Using concept mapping to mobilize a Black faith community to address HIV

Abstract

Research that partners with community stakeholders increases contextual relevance and community buy-in and maximizes the chance for intervention success. Within a framework of an academic-community partnership, this project assessed a Black faith-community’s needs and opportunities to address HIV. We used concept mapping to identify/prioritize specific HIV-related strategies that would be acceptable to congregations. Ninety stakeholders brainstormed strategies to address HIV; 21 sorted strategies into groups and rated their importance and feasibility. Multidimensional scaling and cluster analysis were applied to the sorting to produce maps that illustrated the stakeholders’ conceptual thinking about HIV interventions. Of 278 responses, 93 were used in the sorting task. The visual maps represented eight clusters: church acceptance of people living with HIV; education (most feasible); mobilization and communication; church/leaders’ empowerment; church involvement/collaboration; safety/HIV prevention; media outreach; and, stigma (most important). Concept mapping clarified multifaceted issues of HIV in the Black faith community. The results will guide HIV programming in congregations.

INTRODUCTION

Faith communities, especially black churches, have been suggested as a key partner to address HIV (1,2,3). HIV, or human immunodeficiency virus, can lead to a terminal condition known as AIDS (acquired immunodeficiency syndrome). African Americans are disproportionately affected by HIV (4). The Black church (evangelical congregations predominantly made up of African American members) has been a powerful voice in communities of color, but its role in shaping HIV-risk behaviors and HIV prevention/care has been mixed (1). A national study estimated that 5.6% of U.S. congregations provide programs or activities to people living with HIV (PLWH), which were facilitated by presence of PLWH in the congregation, formal community needs assessment activities, religious tradition (Black Protestantism), and openness to gays/lesbians (5). Another study has shown that only a third of Black Protestant congregations offer HIV prevention/counseling programs (2). The literature has identified stigma linked with religious doctrines and moral positions as a key barrier to effective HIV prevention/care (6). Even churches willing to address HIV in their communities defer from discussing specific HIV-risk behaviors (7). How to tackle doctrinal stances on HIV remains unclear, but mobilization and input directly from faith leaders and faith communities in specific local contexts are emerging as useful approaches (8).

Involving community members in the process is considered as crucial to improving the success of health interventions (9). Research that partners with community stakeholders increases contextual relevance and community buy-in and therefore maximizes the chance for intervention success. As one strategy to HIV prevention, federal agencies have been funding Black churches as partners in HIV prevention (10). Most of this work has been capacity-building and HIV-related training. The development of community-based coalitions and partnerships is another effective strategy (11). Such connections have been seen as major opportunities for faith leaders to gain support and garner resources for faith communities’ HIV involvement. Some faith institutions have been implementing HIV programs and services that they find acceptable within the context of their religious doctrine (12). Researchers have also begun engaging directly with faith leaders to learn about factors that facilitate or inhibit effective HIV prevention/care in at-risk communities (8).

Unfortunately, data from such studies sometimes lack rigor because traditional research and evaluation methods are difficult to implement on a large scale and in “fluid” community settings. There are also several potential barriers to implementing health programs and in particular those addressing HIV within religious settings. These include the presence of mistrust and a reciprocal lack of understanding of the values, norms, and customs between religious organizations and their partners in science, public health, or academia (13). Therefore, innovative methodologies rooted in social sciences, not widely used within public health, are urgently needed. Furthermore, demonstrations and exploratory studies need to be repeated in a broad range of environments and might even be uniquely important in areas outside of epicenters in which relatively more motivations/resources are available. Finally, community mobilization with a focus on HIV can be effective, but such interventions are most effective when they occur spontaneously and emerge directly from communities (rather than being “implemented” by an outside agent) (14). There are few studies describing programs that emerge in such “organic” fashion.

The purpose of the current study was to generate and then prioritize specific strategies to address HIV in a Black faith community. The intent was to inform the design of HIV intervention strategies based on the lived experience of the broader community of stakeholders -- providers, faith-community stakeholders (faith leaders, health ministers, and congregants), community advocates, and health researchers. Necessary here was a method that included the voice of the many and diverse perspectives of the total community and provided a process for meaning to emerge. Notably, this is the first study to examine a faith-community driven approach to HIV in the southern Midwest.

