J Relig Health DOI 10.1007/s10943-014-9932-1 ORIGINAL PAPER

Engaging African American Faith-Based Organizations in Adolescent HIV Prevention Briana A. Woods-Jaeger • Mamie Carlson • Tamara Taggart Linda Riggins • Alexandra F. Lightfoot • Melvin R. Jackson

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 Springer Science+Business Media New York 2014

Abstract To reduce current HIV disparities among African American youth, it is imperative to find effective ways to extend the reach of evidence-based HIV prevention. One promising community resource to support this effort is faith-based organizations (FBOs), a credible and respected resource in the African American community. This paper describes the experiences, perceptions, and challenges that African American FBOs and faith leaders face in engaging in adolescent HIV prevention and highlights facilitators and barriers to implementing HIV prevention in African American FBOs. The findings suggest that African American FBOs and faith-based leaders are uniquely positioned to be instrumental resources in reducing African American youth HIV disparities. Keywords African American adolescents
Community-based participatory research
Faith-based organizations
HIV/AIDS

B. A. Woods-Jaeger (&) Developmental and Behavioral Sciences, Children’s Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA e-mail: [email protected] M. Carlson Department of Community and Behavioral Health, University of Iowa, Iowa City, IA, USA T. Taggart Department of Health Behavior, University of North Carolina, Chapel Hill, NC, USA L. Riggins
M. R. Jackson Strengthening the Black Family, Inc., Raleigh, NC, USA A. F. Lightfoot Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC, USA

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Introduction The HIV/AIDS diagnoses disproportionately affect African Americans, who account for 44 % of new infections each year, despite representing about 14 % of the US population (Centers for Disease Control and Prevention 2011). African American adolescents (age 13–19) account for 69 % of HIV/AIDS diagnoses, yet represent 15 % of this age group population in the United States (Centers for Disease Control and Prevention 2012). In North Carolina (NC), African Americans comprised 67 % of the cumulative reported cases of AIDS up to 2007 compared to 28.1 % among Whites (Centers for Disease Control and Prevention 2010), and in Wake County, home of the state’s capital city, Raleigh, African Americans have represented 58 % of the total HIV cases despite accounting for only 20.5 % of the total population (Wake County Community Health Assessment 2006). These stark disparities underscore a need to couple effective health promotion programs with community resources in order to produce interventions that are culturally relevant and sustainable within African American communities. One promising community resource for African American adolescent HIV prevention efforts is faith-based organizations (FBOs) (Moore et al. 2012; Francis and Liverpool 2009; Coyne-Beasley and Schoenbach 2000). Black Churches have been regarded as central institutions in the African American community and have a long tradition of promoting social service and development among African Americans (Coleman et al. 2012; Taylor et al. 1987). Historically, Black Churches have been involved in youth development programs and support the development of religiosity, a demonstrated protective factor for youth risk behaviors (Francis and Liverpool 2009). Often described as gatekeepers to FBOs, African American faith leaders are highly regarded in their communities and may have a significant role in the success of community health interventions for African Americans (Chatters et al. 1998). Faith leaders also value their role as health advocates and are often asked to intervene in the personal lives of their congregants during the times of trouble (Taylor et al. 2000; Timmons 2009). Hence, African American FBOs and faith leaders have the potential to increase the effectiveness of HIV prevention programs. Faith-Based Organizations and HIV: Barriers and Facilitators The African American Church has also had a significant role in championing the adoption of a variety of health programs and behaviors including physical activity and weight loss (Kim et al. 2008; Whitt-Glover et al. 2008; Wilcox et al. 2007), cancer screenings (Campbell et al. 2004; Husaini et al. 2002; Duan et al. 2000), and disease management (Dodani et al. 2011; Samuel-Hodge et al. 2009; Davis-Smith et al. 2007). Despite the success and longevity of many of these health promotion programs, many African American churches have been reluctant to participate in HIV prevention (Nunn et al. 2012; Francis and Liverpool 2009). Their response to HIV prevention has been hindered by stigma, low perception of risk among congregants, in addition to moral judgment about homosexuality, pre-marital sex, and substance abuse (Harris 2010; Hatcher et al. 2008; Fullilove and Fullilove 1999). Although the response of African American churches to HIV in the Black community is mixed (Fulton 2011), there has been a recent increase in their engagement in HIV prevention activities, suggesting that the African American church remains a viable resource for promoting HIV prevention within the Black community (Wooster et al. 2011; Berkley-Patton et al. 2010). Previously identified barriers to engaging FBOs and faith leaders in HIV prevention include the concern that many congregations and leaders are unable to overlook the moral

