Black PRAISE: engaging Black congregations to strengthen critical awareness of HIV affecting Black Canadian communities

Summary

In Canada, HIV disproportionately affects Black communities. Though Black faith leaders play an influential role engaging Black communities around social care and social justice, their response to HIV has been somewhat muted. Black PRAISE is a novel intervention for Black churches to strengthen congregants’ critical awareness of HIV affecting Black communities. A multi-stakeholder team developed and tested the intervention in 2016 − 17 among six churches in the province of Ontario, where more than half of Black Canadians reside, using a community-based participatory approach. Specifically, the intervention aimed to strengthen how congregants understand HIV among Black communities and reduce their level of stigma toward people living with HIV. We addressed critical awareness among the participating congregations through (i) disseminating a booklet with validated information that promoted critical health literacy related to HIV; (ii) enabling pastors to deliver a sermon on love, compassion and social justice; and (iii) developing and screening a short film that featured Black Canadians discussing their experiences of HIV-related stigma. We assessed changes in knowledge and stigma by surveying congregants (N = 173) at baseline and two follow-ups using validated instruments and other measures. Through Black PRAISE, congregants significantly increased their HIV-related knowledge; moreover, exposure to all the intervention components was associated with a significantly reduced level of stigma. A likely strategic outcome of Black PRAISE is that churches are empowered to help strengthen Black people’s community-based response to HIV and join efforts to eliminate the structural conditions that increase Black people’s vulnerability to HIV.

community-based intervention, HIV, Black churches, critical awareness, Canada

INTRODUCTION AND BACKGROUND

Black PRAISE (Pastors Raising Awareness and Insight of Stigma through Engagement) is a novel intervention for Black church congregations to strengthen their critical awareness of HIV affecting Black communities. We developed and tested the intervention among six Black churches in Ontario, Canada, by assessing changes in congregants’ HIV-related knowledge and stigma consequent to their exposure to the intervention. In this article, we report on the process and outcome of developing and testing Black PRAISE.

HIV is an issue of concern for Black communities in Canada, particularly in the province of Ontario where 52% of Canada’s 1.2 million Black people reside (Statistics Canada, 2019). Black people accounted for 26% of all new HIV infections in Ontario in 2016 − 17, with Black men and women comprising 18% and 54% of new infections among all men and women, respectively (OHESI, 2019). These trends illustrate the disproportionate burden of HIV among Black people, who account for just 5% of the province’s population.

Previous Canadian research among Black communities suggested that HIV-related stigma was pervasive and helped to reproduce Black people’s experiences of social marginalization (Gardezi et al., 2008; Logie et al., 2013). Stigma also undermines community support for responding effectively to HIV (Mahajan et al., 2008; Stangl et al., 2013; Sweeney and Vanable, 2016). Therefore, initiatives to promote critical understanding may help to reduce or eliminate stigmatizing beliefs or attitudes, thereby sustaining a supportive environment for community responses to HIV.

In 2012, Toronto-based researchers, community stakeholders and Black pastors agreed to collaboratively develop and test an intervention to promote critical awareness of HIV among Black congregations. This decision drew on churches’ longstanding tradition of leadership in mobilizing Black communities for equity and justice since the early 19th century, and the tradition of religiosity among Black communities (Gillard, 1998; Calhoun-Brown 2000; Este 2004; Este and Bernard, 2006). This record of leadership for social justice has enabled Black churches to mobilize social capital in support of health promotion and HIV prevention (Eke et al., 2010; Nunn et al., 2012; Stewart, 2015). On the other hand, their teachings about sex and sexuality, and their lack of resources or capacity to develop and implement appropriate programs, are often barriers to action on HIV (Francis and Liverpool, 2009; Nunn et al., 2012; Alio et al., 2014; Mendel et al., 2014; Stewart, 2015). This gap between potential and capacity suggests a role for interventions to build critical awareness of HIV among Black congregations that would enable them to mobilize their members and the wider Black community to address HIV.

Stigma reduction programs in Black churches

Previous reported efforts at stigma-reduction interventions among Black faith communities have been inconclusive. In Kansas City, Taking It to the Pews was not associated with a significant reduction in stigma between or within the intervention or control churches, though participants in the intervention churches were more likely to report getting tested for HIV (Berkley-Patton et al., 2013). In the FAITH study in Long Beach, California (Derose et al., 2016), the intervention was associated with an increase in HIV testing, but the reduction in stigma was similar between the intervention and control churches. However, in the FAITHH study in rural Alabama, the researchers observed a decrease in stigma and an improvement in HIV knowledge in the intervention group compared with the control group (Payne-Foster et al., 2018).

