Examining Church Capacity to Develop and Disseminate a Religiously Appropriate HIV Tool Kit with African American Churches

Abstract

Increasingly, African American churches have been called upon to assist in efforts to address HIV/AIDS in underserved communities. African Americans churches may be well-positioned to provide HIV education, screening, and support services, particularly if they are equipped with church-appropriate, easy-to-deliver HIV tools that can be implemented through the naturalistic church environment. To inform the development of a church-based HIV tool kit, we examined church capacity with African American church leaders (N = 124 participants; n = 58 churches represented by senior pastors). Nearly all participants (96%) wanted to learn more about HIV and how to discuss it with their parishioners. Regarding church capacity, most of their representative churches held three regular services each week, facilitated various inreach and community outreach ministries, and had paid staff and computers. Also, many of their churches facilitated HIV/AIDS education/prevention and adolescent sex education activities. Guided by church capacity findings, an ecological framework, and a CBPR approach, we describe the resulting church-based HIV Tool Kit that “fits” naturalistically within a multilevel church infrastructure, builds upon churches' HIV-related experience, and equips faith leaders to efficiently promote HIV services with the communities they serve.

Introduction

African Americans continue to be disproportionately burdened by HIV. In 2009, African Americans accounted for half of all new HIV cases, although they only comprise 13% of the US population.¹ They also tend to enter HIV treatment at advanced stages of the disease and tend to die from AIDS-related diseases sooner than Whites.^2,3 Clearly, effective HIV education, prevention, and screening intervention strategies that are translatable, scalable, and sustainable are needed to have a public health impact on HIV rates in African American communities.

Public health efforts have increasingly focused on developing community-based HIV interventions that can enhance reach of HIV services beyond traditional medical locations to settings where African Americans live, work, and socialize—including the Black church (churches primarily serving African Americans).^4,5 For example, the CDC Heightened National Response to Address the HIV/AIDS Crisis Among African Americans strategic plan includes a call for African American faith leaders to assist in promoting HIV awareness, prevention, and screening with their church community members.⁴ Also, the National Black Clergy for the Elimination of HIV/AIDS Act of 2009 was introduced to Senate to support Black churches with resources to coordinate church-based HIV services.⁶

The Black church has long been recognized as an influential institution with a rich history of mobilizing communities for social change and with many organizational assets (e.g., stable memberships, large volunteer bases, outreach ministries).⁷ Moreover 50% of African Americans report weekly church attendance.^8–10 Building on these strengths, Black churches have the potential to promote and increase the reach of church-based HIV interventions with many more African Americans. Increasingly, studies have reported on HIV interventions in African American churches.^11–16 Yet, challenges related to church capacity issues (e.g., lack of HIV training, time, and church-appropriate HIV materials) and controversial church topics (e.g., condom use, premarital sex, homophobia) have also been reported as barriers to churches' delivery of HIV interventions.^17–20

Despite the calls for Black churches to help fight HIV and the growing numbers of church-based HIV studies, few reports exist on the availability and utility of church-based supportive tools that build on church infrastructure capacities, address controversial HIV-related issues, and equip faith leaders to efficiently promote HIV awareness, prevention, and screening. This gap in availability of supportive HIV tools for Black churches prompted a collaborative effort to develop a church-based HIV tool kit that could be: (a) built on church leaders' interest and experience in addressing HIV, (b) aligned with church tenets and traditions, (c) embedded in existing church infrastructure, (d) delivered by church leaders, and (e) connected with health and research organizations for sustained, scalable reach with African Americans. The resulting HIV tool kit became the foundation of Taking It the Pews (TIPS), an African American church-based HIV education and screening project.

The Taking it to the Pews Project: Conceptual and Theoretical Background

The TIPS project was first initiated in the Kansas City (KC) metropolitan area in 2006 and then replicated in Montgomery, AL churches beginning in 2010. Born out of the Black (now National) Church Week of Prayer for the Healing of AIDS in KC initiative, TIPS has been guided by a community-based participatory research (CBPR) approach²¹ through collaborative efforts led by Calvary Community Outreach Network (CCON), a faith-based nonprofit organization focused on improving the quality of lives of individuals and families with innovative community programs. Other collaborators included Black churches, health organizations, and the UMKC Psychology Department Community Health Research Group. The TIPS project, fully described elsewhere,¹² was developed in response to KC faith leaders' reported barriers to carrying out HIV education and screening in their churches including lack of training, easy-to-use/religiously appropriate materials, and financial resources. To address these barriers from a faith-based perspective, our CBPR approach engaged faith leaders in all phases of the TIPS project from identifying the research aims to project development, implementation, evaluation, and dissemination.

