentations, group activities, role playing, and videos. The HIV Knowledge Questionnaire, consisting of 18 true or false questions about HIV, was administered before and after each workshop and was used to measure short-term changes in the knowledge of the participants (Carey & Schroder, 2002). The questionnaire consisted of statements about HIV, such as “People who have been infected with HIV quickly show serious signs of being infected” and “Taking a test for HIV 1 week after having sex will tell a person if she or he has HIV.” Correct answers averaged 75% in the pretests for the adult workshops, and increased to 88% average correct answers immediately after the workshops. Overall, there was an average 17% increase in correct answers, a 17% decrease in incorrect answers, and a 92% rate decrease in “don’t know” answers after the workshop (Table 1).

Table 1
Table 1:
Average Knowledge Change in Adult and Adolescent Workshops

A separate four-part HIV education and skill-building intervention for adolescents was also organized in response to community request. The intervention held at the church used an abbreviated version of an HIV curriculum specifically designed to reach African American youth called Rap It Up. Black Entertainment Television (BET) and the Kaiser Family Foundation partnered on Rap It Up, a public information campaign addressing HIV and related issues among African Americans. The purpose of this curriculum was to dispel popular myths and misconceptions, reduce stigma and discrimination, and increase HIV testing. The curriculum included lessons on general HIV knowledge, risk reduction, values and self-identity, self-esteem and self-respect, negotiation skills, media messages, support networks, empowerment, and social change. The workshops included lectures, role-playing, group activities, and videos. A total of 27 adolescents between 12 and 21 years old participated in at least one of the scheduled sessions and 16 completed all four lessons in the education series. Attendance increased slightly at each subsequent session as word of mouth spread to other teens, and the program facilitators made every effort to be flexible to accommodate the teens’ interests and schedules. For example, some participating teens had to leave in the middle of one of the sessions to attend basketball practice, but then rejoined the group afterwards.

Changes in the knowledge among adolescents in the adolescent education series were also evaluated using the HIV Knowledge Questionnaire, which was distributed at the beginning and end of the four-part series. According to the pretest, the teens overall started out with a relatively low level of HIV knowledge, with only 42% average correct answers in the pretests. An analysis of mean pre- and post-test scores of adolescent knowledge demonstrated an average 71% increase in correct answers, 31% decrease in incorrect answers, and 64% decrease in “don’t know” answers (Table 1). When asked to name two resources that they would use to find answers to questions or concerns about HIV or STDs, the adolescents’ top answers in descending order were the Internet, school, and clinic/doctor/parents/family (tied).

In addition to the workshops, an HIV testing and education event at the church was planned and executed. Approval and support were again obtained from the pastor, who agreed to sponsor a well-known outspoken visiting pastor from New York to deliver a sermon promoting a call-to-action for the community and congregation to increase HIV awareness and acceptance of HIV-infected community members and to decrease the stigma of HIV. The HIV Awareness and Testing Day was held on National Black HIV/AIDS Awareness Day in February 2008 and took place directly after the church’s morning services. At this event, 12 certified, experienced HIV counselors and nurses were recruited from six community-based organizations, including two of the partner organizations and three local AIDS service organizations, to perform HIV testing. Nurses from the community organizations assisted with the testing. A total of 145 parishioners and community members were screened for HIV that day; of those who opted for a rapid HIV test, 100% received their results within 20 minutes. Of those who preferred a conventional test, 100% received the results at a 2-week follow-up visit. There were no positive results.

Discussion

The National Black Nurses Association Community Partnership Model advocates collaborations between consumers, health providers, faith-based organizations, and government agencies to effect change that will improve the health status of individuals and communities (Bolton & Georges, 1996). Faith-based organizations—and particularly large centers of worship—have the resources, networks, and social capital to play a major role in HIV prevention efforts (Agate et al., 2005). We report on a project whose success was due to several factors: (a) the strong commitment of the pastor, key leaders, and the congregation, which had a commitment to decreasing the incidence of HIV in the community; (b) the collaboration between a church-affiliated faith-based community organization, a university-based HIV medical clinic, and a community-based maternal health organization that allowed the sharing of each organization’s strengths to make the project successful; (c) involvement of the faith-based community and the target population in design, implementation, and program evaluation; and (d) a strong commitment from the Partnership to present culturally appropriate prevention messages.

Other programs have reported similar results. In a survey of faith-based leaders, Howard Moon found that most respondents were passionate about the issue of HIV, as most had been personally and deeply touched by the epidemic. They reported being “called to the work” and recognized that they had a significant role to play as advocates and healers in their respective communities. (Brown, Howard, Parara, Seele, & Mugarura, 2004). The Broward County Churches United to Stop HIV, Florida-based collaboration of faith-based programs, has provided HIV prevention programs to 32,000 people and trained nearly 3,000 faith leaders, as well as provided technical support to several other churches (Agate et al., 2005). Agate et al. (2005) stressed the commitment of the pastor and congregation as key to successful HIV prevention efforts. The authors recommended offering HIV testing on-site at the point of contact to reduce missed opportunities and strengthen the link between education and services.

In a survey of 35 African American church leaders, one third listed HIV as a priority health issue for adolescents in their churches, 73% reported providing some education on HIV to adolescents, and 97% reported a willingness to discuss HIV with adolescents (Francis, Lam, Cance, & Hogan, 2009). In total, 85% of leaders responded that they would participate in HIV prevention activities, whereas 75% said they would be willing to lead HIV prevention discussions with their communities.

