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JOURNAL OF INTERPROFESSIONAL CARE, VOL. 18, NO. 4, NOVEMBER 2004

Community-based participatory research to prevent substance abuse and HIV/AIDS in African-American adolescents MARIANNE T. MARCUS1, THOMAS WALKER2, J. MICHAEL SWINT3, BRENDA PAGE SMITH4, CLEON BROWN2, NANCY BUSEN1, THELISSA EDWARDS1, PATRICIA LIEHR1, WENDELL C. TAYLOR3, DARRYAL WILLIAMS5 & KIRK VON STERNBERG6 1

University of Texas at Houston Health Science Center School of Nursing, Texas, USA, 2Windsor Village United Methodist Church, Texas, USA, 3University of Texas at Houston Health Science Center School of Public Health, Texas, USA, 4WAM Foundation, Inc., Texas, USA, 5Prairie View A&M University, Texas, USA, 6University of Texas at Houston Health Science Center School of Medicine, Texas, USA

Summary Adolescence is a time for exploration and risk-taking; in today’s urban environment, with the twin threats of substance abuse and HIV/AIDS, the stakes are particularly high. This paper describes a community-based participatory research project to design, implement, and evaluate a faithbased substance abuse and HIV/AIDS prevention program for African-American adolescents. A coalition of university-based investigators and African-American church member stakeholders collaborated on all aspects of Project BRIDGE, the 3-year intervention to reduce substance abuse and HIV/AIDS in African-American adolescents. Our results support the use of community-based participatory research to create desirable change in this setting. Adolescents who participated in Project BRIDGE reported signiﬁcantly less marijuana and other drug use and more fear of AIDS than a comparison group. Project BRIDGE has been designated an ofﬁcial ministry of the church and the program has been extended to others in the larger metropolitan community. The church now has a welltrained volunteer staff. University faculty developed skills in negotiating with community-based settings. The coalition remains strong with plans for continued collaborative activities. Key words: Substance abuse and HIV/AIDS prevention; faith-based program; African-American adolescents; community-based participatory research.

Introduction Participatory research methods are a viable means to respond to complex health issues within communities. Approaches to participatory research include applications variously Correspondence to: Marianne T. Marcus, John P. McGovern Professor in Addiction Nursing, Chair, Nursing Systems, University of Texas at Houston Health Science Center School of Nursing, 1100 Holcombe Blvd., Suite 5.516, Houston, Texas 77030, USA. Tel: (713) 500-2120; Fax: (713) 500-2142; E-mail: [email protected] ISSN 1356–1820 print/ISSN 1469-9567 online/04/040347–13 # Taylor & Francis Ltd DOI: 10.1080/13561820400011776