Along with a CBPR approach, the development of the TIPS project was guided by the socio-ecological model.²² This model posits that behavior change becomes attainable and sustainable for more people when barriers are reduced and supportive, capacity mechanisms are built through multilevel interventions that have overlapping influence on individual, group, organizational, and community level factors. This model intersects with research interest in models of HIV intervention strategies that are designed to be multilevel, build capacity, and be context-driven, culturally appropriate, and sustainable through ongoing community engagement.²³ Consistent with these approaches, development of the TIPS project resulted from ongoing engagement of faith leaders in examining church culture and capacity to develop and implement a religiously appropriate, multilevel, church-based HIV intervention.

Central to developing the TIPS project was the creation of a church-based HIV Prevention, Compassion, and Action Tool Kit, which started with 17 tools and simply became known as the TIPS HIV Tool Kit. The TIPS HIV Tool Kit includes materials and activities that primarily address HIV education, screening, prevention, and stigma. A TIPS project case study in the KC area found that it was highly feasible to implement.¹² Ten TIPS churches, with an average of 200 members each, delivered about two TIPS tools per month over a 9-month period with over 3,400 church/community members exposed through church services and outreach activities in the case study. Members with increased exposure to TIPS tools were significantly more likely to have positive beliefs about the church addressing HIV, fewer HIV-stigma beliefs, increased encouragement from church members, and greater intentions to get tested for HIV.

The TIPS HIV Tool Kit currently consists of more than 40 tools and includes tools that focus on youth protective sexual behaviors.²⁴ Also, the TIPS project has been implemented in 25 churches and has been used with over 8,000 congregants and community members. Here, we fully describe how the examination of church capacity—including church leaders' HIV interest, stigma, knowledge, and HIV testing history—guided the development and dissemination of the church-based TIPS HIV Tool Kit using a CBPR and ecological approach.

Methods

Participants

A convenience sample of 124 African American church leaders participating in one of four CCON-sponsored health ministry training and capacity building conferences and events in KC completed the 10–15 min survey on church capacity. Participating church leaders were provided with consent information about the study prior to completing the survey. The University of Missouri-KC IRB approved this study.

Survey of Church Capacity

Church leader demographics (e.g., age, number of years as member, role in the church) were assessed. To determine the availability of church leaders to deliver a church-based intervention, frequency of church attendance was measured with one item (How frequently do you attend church?) using an 8-point Likert scale ranging from never to once a day. Church leaders' interest in learning more about HIV and how to prevent it with their churches (Yes/No) and whether they had ever received an HIV test (Yes/No) was assessed. Five items measured HIV-related stigma (e.g., concerned about being treated differently if tested positive for HIV; comfortable sharing a pew with someone who has AIDS) using a 5-point Likert scale (e.g., 1 = strongly not concerned to 5=strongly concerned; 1 = strongly agree to 5 = strongly disagree) adapted from the national survey by Herek at al.²⁵ on HIV stigma. HIV knowledge was measured with ten items (True/False/Don't Know); True responses were summed for a knowledge score. Survey items on churches' organizational characteristics included: church demographics (e.g., denomination, membership size), infrastructure (e.g., number of staff, types of worship services and ministries, digital projectors), outreach activities (e.g., afterschool programs, food/clothing pantries), and participation in HIV activities (e.g., HIV education, HIV screening, condom distribution). Data analysis was conducted using SPSS 18.0.

Results

Church Leaders

Among approximately 160 African American church leaders attending health ministry training events sponsored by CCON, 124 (78%) completed the survey on church capacity. The majority of the church leaders were male (65%) and aged 50 and older (63%), as shown in Table 1. Senior pastors were highly represented (47%), and most had 21 or more years of pastoral experience. Most of the church leaders were Baptist (72%) and 86% attended church at least twice a week. Nearly all (96%) wanted to learn more about HIV and how to discuss it with their members. Overall, 67% of church leaders had been tested for HIV in their lifetime. The mean HIV knowledge score was 7.15 (SD = 1.83). The most commonly missed questions were: (1) a condom should be completely unrolled before it is placed on the penis and (2) a person can get HIV by giving blood. Regarding HIV-related stigma, 64% of church leaders were concerned about discrimination if they tested HIV-positive.

Table 1.

