Where is the Faith?: Using a CBPR Approach to Propose Adaptations to an Evidence-Based HIV Prevention Intervention for Adolescents in African American Faith Settings

Introduction

Stark disparities in HIV/AIDS diagnoses burden African Americans, who accounted for 44% of new adult/adolescent infections in 2010 despite representing only 12 - 14% of the U.S. population (Centers for Disease Control [CDC] 2013a). In North Carolina (NC), 66.5% of the cumulative reported cases of AIDS up to 2008 were among African Americans compared to 28.1% among Whites (CDC 2010).

African American youth are at particularly high risk across the nation, representing 57% of all new HIV/AIDS diagnoses among adolescents (ages 13 to 24) (CDC 2013b). In North Carolina the rate of new HIV diagnoses for adult/adolescent Blacks (62.8 per 100,000) is nearly ten times greater than for Whites (6.3 per 100,000) (NC Division of Public Health 2012). Between 2007 and 2011 the proportion of adolescents among HIV disease cases increased from 6 percent to 23 percent in NC with African Americans representing the majority of HIV diagnoses for both men and women in the 13 - 24 age group at 82% for each (NC Division of Public Health 2012).

Findings from the CDC Youth Risk Behavior Survey (YRBS) indicate that NC's teens engage in more risky sexual behavior on average than adolescents nationally (CDC 2011). According to 2011 YRBS data from North Carolina, 61.1% of African American high school students have had sexual intercourse, 16.6% of them had sex before the age of 13, 26.4% have had sex with four or more people, 41.3% had had sex with at least one person in the last 3 months, and 47.9% did not use a condom during last sexual intercourse (CDC 2011).

As a marker for HIV risk, adolescent sexually transmitted disease (STD) rates are a cause for concern. In Wake County, home of NC's capital city of Raleigh, 78% of gonorrhea and 85% of chlamydia cases in the 15 – 24 year age group occur in the African American population (Wake County Public Health Division of Human Services 2012). Many adolescents lack basic preventive skills including accurate knowledge about disease transmission, skills to delay initiation of sexual activity, and basic skills about appropriate condom use (NC Division of Public Health 2006). These findings warrant intensified efforts to target HIV/STD education and prevention efforts to African American adolescents.

It is critical that interventions targeting sexual risk behaviors among African American youth are culturally appropriate and positioned in pre-existing social and community resources, such as the church. According to a Gallup survey, 52% of African American teens say faith is the most important influence in their lives and 71% of all teens report the reason they got involved in a church youth group was to have a place to talk about issues that are important to them (Lindsay 2003). With the alarming disparities of HIV/AIDS among African American adolescents and the importance of faith in their lives, the Black Church is a potential leveraging mechanism for behavioral change.

Religion and the Black Church

Religion and the Black Church have been an essential component of the social, civic, and political experiences of African Americans. Much of the literature describes the Black Church as an institution that facilitates strong social networks, strengthens social norms, and influences individual behavior (Taylor et al. 1987; Campbell et al. 2007). The central role the Black Church plays in the community and its long tradition of promoting social service, political involvement, education, and economic stability, has created a unique outlet for public health interventions grounded in social support and network theories (Rew and Wong 2006). Specifically, incorporating the church and religious rhetoric into health messages has been shown to be effective in impacting health behaviors among African Americans (Campbell et al. 2007).

While African American faith-based organizations have been resistant to HIV prevention interventions in the past (Sutton et al. 2009; Coyne-Beasley and Schoenbach 2000), they have immense potential as settings for these efforts (Sutton and Parks 2013; Griffith et al. 2010; Moore et al. 2012; Francis and Liverpool 2009). This paper will discuss qualitative research findings from a recent study which piloted an evidence-based HIV prevention intervention, Focus on Youth! with Informed Parents and Children Together (FOY + ImPACT), with African American adolescents in three Black churches with the goal of identifying adaptations to increase the intervention's relevance, utility, and efficacy for faith settings.

The CBPR Approach

Community-based participatory research (CBPR) is a useful approach for engaging intended beneficiaries in shaping the research process and refining interventions to increase their relevance and appropriateness for addressing community health challenges (Israel et al. 1998). This study used a CBPR approach to build a community-academic partnership, establish a Community Advisory Board (CAB), and reach out to three Black churches to implement an HIV prevention intervention with African American youth and parents in faith settings (Lightfoot et al. 2012).