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labeled as action research, participatory action research, community-based action research, and advocacy research (North American Primary Care Research Group, 1998). These applications provide a common framework which includes community participation, research, and action directed at resolving problems identiﬁed by community stakeholders (Cornwall & Jewkes, 1995; Israel et al., 1998; Rains & Ray, 1995). The role of the researcher becomes that of facilitator. Knowledge and societal change are literally created by interactions between the researcher and the stakeholders, all of whom are deﬁned as participants in the research. In the health ﬁeld the basic tenets of this form of inquiry are rooted in pragmatism and the work of Kurt Lewin (Brown & Tandon, 1983; Lewin, 1946; Meyer, 1993; Stringer, 1999). Lewin proposed to study social systems through a cyclical process that involves analysis, factﬁnding, conceptualization, planning, implementation, and evaluation. The focus is on solving practical problems while generating new knowledge. Morrison and Lilford (2001) synthesized ﬁve hallmarks of the action research process: (1) ﬂexible planning; (2) iterative cycle; (3) subjective meaning; (4) simultaneous improvement; and (5) unique context. This process has great appeal for teachers, health workers, and clinicians, because human events are complex and dynamic and the action research method is structured to address dynamic complexity in pursuit of human understanding. Stringer (1999) discusses action research that is community-based, noting that it is always carried out with an explicit set of social values. The process must be democratic, equitable, liberating, and life enhancing. The analogue to hypothesis testing in action research is the creation of change that enhances the lives of members of the community. When an action research project fails to make a difference in the lives of all participants it cannot be considered successful (Stringer, 1999). Further, the credibility-validity of knowledge generated through this form of research is measured ultimately according to whether actions that arise from it solve problems (workability and utility) and increase participants’ control in the situation (Greenwood & Levin, 1998; Minkler et al., 2002). In this article, we discuss the use of community-based participatory research (CBPR) as an approach for designing, implementing, and evaluating a unique faith-based HIV/AIDS and substance abuse prevention program for African-American adolescents. The initiative, a demonstration project, is an ongoing research partnership between university-based investigators and African-American church member stakeholders (Willms et al., 1996). All participants are committed to recognizing and valuing the different lived experiences, skills, and priorities each of the participants bring to the endeavor (Israel et al., 1998; Schulz et al., 2002). The challenges and frustrations encountered in developing and implementing a culturally-speciﬁc and age- and gender-sensitive program in a dynamic setting are discussed. In 1999 members of the University of Texas Health Science Center at Houston Schools of Nursing, Public Health and Medicine, the WAM (formerly Windsor AIDS Ministry) Foundation, Inc. and Windsor Village United Methodist Church (WVUMC), formed a coalition to respond to a request for proposals from the Substance Abuse and Mental Health Services Administration’s Center for Substance Abuse Prevention (SAMHSA/CSAP). The speciﬁc request of the agency was for targeted capacity expansion initiatives for HIV/AIDS and substance abuse prevention services in ethnic minority communities. The coalition was built on the trust established between two members of the team, one from the university and one from the church, while working on prior substance abuse initiatives. Our response was a proposal for a 3-year intervention composed of empirically-based components, adapted to a faith-based setting, that targeted the needs of African-American adolescents. The objective of the study was to design, implement and evaluate a faith-based intervention to prevent substance abuse and risky sexual behaviors.

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Methods The routines of look, think, act proposed by Stringer (1999), served as a guide during the process of grant writing, subsequent funding, implementation, and evaluation of our project. Though the routines appear linear in format, Stringer (1999) cautioned that they are to be continually recycled. The process is complex, dynamic, and iterative. We describe the routines and our activities and results in the following section of the paper. Look According to Stringer (1999), the ﬁrst, or look phase of the process is a time to gather relevant data and describe the existing community situation. The grant writing period was a time of intense review of the effectiveness of current goals and services already provided by the church for its youth. The coalition engaged in extensive literature review and in weekly discussions. Data gathered about adolescence in general document that it is a period of transition and vulnerability characterized by major physical, cognitive, social, and emotional changes (Parfenoff & Paikoff, 1997; St. Lawrence, 1993; Wilson et al., 1997). Health behavior patterns are often established during this critical developmental stage. Adolescence is also a time for exploration and risktaking; in today’s urban environment, with the twin threats of substance abuse and HIV/AIDS, the stakes are particularly high. African-American youth are at greater risk of contracting HIV/ AIDS than other population groups (Brunswick et al., 1993; Center for Disease Control, 1992; Jemmott et al., 1998; Koblin et al., 1990; Rodrique et al., 1997; Selik et al., 1998). Also, AfricanAmericans have a disproportionably higher rate of consequences related to illicit drug and alcohol use (Brown & John, 1999). Literature on risk and protective factors for ethnic minority adolescents revealed that they were more likely to engage in health-compromising behaviors (Wilson et al., 1997). Moreover, ethnic minority youth are not as likely as other groups to have regular medical care (Parfenoff & Paikoff, 1997). Urban minority families are over-represented in the population of single parent families. Children of these families are known to be at risk for health-compromising behaviors (Jarrett, 1994). Peer relationships are likely to take on greater signiﬁcance when family and community attachments are weak. Youngsters with weak family and community attachments may feel that they have little to lose by associating with deviant peers (Ellickson, 1999; Petraitis et al., 1995). Other risks, or predictors, for substance abuse, and early sexual activity, include pro-drug social choices; pro-drug beliefs and attitudes including the belief that drug use is normative; weak bonds with school and prior deviant behavior (Ellickson, 1999). Hawkins et al. (1992) identiﬁed protective factors for adolescents including a resilient temperament, positive attitudes, good problem-solving skills, a good relationship with at least one nurturing adult, belief in one’s self-efﬁcacy, clear understanding of behavioral norms and religiosity and spirituality. Wallace and Forman (1998) reported that religious youth in America are less likely to engage in behaviors that compromise their health. The population of African-Americans in Houston (28%) is higher than the national average (15%). African-Americans have a disproportionately high incidence of HIV/AIDS in Houston, a city that ranks fourth among the 10 states and territories reporting the highest number of AIDS cases. This look suggested that African-American youth in Houston could beneﬁt from comprehensive prevention services to halt the devastating health problems associated with substance abuse and HIV/AIDS infection. This ﬁrst phase of the action research process resulted in formation of a coalition starting with the youth from one church and ultimately expanding to the greater metropolitan community. The church, Windsor Village United Methodist Church (WVUMC), is a dynamic and nationally recognized community with more than 14,000 members. WVUMC has strong components of community outreach addressing a wide variety of health-related issues in the