METHODS

Study setting and population/participants

This study was conducted in Cincinnati/Hamilton County, Ohio. Hamilton County is considered a low-to-moderate HIV prevalence area with an estimated 274 per 100,000 residents living with a HIV diagnosis (15). Most (57%) of these cases are among non-Hispanic black/African Americans, and two of three Blacks with HIV in Ohio reside in Hamilton County.

A previous study has identified about 450 religious congregations in the Greater Cincinnati area, with over 100 located in the City of Cincinnati (2). About a third of Black Protestant congregations in Greater Cincinnati have offered HIV prevention/counseling programs, compared to 3–4% of other types of congregations. However, the differences in the provision of HIV programs by theology-polity have been linked to urban location, organizational resources, and broader community service (2).

The current study was conducted in the context of an academic-community partnership and a pilot project that involved a selected group of Black churches serving high HIV-risk neighborhoods. The program aimed to educate faith leaders about HIV and assist churches with the development of suitable, faith-based HIV stigma reduction and prevention programs. Participants in the current study were recruited from faith and other community members who attended a town hall meeting organized by the academic-community partners. The target audience was faith and community leaders, health professionals, and HIV-infected or at-risk individuals. The study was approved by the University of Cincinnati Institutional Review Board.

Study design

We used concept mapping to generate and then prioritize specific strategies to address HIV in a Black faith community. Concept mapping is a mixed-method, participatory research methodology. Through brainstorming and sorting steps followed by multidimensional scaling and hierarchical cluster analysis, concept mapping results in a structured, data-driven visual representation of thoughts or ideas of a group (16). Concept mapping is an ideal participatory framework for the study of community health issues, and an extensive methodological work has demonstrated both its validity and utility. Concept mapping has been used to address substantive issues in culturally competent intervention services and health disparities (17,18). The aim of the current study was to apply concept mapping to identify contextually relevant HIV interventions in the Black faith community and expand on prior research by involving community members in the process.

Procedure

Step 1: Brainstorming

As part of an evaluation at a community town hall meeting about HIV sponsored by our partnering community organization, attendees were asked to generate items that completed a partial statement (focus prompt) relevant to HIV in their community—”To address HIV/AIDS in the Black faith community, I believe we need to….” In concept mapping methodology, the intent of the focus prompt is to focus respondents on a specific issue, addressing HIV within the Black faith community in this case, and then ask them to provide brief responses that complete the prompt. The focus prompt was administered as part of the town hall meeting evaluation, and as such was included on a questionnaire given out at the beginning of the meeting. Attendees responded anonymously in writing with 3–5 brief responses that completed the focus prompt.

Step 2: Statement editing

Items generated in Step 1 were edited by the research team in order to reduce the number of items to a manageable set of less than 100 responses (18). The research team eliminated items not consistent with the focus prompt or items expressing similar ideas. Further editing was done for grammar and clarity of expression without altering the original meaning of the responses. The outcome of the editing process was a manageable number of items for the sorting task in Step 3.

Step 3: Sorting & rating

A smaller number of stakeholders from the same broad categories of attendees (i.e., professionals, community/church, and those personally affected by HIV) sorted the items into groups of similar ideas (19,20). Sorters were asked to identify their involvement within the HIV community (e.g., clinicians, researchers, service providers, community members, community agency, a person with HIV, and/or family member of a person with HIV (sorters could choose more than 1 category). The sorters received a deck of cards and were directed to complete the sorting task. Each card contained one item generated in response to the focus prompt along with an identification number. The sorters were asked to individually sort cards into groups based on their perception of similar ideas. Next, the sorters were directed to place each group of cards into separate envelopes. On the front of the envelope, the sorters were asked to provide a label/name for each group of cards and to rate each group of cards in terms of importance and feasibility on a 5-point Likert scale.

Data analysis

Sorting data from each individual resulted in a symmetric matrix with a column and row for each of the responses. Cells in the matrix represented the intersection of each item with every other item and contained a 1 if the intersecting items were placed in the same group by the respondent or a zero if not placed in the same group. A dataset of all of the respondents’ matrices was analyzed using multidimensional scaling (21) to create x,y coordinates and position the ideas as points in a two-dimensional map. Items that were often sorted together by different respondents shared a conceptual similarity in the minds of the sorters and, as a result, these items had x,y coordinates close to each other. Cluster analysis was applied to the x,y coordinates of the points to determine where boundaries could be drawn around groups of items (22). A judgment had to be made about the appropriate number of clusters because cluster analysis results in as many clusters as there are sorted responses. The goal in this interpretive process was to describe the issue in the map with as few clusters as possible but express sufficient detail. In this case, the academic-community partnership team reviewed multiple cluster solutions and determined the appropriate number of clusters. A final step was to create a label for each cluster that succinctly expressed the theme for a cluster while remaining grounded in the meaning provided by respondents. As such, the academic-community partnership team reviewed the labels used by respondents as a guide for creating final names for the clusters.