Characteristics of African American church leaders and their churches

Church leader characteristics (N = 124)	N (%)
Gender
Male	81 (65.3)
Female	43 (34.7)
Age (years)
18–24	3 (2.4)
25–39	18 (14.5)
40–49	25 (20.2)
50–65	54 (43.5)
66 or older	24 (19.4)
Leadership role in church
Senior pastor	58 (46.8)
Pastor's spouse	4 (3.2)
Assistant/Associate pastor	10 (8.1)
Church staff member	13 (10.5)
Ministry leader	15 (12.1)
Deacon	5 (4.0)
Teacher (Sunday School or other)	8 (6.5)
Other (e.g., Trustees, Ushers)	11 (8.9)
Tested for HIV ever	83 (66.9)
HIV-related stigma
Comfortable sharing a pew with someone who has AIDSa	106 (85.5)
Trust scientists and doctors to tell the truth about AIDSb	99 (79.8)
Concerned about being treated differently due to HIVc	80 (64.5)
HIV-positive persons responsible for their diseaseb	59 (47.6)
Afraid of people who have AIDSd	10 (8.1)
Represented churches (N = 58 churches)
Church denomination
Baptist	49 (84.5)
Non-denominational	2 (3.4)
African Methodist Episcopal	2 (3.4)
Church of God in Christ	1 (1.7)
Pentecostal	2 (3.4)
Other	2 (3.4)
Church attendance
Less than 100	25 (43.1)
100–199	12 (20.7)
200–399	11 (19.0)
400–999	7 (12.1)
More than 999	2 (3.4)
Youth Attendance
Less than 10	4 (6.9)
10–20	14 (24.1)
21–50	20 (34.5)
51–100	14 (24.1)
200 or more	5 (8.6)

^aSomewhat to very comfortable

^bSomewhat to strongly agree

^cSomewhat to strongly concerned

^dSomewhat to very afraid

Church Infrastructure and HIV-Related Activities

Among the churches led by the senior pastors (N = 58), the median church size ranged from 100 to 199 members. Almost all of the senior pastors' churches held three regular services per week (Sunday School, Sunday morning service, and Wednesday bible study), as shown in Table 2. Many of their churches facilitated inreach church ministries across the spectrum of age (e.g., youth, seniors) and marital status (e.g., singles, marriage counseling). Also, many of the churches facilitated outreach services, primarily through food, clothing, and childcare programs. Some also facilitated prison outreach ministries. Almost all of the churches had computers and paid staff, and less than half of the churches had membership information management systems and digital projectors. As shown in Table 3, the most frequently noted HIV-related activities that churches participated in were: HIV/AIDS education and prevention activities, provision of sex education to adolescents, and HIV/AIDS workshops and conferences. Activities with the least amount of participation included providing HIV/AIDS housing, condom distribution, and HIV/AIDS peer programs.

Table 2.

Church characteristics: communication channels, inreach and outreach ministries, and infrastructure

Church characteristics (N = 58 churches)	N (%)
Church services and communication channels
Church bulletins	54 (93.1)
Sunday school services	53 (91.4)
Midweek evening services (Bible Study)	53 (91.4)
Sunday morning services	52 (89.7)
Bulletin board(s)	48 (82.8)
Resource tables	33 (56.9)
Pastoral comments	34 (58.6)
Inreach ministries
Youth ministry	47 (81.0)
Marriage counseling	29 (50.0)
Health ministry	29 (50.0)
Seniors ministry	24 (41.4)
Singles ministry	16 (27.6)
Couples ministry	11 (19.0)
Outreach ministries
Outreach ministry (general)	41 (70.7)
Food pantry/food service/summer food program	36 (62.1)
Clothing pantry	24 (41.4)
Summer school programs	17 (29.3)
Prison ministry	18 (31.0)
After school programs	13 (22.4)
Infrastructure characteristics
Computers	50 (86.2)
Paid staff	44 (75.9)
Website	30 (51.7)
Membership information management systems	28 (48.3)
Digital projector	25 (43.1)
Financial management system	28 (48.3)

Table 3.