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African-American community. The youth population is approximately 1100 individuals. They are served by a youth minister, who is a key member of the coalition. At the time of planning the study, the young people attended programs at the church on Wednesday evenings. The programs included scripture readings, music and prayer followed by an open discussion of topics of interest to the adolescents and their parents. Occasionally substance abuse and sexuality were topics of discussion. The youth pastor acknowledged that the concept of a youth ministry was relatively new to ethnic minority churches and that many programs lacked structure and evaluation. He relied heavily on intuition and the knowledge that principles of faith, AfricanAmerican traditions, and caring for others are strong guiding forces for young people. Think The second or think phase of Stringer’s (1999) action research process is a time for analysis and interpretation. With consideration of factors identiﬁed in the look phase, and the combined expertise of key members of the academic and faith communities, a multifaceted, evidence-based comprehensive intervention was planned. The intervention, Project BRIDGE (Bold, Ready, Intelligent, Dedicated, Guided, Equipped) would speciﬁcally target AfricanAmerican middle school adolescents, who by virtue of their age, are living through a time of particular vulnerability. Moreover, while adolescents who would attend Project BRIDGE might be expected to have the protective beneﬁt of religious afﬁliation, many would also have the risks associated with growing up in single-parent homes and living the African-American experience known to include greater risk-taking (Wallace & Forman, 1998). The proposed intervention included four components (Table 1): (1) Life Skills Training (LST) (Botvin et al., 1992, 1994; Botvin, 1996; Botvin et al., 1997) (Table 2); (2) Spreading the Word; (3) Choosing the Best (Cook, 2002) (Table 3); and (4) a faith component. The faith component was to be woven throughout. BRIDGE would provide a structured program for sixth, seventh and eighth graders on Wednesday nights during the school year. There was a plan to sustain, institutionalize, and expand the project beyond WVUMC following the grant period and to assess accomplishment with cross-site evaluation instruments developed by the granting agency. Focus groups with students, parents, and teachers would provide supplemental assessment of BRIDGE. The research team prepared and critiqued multiple

Table 1. Project BRIDGE curriculum Year

Primary

Description

One

(a) Faith component

Two

(b) Life Skills Training—Level One (a) Faith component

(a) Scripture-based lessons designed to reinforce corresponding LST curriculum (b) Cognitive – behavioral substance abuse prevention program (a) Scripture-based lessons designed to reinforce corresponding LST curriculum (b) Cognitive – behavioral substance abuse prevention program (c) Afrocentric prevention alternatives based on arts, media, communication, music and physical activity strategies (a) Scripture-based lessons designed to reinforce corresponding LST & CTB curriculum (b) Cognitive – behavioral substance abuse prevention program (c) Afrocentric prevention alternatives based on arts, media, communication, music and physical activity strategies (d) An abstinence-focused curriculum using real life case studies and small group discussions

(b) Life Skills Training—Level Two (c) Spreading the Word Three

(a) Faith component (b) Life Skills Training—Level Three (c) Spreading the Word (d) Choosing the Best

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Table 2. Life skills training program: structure & content by level/grade Units

Level One: 6th

Level Two: 7th

Level Three: 8th

1 2 4 1 1 2 1 1 2 1 2 0 18

0 1 1 1 0 2 1 1 1 1 1 2 12

0 1 1 1 0 1 1 0 1 1 1 1 9

Self-image & Self-improvement Decision-making Substance use/drug abuse Advertising/media inﬂuences Violence and the media Coping with anxiety Coping with anger Communication skills Social skills Conﬂict resolution Assertiveness Resisting peer pressure Total unit periods (Botvin, 1996).