Concept maps illustrate what a group thinks about a particular issue. While the group involved in concept mapping is composed of individuals with an informed perspective, members of the group often represent multiple and diverse perspectives on the issue under consideration. An additional step that can be applied to the concept maps is to elicit the value system of the various stakeholder groups to determine the extent to which groups are in agreement. This step is accomplished by comparing value ratings provided by different stakeholder groups and then displaying and comparing the pattern of value among different groups. Termed “pattern matching” (16), the intent is to focus on the differences and similarities in the patterns of value across all of the concepts/clusters. The value that a sorter gave each group of items was assigned to all items in that grouping. The mean value for each item was then calculated across all raters, and the average value of all items in a cluster was calculated from the item means. The pattern of results was examined across all participants and within three stakeholder groups by rank-ordering the final clusters on a vertical number line for importance and feasibility. The three stakeholder groups were categorized as: 1) professionals (e.g., clinicians, researchers, service providers, etc.); 2) community (e.g., members, churches, agencies); and/or, 3) individuals personally affected by HIV (e.g., self/HIV-infected or at-risk, family members).

RESULTS

Participants

A total of 90 attendees to a community town hall meeting identified themselves via self-report (attendees could select more than one option) as church members/leaders associated with the project (42%), community members and members of agencies interested in addressing HIV/AIDS (45%), PLWH (8%), family member of PLWH (11%), clinician/researcher working with PLWH (20%), and other (students, visitors from another city, etc.; 13%). As part of the town hall meeting, the participants completed an evaluation that included a question about strategies to address HIV/AIDS in the Black faith community. A smaller group of stakeholders from the same broad categories (n = 21) worked individually to complete an unstructured sorting of these strategies into groups of similar ideas.

Brainstormed items

Stakeholders brainstormed a diverse set of 278 items from multiple perspectives that were relevant to addressing HIV in the Black faith community. After editing to eliminate redundant ideas and deleting items that did not respond to the focus prompt, 93 items were used in the sorting task.

Concept maps

The multidimensional scaling results (Figure 1) show how the 93 items are arranged in relation to each other; points close together represent items that the sorters considered as similar. The results also show how the 93 items coalesce into groups in the cluster analysis.

Figure 1. Point and cluster map -- strategies to address HIV in a Black faith community^a (BC = Black church).

^aClusters:

1. Black churches’ acceptance of and openness to PLWHs
2. Education about HIV among Black youth, families, and communities
3. Black community mobilization and honest communication about HIV
4. Engaging and supporting church members and leaders in talking about HIV
5. Direct actions churches can take in addressing HIV
6. Suggested strategies for HIV safety and prevention
7. Media methods to increase awareness about HIV
8. Addressing sexual and other stigmas about HIV

Ignoring for the moment the boundaries drawn around groups of points and the labels for those boundaries, the points alone illustrate the most detailed perspective. Based on the x,y coordinates produced by multidimensional scaling, the locations of items and the distance between items can be explored because distance between points has meaning. For example, two statements located in the lower right portion, cluster 6, are item 69, “practice safe sex,” which is close to item 15, “have condoms more available,” but neither of these items are close to item 47, “give people with HIV/AIDS love - God loves them - we should too” located on the opposite left hand top corner of the map. The location of these points indicates that the sorters more often sorted items 69 and 15 into the same group which signifies that they thought the ideas expressed in these two items were conceptually similar. The sorters never sorted items 69 and 15 together with item 47 because the sorters saw these items as conceptually dissimilar. The multidimensional scaling routine takes the multiple data from multiple sorters and finds a single solution with best location for all points in a two-dimensional arrangement by placing the conceptually similar items closer together and the dissimilar items further apart. Because the sorting process was done individually, the sorters varied in how they organized items. For instance, items 69 and 15 may have been sorted into the same group by different sorters, but each sorter may have had different other items in the group in which 69 and 15 were placed, so these other points are nearby and still conceptually related. However, there is not complete agreement on all responses from all sorters. This illustrates a methodological nuance that is important in concept mapping -- it is not necessary to facilitate consensus in the group and thereby eliminate individual differences. Individual sorters provided their individual perspective, and the process enabled a single picture to emerge that shows where consensus exists (e.g., items 69 and 15) and where slight differences emerge (e.g., items near 69 and 15 in nearby clusters).