Churches' participation in HIV-related activities

HIV education, prevention, and screening activities (N = 58 churches)	N (%)
HIV/AIDS education and prevention	26 (44.8)
Teaching adolescents about sexual behavior	21 (36.2)
Drug prevention and treatment materials/programs	18 (31.0)
Bereavement support	25 (43.1)
Black Church Week of Prayer	20 (34.5)
Church conferences, trainings, or workshops on HIV/AIDS	21 (36.2)
Drug prevention and treatment services	14 (24.1)
World AIDS Day, National Black Awareness Day, and/or National Testing Day	15 (25.9)
HIV/AIDS support group	10 (17.2)
HIV testing	12 (20.7)
Food assistance for persons living with HIV/AIDS or caring for someone with the disease	8 (13.8)
Referrals for STD and HIV/AIDS testing	10 (17.2)
HIV/AIDS peer program	4 (6.9)
Condom distribution	4 (6.9)
HIV/AIDS housing or housing assistance	3 (5.2)

Examining Church Capacity to Develop the TIPS HIV Tool Kit

Our study found church infrastructure characteristics (e.g., multiple church services, inreach and outreach ministry groups, technology supports) and experiences with HIV-related activities (e.g., HIV education, youth sex education) that pointed to the potential of delivering of a comprehensive church-based HIV intervention based on an ecological framework. Also, nearly all of the church leader participants wanted to learn more about HIV and how to discuss it with their members, and most had been tested for HIV; however, most also feared discrimination if they were to test positive for HIV.

In reviewing church capacity study findings, TIPS church partners believed that church leaders and members could provide HIV educational messages and HIV testing support for parishioners and community members through naturally occurring church infrastructure and activities indicated in the study findings. They also stressed the importance of developing TIPS tools that addressed HIV stigma and compassion for HIV-positive persons, motivated members to take an HIV test, and normalized receipt of testing. Guided by a socioecological framework and church partners' overall input on the capacity study findings and on church culture, the TIPS HIV Tool Kit was developed with and delivered by church leaders through multilevel church dissemination outlets, as shown in Table 4 and described below.

Table 4.

A socio-ecological framework for disseminating the TIPS HIV Tool Kit

Dissemination level	Delivery mode	TIPS tool kit materials and activities	Church/community member responsible for implementing
Community	Training on HIV with church leaders	Reaching All God’s Children conference	Church leaders, health educators and screeners, policymakers, researchers
		• HIV Education
		• TIPS overview and demonstration of Tool Kit
		• Linkage of churches and HIV screening organizations
		TIPS Revival services procedures
		Church Liaison Roles and Responsibilities checklist
		TIPS Reunion and booster meeting procedures
	TIPS Training with HIV screeners	Presentation on TIPS and church culture	Health organization screening/epidemiology staff, researchers
	HIV screening events for church community	HIV testing event request form	Church liaisons, HIV screeners
		Testing event promotion and planning checklist
Church-wide (During congregation services)	Pastoral guides for pulpit messages	Sermon guides	Pastors and other church leaders
		• What You Do Unto the Least of You (HIV stigma & testing)
		• Ready, Aim … Fire! (Parent-child sex communication)
		Pastoral comments guides
		• Awareness, Love & Action (HIV stigma and screening)
		• Youth Promise (Parent-child sex communication)
	Responsive readings	A Call for Action (HIV testing)	Pastors and other church leaders
		A Call to Talk It Over (Parent-child sex communication)
	HIV screening events	HIV screening event procedures checklist for churches	Church liaisons, pastors/pastor’s spouse, HIV screeners
	Video RMS testimonials	Tonya's story: Female perspective on HIV testing	Church liaisons, church media team
		Pastor Davis' story: Male perspective on HIV testing
	Mini- documentaries	The Role of the Church in Addressing HIV (HIV Stigma and the Church)	Church liaisons, church media team
		From a Brother with Love (HIV Stigma and the Church)
	Bulletins and brochures	HIV Basic Information	Church liaisons, church ushers, pastors
		Myths and Facts
		HIV and Women
		Definition of HIV & AIDS
		Stop Hatin'… Keep Lovin” (HIV stigma and the church)
	Other print and promotional materials	Stained Glass Window on HIV (Posters)	Church liaisons, ushers
		Keep the Promise: Spread the Word (Resource card )
		Bringing It Home (Bible bookmarks on local HIV data by gender)
		Together, go Take the Test (Church fans and t-shirts)
Ministry Groups	Educational games	HIV 101 Jeopardy	Community health educators, church liaisons, church ministry leaders
		STI/HIV Youth Jeopardy
		HIV Testing Jeopardy
		Wheel of Awareness
		HIV Transmission Game
	Printed Role Model Stories	Tenesha's Story (HIV testing testimonial) and facilitator guide	Community health educators, ministry group leaders
		James Story (HIV testing testimonial) and facilitator guide
		Female Youth Story(Parent-child sex communication)
		Male Youth Story (Parent-child sex communication)
		Parent Story (Parent-child sex communication)
Individual	Peer-to-peer interactions	Personal contact encouraging HIV testing	Pastors, church liaisons, church members
	Telephone tree messaging	Phone messages to promote HIV testing	Church liaisons, pastors
	Text messages	Text messages to promote abstinence and sexual health	Church liaisons, youth ministers