Table 3. Choosing the Best Curriculum Lesson

Title

Description

One

Sex: Everyone’s talking about it The risks of STDs and HIV/AIDS

Teens hear what others say about sex and discover the overlooked emotional consequences of sexual activity. Often believing, ‘It can’t happen to me,’ students hear from teens like themselves who have STDs and AIDS. They study the most common STDs and how they are spread. Teen parents share the lost dreams of youth before students learn the truth about ‘safe sex.’ Students identify and discuss four major pressures, including alcohol use and abuse, that contribute to teens’ sexual activity, and they learn how to overcome these pressures. After hearing other teens, married couples and sports and entertainment personalities present the case for abstinence, teens are encouraged to make their own commitment for abstinence until marriage. The Need for Boundaries is a fun activity. Students see what guys and girls look for in a relationship, while learning about infatuation and love. Self-discipline helps them set personal boundaries. The Need to Speak Up allows students to learn the skills of saying ‘No’ and enables them to put them into practice, ﬁnding out that it often takes courage. The Need to Be Assertive presents four role-play activities that provide practical ways for teens to test their newly acquired skills, as they recognize the need for perseverance.

Two

Three Four

Teen pregnancy and ‘safe sex’? Pressures to be sexually active

Five

Choosing the best path

Six

Set it!

Seven

Say it!

Eight

Show it!

(Cook, 2002).

iterations of the grant proposal taking care to value the suggestions of all team members. The initial think phase of the process concluded with submission of the grant. Act The third, or act, phase of the action research model is a time for ﬁnal planning, implementing, and evaluating the proposed intervention (Stringer, 1999). The act phase began in 1999. We obtained approval from the University’s Committee for the Protection of Human Subjects and a federal Certiﬁcate of Conﬁdentiality. Focused planning and preparation of the team was

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initiated. We began by preparing ourselves, and a cadre of adult volunteers from the church, to teach LST. The ﬁrst adolescents were enrolled in February, 2000. Each parent and child gave written consent. LST was taught over the next 15 weeks on Wednesday evenings. Each lesson was accompanied by appropriate scripture readings. We quickly realized that the youngsters required more recreational time, so trips to the beach, bowling, or sports activities were scheduled on other days. In the second year, Spreading the Word, the unique Afrocentric component of the program focused on risk prevention alternatives, was begun. Second year students were given opportunities to design media, write and produce plays, compose music and gather grandparent life histories. An esteemed African-American playwright, Thomas Meloncon, guided the drama segments, which incorporated prevention messages from LST. The life history component included instructions for the adolescents on interviewing and photographing signﬁcant elders in their lives. Students were given disposable cameras so that they could take pictures to illustrate the histories. The activity produced some meaningful accounts of what it was like to be an African-American adolescent two generations ago. Students also engaged in praise and worship through music. Some of the activities were recorded on videotapes and have been shown to the WVUMC congregation at large. In the third year, the focus was on sexuality and more in-depth information about substance abuse. Activities during this year were guided by the Executive Director of WAM (formerly Windsor AIDS ministry) Foundation, a separate non-proﬁt organization. There were many discussions to resolve the issue of which speciﬁc sexuality curriculum to deliver to BRIDGE adolescents. In keeping with the teachings of the church, we chose an abstinence-focused curriculum, Choosing the Best (Cook, 2002). The team and additional volunteers were trained in this curriculum. A team member, who is a college drug prevention counselor, facilitated the more in-depth discussions of substance abuse in the third year. Cultural sensitivity was addressed by ongoing team interaction as each phase of the project was implemented. Church-community members of the team, who were African-American, and primarily Anglo-American university team members, met regularly to create a common ground of understanding related to cultural issues. A new cohort of adolescents was enrolled each year and modiﬁcations were made to the program based on input from students, parents, volunteer teachers and the research team. The act phase of this demonstration project typiﬁed ﬂexible planning, one of the hallmarks of action research (Morrison & Lilford, 2001). Two of the other hallmarks, the iterative cycle and simultaneous improvements (Morrison & Lilford, 2001) are demonstrated through the following examples. Peer education During evaluative focus group discussions conducted at the end of year one, the students recommended that we provide more opportunities for them to lead activities; and they expressed enthusiasm for sharing their knowledge with others outside of the church setting. These ideas led to the implementation of an adolescent leadership component and preparation to share ‘Spreading the Word’ activities with other youth groups. Peer education, which is supported as an effective strategy to engage youth in risk prevention activities (Ebreo et al., 2002; Main, 2002; Shah et al., 2001; Simons-Morton, 2001; Smith et al., 2000; Smith & DiClemente, 2000), has become a regular feature of BRIDGE. Time change In the second year of the project, the regularly scheduled Wednesday evening meetings were preempted by Bible study. BRIDGE moved to Saturday evening, a time when many of the