In terms of interventions among Black churches where stigma reduction is a secondary outcome, researchers noted increased communication with religious leaders among the P4 participants in Atlanta, Georgia, which may suggest a reduction in stigma (Wingood et al., 2013). However, Your Blessed Health (YBH), an intervention among African American congregants in Flint, Michigan did not achieve any significant improvement in youths’ knowledge, or their comfort discussing sex, HIV or STIs with their elders (Griffith et al., 2010).

Scholars have drawn attention to methodological challenges in stigma reduction studies, and the lack of clarity about what these interventions can achieve. We address these issues and others below in relation to Black PRAISE.

DEVELOPING AND IMPLEMENTING BLACK PRAISE

Conceptual basis for Black PRAISE

Black PRAISE is a congregation-based intervention to strengthen Black faith communities’ critical awareness of HIV affecting Black communities. Critical awareness is a process through which communities understand their wellbeing in relation to broader systemic conditions. It opens the way for communities to collectively develop effective, socially enabling responses to HIV (Minkler et al., 2008). Black PRAISE may prompt people to critically appraise their individual prejudices and the systemic basis of HIV-related stigma, so that over time they can address the laws, policies and institutional practices that reproduce stigma. The research team and church leadership supported the intervention and congregants’ participation, but Black PRAISE also attempted to build the churches’ capacity to understand and resolve critical issues in health and social care among Black communities.

Scholars have noted a number of conceptual and methodological weaknesses with research on church-based health promotion interventions (Sengupta et al., 2011; Stangl et al., 2013). For example, many studies do not report a theoretical framework, some rely on instruments that have not been previously tested and validated, and others provide insufficient detail on the intervention process (Stangl et al., 2013; Kemp et al., 2019). In addition, some studies may insufficiently engage church members and leaders in decision-making about the interventions (Campbell et al., 2007). In response, we followed a community-based participatory framework (Israel et al., 2003) to engage the congregations and pastors in the process of strengthening critical awareness of HIV among Black communities. We also used validated instruments to assess HIV-related knowledge and stigma. Moreover, in the following sections we describe our process in appropriate detail.

Black PRAISE incorporated elements of successful congregation-based health programs (Francis and Liverpool, 2009; Williams et al., 2011; Mak et al., 2017). A diverse group of stakeholders, including pastors and congregation members, collectively developed the intervention and the accompanying surveys. Our approach incorporated multiple opportunities through different communication channels for congregants to reflect on how they understood HIV. The research team provided the churches with financial subsidies to support their participation, and likewise supported the collaborating community-based agencies and their volunteers.

Content and structure of the Black PRAISE intervention

We organized and delivered information to participating congregations about HIV among Black communities through a booklet, a sermon and a short film. Our multi-stakeholder team developed all the components collaboratively along with the pastors of the six participating churches. The three components addressed complementary aspects of HIV-related knowledge and stigma, respectively, and reinforced each other to promote critical awareness. The three components were as follows:

• Booklet (‘Wisdom is the Principal Thing’): the team developed and distributed this resource among the congregations. The booklet addressed inappropriate fear of HIV transmission by conveying validated user-friendly information about: HIV transmission, testing and prevention for Black communities; equity, justice and the social determinants of health; epidemiological data that illustrated the disproportionate effect of HIV among Black communities; and HIV-related programs available for Black communities throughout Ontario.

• Sermon (‘A place to be made whole’): the team developed a detailed outline for a sermon on love, compassion and social justice that pastors delivered to their congregations. The sermon illustrated the significance of biblical teachings to stigma reduction through anecdotes that we developed about experiences of people in church settings. Therefore, the sermon also provided indirect exposure to the voices of people living with HIV. In addition, the sermon indirectly addressed issues related to the social determinants of health.

• Film (‘When it comes to HIV stigma and being Black…’): this 8-min film featured Black Canadians discussing their experiences of stigma and the likely role of churches in reducing stigma. The film afforded congregants the opportunity to hear from people who were affected by HIV stigma, introduced congregants to the concept of compounded or layered stigma (i.e. the compounding effect of racism, heterosexism, homophobia and sexism) through personal experience, and illustrated the diversity of Black population segments that are directly affected by HIV. The film was available to each congregation as a password-protected file on a website and an USB drive.