Community-Level Approaches

Similar to other studies,^18,20,26 we found that most church leaders were very interested in learning more about HIV in order to better inform their members, and 45% of their churches had participated in HIV/AIDS prevention education activities. Our preliminary focus groups and ongoing discussions with church leaders further indicated the need to increase HIV education among church leaders, which is reported elsewhere.¹² In addition, a promising number of churches had facilitated HIV screening events. To increase communitywide church capacity to address HIV education and screening, the development of the TIPS Project and its tools included creating several routinized strategies to train church leaders on HIV topics and the HIV Tool Kit, and to simplify the process for their churches to facilitate HIV screening events.

Trainings for Church Leaders and Community Partners

Local and regional leaders from church, community, health, and government organizations participated in communitywide trainings on health ministry development and TIPS. For example, the Reaching All God's Children conference was held annually to provide workshops on: (a) church capacity for development of health ministries (e.g., strategic planning, grantwriting, and 501c3 development); (b) HIV topics (e.g., HIV basics, HIV and the KC African American community, HIV stigma and the Black church); and (c) the TIPS Project (e.g., TIPS tools, intervention procedures, evaluation activities). Also, quarterly to bi-annual meetings were held with TIPS leaders and incorporated training/discussions on: (a) HIV topics including HIV screening procedures; (b) TIPS project accomplishments, challenges, and data; and (c) new TIPS tools.

To further disseminate HIV education and screening and TIPS tools to other African American churches, experienced TIPS pastors taught about HIV during annual TIPS Revivals at host churches that had no experience in holding HIV-related activities. The revival format included: (a) the guest pastor giving a sermon on HIV awareness, compassion, and importance of screening; (b) ushers handing out TIPS HIV education tools; (c) an HIV-positive African American churchgoer giving their testimony about living with HIV; (d) viewing of a TIPS video; (e) the host church pastor getting tested for HIV in front congregants; and (f) offering of HIV testing throughout the revival service. Also, the guest churches brought their choir and ushers to assist in the service.

In addition, local STD/HIV health department staff received training on the TIPS project and how it fit within the African American church infrastructure and culture. Likewise, TIPS project staff received training on protocols related to HIV screening to enhance assistance in coordination of HIV screening events with African American churches. Also, local health department epidemiologists provided ongoing updates on local HIV surveillance data directly to TIPS project staff, which assisted in maintaining the flow of current HIV information to TIPS partners and kept TIPS tools up-to-date with current data. All of these training formats have been routinized for ease in TIPS project diffusion with new churches and communities.

Furthermore, at least two church liaisons in each TIPS church were trained on HIV basics and delivery of TIPS HIV Tool Kit materials and activities. Their training consisted of a review of the TIPS Church Liaison Roles and Responsibilities description which included: (a) delivering two TIPS tools monthly; (b) coordinating church-based HIV testing events with community health partners; (c) providing evaluation data on implementation of TIPS tools; and (d) meeting quarterly with the TIPS project research team to receive ongoing training and technical assistance. They also worked with their pastors and other church leaders to schedule delivery of TIPS tools to coincide with regular and special church events.

Church Community HIV Screening Events

Only 21% of the represented churches had experience in facilitating HIV screening events, which was quite lower than church participation in HIV testing found in another study.²⁶ However, our church partners believed that more churches would be amenable to providing HIV screening if coordination of church-based screening was made easy. To assist them in efficiently organizing screening events, a TIPS HIV testing event checklist and an accompanying HIV screening request form were developed. The checklist consisted of: (a) strategies to promote church-based screening events; (b) confirmation of visible church leaders and ministries (e.g., choir, ushers) volunteering to get tested; and (c) collection of testing outcomes aggregate data from the screening health agency. The HIV screening event request form was adapted from an existing KC health department form for specific TIPS use. TIPS church liaisons submitted the form to the health agency, who in turn would respond with an appropriate number of screeners and test kits for TIPS HIV screening requests, such as holding an HIV screening event during Sunday morning services. The form also indicated the churches' goal for number of persons to be screened and whether screeners are permitted to discuss/distribute condoms, provide other STI screenings, or give an STI/HIV educational presentation.