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parents attend church services and would be available to bring the youngsters. Attendance at BRIDGE dropped off, threatening the ﬁdelity of the curriculum. To compensate, an intensive summer camp experience, which enabled combined fun and learning over a 1-week period was arranged. Summer camp programming is now a regular feature of BRIDGE, drawing over 200 youth each year. The camp experience attracts both regular BRIDGE participants and youth who have not previously participated. In this way the camp experience becomes an opportunity for BRIDGE participants to informally share their knowledge, addressing one of the recommendations the adolescents raised in evaluative group discussions. Recruitment and retention There are many competing demands on the time and attention of adolescents. To improve recruitment and retention, incentives such as tee shirts, movie passes, recreational activities, rallies, certiﬁcates and awards, were added. Youngsters from BRIDGE recruited friends from all over the city to attend youth rallies where HIV/AIDS and substance abuse messages were featured along with music, dancing, and refreshments. Five to six hundred youth attended the rallies. The rallies were a response to a student mandate to ‘make the message fun’. By delivering risk-reduction information in this format, BRIDGE extended its potential to reach the larger metropolitan community. Evaluation A consistent interest for the university research team members was the acquisition of a comparison group. There were many discussions about this issue in research team meetings. Questions arose as to how to identify the comparison group. One additional issue was simply the idea of research and the concerns of church team members that the adolescent participants not be ‘objectiﬁed’ in this process. After months of ongoing dialogue, another large AfricanAmerican church in Houston with a comparable youth ministry was identiﬁed. The comparison group was given incentives for their participation and their staff and volunteers were offered training to fully implement BRIDGE in their setting at a later time. Church team members shifted their views about the value of comparison groups over time with the realization that the comparison group would substantiate changes they were seeing and, thus, enable the team to attract future funding and to serve larger numbers of young people. These examples illustrate the dynamic evaluation, which was ongoing with BRIDGE. Ideas for program improvement were repeatedly implemented, evaluated, and reﬁned as each dimension of the programming contributed to the other. BRIDGE was an iterative process of continuous simultaneous improvement within a unique community. It demanded ﬂexible planning, relying heavily on the subjective meaning attributed by all the stakeholders to each endeavor. Thus, BRIDGE incorporated all the hallmarks of action research (Morrison & Lilford, 2001; Stringer, 1999). Results The project results will be reported relative to each stakeholder group. The stakeholder groups included the volunteers, students, faculty, and church youth ministry. Volunteers A primary objective of BRIDGE was to increase the capacity of WVUMC to provide a range of substance abuse and HIV/AIDS prevention and training opportunities to African-American