The partnership involved a community-based organization (CBO) in Southeast Raleigh, NC, an historically African American community, and researchers from a local academic institution. When a funding opportunity through the Carolina Comprehensive National Institute of Minority Health Disparities Center (Project EXPORT) that prioritized collaboration with its faith-based research network of churches (Goldmon et al. 2008) became available, the CBO reached out to the research team to propose approaching network churches as intervention sites.

Our community-academic research team included expertise in adolescent health, African American health disparities, CBPR, HIV intervention and, critically important, the institutional culture and customs of the Black Church, through our Project Coordinator, a lay leader and “cultural insider.” We augmented our team's expertise by recruiting a diverse CAB with faith leaders of different perspectives, youth and adult community members, educators, and congregants. The CAB played a key role in helping us understand the facilitators and barriers to implementing an HIV prevention curriculum in African American faith settings. The CAB also helped us determine adaptations to make FOY more relevant to the church context, however, we had to pilot the intervention without modification in order to determine if there was a need to adapt it in faith settings.

FOY + Impact Intervention

In seeking to expand its HIV prevention efforts into faith settings, the CBO identified FOY + ImPACT as an intervention that could complement church teachings. FOY is a skill-building intervention proven effective with African American youth ages 12 – 15 in urban settings (Lyles et al. 2007; Li et al. 2002; Stanton et al. 1996). Its goals are to increase knowledge and skills about sexual health issues, build awareness of HIV/AIDS, improve decision-making skills, and increase communication among youth and parents. The intervention promotes abstinence as the only sure way to prevent STDs/HIV, along with education and skill-development to reduce risk behavior. It is conducted within the context of friendship groups, which seemed to be a good fit with church youth groups. The intervention includes ImPACT, a critical programmatic element designed to help parents learn and practice skills to foster good parent-child communications around sexual risk reduction (Diffusion of Effective Behavioral Interventions [DEBI] 2009). The FOY + ImPACT intervention is based on the Protective Motivation Theory (Rogers 1983), which takes into account the combined influences of peer pressure and familial relationships as key factors that motivate youths’ intentions to adopt protective behaviors (Li et al. 2000; Li et al. 2002; Stanton et al. 2004).

Research Objectives

With this backdrop, our study addressed the following research questions: 1) Would FOY + ImPACT, an intervention proven effective with African American youth in urban community settings, work in the context of faith-based organizations in Wake County? 2) What adaptations are needed, if any, to ensure relevance, uptake, and sustainability of the FOY + ImPACT intervention in faith-based organizations? To the researchers’ knowledge, FOY + ImPACT has never been tested in a church setting.

Methods

Design

The research team collected both quantitative and qualitative data to measure intervention effectiveness and impact. This paper focuses on findings from focus groups conducted pre-intervention with the CAB and post-intervention with parent and youth intervention participants. The study was approved by the University of North Carolina's Institutional Review Board.

Pre-intervention focus groups with CAB youth and adults

As recommended by the FOY Evaluation Field Guide (DEBI 2009), we conducted two pre-intervention focus groups with youth and adult members of the CAB to gain understanding of the community context for the intervention and to determine effective ways to engage target churches. We added several questions to the FOY guide to gain insight into participants’ perspectives on the role faith plays in their lives and the challenges and opportunities of implementing the FOY curriculum in a faith-based setting. Additional participant questions included parental, peer, and community influences on youth decisions, community assets, and the role of religion and faith in youth decisions. These focus groups were held at the community-based organization.

Post-intervention focus groups

Semi-structured focus groups with youth and parent participants were conducted at the three participating churches following the intervention. Our research team worked in conjunction with CAB members to develop the post-intervention focus group guides. Participant questions included evaluation of FOY + ImPACT curriculum and activities, assessment of intervention impact, youth challenges to making healthy decisions, and current church messages about sexual health. Parents were also asked to give their perceptions of their children's response to the intervention and understandings of community factors influencing youth decisions.

Characteristics of focus group participants

Two pre-intervention focus groups were held with CAB members, one for youth and the other for adults. There were six participants in the youth CAB focus group and ten participants in the adult CAB focus group. All participants were African American. Nineteen youth ages 12-14 years participated in the youth post-intervention focus groups. Sixteen parents participated in the adult post-intervention focus groups. All focus groups had a moderator and a note taker from the research team.