Churchwide-Level Approaches

Almost all of the represented churches had weekly church-wide services including Sunday school, midweek evening services (e.g., bible study), and Sunday morning services. In addition, we found that most of the church leaders attended church at least twice per week. This is important to note since these church leaders could have several opportunities each month to disseminate the TIPS tools through church services. Also, national studies have indicated that African Americans tend to be frequent churchgoers.^8–10 Therefore, congregants who may otherwise go untouched by HIV education and screening provided by health organizations could have increased opportunities for exposure to these HIV activities through church services. Thus, TIPS tools were developed for delivery through churchwide services.

Pastoral Guides

Along with having weekly church services, represented churches also used sermons and observational comments as pastoral communication strategies. Pastoral partners commented that although they each had their own style of preaching, sermon/teaching guides with relevant HIV content material could help them deliver messages about HIV during church services. Hence, pastoral partners led the development of pastoral sermon and observational guides to enhance the ability of their pastoral peers to deliver HIV prevention, screening, and stigma reduction messages. Pastoral partners wrote the guides' content on various topics (e.g., HIV stigma and compassion for HIV-positive persons, sexual risks and get tested for HIV, abstinence and monogamy) within a biblical framework. As a quick reference in a sidebar column, the sermon guides included HIV information to incorporate in sermons (e.g., define HIV, preach abstinence/teach prevention, promote HIV testing, inform members about new HIV treatments). Also, all guides included several scriptural references to support the topic discussed. For example, a sermon guide on HIV stigma and compassion was based on the story of the Good Samaritan (Luke 10:25–37).

HIV Screening Events During Church Services

Most of church leaders (67%) had been tested for HIV in their lifetime, which was consistent with national HIV testing rates among African Americans.^27–29 Yet, confidentiality about test results and fear of discrimination if tested positive for HIV were evident primary concerns. To address these stigma-related issues, reduce gossip about persons getting screened, and promote HIV screening as a routine health screening, our church leaders recommended that all adults, regardless of perceived level of HIV risk, should be encouraged to get an HIV test. These recommendations were consistent with CDC recommendations on routine HIV testing for older teens and adults.³⁰ We therefore created an HIV testing event procedures checklist guided by social learning theory³¹ to have church leaders model getting tested, demystify the testing process, address HIV stigma fears, and normalize and rejoice receipt of an HIV test. The procedures included: (a) having the pastor/pastor's spouse model getting tested in view of congregants; (b) making announcements about the offering of HIV screening throughout the church service; (c) having HIV screeners fully explain the testing process including the types of test kits, how the test is given (orally, by finger prick, and blood draw), how the test is analyzed, and follow-up/linkage-to-care procedures for anyone testing positive for HIV—all while by administering the test with the pastor/pastor's spouse; (d) having an HIV-positive person give their testimony about getting tested and living with HIV; and finally (e) having the pastor encourage members to get tested and celebrating the increasing number of members getting tested throughout the service. Additionally, liaisons coordinated having key visible ministry groups (e.g., choir members, ushers, mothers of the church) volunteer to take the lead in getting tested.

Responsive Readings

Although it wasn't included in the survey on capacity, church leader partners indicated that responsive readings, a call and response format akin to a liturgical reading and usually led by the pastor, was a common activity in many African American churches. To enhance social cohesion and support in the church setting,³² TIPS responsive readings were developed to increase congregants' HIV awareness and enhance unity in taking action against HIV/AIDS in the African American community. The responsive readings are separated into three parts: (a) HIV informational and call to action statements read by the church leader, (b) empowering action statements read by the congregation, and (c) a commitment to action statement read by all. Also, a listing of HIV testing locations was printed on the back of the responsive reading and other printed educational tools. Printed versions of the responsive readings were handed out by church ushers, and electronic formats were provided to church media teams for display on the sanctuary projection screen for reading during services.

Church Bulletins, Brochures, and Other Educational Print Materials

Nearly all of the represented churches (93%) used church bulletins to disseminate pertinent church information to their congregants. We therefore, created a series of TIPS bulletin inserts and brochures, which cover topics on HIV basics, myths and facts about HIV, HIV and women, and compassion for HIV-positive persons. The bulletins and brochures included relevant scriptural references and were graphically appealing with motivating messages to reduce HIV risk. Based on feedback from church leaders, a limited amount of condom information was restricted to two brochures to ensure that church leaders who did not want to distribute this information still had ample choices of other TIPS materials to use. Typically, church ushers passed out the TIPS printed tools along with church bulletins to congregants as they entered church services. Pastors and other church leaders discussed these materials during church services.