While understanding the nuance of point location is useful, it is also useful to see the bigger picture -- that is, applying cluster analysis to determine how multiple individual ideas represented by points coalesce into a smaller number of key concepts (clusters) in a map. The academic-community partnership team agreed that an eight-cluster map illustrated the key issues. Each cluster was named through a consensus process; for example, Cluster 1 was given the title, “Black Churches’ Acceptance and Openness to PLWHs” which consisted of related responses about the church accepting PLWH (e.g., “allow faith to evolve and progress in order to become more accepting of different lifestyles”; Table 1).

Table 1.

Example responses in each cluster

Cluster 1: Black churches’ acceptance of and openness to people living with HIV (PLWH)

1. Help the churches become more accepting of men that have sex with men

2. Allow faith to evolve and progress in order to become more accepting of different lifestyles

21. Address the issue in church - we know abstinence is not the message, so let’s get real

Cluster 2: Education about HIV among Black youth, families, and communities

30. Educate the public on the risks involved with unprotected sex

89. Get young people talking about HIV/AIDS and educate them

14. Acknowledge that this epidemic is impacting our community

Cluster 3: Black community mobilization and honest communication about HIV

13. Mobilize community to talk about the issue (prevention, social and population behaviors)

57. Encourage HIV/AIDS at home conversations with families or at family reunions

85. Discuss contextual factors that affect African American women and female adolescents such as SES, negotiation skills, etc.

Cluster 4: Engaging and supporting church members and leaders in talking about HIV

8. For the church leadership to proclaim their support of HIV/AIDS prevention and pass this on to their congregations

46. Listen to members of the church and how they deal with HIV/AIDS

79. Address it openly and lovingly in church - no shame! Within the church (pastor and family included)

Cluster 5: Direct actions churches can take in addressing HIV

12. Have more churches collaborating on prevention/education activities

53. Work it through our health ministry

83. Offer HIV testing at the church

Cluster 6: Suggested strategies for HIV safety and prevention

16. Prevent - offer contraception as opposed to just abstinence

69. Practice safe sex

92. Develop interesting ways to engage youth and encourage youth testing (events, concerts famous people endorsements)

Cluster 7: Media methods to increase awareness about HIV

50. TV- radio - public announcements

51. Upgrade marketing efforts in the faith initiative every sermon - billboards – public service announcements - radio announcements Sunday

71. Hit social media, that’s where the youth reside

Cluster 8: Addressing sexual and other stigmas about HIV

25. Take it out of the closet and educate that HIV/AIDS is now a heterosexual problem

37. Openly discuss issues pertaining to the gay Black community

76. Address the sense of homophobia/stigma that is so often attached to feelings regarding homosexuality in this community

Pattern Matching

The importance and feasibility of the eight strategies were compared for each of the three stakeholder groups (i.e., professionals, community/church, and those personally affected by HIV). Keeping in mind that all items and clusters are important and to some extent feasible, pattern analysis visually orients stakeholders’ priorities and beliefs about importance and feasibility. For example, across all the sorters, Cluster 8, Addressing HIV-Related Stigma, was rated as most important while Cluster 4, Engaging/Supporting Church Members, was rated as least important (Figure 2). Cluster 2, HIV Education, was rated as most feasible, and Cluster 1, Black Church Acceptance and Openness, was as least feasible (Figure 2).

Figure 2. Pattern matching of rank-ordered clusters by importance and feasibility^a: all sorters^b (BC = Black church).

^aHigher values indicate greater importance and greater feasibility

^bProfessionals, community, and individuals personally affected by HIV (i.e., HIV-infected and at-risk individuals; family/friends of people living with HIV [PLWH])

Pattern analysis was also used to explore the beliefs about importance and feasibility within stakeholder groups. For example, the professionals rated Cluster 8, Addressing HIV-Related Stigma, as most important and Cluster 5, Direct Actions by Church, as least important (Figure 3). They rated Cluster 6, HIV Safety & Prevention, as the most feasible and Cluster 1, Black Church Acceptance and Openness, as the least feasible strategy. The community group rated Cluster 3, Community Mobilization & Communication, as most important and Cluster 5, Direct Actions by Church, as least important (Figure 4). The community group rated Cluster 2, HIV Education, as most feasible and Cluster 1, Black Church Acceptance and Openness, as least feasible. Finally, the group personally affected by HIV rated Cluster 6, HIV Safety & Prevention, as most important while Cluster 4, Engaging/ Supporting Church Members, was rated as least important (Figure 5). For those personally affected by HIV, Cluster 8, Addressing HIV-Related Stigma, was rated as most feasible, and Cluster 1, Black Church Acceptance and Openness, was rated as least feasible.