All youth participating in the FOY + ImPACT intervention filled out a pre-intervention survey. This survey asked questions about demographics, sexual behaviors, and other risk behaviors such as drug and alcohol use. Results from this survey were used to determine if there were significant differences among the three intervention sites and indicate that youth across the churches were similar in age, education, and behaviors.

Analysis of qualitative data

Audio recordings of the focus groups were transcribed verbatim and these transcriptions in addition to notes written during the focus groups were used for the analysis. The second author, who served as the lead in the qualitative analysis process, initially wrote topical summaries of each focus group using the focus group protocols and research questions as a guide. These summaries were completed early in the analytic process and combined with other quantitative and qualitative data to help guide the research team's data discussions. After discussing preliminary findings from the data, thematic codes were developed to categorize the transcripts and develop a codebook. This initial round of coding and discussing data with the research team was an iterative process, supported by weekly data discussions and memoing about emergent topics. The second author continued inductive open-coding such that emergent concepts were connected across focus groups. Midway through this coding cycle, the research team reviewed the codebook, summaries, and memos to focus the analysis on tailoring FOY + ImPACT to a church setting. The second author then reviewed all of the coded transcripts and wrote additional summaries that categorized codes based on the aim of adapting FOY + ImPACT to a church setting. The research team identified patterns and themes across the focus groups based on these summaries and previous coding in order to generate four overarching themes related to the research aim. As a final step in the analysis process, the research team presented and discussed the overarching themes to the CAB as a way to member-check their accuracy. The four themes work in concert to inform recommendations for adapting FOY + ImPACT to the church setting.

Results

Data analysis of the eight focus groups revealed several themes associated with implementing an HIV prevention program for African American youth in a church setting. In addition, careful review of both the pre (CAB) and post-intervention focus group data indicates several recommendations for how to tailor FOY + ImPACT to increase participant receptivity and uptake of intervention components. The results presented are discussed in two categories:

The strength of using a church setting for FOY + ImPACT and Barriers to receptivity and implementing FOY + ImPACT in a church setting

Four themes are presented to explicate on these broad categories. All eight focus groups were analyzed to generate the themes presented below. The quotations and summaries used to expand upon the themes begin with data from the adult CAB and/or post-intervention groups and are followed by the youth CAB and/or post-intervention groups’ comments on the same theme.

The Strength of using a church setting for FOY + ImPACT Theme 1: Church network

Consistent across all eight focus groups, participants emphasized many positive factors associated with conducting this HIV prevention program in a church setting. Multiple comments from adult CAB and post-intervention participants stressed that individuals trust their church and its ministry. Conducting the intervention in a church setting meant that both youth and adult participants were more receptive and trusting of the information being presented to them. Adult participants praised the strong social networks created and supported by their churches which encourage congregants to feel as though they are each other's “Brothers’ and Sisters’ Keepers” (Adult CAB participant). This strong atmosphere of support within the church helps them make health decisions, including the decision to participate in this intervention. Adult participants vocalized their desire to see more programs linking the secular community and academic resources to their churches, which is perceived as a safe and appropriate place for supporting and engaging youth.

I thought the church was a wonderful place to have it [FOY +ImPACT] because, like you said, they feel safe, it's a familiar surrounding, other than home, church is like a second home to them, to a lot of them. So I felt like this was a good place for that. (Adult post-intervention participant)

This quotation illustrates adult congregants’ belief that the church is a positive space for youth and appropriate for the kind of sensitive information delivered through the FOY intervention. Their discussion affirmed that the church remains a valuable asset in the community and has an audience that is open to participating in health interventions brought in from outside the church.

Youth CAB and post-intervention participants arrived at a similar conclusion, including that the church highlights the positive attributes of their African American community and contradicts the many negative stereotypes shown by the media about their community. Many expressed that the church and its youth programs are a way to showcase the positive work ethic and values of African Americans in their community. Focus group participants felt there were many positive aspects of conducting an HIV prevention intervention within the church setting in terms of “ending the silence” and generating discussion about sexual health issues within a safe and credible place within the African American community.

The results above highlight the many positives associated with integrating an HIV prevention intervention into a church setting. However, three major themes emerged from the data as potential barriers to conducting a non-faith based HIV prevention program in a church setting.