A review of faith-based HIV prevention programs in African American communities found the following five key elements to successful programs: involving community members in program design, execution, and evaluation; designating a church liaison with interest and experience in HIV prevention activities; designing programs on the basis of compassion and spirituality rather than fear or judgment; using culturally competent programs and materials; and developing a sense of ownership within the faith-based organization to gain support and participation (Francis & Liverpool, 2009). All of these strategies were incorporated into our Partnership and greatly contributed to its success (Table 2).

Table 2
Table 2:
Strategies for Working With Faith-based Organizations for HIV Education and Prevention

The Partnership between the three organizations described was developed to increase each organization’s capacity to address the disproportionate effect that HIV has had on the African American community. The intended outcome of the Partnership was the development of new initiatives in a faith-based setting to educate members on the disproportionate effect of HIV on minority populations and to reduce the social stigma of the illness. The success of this project was due to the development of a joint venture that coordinated HIV education, prevention, and screening efforts and increased the capacity of each organization to address the issue of HIV in a faith-based community. This was done through activities that were ethnically and culturally relevant, medically accurate, and age-appropriate to each target population.

Workshops were tailored to the congregation’s needs and demonstrated an increased knowledge among the congregation about HIV prevention. There is some evidence that tailored education interventions can show effectiveness in decreasing risk behaviors such as reduced likelihood of unprotected sex among participants (Kennedy, Mizuno, Hoffman, Baume, & Strand, 2000). Recent national public health activities have focused on expanding HIV testing and prevention efforts into minority communities to help address the racial disparities that persist in HIV infection rates (Schlaff, 2005). The HIV testing event at the church was organized in response to increased interest among church members and leaders. After that event, the faith-based organization reported having increased numbers of congregants approach them with questions and confidential issues related to HIV. The church is now being seen as a resource for HIV-related issues and education by other faith-based organizations and churches.

The leadership of the church affiliated with the faith-based organization in our project has profoundly changed their approach to HIV since the early 1990s, when efforts to plan HIV education in the church were initially denied. The effect of HIV’s devastating and disproportionate effect on African Americans has subsequently changed this view. The congregation’s youth leaders and key adult ministry leaders supported education programs and consistently provided important input throughout the planning process for all of the activities. Integrating HIV education activities into the church’s bustling schedule—including holiday events, religious observances, meetings, choir practices, and the activities of other ministries and community activism—as well as the other partner organizations’ business, fiscal, and academic priorities and obligations within the timelines promised in the grant was often a challenge. The participation and support of congregation members contributed significantly to the events’ success.

Several challenges were faced by the Partnership in setting up this program. The Partnership, which had a collaborative model of leadership, needed to accept an autocratic leadership style in the church. Having respect for the ways decisions were made by the church helped develop cultural sensitivity within the group. Discussions were held consistently within the Partnership to develop racial and cultural sensitivity. The Partnership recognized that race and cultural competency must be acknowledged and discussed throughout the partnership process. Howard Moon reported that establishing a common mission and respecting the religious beliefs of others were important in building effective interfaith collaborations (Brown et al., 2004).

Conclusion

Because of the disproportionate effect that HIV has on African American communities and the strong role the church plays in this community, faith-based organizations are in a strategic position to implement HIV prevention programs. There is a need for innovative prevention programs and collaborations that include faith-based organizations, public health, and HIV-care organizations as part of prevention efforts. Through the use of the National Black Nurses Association community collaboration model, our Partnership used nurses, other health care personnel, and community members in collaboration with the organizational partners to influence healthy behavior among individuals and communities (Bolton & Georges, 1996). The Partnership was successful in obtaining support from the pastor and other key congregation ministries and stakeholders, and collaborating with local community organizations and medical facilities involved with HIV care.

Stigma, discrimination, and fear continue to be barriers to HIV prevention. Collaborations between faith-based organizations, public health, and HIV medical institutions are needed to help alleviate these barriers. The reported project results are encouraging and lend support for a larger, multisite, research design to assess replicability by other faith-based community groups that would like to increase HIV education and decrease stigma in their congregations.

Clinical Considerations

  • To increase the number and capacity of a community-based minority serving organization and a faith-based community organization to address the HIV epidemic, measures must be used by providing education, increasing awareness, and decreasing the stigma of HIV.
  • The socio-cultural barriers to HIV treatment can be decreased by increasing the number of individuals seeking and accepting HIV testing services, by developing and implementing HIV prevention interventions, and through educational efforts targeted at minority populations.
  • The National Black Nurses Association community collaboration model can be used to gain support of individual and organizational partners to influence healthy behavior among individuals and communities.
  • Securing support and assistance from the pastor and other key congregation ministries and stakeholders, and collaborating with local community organizations and medical facilities involved with HIV care can lead to successful promotion of HIV educational programs in a faith-based organization.
  • Tailored interventions and curriculums that are developed for the needs of a specific community can demonstrate effectiveness in the increased knowledge about HIV prevention among the people.

Disclosures

The authors report no real or perceived vested interests that relate to this article (including relationships with pharmaceutical companies, biomedical device manufacturers, grantors, or other entities whose products or services are related to topics covered in this manuscript) that could be construed as a conflict of interest. Ms. Aaron has no conflicts of interests and no relevant financial relationships to report. Dr. Yates has no conflicts of interests and no relevant financial relationships to report. Ms. Criniti has no conflicts of interests and no relevant financial relationships to report.

Acknowledgments

This study was supported by the U.S. Office of Minority Health—Minority Community Health Partnership HIV/AIDS Demonstration Grant.

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Keywords:

faith-based organization; HIV education; HIV prevention; HIV testing

© 2011Elsevier, Inc.