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implications of HIV/AIDS or face larger denominational or organizational constraints to engaging in comprehensive HIV prevention activities (Cunningham et al. 2011; Coleman et al. 2012). Additionally, religious stigma associated with HIV-related risk behaviors and discomfort with discussing sexual health in sacred or faith settings has also been identified (Sutton et al. 2009; Coyne-Beasley and Schoenbach 2000). Despite many noted barriers, several factors have been identified in the literature to facilitate engaging African American FBOs and faith leaders in HIV prevention efforts. These include congregational and leadership support for HIV prevention activities, access to culturally sensitive HIV prevention materials, and training and support on how to implement community health promotion programs on sexual health (Coyne-Beasley and Schoenbach 2000; Cunningham et al. 2011; Hicks et al. 2005). Further, specific to faith leaders, facilitating factors include enhancing individual agency to introduce discussions of sexuality and HIV prevention into church activities and sermons, recognition of HIV as a major issue in their community, and knowing a relative or close friend who is HIV positive (Coleman et al. 2012; Foster et al. 2011; Moore et al. 2012). Recent research demonstrating African American faith leaders are supportive of adolescent HIV prevention and are increasingly implementing HIV prevention efforts within their congregations (Pichon et al. 2013; Williams et al. 2011) supports greater focus on understanding their potential role in HIV prevention. Participatory methods have been shown to be successful in engaging African Americans in church-based settings by increasing intervention uptake, improving design and fit of interventions, and promoting program ownership (Campbell et al. 2007; Summers et al. 2013). In particular, partnership approaches are advocated in implementing HIV prevention in faith settings (Derose et al. 2014; Steinman et al. 2005; Wingood et al. 2011), and several researchers have engaged in a community-based participatory research (CBPR) approach to develop and implement interventions in African American FBOs, specifically engaging faith leaders throughout the process (Berkley-Patton et al. 2010; Griffith et al. 2010; Williams et al. 2011). Using a CBPR approach, we explored African American faith leaders’ experiences and perceptions of the role FBOs and faith leaders can play in HIV prevention to obtain an understanding of barriers and facilitators to engaging the Black Church in Wake County, NC, in HIV prevention efforts. This study was formative work for a larger CBPR study that aimed to implement and evaluate an evidence-based HIV prevention intervention, Focus on Youth (FOY) ? ImPACT (Informed Parents and Children Together) (Lightfoot et al. 2012), and propose adaptations to increase cultural relevance for African American faith-based settings (Lightfoot et al. 2014). This study involved a partnership between Strengthening The Black Family, Inc. (STBF), a community-based organization in southeast Raleigh, NC, whose mission is ‘‘to improve the quality of life for families in Wake County and beyond with a special emphasis on Black families’’ and researchers from the University of North Carolina at Chapel Hill (UNC). STBF has played a leadership role for several decades in youth HIV prevention in Wake County and has a strong existing relationship with UNC.

Methods For this formative research study, we conducted semi-structured interviews with 20 African American faith leaders in order to capture the experiences, perceptions, and challenges FBOs and faith leaders face in engaging in adolescent HIV prevention programs. These interviews took place in the spring and summer of 2011, and were carried out