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youth. Some ways this objective was achieved were through added physical resources that facilitated the youth learning process (audio-visual equipment, etc.) and through the development of staff and active volunteers. The church now has staff and volunteers who have the background, training and commitment to continue with BRIDGE. Volunteers for BRIDGE now agree to a 1-year minimum commitment. They receive curriculum training, youth ministry orientation and a safety workshop. Two research team members, also members of the church, are now certiﬁed to prepare teachers for the Life Skills Training curriculum, which is the ﬁrst-year foundation for the project, assuring the future of volunteer training. One volunteer who was hired by the university as project coordinator of BRIDGE, received indepth experience in grants management and has subsequently written funded projects for the African-American community. Students A key goal of BRIDGE was to assist an African-American community to document and assess the effectiveness of a comprehensive substance abuse and HIV/AIDS prevention program targeting adolescents. The following data provide an overview of analysis and results for BRIDGE participants compared to adolescents from another large church in Houston serving primarily African-Americans. Analysis The primary measure used for the objective evaluation of the adolescents was a multi-site instrument provided by the granting agency. The instrument included items that addressed perceived school achievement and engagement; peer and self-attitudes towards alcohol, cigarettes, and other drugs, as well as drug use; knowledge and attitude questions about HIV/AIDS; perceived parental and peer inﬂuence; and communication style. Primary outcomes of interest for these analyses were alcohol and drug use, and HIV/AIDS knowledge and attitudes. The ﬁrst administration of the instrument took place in year 3 when the instrument became available from the granting agency. The instrument was also administered to the comparison group at this time. Adolescents between the ages of 13 – 14 who had been exposed to the ﬁrst year of BRIDGE were compared with adolescents of the same age who had not been exposed to BRIDGE. The comparison group was chosen for its similarity in race, age, and religious involvement to the BRIDGE youth. Chi-square (dichotomous variables) and t-tests (continuous variables) were done to determine if there were differences between the adolescent groups. The primary analysis consisted of a cross-sectional comparison of the 13 – 14 year olds in the BRIDGE and comparison groups. A series of chi-square analyses were conducted on the dichotomous variables of drug use in the last 30 days (yes/no) and true/false items addressing students’ general knowledge and attitudes towards HIV/AIDS. Results For the primary analysis, we were interested in those students who had at least 1 year of BRIDGE programming and were 13 to 14 years of age (n = 34). There were 27 adolescents from the comparison group church who were 13 – 14 years of age. The BRIDGE students were all African-American and all but one, 26/27 (96%), of the comparison group participants were African-American. There was no signiﬁcant difference in the gender for the BRIDGE and comparison group (chi2 = 0.69; p = 0.406) with 20/34 (58.8%) (Table 4). Over half of the BRIDGE participants lived with their mother and father

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Table 4. Year 3—Project BRIDGE students by comparison group: demographics and substance abuse behaviors Multi-site childrens’ assessment

BRIDGE Student n = 34

Age Gender

13/14 years F: n = 20 (58.8%) M: n = 14 (41.2%)

Live with both mother & father (or step parent) In past 30 days: Drank alcohol Smoked cigarettes Smoked marijuana Sniffed glue, gases, or sprays Used any drug(s)

n = 19 n 0 0 0 0 0

(55.9%) (%) (0.0) (0.0) (0.0) (0.0) (0.0)

Comparison n = 27 13/14 years F: n = 13 (48.1%) M: n = 14 (51.9%) n = 9 (33.3%) n (%) 2 (7.4) 1 (3.7) 4 (14.8) 1 (3.7) 5 (18.5)

Chi2/p = NA 0.69/.406 3.08/.079 Chi2/p = 2.45/.117 1.21/.272 5.09/.024 * 1.21/.272 6.48/.011 *