We implemented the Black PRAISE components sequentially in October and November 2016 among the six Black churches. The activities (distribution of the booklet, delivery of the sermon and viewing the short film) took place on specific dates at the main Saturday or Sunday services.

Engagement and recruitment

We identified likely churches through consultation and referral among community stakeholders, and subsequently held several meetings with the pastors and leadership from eight interested churches with at least 85% Black membership. Two declined to participate due to other responsibilities. Four of the churches were located in Toronto, and the other two were located in Mississauga (neighboring Toronto) and Ottawa, respectively. One church was non-denominational, and five were affiliated with various minority denominations. One church dated from the 19th century, and the others from the 1980s and later. The six lead pastors were men of Caribbean or African background, though one pastor was assisted by a white female pastor.

Any or all congregants could be exposed to the intervention if they were in church when an activity took place. However, only congregants who self-identified as African, Caribbean or Black and were 16 years or older were eligible to participate in the baseline and follow-up surveys that examined changes in HIV-related knowledge and stigma consequent to the intervention.

Data collection

We assessed participants’ HIV-related knowledge and stigma at baseline (mid to late October 2016), post-intervention (November/December 2016) and the 3-month follow-up (February/March 2017) to determine changes in knowledge and stigma following the intervention. The surveys also solicited data on participants’ socio-demographic background, involvement in HIV issues, HIV testing and other factors. At baseline, we guided participants in constructing a unique code that they appended to their questionnaire and repeated the instructions at each of the two subsequent surveys. These codes allowed us to track anonymized individuals across the three surveys. Across the six participating churches, we estimated participation rates of 68%, 76% and 80% in the three surveys, respectively. Here we report on the 173 eligible participants who were exposed to at least one intervention component, and completed the baseline and one or both of the follow-up surveys.

The surveys took place among congregants on an agreed schedule after the main Saturday or Sunday services. The Research Ethics Boards of the universities of Toronto and Windsor (in Canada) and Louisville (in the USA) approved the protocol. Participants gave signed consent and received an honorarium for each of the three surveys. Members of the research team and trained personnel from the collaborating community-based agencies administered the surveys.

Measures of HIV-related knowledge and stigma

We used the HIV-KQ-18 tool to assess participants’ knowledge about HIV transmission (Carey and Schroder, 2002). Participants rated each of 18 statements about HIV transmission as ‘true’, ‘false’ or ‘don’t know’, and each participant’s overall knowledge score is the percentage of items scored correctly. The scale demonstrated high reliability (α = 0.9) that is similar previous studies with Black populations (Ojikutu et al., 2013; Kerr et al., 2018).

We used the SAT-PLWHA-S instrument to measure stigma toward people living with HIV (Beaulieu et al., 2014). The scale comprises seven factors that capture the complex multi-dimensional reality of stigma (e.g. criminalization, discrimination, blame etc.). Respondents indicated their level of agreement/disagreement with 25 statements about people living with HIV (strongly disagree; disagree; agree; strongly agree). The original version of the SAT-PLWHA-S included three statements related to whether someone living with HIV should face criminal prosecution for allegedly not disclosing their HIV status to a sex partner. However, in light of recent advances in understanding the issue, we substituted a single criminalization item that read: ‘Transmitting HIV without taking precautions should be punishable by law’. We calculated an overall stigma score for each participant by summing the score that the participant gave to each statement on the instrument. Higher overall scores indicated a higher level of stigma. The scale demonstrated high reliability (α = 0.88), similar to when originally published.

As expected, some participants did not rate all of the statements on either the knowledge or the stigma scale, which resulted in a few instances of missing data on both scales that varied from statement to statement. We used multiple imputation to derive statistically plausible estimates for the missing values, based on the recommended 5 imputations (Eekhout et al., 2014).

Data analysis

To assess changes in knowledge and stigma from baseline to follow-up, we first tested for differences in the mean scores for knowledge and stigma, respectively, using a paired t-test with a significance level (two-tailed) of 5%. We tested for differences in knowledge and stigma over time among participants in each of the following groups: Group 1 included congregants who participated at baseline and both follow-up surveys (N = 78); Group 2 included those who participated at baseline and post-intervention only (N = 61); Group 3 comprised congregants who participated at baseline and 3-month follow-up only (N = 34). Further, we also grouped together all participants at baseline and post-intervention as Group 4 (N = 139; i.e. Groups 1 and 2 combined); while Group 5 includes all participants at baseline and 3-month follow-up (N = 112, i.e. Groups 1 and 3 combined). In each group, the baseline and follow-up participants are the same.