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by a team of community and academic interviewers familiar with the culture and customs of the Black Church. Three interviewers were community members affiliated with STBF or the larger study’s Community Advisory Board (CAB), a diverse group of community stakeholders with a variety of perspectives and experiences related to HIV prevention. The CAB consists of 35 members, including youth aged 13–18 (25 %) and adults (75 %). Adult community members of the CAB include educators, youth service providers, faith leaders, and retired professionals interested in youth and health. Other adult members represent local agencies such as county social services, the public school system, faith organizations, HIV/AIDS service providers, a local community center, a health care entity, and two local public officials. The group includes several adult members living with HIV and one parent of an HIV-positive child. The other two interviewers included the principal investigator (PI) for this formative study and the project coordinator for the larger CBPR study, a community member with strong connections in the local faith community. The interviewers were assigned to participant interviews based upon the availability, with the goal of meeting our participants’ most preferred interview time and place requests. Community interviewers were formally trained in the interview process, including certification in human subjects research through UNC’s Institutional Review Board, which also approved the study protocol. Faith leaders were recruited from a convenience sample of five churches in the community of focus. The churches ranged in congregation size, from very small (less than 40 members) to mid-size (less than 300) to large (approximately 1,500 members) to very large (over 2,000 members). Two of the five churches are Baptist, while the other three are nondenominational. All five churches have a youth ministry, and four of the five have a health ministry. An information sheet describing the study was provided to all potential participants as identified by the project coordinator. An effort was made to recruit at least three different types of faith leaders from each church to provide a greater diversity of faith leader perspectives. This was followed up by a face-to-face process of recruitment, building on personal connections at each church. All potential participants identified by the project coordinator who expressed interest were interviewed. The project coordinator oversaw this process with each church to ensure that no one felt coerced to participate and that they understood their rights as research participants. Semi-structured interviews were conducted at the churches, homes of the participants, or STBF office. All interviews were audio-taped and transcribed verbatim by the interview team. Faith leader interviews lasted between 60 and 90 min. The semi-structured interviews included open-ended questions to explore (1) the role African American faith-based organizations (FBOs), and faith leaders can play in HIV prevention; (2) the barriers and facilitators to engaging African American FBOs in HIV prevention efforts. In particular, interview questions focused on African American faith leaders’ values, beliefs, and experiences and their relation to adolescent HIV prevention and theology, Biblical principles, and church activities and services for adolescents in African American FBOs that promote health. The interview guide was developed by the community–academic research team and revised based on the feedback from the larger study’s CAB as well as the community interviewers hired to conduct the faith leader interviews. In addition, participants completed a brief demographic questionnaire (age, gender, religious denomination, length of time at church, marital status, and parental status) and a modified version of the Perceived Community Support Questionnaire (PCSQ; Herrero and Gracia 2007). The PCSQ is a 14-item measure comprised of three scales that assess three dimensions of community support: community participation, community integration, and community organizations. Responses are rated on a 5-point scale from (1) strongly

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disagree to (5) strongly agree. The measure was modified to measure faith leaders’ perceptions of community social support for youth church members, by modifying each question to ask about ‘‘youth in my congregation.’’ The demographic questionnaire and PCSQ were analyzed in SPSS to generate descriptive statistics for the sample. Qualitative data were analyzed using a CBPR approach involving academic and community partners. Academic and community partners engaged in conventional content analysis (Hsieh and Shannon 2005). A coding team comprised of the PI, project coordinator, and graduate research assistant read all transcripts and notes. This coding team developed a descriptive coding scheme based on what emerged from the transcripts. The project coordinator and graduate research assistant then coded each transcript using this coding scheme. They then met with the PI to review quotations for each code and began identifying recurring themes in the interviews. Recurring themes were shared with the CAB for the larger CBPR project, and feedback from these discussions was incorporated to further define and describe themes. Themes related to the role African American FBOs and faith leaders can play in HIV prevention and barriers and facilitators to engaging African American FBOs and faith leaders in HIV prevention efforts are presented in the results.

Results Twenty faith leaders were interviewed. Over half the sample (55 %) was male and the majority was married (60 %) and had children (75 %). Faith leaders’ age ranged from 22 to 76 years, with a mean age of 46.7 years. Participants were self-identified as Baptist (40 %), Christian (25 %), non-denominational (20 %), and Pentecostal (15 %). Faith leaders represented a broad range of roles within their church. Almost half of those interviewed were church pastors (45 %), while other roles included church leadership such as deacons and committee members (35 %), Bible study teachers (10 %), paid church staff (5 %), and an active church member (5 %). Length of affiliation with one’s current church ranged from 3 to 34 years, with a mean of 17.9 years. Faith leaders reported varying levels of focus and involvement in HIV prevention activities within their church. Overall, faith leaders interviewed perceived that youth in their congregation have high community integration, participation, and organizational support with an average on each subscale that is above previously used standards indicating high support (i.e., Jimenez et al. 2009). Further research with a larger sample is needed to determine whether this represents the larger congregations’ perceptions of the level of community support for youth in their congregation. Demographic information and PCSQ means and standard deviations are presented in Table 1. Themes Related to Facilitators Three themes emerged related to factors that facilitate successful engagement of African American FBOs in HIV prevention efforts. These themes included The Church as a Trusted Resource, Church Call, and Biblical Guidance. These facilitating factors uniquely position faith-based settings to implement successful HIV prevention activities (Table 2).