The TIPS Tool Kit also consisted of other print materials such as posters, resource cards, bible bookmarks, and church fans. Posters were designed in the shape of a stained glass window with KC (and later Montgomery, AL) HIV statistics, compassion, and action messages, and relevant scriptures and were typically hung in common areas of the church and in restroom stalls. Wallet-sized resource cards were designed to provide youth congregants with information on local HIV testing sites and the financial costs of sex-related outcomes including abstinence, condoms, HIV medications, and raising a child. National and local HIV statistics related to African Americans were included on bible bookmarks along with the TIPS HIV testing messages (e.g.,“Take someone's hand, Together go Take the Test”). HIV testing messages were also included on church fans.

Testimonial Role Model Story Videos

Over 40% of the representative churches had digital projectors, and church leaders commented on the need to use more media-type formats, such as videos, for TIPS tools. Hence, role model story (RMS) testimonial videos on getting tested for HIV were created. RMS, akin to storytelling in the African American heritage and particularly used in the church through parables and preaching, can be a culturally appropriate way to share experiences³³ and increase acceptability and utilization of HIV services.³⁴ RMS storyline elements were guided by social learning and transtheoretical theories³⁵ and consisted of male and female role models sharing their testimonies on moving from ambivalence about HIV testing to getting tested and experiencing the benefits of doing so (e.g., peace of mind). RMS videos were kept to 5 min to allow for viewing time during regular church services. Also, 15–20-min documentaries were developed on the role of the church in addressing HIV stigma and compassion for HIV-infected/affected persons to show during special Sunday services when more time may be available.

Ministry Group Level Approaches

Our study identified church inreach (e.g., youth, senior, women, singles, couples ministries) and outreach ministries (e.g., food/clothing pantries, prison ministries, afterschool programs) for potential targeted and group-based HIV programming. Church leader partners saw the ongoing and group format of these ministries as prime outlets for more interactive and printed HIV tools with priority populations (e.g., youth, singles, women) using a variety of strategies.

Interactive Educational Games

Research has demonstrated that entertainment education can be an effective HIV education approach, particularly when combined with other intervention strategies.³⁶ TIPS HIV educational games, a form of entertainment-education, were designed to engage church and community members in learning about and discussing sensitive HIV topics through play and constructive discourse with their peers, church leaders, and community health educators in many inreach and outreach settings, particularly with youth and young adults. TIPS educational games were based on popular game shows for play in a fun, competitive team format (e.g., HIV Jeopardy games, Wheel of HIV Awareness).³⁷ The HIV Jeopardy and Wheel of Awareness games were designed in a hard copy format, and the Jeopardy games were also delivered in a PowerPoint format. The HIV Transmission Truth or Consequences game was developed to simulate face-to-face interactions with “real world” relationship dynamics in which choices and consequences are discussed from a public health and religious perspective. Facilitator guides were created for all games and included game material lists, instructions, and answer sheets.

Printed Role Model Stories

Similar to the video testimonial RMS described above, the printed RMS were guided by transtheoretical and social learning theories along with narrative communication principles,³⁸ with the intention of motivating ministry group members to reduce their HIV risks and to know their HIV status. The printed male and female RMS are brief (about 250 words) and use language and issues identified by church leaders (e.g., addressing gossip about those getting an HIV test including encouraging friends to get tested, promoting abstinence and monogamy). The printed RMS also include ten reasons to get an HIV test (e.g., “To support a friend, family member, or church member”) and a listing of local HIV screening sites. An accompanying facilitator guide was created to assist ministry leaders in leading group discussions about the RMS (e.g., “How can you help Black women reduce their HIV risk? How can the church encourage more people to get tested?”) with their ministry group members. The printed RMS were also distributed to community members using outreach services, such as through food pantries and church-based social services.

Individual Level Approaches

Represented churches in our study had several technology capacities that could assist in the delivery of HIV-related information, including membership management systems (48%), websites (52%), and computers (86%). Church liaisons used many of these technology assets to provide peer-to-peer delivery of tools and support. They also passed out printed TIPS tools directly to individual church members, encouraged them to get tested for HIV at their church HIV testing events, and answered questions and directed members to HIV resources in the local community. They also used church resource tables in their peer-to-peer HIV efforts with church and community members.