Next, we used multi-variable linear regression to assess whether, allowing for their baseline scores, congregants’ socio-demographic status, prior involvement with HIV, and amount of exposure to the intervention predicted their final scores on knowledge and stigma. In particular, we expected that improvements in knowledge and decreases in stigma should accompany higher levels or intensity of exposure to the intervention. This, together with significant changes in the mean scores in the expected direction would constitute strong evidence that Black PRAISE was associated with improved knowledge about HIV and a reduction in HIV-related stigma. We used SPSS 24 for data imputation (outlined above) and the analyses reported below.

RESULTS AND OUTCOMES

Who participated in black PRAISE?

Congregants identified predominantly as: Caribbean or Black, female, Christian, heterosexual, foreign-born and as frequent church attendees (i.e. at least weekly) (Table 1). Slightly less than half of all participants indicated that they had ever tested for HIV, though this varied noticeably among the different survey groups. Almost all participants indicated that they had never been diagnosed with HIV. Almost half (46.8%) indicated that they were exposed to one component of the intervention, and more than one-third indicated being exposed to all three components.

Table 1:

Profile of Black PRAISE participants: percent of participants in each survey group and overall

	Group 1 (baseline and both follow-up surveys) (N = 78)	Group 2 (baseline and post-intervention only) (N = 61)	Group 3 baseline and 3-month follow-up only (N = 34)	Overall (N = 173)
Self-identified ethno-racial backgrounda
African	25.6	18.0	17.6	21.4
Caribbean	50.0	60.7	52.9	54.3
Black	43.6	63.9	50.0	52.0
Selected socio-demographic indicatorsb
Christian	98.7	100.0	96.9	98.8
Heterosexual	97.3	98.3	96.6	97.5
Attend church/religious events at least weekly	85.7	82.0	72.7	81.9
Women	71.4	75.4	76.5	73.8
Not born in Canada	69.7	70.5	61.8	68.4
Aged 40–59 years	36.4	43.4	47.0	41.0
Married	34.2	41.0	44.1	38.6
College or university graduate	48.7	59.0	50.0	52.7
Employed/self-employed fulltime	61.6	50.0	56.7	56.7
Ever tested for HIV	47.9	54.4	33.3	47.7
HIV-negative/never diagnosed	97.0	96.2	88.0	95.2
Intervention components received
1 component	37.2	29.5	100.0	46.8
2 components	19.2	19.7	0.0	15.6
3 components	43.6	50.8	0.0	37.6
Total	100.0	100.0	100.0	100.0

a

Percent of African, Caribbean and Black do not add to 100% because participants were allowed multiple responses.

b

For the socio-demographic indicators, the number of missing cases is small for most variables (i.e. 2% or less of all cases in each group), except for employment status (where up to 10% of the cases were missing); the reported percentages exclude missing cases.

Changes in HIV-related knowledge and stigma among the congregations

The mean knowledge scores increased from baseline to follow-up among all groups, but the trend for stigma is less obvious (Table 2). Across all groups, congregants became significantly more knowledgeable about HIV after exposure to the intervention (Table 3). Moreover, for Group 1, the gain in knowledge was evident at the 3-month follow-up. On the other hand, stigma initially decreased significantly only among Group 2. We then selected participants from Groups 4 and 5 who recorded high levels of stigma at baseline (i.e. their scores at baseline exceeded the mean for those groups), and organized them into Groups 6 and 7, respectively. Those high-stigma participants demonstrated a significant reduction in stigma at follow-up (Table 3).

Table 2:

Descriptive summary of knowledge and stigma scores among Black PRAISE participants