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J Relig Health Table 1 Demographics of faith leaders and perceived community support %

N

Male

55

11

Female

45

9

Gender

Marital status Single

25

5

Married

60

12

Separated

0

0

Divorced

15

3

Widowed

0

0

No children

25

5

Children in the household

40

8

Children outside of household

30

6

5

1

Non-denominational

20

4

Christian (unspecified denomination)

25

5

Baptist

40

8

Pentecostal

15

3

Pastor

45

9

Church leader

35

7

Bible study teacher

10

2

Parental status

Children both in and outside the household Religious denomination

Role within the church

Staff

5

1

Congregation member

5

1

M (SD)

N

PCSQ total

3.74 (.40)

20

Community organization

3.85 (.62)

20

Community participation

3.75 (.41)

20

Community integration

3.58 (.42)

20

Perceived community support

‘‘The Church as a Trusted Resource’’ Faith leaders identified African American FBOs as a trusted community resource and provider of health information and educational services/programs. There’s always someone here who can help them understand what’s going on with their bodies… And it’s totally confidential. And we have a, a line that’s drawn, because you know, there’s some things we can’t tell them unless the parents are involved. But the parents know that we’re not going to, to give the children any information to their detriment.

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African American faith leaders and FBOs have a calling or responsibility to address the needs of the congregation and broader community The call to assist in ‘‘raising up a child’’ is prominent in FBO mission statements and activities

Biblical principles are often the foundation for HIV prevention among African American FBOs. These principles inform their approach to mentoring and engaging at-risk youth Biblical principles shape health messages and guide dialogue regarding HIV risk Biblical stories and excerpts are commonly used to connect church principles with desired youth behavior

Church call

Biblical guidance

Silence regarding HIV within the African American community was commonly identified as barrier to HIV prevention Two forms of silence were described by faith leaders An overall aversion to talking about HIV in the home, the community, and within the Black Church Limited FBO sponsorship of prevention messages and activities, often attributed to limited HIV knowledge and experience within the faith community

Faith leaders commonly cited the tension between evidence-based comprehensive approaches to HIV prevention and faith-based beliefs regarding abstinence as a common challenge to making decisions regarding their role in HIV prevention Questions commonly named by faith leaders include (1) whether or not to engage in HIV prevention, (2) whether a comprehensive or abstinence approach should be used, (3) how FBO sponsored prevention messages should frame risk and protection

Faith leaders expressed feeling discouraged and overwhelmed with the task of counteracting a highly sexualized contemporary society Faith leaders highlighted that youth are inundated by a broad range of messages, imagery, and interpersonal pressures/ interactions in their daily lives that establish and reinforce norms that promote risk-taking behavior

Silence surrounding HIV

Tension between comprehensive HIV prevention and church teachings

Unhealthy pressures/influences that encourage risk-taking

Barriers

African American faith-based organizations (FBOs) are commonly viewed as a trusted community resource, particularly as a source of health information and services/programs FBOs are settings that provide mentors, role models, and opportunities to strengthen positive social networks and prosocial norms, which are known to reduce HIV risk among youth

The church as a trusted resource

Facilitators

Table 2 Common themes and findings

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Faith-based organizations and faith leaders were also identified as a source of guidance, through trusted adult mentors and role models assisting youth as they face difficult life challenges. One faith leader illustrated the significance of trust, experience, and advice in these relationships as: Give them a mentor they could talk to, somebody with young people that, somebody they can trust, that they can talk to openly, without anybody knowing all over the community that he or she is doing this [laughs] he or she has done that. And those mentors, they pretty much give them Biblical advice and as well as they can share their own testimonies, ok I’ve been there done that. This statement also suggests that the FBOs and faith leaders see themselves as creating a safe space for open dialogue and respecting confidentiality. This results in trust and comfort, which are critical when addressing sensitive health topics such as HIV/AIDS. A statement by another faith leader illustrates the level of perceived trust of adults within one faith-based context as: Actually our director took a little survey with our youth about how comfortable or trust worthy they feel adults are versus their friends and they actually felt that adults were more trust worthy, that they actually trust adults more than they trust their friends. Another faith leader stated that I think one of the ways that our church has been successful with that is having the right people involved with the youth. Because it takes a special person to really know how to talk to young people and keep them listening. I would say. So, you know, not that you can necessarily choose a wrong person. But, they seem to have chosen people who are good with young people. And I think that’s what helps keep the ball rolling with that program. In addition to providing trusted adult mentors and role models, faith leaders indicated that faith-based settings provide opportunities for youth to strengthen their social network by connecting with peers and trusted adults through various activities and events. These opportunities may be in the form of structured programs such as mentoring programs, Bible study, and sports groups, but also through informal activities such as church-sponsored luncheons and dinners. These existing structured and informal activities present an opportunity to build on protective factors for sexual risk behavior that already exists in the church (e.g., prosocial engagement, and connectedness) to support specific HIV prevention initiatives. ‘‘Church Call’’ During the interviews, faith leaders expressed that African American FBOs have a calling or responsibility to address the needs of the congregation and the broader community through their mission and activities. Faith leaders often associated this calling with providing a church environment that promotes healthy decision making among youth, including avoiding HIV risk. FBO strategies most commonly described for reducing youth HIV risk included being a source of factual information and fostering safe spaces for questions and open dialogue regarding sex and HIV/AIDS. Participants often acknowledged that HIV prevention efforts required educating both youth and their parents. One faith leader stated that