Telephone Tree Messaging

Churches have historically used “phone trees” (i. e., members calling other members to inform them of upcoming events), to spread important news to church members, and as prayer chains. In the TIPS project, church liaisons used their membership management systems in coordination with church telephone tree messaging systems to deliver messages about upcoming HIV testing events to their church members and community members who use church outreach services. Liaisons assisted in writing the telephone messages and pastors recorded the messages.

Text Messages

While not assessed in our study, our TIPS church partners suggested additional communication strategies, particularly sexual health text messages to youth. Twenty-seven brief text messages with the corresponding number of text characters (e.g., The only way 2 protect urself 100% is abstinence [no sex @ all], 63 characters; Encourage a friend 2 not have sex, remind urself 2 w8, 53 characters) were created to assist youth pastors and church liaisons in sending protective sexual health messages to youth members. The text messages aimed to remind youth to consider alternatives and consequences of sexual activity. The youth members were also encouraged to share these messages with their friends. A sign-up sheet was provided to collect youth names, their cell phone numbers, and parent signatures giving permission for their youth to be contacted with sexual health messages on their cell phones.

Discussion

As HIV infection rates continue to burden African American communities, there is a need for wide-reaching HIV interventions in community settings. Despite the calls for the Black church to mobilize against HIV, there have been limited reports on practical intervention tools that increase African American church capacity to address HIV. Our study is one of the first to examine African American churches' capacity in order to develop an HIV Tool Kit that could “fit” naturalistically within existing church infrastructure and culture. We have described how the TIPS HIV Tool Kit can support these efforts by building on existing church capacity and assisting church leaders in efficiently taking sustained action with easy-to-use, religiously appropriate, supportive tools.

Yet, this descriptive study had its limitations. First, participating church leaders who completed capacity surveys were a convenience sample attending health ministry training events that included topics on HIV; thus, their opinions (and their churches' experiences) may not generalize to other African American faith leaders. Yet, our HIV-related work with churches has taught us to seek out faith leaders who are interested in working on building their health ministries, as demonstrated by their attendance at such training events, and who may have some interest in learning more about HIV. Second, we have yet to develop TIPS tools that directly address condom use and gay/bisexual Black men—a critical HIV prevention strategy and priority population, yet highly controversial church topics. Several of our faith partners believed taking on these HIV topics may alienate some church leaders who would otherwise be willing to address HIV. Their preference was to collaborate with other organizations that conducted condom education or targeted gay/bisexual men—but not in the church. Finally, although a TIPS case study found that increased exposure to TIPS tools was related to lower HIV stigma and increased HIV testing intentions,¹² future tool kit research using community trials is needed. To this end, we are pilot testing a TIPS HIV Tool Kit intervention versus a standard HIV information intervention on HIV testing rates with church members and community members who use church services.

Although there has been a growth in church-based HIV research, there is still much to learn about the development, implementation, and assessment of tool-supported HIV interventions in African American churches. We used theoretical models and a CBPR approach to guide the development of many of the tools' content and delivery, yet further research on theoretical models (e.g., diffusion of innovations, theory of planned behavior), cultural features (e.g., pastoral influence, social cohesion and support, ethnic identity, religiosity, language, and images), and tool dosage/saliency is needed to best shape development of tool-supported HIV interventions in African American churches. Studies are also needed on how best to deliver church-based HIV tools to community members who use church outreach services and who may be at increased risk for HIV. Additionally, future research is needed on how enhancement of church capacity infrastructure may assist in the uptake and sustained use of church-based HIV tools. Enhancing church technology resources—such as computers, telephone tree messaging systems, copy machines, and digital projectors, along with paid trained church staff and ongoing technical assistance, may greatly enhance dissemination of multilevel, multimodal church-based HIV intervention tools. Finally, future research and practice is needed on how the TIPS HIV Tool Kit can be adapted for use with other health screenings (e.g., cholesterol, blood pressure, other STDs) that can be provided in the church setting.

Given the highly disproportionate rates of HIV among African Americans, dissemination of wide-reaching, community-based HIV interventions are needed. The Black church has relevant capacity and potential to extensively deliver tool-supported HIV interventions through existing community, church service, ministry group, and peer-to-peer dissemination outlets. Enhancing church capacity by equipping church leaders with church-appropriate, supportive HIV tools may be an expedient scalable strategy to address HIV in African American communities.