	Knowledge		Stigma
	Mean	Std. deviation	Mean	Std. deviation
Group 1 (N=78)
Baseline	63.18	20.40	51.18	9.79
Post-intervention	71.79	17.43	50.64	10.16
3-Month follow-up	73.29	15.58	51.51	12.95
Group 2 (N=61)
Baseline	60.74	25.91	52.17	11.51
Post-intervention	70.40	19.84	49.55	10.39
Group 3 (N=34)
Baseline	50.16	27.20	55.65	12.03
3-Month follow-up	66.83	20.07	55.49	11.38
Group 4 (N=139)a
Baseline	62.11	22.93	51.61	10.55
Post-intervention	71.18	18.47	50.16	10.24
Group 5 (N=112)b
Baseline	59.23	23.34	52.53	10.66
3-Month follow-up	71.33	17.24	52.72	12.58
Group 6 (N=76: baseline stigma > mean in Group 4)
Baseline			59.49	6.36
Post-intervention			54.00	9.52
Group 7 (N=57: baseline stigma > mean in Group 5)
Baseline			60.85	6.93
3-Month follow-up			57.87	10.27

a

Group 4 includes all participants who completed the baseline and post-intervention surveys (i.e. 78 participants in Group 1 and 61 participants in Group 2); Group 5 includes all participants who completed the baseline and 3-month follow-up surveys (i.e. 78 participants in Group 1 and 34 participants in Group 3).

b

Group 6 includes congregants from Group 4 with baseline stigma scores greater than baseline mean for that group; Group 7 includes congregants from Group 5 with stigma scores greater than the baseline mean for that group.

Table 3:

Change in participants’ HIV-related knowledge and stigma from baseline to follow-up

	Knowledge				Stigma
	Mean difference	Std. deviation	t value	p*	Mean difference	Std. deviation	t value	p*
Group 1 (N = 78)
Post-intervention versus baseline	8.62	16.26	5.32	<0.01	0.54	9.09	0.52	0.60
3-Month follow-up versus baseline	10.11	17.40	5.13	<0.01	−0.33	11.37	−0.26	0.79
3-Month follow-up versus post-intervention	1.50	16.16	0.82	0.42	−0.87	10.83	−0.71	0.48
Group 2 (N = 61)
Post-intervention versus baseline	9.65	20.54	3.67	0.01	2.63	9.58	2.14	0.04
Group 3 (N = 34)
3-Month follow-up versus baseline	16.67	18.35	5.30	<0.01	0.15	8.40	0.11	0.92
Group 4 (N = 139)a
Post-intervention versus baseline	9.07	18.20	5.88	<0.01	1.46	9.34	1.84	0.07
Group 5 (N = 112)a
3-Month follow-up versus baseline	12.10	17.87	7.17	<0.01	−0.19	10.52	−0.19	0.85
Group 6 (N = 76: baseline stigma > mean in Group 4)b
Baseline versus post-intervention					5.49	10.07	4.75	<0.01
Group 7 (N = 57: baseline stigma > mean in Group 5)b
Baseline versus 3-month follow-up					2.98	9.42	2.39	0.02

a

Group 4 includes all congregants who completed the baseline and post-intervention surveys (i.e. the total of Groups 1 and 2); Group 5 includes all congregants who completed the baseline and 3-month follow-up surveys (i.e. the total of Groups 1 and 3).

b

Group 6 includes congregants from Group 4 with baseline stigma scores greater than baseline mean for that group; Group 7 includes congregants from Group 5 with stigma scores greater than the baseline mean for that group.

*

p values in bold indicate significant difference in the mean values under comparison.

Factors influencing final knowledge and stigma outcomes

Except for participants’ baseline knowledge score, none of the predictors in the multi-variable model significantly affected congregants’ knowledge score after exposure to the intervention (Table 4). For stigma, we excluded country of birth, education and church attendance from the multi-variable model because they did not predict the outcome values in bivariate analysis. The analysis showed that congregants who were exposed to all three intervention components achieved a significant reduction in stigma compared with those who were exposed to just one or two components (Table 4). We illustrate this effect in Figure 1, which shows a significant decline in adjusted mean stigma scores with increased exposure to the intervention.

Fig. 1:

Change in stigma with increased exposure to Black PRAISE.

Table 4:

Predictors of HIV knowledge and stigma at follow-up: multivariable linear regression model