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To just stay abreast on what’s going on (regarding HIV), and put some things out there for them. Some literature maybe, some pamphlets, or whatever… And not just for the children, but for the adults too. Health-focused events and activities were the most commonly described strategy for providing health education, such as the family centered event described by one faith leader as: We actually had planned this event. It was a family event… Where we had HIV classes and you know, just so you can be aware of what’s going on and you know, how to properly put on a condom and stuff like that. In addition, multiple participants described how creating an open and non-judgmental atmosphere assists HIV prevention efforts by encouraging youth to talk to adults about sex. One faith leader stated that We address it (HIV prevention) head on, you know … Like our pastor is very open, so if someone has a question about sex, like a lot of pastors, like our youth feel comfortable going to our pastor. Or they’ll come to me. You know what I’m saying. I mean, I’ll let them know whether they, you know they need condoms or what not. Because I’d rather them be safe than sorry, you know…I’d rather them not have it (sex). But the fact is they’re having it (sex). You know what I’m saying. Whether you want to talk about it or not, they’re having it. So, I mean, I might as well educate them. So one, they’d know for themselves and then they could educate somebody else. In addition to these specific strategies described for reducing youth HIV risk, faith leaders discussed the importance of expressing positive expectations of youth and providing youth support to meet those expectations in the present and in the future as a way to support them in avoiding HIV risk behavior and making healthy decisions. Raising up kids in the way they should behave and what they should know about certain things. It’s about not selling them short, and giving the information they need to survive, to go out and for the future to live today and tomorrow. They got to learn it and I believe we at the church, we are believing in them that we are trying to train them to do just that. ‘‘Biblical Guidance’’ Multiple faith leaders described the use of Biblical guidance for addressing youth HIV risk. As expressed by one faith leader, ‘‘I believe they should be nurtured and should be taught Biblical principals, I believe, about how to live, how to act.’’ Biblical principles were often described as the foundation for health and other messages that they share with youth. So it speaks of moderation. Cause certainly Christ partook of wine, but they took it for stomach sake, medicinal purposes or whatever, but they also speak of not overindulging in anything. Wine is a mocker, it will use you, you know, it will trick you if you’re not, and it, it will use you, and it will influence you in the wrong way. He who is deceived by it is a fool. So, I think those passages of scripture certainly teaches that God speaks to everything that exists in life, finance, money, relationships, marriage, sexual promiscuity, everything. How to dress, you know, how to