Barriers to implementing FOY + ImPACT in a church setting Theme 2: Contradicts church teachings

FOY + ImPACT is an abstinence plus model intervention, meaning the curriculum emphasizes abstinence but also provides comprehensive sexual education information on alternative means of HIV/STD and pregnancy protection, which includes a condom demonstration as a core element. In the Adult CAB focus group, the discussion was heated as several members expressed feeling uncomfortable and concerned because of the comprehensive sexual education in the intervention curriculum. Some participants felt that the inclusion of these intervention components would be contradictory to the church's abstinence teachings.

I just don't see how you can teach abstinence and teach a condom demonstration in the same situation; it's contradictory. It's kind of like saying you know you're trying to keep people from doing drugs; we don't want you to do drugs, but if you have to, here are some clean needles. No, no you can't do that. (Adult CAB participant)

The above quotation demonstrates the sense of contradiction perceived by some of the adult CAB members. Several participants in the CAB focus group were concerned that teaching how to use a condom would cause youth to question the church's “abstinence until marriage” teachings and possibly increase the chances of youth engaging in premarital sex. Adult post-intervention participants, who participated in their own condom demonstration as part of the ImPACT session, also stated that they initially felt uncomfortable discussing condoms when their church teaches abstinence. Nevertheless, most agreed that the “abstinence until marriage” messages taught in their churches ignore the changing youth social environment and the pressures youth face in their community.

[The church teaches] Abstinence, abstinence, abstinence, but the reality of life is, when they get out there, I'd rather, it's better to have it when you need it than to don't have it when you need it. (Adult post-intervention participant)

Adult post-intervention participants concluded that teaching proper condom use, in the context of a comprehensive sexual health program, provided the information they felt their children needed to navigate their changing social environment and would not encourage premarital sex. Conducting the intervention in the church setting, in fact, eased their concerns about condoms being promoted over abstinence.

Like, ok, you gotta use condoms...I believe in abstinence until you get married. That's just the way, you know, we teach it so I was just a little more concerned...were they going to push that per se, instead of abstinence per se, so I was very pleased to know that. The setting really encouraged that. (Adult post-intervention participant)

Others agreed, adding that they gained confidence knowing that their church leaders had approved the intervention, which signaled for them that abstinence would be a key component of the program.

Youth post-intervention participants echoed the concerns addressed by the adult CAB focus group participants stating that “talking about sex in church, that's not really good...to talk about sex in front of God” (Youth post-intervention participant). Similar to statements made by some participants in the parent group, some youth participants stated that they were initially uncomfortable with learning about condoms in church, but ultimately believed it was important for all youth to have comprehensive sexual education. Many youth felt that the church's silence about sex or promotion of “abstinence only” messages did a disservice to church youth by not adequately addressing their concerns and the realities they face in their communities.

[The church] is reluctant to educating teens about condoms and they I guess they don't believe in that because in the church community it's always been preached that there's abstinence there should be no sex before marriage, but also I think that at a point in time you have to be real...people are going to do it anyway so what better help than just to if people are going to do it what better help is just to help them be safe. (Youth CAB participant)

Those youth who believed that the intervention's teachings did not contradict church messages endorsed intervention lessons that taught them important decision-making and goal setting strategies relevant to their daily lives.

Theme 3: Where is the faith?

FOY + ImPACT is not a faith-based intervention. Though it was tested in the church setting for this pilot, it does not incorporate elements of faith or religiosity in its curriculum. Adult CAB and adult post-intervention focus groups both questioned why the intervention did not include more of a faith-based approach, particularly during more controversial sessions such as the condom demonstration session, would make intervention participants feel more at ease.

Since it is [at the church] I think maybe you should allow for prayer to begin that session and uh maybe close that session (Adult CAB participant)

While the church was seen as a “great environment” for the intervention because it is a “second home” for many youth, adult participants recommended more overt inclusion of faith tools, such as prayer, songs or scripture to help participants feel more comfortable during sessions and the intervention more connected to the church environment.

The concept of incorporating more faith-centered messages in the curriculum as a way to further integrate FOY into the church supports what many of the youth CAB participants said about the importance of faith and the church in their lives. Youth CAB participants agreed that faith has a significant role in their lives and that the church is like a sanctuary to them. They consistently expressed that they rely on their faith as a source of guidance and help in making life decisions.