Figure 3. Pattern matching of rank-ordered clusters by importance and feasibility^a: professionals (BC = Black church).

^aHigher values indicate greater importance and greater feasibility

Figure 4. Pattern matching of rank-ordered clusters by importance and feasibility^a: community (BC = Black church).

^aHigher values indicate greater importance and greater feasibility

Figure 5. Pattern matching of rank-ordered clusters by importance and feasibility^a: individuals personally affected by HIV (BC = Black church).

^aHigher values indicate greater importance and greater feasibility

DISCUSSION

There is increasing interest and research activity on African American faith community’s involvement in HIV prevention. Concept mapping was used in the current study to identify and prioritize contextually relevant HIV-related strategies within a local Black faith community. Community-based approaches are recognized for their utility in disparities reduction efforts, due to their emphasis on inclusion of those communities most directly affected by the disparity to identify problems and potential solutions. Without these perspectives, public health, HIV treatment, and research professionals may not identify the complexity of issues that could have an impact on outcomes. To develop the concept maps, we sought to obtain diverse perspectives on faith-based HIV prevention by including church members and leaders who were currently involved in an HIV prevention project, PLWH and their family members, HIV clinician/researchers, and other community members who had expressed interest through their attendance at a community town hall meeting on HIV in the African American faith community. In doing so, we were able to represent views from both inside and outside of the social systems that might be involved in a community response to HIV. By maximizing the diversity of the respondents, the resulting concept maps can be placed in the context of stakeholders’ collective experience and values.

Like any methodology, concept mapping has limitations including nonrandom sampling, small sample size, and the time and labor-intensive process required to involve multiple stakeholders. However, concept mapping provides researchers and practitioners with a unique, participatory data collection and intervention design process that allows for individual-level responses (brainstorming) and group-level wisdom (sorting and data analysis). In addition, this study was specific to one geographic location and a selected group of individuals within a specific faith community and that group’s particular concerns; thus, the content of the results may not be applicable to other contexts.

These limitations notwithstanding, this study offers useful insights into the faith community’s perspective on how faith leaders and congregations can engage in public health efforts to address HIV among African Americans. One key finding in our study was the high importance of addressing HIV-related stigma in faith settings and some problems with (lower feasibility of) this strategy. Previous research has shown that faith communities have frequently shunned persons at risk of HIV, such as men who have sex with men and drug users, because of strict doctrinal interpretations of religious texts and a culture of silence, stigma, and homophobia (1). Indeed, representatives of various groups, including faith leaders, HIV activists, and researchers, have claimed for over a decade that homophobia is the key factor blocking the Black church’s response to HIV (23,24). These attitudes hinder effective HIV prevention and care in at-risk communities (10). Many studies have identified stigma as a specific barrier to congregational involvement in HIV prevention (25).

The fact that the faith community in our study considered addressing stigma as less feasible than some other strategies suggests that the Black church is not as well equipped to tackle HIV stigma versus delivering HIV education or mobilizing. However, although HIV stigma is typically an issue within conservative churches, some denominations and churches have been able to address stigma despite conservative theologies (25). For example, congregations can donate resources to support HIV-related programs, such as condom distribution and clean needle exchanges, as part of their service mission, without engaging in such activities directly (26). Other congregations simply follow their ideology of welcoming all people, regardless of their lifestyles (e.g., homo-/bi-sexuality) or disease (e.g., HIV) states or risks (27). Research shows that presence of PLWH in the congregation and openness to gays/lesbians, among other factors, helps to enhance congregational HIV programming (5).

In our study, addressing stigma and community mobilization were identified as distinct strategies (i.e., different clusters). However, the literature suggests that they are more intertwined. For example, Tyrell and colleagues (28) propose that the faith community history of shaming and blaming deters HIV prevention efforts, and the way to address this is by engaging faith leaders who are historically the community mobilizers in the Black community. The impact of stigma on behaviors and self-perceptions of PLWH is important because those who are stigmatized are less likely to display health-seeking behavior. Stigma can make people less likely to seek an HIV test, less likely to disclose HIV status if they are positive, and more likely to engage in high-risk sexual activities (28), further emphasizing the importance of our study in aiding the Black church in choosing interventions that can lessen HIV- related stigma.