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relate to others, you know. There is nothing that, you cannot find in scripture, that does not give some type of lesson toward a rule of conduct. Faith leaders often use Biblical stories and excerpts as a starting point for discussion that connects church values with youth behavior including sexual behavior. One faith leader described using stories in the Bible to facilitate discussion regarding current external pressures and influences: All the pressures and influences of the world is in the Bible. I mean, you just have to read about it. We’re just open about it, and answer any questions, and just teach that, I mean, how could you avoid that. Faith leaders in our study consistently discussed the relevance of Biblical teachings to HIV prevention and provided examples of how they have integrated that into their HIV prevention messages. Further, Biblical guidance was not only used by faith leaders to shape health messages related to risk and behavior, but also to influence how faith leaders engaged youth. Many faith leaders indicated that Biblical principles and scripture often shaped faith leaders’ approach to mentoring. One pastor stated that When Christ taught the disciples, he didn’t say, well, I want you all to be just like me … He always taught them that they wanted to do better, to strive for highs, and deeper depths, and greater things. And that’s what we try to instill in our youth as well. Just because we did those things, they were mistakes. And instead, we learned to learn, to abstain from our mistakes. We’ve come to be a better people. So we choose you all to be that greater. Many faith leaders described Biblically grounded health promotion as an approach where physical, spiritual, and emotional health intersect. As stated by one participant, ‘‘Healthy youth means a youth that takes care of their body physically, mentally, spiritually, and does the best that they can to be healthy.’’ Such an approach facilitates a more holistic approach to health and HIV risk reduction among youth. One faith leader expressed as: A healthy youth, number one, physically healthy. One that is taken care of. One whose body is developing normally. One whose mind is developing normally. One that has exposure to the goodness of God. One that realizes that there is nothing that they can go through that God would not help them with. They need that spiritual life to be totally healthy. Faith leaders expressed the importance of active engagement with sensitive and challenging topics including HIV/AIDS. Biblically based health promotion builds upon African American FBOs’ sense of responsibility to its members and broader community, as described above, and focuses upon current and varied needs of the community including HIV prevention and sexual health. One faith leader nicely summed up this idea: And so by understanding that we have to put ministries together that will address the needs of our people. And understanding that when people come into the church they come with all types of needs and concerns and failures. Themes Related to Barriers Faith leaders identified three primary themes related to barriers to HIV prevention implementation in faith-based settings. These themes include silence surrounding HIV, (2)

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tension between comprehensive HIV prevention and church teachings, and (3) unhealthy influences and pressures that encourage risk-taking. ‘‘Silence Surrounding HIV’’ Silence surrounding HIV was a prominent barrier identified in our analysis. Participants expressed the need for open and honest dialogue and education regarding HIV risk and prevention among youth and the broader church community, and some gave examples of this taking place within their congregations. However, many faith leaders described an overall aversion to discussing HIV within the community, in the home, and also in the Black Church, as expressed by this interviewee, ‘‘but it’s such a closeted thing, I mean, no one wants to talk about, especially in an African American church, for some odd reason.’’ Limited knowledge and experience regarding HIV prevention was described as an inhibiting factor related to HIV prevention health education messages and activities sponsored by FBOs and faith leaders. One faith leader expressed how this could lead to silence regarding HIV prevention within a faith community: There’s just been a void in that area, I’ve been in this particular church where I am for almost 16 years that’s an area that we just don’t know a lot about. There hasn’t been seminars or we haven’t had people come into talk about it to the church so it’s a big sort of void and I think it’s something that’s really needed. The church needs to be more involved in that process. Another participant further expressed this perspective by stating What we don’t do enough of is the whole thing on sex education, sexually transmitted diseases, HIV/AIDS, there has not been a lot of influx of information given to the youth in the church about that subject, it’s a void there … the church community has to tackle that because the young folks don’t know a lot about it … over the years the church community has done a lot with abstinence part, but you got to know about, you gotta know the bigger picture too, it’s not just you know, safer sex is to abstain. This example suggests that abstinence-only messaging is an additional form of silence within African American FBOs in addressing HIV risk. By not presenting the ‘‘big picture’’ or a more comprehensive HIV prevention message, FBOs and faith leaders may miss an opportunity to meet the needs of many youth. The importance of FBOs providing such information to youth was echoed throughout many interviews. However, the exact role of FBOs in providing HIV prevention activities continues to be debated. ‘‘Tension Between Comprehensive HIV Prevention and Church Teachings’’ Faith leaders often described a tension between comprehensive HIV prevention and what was appropriate or aligned with church values, teachings, and beliefs regarding abstinence. Many faith leaders acknowledged the barrier this tension presents to the implementation of HIV programs in FBOs. Faith leaders discussed the challenge of deciding whether to address HIV risk within the context of faith-based settings and determining what programs, if any, should be implemented and what health messages would complement traditional teachings.