Theme 4: Church leadership's role in promoting (or hindering) open discussion about sexual health issues

All six post-intervention focus groups were asked to describe some of the previous activities and messages their church had offered regarding HIV/AIDS before introducing the FOY + ImPACT curriculum into the church environment. Responses ranged across the three churches from a discussion of the messages coming directly from church leadership in the pulpit to activities led by youth ministers and other congregation members targeting youth risk behaviors. Some adult post-intervention participants recalled ministers at their church speaking openly about sex and the negative consequences of sex, which they believed made it easier for youth to talk about peer pressure and ask questions about sexual health decisions. Other adult post-intervention participants described church messages as focusing solely on the importance of abstinence until marriage. Many of the adults in the post-intervention group supported the activities and messages their church offered regarding abstinence, but wanted their church to have more activities that could address media influences and social messages that promote risky sexual behaviors among youth. Adults also wanted help in how to talk to their children about sex, given the changing social and media context youth face.

Youth post-intervention participants did not recall much discussion within their church related to sexual health or HIV prevention. A few youth described an activity their church planned which was intended to encourage open discussion about sexual health, but the program had the opposite effect on them. Rather, it increased youth discomfort with discussing sexual health within the church because of the program's tone and content. Within this one activity, youth described concerns about confidentiality and fear of being shamed by being “open” about their sexual experiences and questions in the church environment.

Yeah, it's like. I feel, that if like, they [ministers] ask me a question [in church], that I have to be like really honest with, I'll avoid answering that question because I don't trust them. (Youth post-intervention participant)

As the participant describes, for several youth what was intended to bring about “open discussion” resulted in wariness, distrust and disconnection between youth congregants and faith leaders. At the same time, many youth expressed the need to gain essential knowledge about how to reduce STD/HIV risk and to have a safe space, such as the church, to discuss sexual health needs.

Discussion

The FOY + ImPACT intervention is designated by the CDC as a high impact intervention for African American youth who are at risk for STDs/HIV (DEBI 2009). Future implementation must include the program's core elements, but findings from our pilot study suggest potential enhancements that could increase the curriculum's relevance for African American youth in faith settings. The adaptations proposed here were developed from further explication of the importance of the Black Church and strength of its network, in addition to documenting potential barriers to conducting a non-faith based HIV prevention program in a faith setting. These barriers were that FOY + ImPACT contradicts church teachings about sex; Congregation resistance to teaching a curriculum that does not include faith; and Church leadership as promoting (or hindering) sexual health discussion in the church context. Careful review of these themes in addition to incorporating recommendations from intervention participants has led to five distinct recommendations for adaptations to the intervention. These recommendations, discussed in detail below, are to focus on the curriculum's assets in helping youth navigate other life decisions, enhance parent participation in intervention activities beyond the one ImPACT session, emphasize linkages between curriculum and faith, support church leaders in using intervention principles, and facilitate group trust as a precursor to FOY intervention sessions.

Recommendation 1

In addition to making decisions about sexual risk behaviors, youth (and parents) shared concerns about the many media and social pressures youth must navigate in order to make healthy decisions. Emphasizing how the FOY + ImPACT curriculum can help youth manage these other issues through the lessons provided on values clarification, goal setting, and decision-making may mitigate concern about the intervention contradicting church teachings. The curriculum's focus on providing skills, knowledge, and practice that help youth navigate both sexual risk behaviors and the broader social and environmental challenges they face is a strong asset, recognized by CAB, youth and parent focus group participants.

Recommendation 2

The FOY curriculum engages parents in a single skill-building ImPACT session with their participating children. This session is intended to increase parent-child communication, but FOY + ImPACT does not provide sustained opportunities or further training to help parents facilitate ongoing and increasingly complex discussions with their children. We recommend adding one ImPACT booster session midway through the intervention and one at the end to strengthen parent involvement and reinforce their learning about how to communicate with youth over time about risk decisions and social/environmental influences. Enhancing parent support and capacity will help youth make stronger connections between the decision-making, goal setting, and values clarification components of the intervention and understand how those relate to their daily lives. Parents can also use these opportunities for greater discussions of faith with their children and consideration of how it relates to the intervention.