(or step-father) while one third of the comparison group youth lived with both parents (chi2 = 3.08; p = 0.079) (Table 4). The comparison group endorsed signiﬁcantly more use of marijuana (chi2 = 5.09; p = 0.024) in the past 30 days and when drug categories were collapsed, the comparison group had more use of any drug in the past 30 days (chi2 = 6.48; p = 0.011). Any drug use was endorsed by 18.5% of the comparison group and by none of the BRIDGE participants (Table 4). Although there was no difference in HIV/AIDS knowledge between the groups, there were practical differences on items addressing attitude towards HIV/AIDS which were not statistically signiﬁcant (chi2 = 5.28; p = 0.071). In the comparison group, 90.2% of the youth were afraid of getting AIDS while 100% of the BRIDGE youth reported being afraid of getting AIDS. In addition, signiﬁcantly more BRIDGE youth agreed people with AIDS need to be treated with compassion than the comparison group (chi2 = 6.71; p = 0.035). The BRIDGE students were also more likely to talk to their parent/guardian (chi2 = 6.91; p = 0.032) or to another family member (chi2 = 7.04; p = 0.030) about questions and concerns. In addition to the differences in knowledge, attitudes and behaviors related to substance use and sexual activities, the BRIDGE adolescents have become a force in the growing church capacity as they have begun to participate in teaching younger students coming into BRIDGE, and to act as role models for their high school peers who did not have the opportunity to go through the program. Furthermore, they will be instrumental in instilling the concepts they have learned and their enthusiasm into ongoing WVUMC programs for high school aged youth. Faculty University faculty beneﬁted from the program in several important ways. Faculty participants were trained in all curricula and methods of evaluation used by the project and given the opportunity to implement them. Moreover, they were able to provide learning experiences for students in the process of CBPR. The collaboration between university and church established by this project also provides a foundation for future service learning opportunities. Servicelearning requires that community partners be fully involved in the design, implementation and evaluation of student learning experiences. This type of learning correlates well with CBPR (Bailey et al., 2002; Herman & Sassotellu, 2002; Seifer, 2002). The program has also contributed to faculty scholarship as they engage in dissemination activities. Perhaps of greatest signiﬁcance, faculty learned key skills in negotiating and collaborating with community-based organizations. This led to increased ability to appreciate and value the credibility of community stakeholders as authorities.

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Church youth ministry The Youth Ministry of WVUMC has developed allies and support systems through participation in BRIDGE development. They have been exposed to and actively participated in the process of grant development, submission, and management of federal funds. Accordingly, they have increased their capacity to identify science-based programs and assess their value for the target audience. The Youth Ministry can now frame their enthusiasm and passion for developing youth within the context of a structured and empirically-tested format. BRIDGE activities also provided increased understanding and appreciation for the evaluation process and its importance as a measure of outcomes and program accountability. BRIDGE has been designated an ofﬁcial ministry of the church with the express objective of serving middle school youth. WVUMC grant team members have attended and facilitated several scientiﬁc workshops and meetings at the national level. They now have a BRIDGE implementation guide to share with other churches or community settings interested in the format. To date, the program has been offered to local churches and is being implemented in two local schools and a high school in the Greater Houston area. Discussion While adolescents are a small percentage (14.5%) of the population, they are more ethnically diverse and at greater disadvantage politically in the competition for limited societal resources (Brindis & Oh, 2002). At the same time, adolescence is a time when young people are particularly vulnerable to making poor decisions which may have profound negative consequences on their health (Nightingale & Fischhoff, 2002). The goal of this demonstration project was to design, implement, and evaluate an ethnically appropriate prevention program for two signiﬁcant health threats facing today’s adolescents, substance abuse and HIV/AIDS. A second goal was to increase the capacity of the church community to sustain the program and extend it to greater numbers of young people. BRIDGE is now an ofﬁcial ministry of the church. More than 40 volunteers have been trained to deliver the curriculum. Young people in the church and, in after school programs in the community, continue to attend the sessions. The data presented here indicates that BRIDGE has positively affected the youth it serves and that the primary goal of preventing drug use has been met. There was no drug use reported in the BRIDGE youth while nearly one-ﬁfth of the comparison group of church-based youth of the same age and race reported current drug use, primarily marijuana. Additionally, although general knowledge of HIV/ AIDS was equally strong across groups, there is indication that HIV/AIDS is viewed in the BRIDGE youth with fear, as a real and dangerous threat. Exposure to the HIV/AIDS components of BRIDGE may have aroused a greater compassion for victims of AIDS in the youth and inﬂuenced a level of comfort in discussing questions they may have about the disease with parents and family. There are many indicators of the positive effect that BRIDGE has had on the youth at WVUMC. The credibility of these ﬁndings is enhanced by the comparison group data. There are, however, limitations to the ﬁndings. Among these are a relatively small sample size and the possibility that the youth were inﬂuenced by the church environment. Every effort was made to separate the evaluation from the program and to stress conﬁdentiality. The assessment administration was conducted by the evaluator and his staff of volunteers and removed to the university ofﬁces with coded identiﬁers. However, given the church environment and the youth’s familiarity with the evaluators who took an active role in the participatory research, it is likely that some degree of social desirability affected the responses of the BRIDGE group.