Predictor variables	Knowledge			Stigma
	Effect	95% CI	p*	Effect	95% CI	p*
Baseline HIV knowledge score	0.45	0.35, 0.55	<0.001
Baseline HIV stigma score				0.55	0.44, 0.67	<0.001
Age group
16–29 (ref group)	0	−	−	0	−	−
30–59	1.73	−5.72, 9.18	0.647	0.44	−3.32, 4.20	0.818
60 and older	−5.66	−14.49, 3.17	0.208	1.41	−2.95, 5.78	0.524
Country of birth		—	—
Canada	−4.34	−10.51, 1.84	0.167
Other (ref group)	0	—	—
Highest level of education
Graduated university	−1.49	−8.94, 5.96	0.693
Graduated college/some university	1.14	−6.02, 8.30	0.753
Trade/technical/some college	2.06	−5.70, 9.83	0.600
High school or less (ref group)	0	—	—
Church attendance
At least one a week	−0.87	−7.09, 5.34	0.781
Less frequent than once/week	0	—	—
Intervention exposure
All three components	−0.71	−6.90, 5.47	0.820	−4.43	−7.82, −1.05	0.011
Two components	2.18	−5.19, 9.54	0.560	−2.71	−6.83, 1.41	0.196
One component (ref group)	0	—	—	0	—	—
Church
1	−3.12	−14.24, 7.99	0.580	−0.34	−6.55, 5.88	0.915
2	3.95	−5.63, 13.54	0.416	0.97	−3.94, 5.89	0.696
3	4.42	−5.31, 14.15	0.371	−1.68	−7.27, 3.92	0.554
4	−0.69	−9.75, 8.36	0.880	0.85	−4.41, 6.10	0.751
5	2.73	−7.23, 12.69	0.589	−5.44	−10.95, 0.07	0.053
6 (ref group)	0	—	—	0	—	—

*p values in bold indicate a statistically significant relationship.

DISCUSSION, IMPLICATIONS AND CONCLUSION

A multi-stakeholder team collaboratively developed and tested Black PRAISE among six Black congregations. Our results indicate that Black PRAISE is a promising intervention for promoting critical understanding and engagement with HIV among Black Canadian church congregations. Congregants became significantly more knowledgeable about HIV consequent to their exposure to Black PRAISE, and those who demonstrated high levels of stigma at baseline achieved significant reductions thereafter. Importantly, in terms of the intervention design, stigma decreased significantly as participants’ level of exposure to the intervention increased.

Our efforts also yielded key lessons about interventions to strengthen critical awareness of HIV among Black faith communities. First, community-based interventions are warranted to strengthen critical awareness of HIV among Black faith communities. However, Black churches and other institutions should be supported to collaborate in developing and testing interventions, and to incorporate effective interventions into their regular programs.

Second, interventions for Black churches are more likely to succeed if they incorporate multiple ways of engaging communities or providing information and provide opportunity for congregants to appreciate why they should be concerned about HIV. In Black PRAISE, we provided user-friendly information to the congregations, in different formats sequenced over time, about HIV among Black Canadians. This design addressed multiple issues embedded in stigma through different types and levels of exposure to the intervention.

Third, stigma is not simply a function of how much validated knowledge people have. For example, stigma decreased significantly as congregants intensified their exposure to the intervention, but there was no similar result for knowledge. Stigma, like racism and other forms of social oppression, may reside in stereotypes that people hold, irrespective of how much formal knowledge they have. It may function to reinforce boundaries of privilege that may be relatively immune to ‘objective’ knowledge.

Black PRAISE experienced limitations that warrant attention for subsequent phases. First, we implemented the intervention among a limited number of small or modestly sized Black English-speaking congregations, mainly in Toronto. Phase 2 may include a larger and more diverse set of churches dispersed in different regions of Ontario and Canada. Second, knowledge about HIV is evolving rapidly. This affects the applicability of validated instruments to assess knowledge and stigma, and also means that the Black PRAISE resources may require frequent revision.

On the whole, as congregants develop more favorable attitudes and greater openness about HIV because of Black PRAISE, Black churches may be more confident and equipped to join other community stakeholders in challenging the institutional basis of HIV-related stigma and working to eliminate the structural conditions that make Black communities particularly vulnerable to HIV.

ETHICAL APPROVAL

‘HIV stigma reduction intervention with African, Caribbean and Black faith communities in Ontario’ (Black PRAISE). University of Toronto, 2015, 2017 (protocol reference no.: 32082) (lead institution); University of Windsor, 2015 (REB no.: 32806); University of Louisville, 2015 (ref no.: 441240).

ACKNOWLEDGMENTS

The authors would thank to the pastors and congregants; survey assistants and collaborating agencies; George Okoth Otura, Valérie Pierre, Ken English, and Tsegaye Bekele; and other stakeholders who contributed to the development, implementation and data analysis for Black PRAISE.

FUNDING

This research was supported by the Canadian Institutes of Health Research (CBR 135610) and the CIHR Canadian HIV Trials Network (CTN 297). Neither funder is responsible for the content of this manuscript.

CONFLICT OF INTEREST STATEMENT

None declared.