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We have struggled trying to determine whether or not telling folk the proper way is condoning (sex) … How, how does the church encourage safer sex, versus no sex. We know it’s going to happen for the most part. So then, what do we say? Do we stick our heads in the sand and act like it’s not happening or do we address, ok, if you’re going to do this, this is what you need to do… Many faith leaders recognized that some youth are engaging in sexual activities and suggested that faith leaders need to address the informational gap often found in faithbased settings. Participants cited sexual risk behavior research and statistics as an indication of the need for church-sponsored HIV prevention and a justification for more comprehensive HIV prevention efforts. As one faith leader stated, ‘‘Well, research says that a lot of the young folks, they’re involved (in sexual behaviors) so you have to do a little more than say just don’t do it.’’ Although many faith leaders expressed that abstinence messages are in alignment with Biblical teachings and beliefs, they also acknowledged the need to go beyond abstinenceonly messaging to provide necessary information to youth at risk. Abstinence, abstinence, and more abstinence. And, if they’re not abstinent, then they need to practice safe sex. You know, letting them know what is available to them, to keep themselves safe. To keep them, to keep themselves from becoming HIV positive, so, that’s what I would say to that. Decisions regarding HIV prevention efforts in faith settings are complex and involve many considerations. FBOs and faith leaders must decide how to present prevention messages and frame risk and protection. Questions regarding whether to address issues such as appropriate condom use or to include factors that shape decision making, such as interpersonal relationships and religiosity, were often unresolved. One faith leader illustrated this by stating that I think that you get on very touchy and sensitive ground when you ask the church to promote safe sex and to hand out condoms and to do things like that because it does go against the foundation of faith for the church. It doesn’t mean that the church doesn’t believe in safe sex you know, it does believe that should happen, but our main focus is to help children understand relationships, and understand the importance of the sexual relationship and just, you know where trust is a part of that, you know, the emotional and spiritual aspects of it, not necessarily, but if you want to have sex, make sure you put a condom on … So although I’m definitely for educating our youth, and you know, helping them understand what they’re choices lead to, I’m not necessarily convinced about some of the ways that we do that in society and that we try to get the church to do. ‘‘Unhealthy Influences and Pressures that Encourage Risk-Taking’’ Faith leaders highlighted that youth encounter a range of unhealthy or negative interpersonal pressures, messages, and interactions in their daily lives. Faith leaders viewed such influences as a significant challenge to HIV prevention and other health promotion activities. Participants identified multiple sources of information that promote sexual activity and other risk-taking behaviors such as television and music. Being inundated with television and media with sexual situations. They are appealing to them at an earlier age. It used to be where sexual advertisements where directed

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toward adults and it was understood adult thing. Now you have children who have sexually explicit lyric in their music and they are not even 18. Faith leaders indicated the importance of addressing the negative pressures and messages that are embedded in the broader culture that youth currently live in. I think the culture that the adolescent youth are in, that’s a challenge to our youth today to, to come away from just what everybody else is doing and live healthy, mind, body, spirit, and soul. And the church’s responsibility is to do more of that with the youth and I think we’re working on it, but there’s a long way to go with that. In addition, many leaders attributed sexual risk-taking to living in a context where children are exposed to sex early in life. There are still aspects of life that children need to grow into naturally, but at three, four, five, six years old, they’re, they’re exposed to sex rather than growing into it naturally. So then by the time they reach puberty, they know it all. And that’s the cause of it. And, you know, peer pressure. And just the, the media in general. Peers were also identified as potential sources of negative influence on youth health behavior. As one participant suggested as: So they’re just sort of out there on their own and they just fumbling through trying to figure out do I go here, or do I do what this person, my peer, is saying I should do or do I go and talk to my parent. Many faith leaders expressed that the desire to fit in is what makes peer influence so strong. As one pastor stated, ‘‘Peer pressure, is I think is the biggest challenge that they have. Because youth just like, they just like to belong, to feel like they are part of something.’’

Discussion This study sought to characterize the role African American FBOs and faith leaders can play in HIV prevention and identify barriers and facilitators to engaging them in HIV prevention efforts. The Black Church has a long history of engaging in health promotion programs; however, many FBOs have not been active in addressing HIV and sexual health in their communities. Their inaction highlights the importance of identifying barriers and facilitators to addressing sexuality and HIV in faith settings. Our study supports many factors described in the literature as barriers to HIV prevention in African American faith-based settings in an urban, southern city. In particular, silence about HIV, tensions between comprehensive HIV prevention and Church teachings, and youths’ exposure to unhealthy influences and pressures are perceived as barriers to addressing HIV and sexual health in these faith-based settings. Religious stigma associated with HIV-related risk behaviors and discomfort with discussing sexual health are barriers that have been identified in previous studies (Sutton et al. 2009; Coyne-Beasley and Schoenbach 2000). Youths’ exposure to unhealthy influences and pressures, described by many of our participants as overwhelming, is an additional barrier that presents an important context for churches to consider in their approach to HIV prevention. This is in line with scholars who have highlighted the importance of the Black Church ‘‘taking into account sociohistorical and material circumstances’’ in their approach to sex and sexuality