Recommendation 3

Incorporating more faith tools into the curriculum will enhance its relevance for the church setting (Berkley-Patton et al. 2012; Berkley-Patton et al. 2010) and address concerns about the intervention contradicting church teachings. The curriculum recommends that Curriculum Facilitators and youth participants establish a ritual appropriate for the community context in which the intervention is being implemented as a way to open and close each FOY session. Within the church setting, these rituals could incorporate tenets of faith and spirituality, scriptural references, or spiritual tools such as song and prayer, to better link this non faith-based intervention to the faith environment. The inclusion of more faith tools will reinforce FOY + ImPACT as a complementary, not contradictory, intervention appropriate for faith settings.

Recommendation 4

Our findings suggest the importance of building a more active role for faith leaders to support and promote HIV prevention messages both within the church and throughout their networks. Building capacity of church leaders to address HIV/AIDS has been shown to bolster HIV prevention activities in African American faith-based organizations (Pichon et al. 2012; Berkley-Patton et al. 2012; Berkley-Patton et al. 2010; Griffith et al. 2010). In future iterations of FOY + ImPACT in faith settings, we recommend providing pastors with supplemental information about intervention content, training to support their crucial role in normalizing prevention messages and reducing stigma, and encouragement, support and opportunities to advocate for HIV prevention in and across faith settings.

Recommendation 5

FOY + ImPACT was designed to be conducted with “natural friendship groups” to build upon the comfort and camaraderie youth have in their peer circles. When we decided to implement the intervention in churches with tightly-woven congregations, we assumed that church youth group participants were “friends.” We discovered, however, that our FOY groups were artificial constructs, comprised of youth congregants whose parents were interested in their participation in the curriculum. This construction may have been a barrier to intervention uptake and contributor to feelings of discomfort expressed by youth. Though FOY does include team-building exercises, we recommend enhancing this aspect within the church context by holding pre-intervention sessions with youth to help them build a sense of comfort and trust with each other if they are not in fact “natural friendship” groups. Interestingly, parents whose children participated in the FOY intervention gained a sense of social support, though they never met together except for during the focus group discussions. FOY parents noted that the intervention had a positive influence within the church, creating a sense of support among members connected through the common experience of participating in FOY + ImPACT. Through the project they gained a network of informed parents with shared knowledge with whom they could discuss pressures and promote risk reduction strategies.

There are several limitations to the analysis presented. First, the intervention was conducted using a convenience sample of three African American churches, two of which are part of a research network that focuses on addressing health disparities in their community. Though they vary in denomination, these churches are similar in demographics, location, and size. Recruiting a larger, more heterogeneous sample of churches to the study may provide different results that would challenge the transferability of the recommendations presented above. Second, the long-term impact of this intervention and its adaptation is difficult to assess given the timeframe of this pilot study, and because we did not assess risk behaviors post-intervention.

Despite the above limitations, the primary goal of making recommendations for adaptations to the intervention for faith settings was achieved. In addition to these recommendations it should also be noted the many additional community activities that have been supported by the research team as a result of this intervention. The CBPR approach enabled us to address broader community concerns identified by our CAB by developing several spin-off projects, one which engaged twelve youth in a photovoice project exploring the social and environmental context for HIV risk factors in Wake County and another that engaged four adults in a similar exploration. Finally, in response to the findings from the youth photovoice project, which identified lack of social support and the need to promote and support youth engagement in pro-social activities, we launched a peer-driven capacity-building initiative, Youth Empowered Advocating for Health (YEAH). Findings from these projects have been presented in community forums and at national conferences by youth and adult presenters and additional manuscripts for peer review journals are under development. Our next steps are to test the proposed adaptations of the FOY + ImPACT curriculum to determine if the recommendations proposed here increase uptake and receptivity of the intervention in varying African American faith settings.

Biography

Alexandra Lightfoot, EdD, received her doctorate in educational research from the Harvard Graduate School of Education. She directs the Community-Based Participatory Research (CBPR) Core at the Center for Health Promotion and Disease Prevention at the University of North Carolina at Chapel Hill. She is also Adjunct Assistant Professor in Health Behavior at the UNC Gillings School of Global Public Health. She promotes the use of CBPR, teaches a graduate seminar in CBPR and Photovoice, and provides CBPR trainings and technical assistance to community and academic research partners. Her research focuses on HIV/AIDS disparities and community- and faith-based adolescent HIV prevention.