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The coalition established to develop the program continues to be strong with plans to disseminate ﬁndings and assist others to engage in similar studies. It would not have been possible to conduct this project without the intense level of collaboration inherent in the CBPR method. The initial idea was generated by the coalition, combining the scholarly interests of the university faculty, representing nursing and public health, and the unique knowledge and service commitment of the church team members. Access to the population was facilitated by the youth pastor, who could convey his conﬁdence and trust in the process to the youth and parents because he was fully involved in the design of the study. When youth participation rates declined in the second year, it was possible to reﬁne the project design and add a summer camp experience, which then became an integral part of the program. CBPR also facilitated data collection and analysis methods. The desire of the church team members to deliver service and minimize response burden for adolescents was tempered by the persistence of the university team members regarding the importance of assessing the BRIDGE youth in relation to a comparable group. All team members were always aware of a healthy tension between the service component of the project and the research imperative. CBPR methods facilitated ﬂexibility that fostered the healthy tension. For this team, BRIDGE has served as a foundation for CBPR experience enabling future work. The results of this demonstration project are shared to illustrate the potential of CBPR and to invite other scholars to evaluate the merits of this form of inquiry as it may apply to their own work. Acknowledgements Funded by Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Prevention, # 1 U79SP08954. References BAILEY, P.A., CARPENTER, D.R. & HARRINGTON, P. (2002). Theoretical foundations of service-learning in nursing education. Journal of Nursing Education, 41(10), 433 – 436. BOTVIN, G.J., DUSENBURY, L., BAKER, E., JAMES-ORTIZ, S., BOTVIN, E.M. & KOENER, J. (1992). Smoking prevention among urban minority youth: Assessing effects on outcome and mediating variables. Health Psychology, 11(5), 290 – 299. BOTVIN, G.J., EPSTEIN, J.A., BAKER, E., DIAZ, T., IFILL-WILLIAMS, M., MILLER, N. et al. (1997). School-based drug abuse prevention with minority youth. Journal of Child and Adolescent Substance Abuse, 6(1), 5 – 20. BOTVIN, G.J., SCHINKE, S.P., EPSTEIN, J.A. & DIAZ, T. (1994). Effectiveness of culturally-focused and generic skills training approaches to alcohol and drug prevention among minority youths. Psychology of Addictive Behaviors, 8, 116 – 127. BOTVIN, G.J. (1996). Substance abuse prevention through Life Skills Training. In: R.D. PETERS & R.J. MCMAHON (Eds), Preventing childhood disorders, substance abuse and delinquency (pp. 215 – 240). Thousand Oaks (CA): Sage Publications. BRINDIS, C.D. & OH, M.A. (2002). Adolescents, health policy and the American political process. Journal of Adolescent Health, 30(1), 9 – 16. BROWN, L.D. & TANDON, R. (1983). Ideology and political economy in inquiry: Action research and participatory research. The Journal of Applied Behavioral Science, 19(3), 277 – 294. BROWN, L.S. & JOHN, S. (1999). Substance abuse prevention in African-American communities. In: S.B. KAR (Ed), Substance abuse prevention: A multicultural perspective (pp. 171 – 184). Amityville, NY: Baywood Publishing Company, Inc. BRUNSWICK, A.F., AIDOLA, A., DOBKIN, J., HOWARD, J., TITUS, S.P. & BONASZAK-HOLL, J. (1993). HIV-1 seroprevalence and risk behaviors in urban African-American community cohort. American Journal of Public Health, 83(10), 1390 – 1394. CENTER FOR DISEASE CONTROL AND PREVENTION (CDC) (1992). Sexual behavior among high school students. Morbidity and Mortality Weekly Report, 40, 885 – 889. COOK, B. (2002). Choosing the best way: An abstinence focused curriculum. Atlanta, Georgia: Choosing the Best Publishing, LLC.

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