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(Cuffee 2007). To address these barriers, it is imperative to work in partnership with faith leaders and FBOs to enhance the response to HIV/AIDS among African American youth and collaboratively develop culturally sensitive prevention materials that align with church teachings and values as well as address current youth needs and social context. Despite several barriers, our study also revealed many strengths and facilitators, including the role of FBOs and faith leaders as trusted resources, their call or mission to serve the African American community, and the use of Biblical guidance for addressing youth HIV risk. These facilitating factors support conducting HIV prevention in faithbased settings, building on the specific strengths of African American FBOs. The historic role of the Black Church as an essential component of the social, civic, and political activities in the Black community (Thomas et al. 1994; Billingsley 1999) uniquely positions African American FBOs to build on their foundation of community trust and strong tradition of responding to community needs to respond to the current HIV disparities facing African American youth. Importantly, the emphasis on the role Biblical principles can play in HIV prevention was particularly strong and an important contribution of this study. Biblical principles were described as the foundation for youth HIV prevention messages and Bible stories, and excerpts were identified as tools for beginning a conversation with youth that connects church teachings and values with youth risk behavior prevention. Faith leaders described seeking Biblical guidance not only in framing health messages related to risk behavior, but also in guiding their general approach to youth. This is especially important as there is often a perception that HIV prevention contradicts church values and teachings, and this suggests instead church values and teachings grounded in the Bible can provide a strong and comprehensive foundation from which to approach HIV prevention and break the silence around sex and sexuality often present in the church. In addition, it is notable that many faith leaders in our study already engaged in discussions and education about HIV risk and prevention. This is in line with previous studies with African American FBOs that have demonstrated the potential of faith leaders comfortably delivering HIV prevention messages and skills (Pichon et al. 2012). Our study took a CBPR approach to better understand facilitators and barriers to engaging African American FBOs in Wake County, NC, in HIV prevention efforts. Through exploring African American faith leaders’ experiences and perceptions of the role of faith-based organizations in HIV prevention, we uncovered important challenges to address as we work to adapt an evidence-based HIV prevention intervention, FOY ? ImPACT, to increase its relevance for African American faith-based settings. These challenges include silence about HIV, tensions between comprehensive HIV prevention and church teachings, and youths’ exposure to unhealthy influences and pressures. Monitoring and addressing barriers such as these throughout the implementation process is recommended as they will likely influence intervention uptake, feasibility, and sustainability. In addition to highlighting important challenges, our study emphasized the numerous strengths of African American FBOs that can facilitate the implementation of evidence-based HIV prevention. Respect and attention to the role of faith leaders as trusted resources and the Church’s mission to serve the African American community are critical strengths in partnering with African American FBOs in HIV prevention. Recognizing and building upon these strengths is recommended to enhance the effectiveness of HIV prevention efforts. Further, it is imperative to work with faith leaders to incorporate Biblical guidance in adapting evidence-based HIV prevention programs such as FOY ? ImPACT to African American faith-based settings. There are some limitations to the current study. In using a convenience sample and purposively identifying specific faith leaders to recruit, we may have limited the variability

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in our sample. Faith leaders who agreed to participate may have different views than those who were not approached. It is possible that those who have stronger beliefs and views against HIV prevention or less awareness and experience with HIV prevention were missed. Building upon this study, we recommend future studies explore the influence of lack of awareness, experience, and training on implementation of HIV prevention among FBOs as previous studies suggest these factors play a role (Pichon et al. 2012). In addition, our sample excluded youth within the congregations sampled. Future studies focused on gaining the youth perspective on facilitators and barriers to engaging African American FBOs in HIV prevention efforts are critical. Despite these limitations, our study findings indicate that FBOs can be instrumental resources in African American communities for addressing adolescent HIV prevention and provide important insight into factors that are important to address when implementing HIV prevention in faith settings. Our findings illustrate there is diversity of opinion, experience, and approach within African American FBOs, which can provide both opportunities and challenges to navigate. Some of our participants provided examples of active engagement with HIV prevention within African American FBOs and shared their awareness and knowledge of facts and research related to HIV/AIDS among African American youth. However, other participants highlighted general avoidance of discussing HIV, limited knowledge about HIV prevention, and a narrow HIV prevention approach that consists of abstinence-only messages with African American FBOs. We recommend respecting the diversity among African American FBOs, approaching each FBO with cultural humility and engaging in a process of working toward a shared vision of how to eliminate HIV disparities among African American youth.

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