Interestingly, people affected by HIV rated tackling stigma lower in importance than the other groups in our study while they rated this strategy as the most feasible. One potential explanation for such views is the perception that attitude change does not require resources. Another explanation could be that people affected by HIV often participate in settings that welcome them, and stigma appears not to be a significant problem in those settings. Further research will need to clarify the perspectives of people affected by HIV on the stigma problem within faith communities.

Another cluster of strategies proposed by the faith community in our study focused on the need for community outreach. Previous research has shown that faith leaders and congregations are often unaware of the extent of the HIV epidemic in their surrounding communities and thus feel no sense of need or urgency (25). If an intervention can rectify this issue, churches may be willing to engage in HIV-related activities. For example, in one project, data were presented to churches on various health problems, including HIV, in the geographic communities surrounding the churches, and the congregations chose themselves to target HIV and youth sexual risk behaviors in their health programming (29). Research at the national level shows that formal community HIV-related needs assessments facilitate the provision of HIV programming (5). Raising awareness through dissemination of data about the local epidemic is also one strategy to change attitudes about and increase compassion for persons with or at high risk of HIV in the faith communities (30).

Our data suggest that faith community mobilization is a key component of HIV-related community outreach and that supporting the Black faith community mobilization efforts is highly feasible as well as highly important. Many Black churches around the country have taken a stance on homophobia and have led efforts locally and nationally to address HIV stigma, for example, the Trinity United Church of Christ, a Black-mega church; the Balm in Gilead, an organization based in New York City that has championed HIV awareness and intervention for three decades; the Regional AIDS Interfaith Network in North Carolina; and, Unity Fellowship Churches based in several large metropolitan areas (24,31). Church-public health/academic partnerships have emerged all across the country. Some of these coalitions engage large numbers of churches; for example, a Michigan program engaged more than 40 congregations (32). The evidence suggests that with resources and multiple stakeholders at the table, faith-based community outreach is highly feasible. Although sustainability of programs remains limited, community-driven interventions have unique potential vis-à-vis other types of interventions because they capitalize on strengths of communities and attain community trust needed to address HIV (32).

The findings from our study also indicate the high importance and feasibility of faith-based educational and media campaigns. The use of faith communities as both agents and target audiences in the dissemination of HIV-related information and messages is innovative and can supplement traditional educational and media approaches. The need for HIV safety and prevention knowledge dissemination in this faith community was rated among the top three items in importance and feasibility. However, the literature suggests that only certain messages tend to be acceptable in faith-based settings. For example, one study showed that faith leaders have a strong preference for abstinence-based sex education, and they are not willing to discuss specific behaviors associated with HIV transmission (7). Furthermore, engaging and supporting church members in discussing HIV at the congregational forum were rated low in importance and feasibility among our community stakeholders. These findings indicate limited readiness of this community to address the faith/doctrinal aspects related to HIV. The community partners in our project repeatedly stressed the importance of “meeting the churches where they are” -- that is, offering congregations options for HIV involvement that would not compromise or negate their religious doctrine.

In our sample, respondents were able to identify and had fair levels of agreement about specific strategies to address HIV within the Black church, as evidenced by content areas involved in the clusters. Next steps include forming action groups at the participating churches composed of church members who are interested in developing specific interventions to address HIV based on the identified clusters. The eight-cluster concept maps will be used to guide the process and ensure that all viewpoints are considered, rather than the individual church or one group of stakeholders having a dominant voice. Specific brainstormed responses underlying the clusters can be consulted alongside existing models and research about how to best address HIV within this Black faith community. The concept maps can also facilitate considerations of various levels to address (e.g., church, broader community, society) within the design of an HIV-related intervention or program.

The eight clusters identified in this study can serve as a roadmap for an improved understanding of the types of HIV approaches that are most promising and those that are less likely to be acceptable to this Black faith community for implementation. Without input from and inclusion of all relevant stakeholders, interventions may be void of the lived experience and daily lives of those affected. Efforts to eliminate or reduce HIV-related disparities must involve local communities and consider their views, thereby increasing individual and community ability to address the existing concerns in the community.