‘We can act different from what we used to’: Findings from experiences of religious leader participants in an HIV-prevention intervention in Zambia

ABSTRACT

Faith-based organisations (FBOs) have long been part of the fight against HIV and AIDS. International bodies continue to collaborate with FBOs to implement HIV-prevention programmes with mixed success. Zambia has been a target of such programmes in part due to its high HIV prevalence. The Trusted Messenger approach to provide religious leader networks with biomedical, science-focused education about HIV and AIDS was piloted in 2006, but participant experiences of the intervention have not been explored qualitatively. In 2016, in-depth interviews were conducted of 34 randomly chosen individuals who attended Trusted Messenger workshops between 2006 and 2016 in Livingstone, Lusaka, and the Copperbelt region. Findings indicate that the religious leader attendees gained scientific insights about HIV which motivated their action in personal, social, and religious contexts. Participants found the science comprehensible and empowering and identified workshop frequency and language as challenging. Utilising science-focused education within contextual settings of religious leader networks can combat the spread of HIV and the mistreatment of people living with HIV and AIDS.

KEYWORDS:

• HIV and AIDS
• qualitative research
• religious leader networks
• science-based intervention
• faith-based organisations

Introduction

Sub-Saharan Africa (SSA) continues to bear an overwhelming majority of the HIV and AIDS burden, with the highest number of new infections and AIDS-related deaths for all ages annually. Several countries have an HIV-prevalence of more than 10% (Kharsany & Karim, 2016). Efforts by local and international governments and agencies have reduced transmission rates and increased treatment access and uptake, but multiple challenges remain (UNAIDS, 2016b). Faith-based organisations (FBOs) have assumed a prominent role in the efforts and challenges of HIV programmes in the region (Múnoz-Laboy, Garcia, Moon-Howard, Wilson, & Parker, 2011). This is partly due to researchers’ and interventionists’ growing appreciation for the centrality of religious identity among sub-Saharan Africans and the influence of religious leaders on congregants (Dilger, Burchardt, & Van Dijk, 2011; Fort, 2017; Trinitapoli, 2009). Collaborative efforts between FBOs and secular – often international – organisations to implement HIV and AIDS programmes in the region achieve varying degrees of success (Alubo, Zwandor, Jolayemi, & Omundu, 2010; Bazant & Boulay, 2007; Boyd, 2009; Endeshaw et al., 2017; Global Health Council, 2011; Lindgren et al., 2013; Prince, Denis, & Van Dijk, 2009; Rankin, Lindgren, Kools, & Schell, 2008; Swidler & Watkins, 2017).

The Trusted Messenger approach (Trusted Messenger), a collaboration initiated at the request of highest authority officials of a network, is an HIV-prevention intervention that utilises science education within established religious leader networks. In interactive two-day workshops, network members receive biomedical education that focuses on the biology, not the morality, of HIV and AIDS (Fuller & Goins, 2018). The approach emphasises that HIV infection is preventable and stresses the importance of testing and linkage to healthcare. The goal is to equip religious leaders with accurate, in-depth, scientific information about HIV and AIDS-related illnesses so they can confidently disseminate it to strengthen their communities (Thomas-Slayter & Fisher, 2011). Zambia was an appropriate context in which to implement Trusted Messenger because of its mainly Christian populace of 85% (World Christian Database, 2015), large number of FBOs that embrace a spiritual-moral view of HIV (Mukuka & Slonim-Nevo, 2006), and HIV prevalence ranging from 12% to 15.7% (Ministry of Health, 2017; UNAIDS, 2016a).

Piloted in Zambia in 2006, Trusted Messenger employs quantitative and qualitative methods to measure multiple outcomes (Fuller & Goins, 2018). Here, we have utilised the latter to elicit perspectives and experiences of Trusted Messenger directly from participants. Qualitative data of participant experiences can provide insight on how the science-focused approach has impacted attendants’ views on HIV and AIDS, can suggest ways in which the intervention might be improved and may have implications for other HIV-prevention interventions in SSA. The aims were to (1) gauge how Trusted Messenger has affected religious leaders’ knowledge, views, and actions regarding HIV and AIDS; (2) understand the extent to which in-depth scientific information has positively or negatively influenced their perspective and actions; and (3) gain insights on how the intervention may be improved for future implementation.

Methods

The research design targeted attendees of Trusted Messenger workshops from the initial 2006 piloting through recent 2016 workshops for individual, in-depth, semi-structured interviews. The sampling frame was based on four participant characteristics: timing of Trusted Messenger attendance (in 2016; up to 3 years ago; 4+ years ago), gender, residence (urban/peri-urban), and age. Participants who fit into the profiles constructed from the sampling frame were randomly selected and invited to join the study. Two interview guides were developed, one for prior workshop attendees (2006–2015) and one for new attendees (2016). Guide development was iterative. Table 1 provides a list of domains explored in the interview guides. Final topics included reasons for attendance, experience of the workshop, lessons learned, and areas for improvement.

Table 1. Domains explored in interview guides for Prior Attendees (PA) and New Attendees (NA).

Individual’s church and their specific leadership role at church (PA, NA)

Reasons for participating in Trusted Messenger (PA, NA)

Individual’s description of the Trusted Messenger workshops (PA, NA)

Individual’s feelings while attending the workshops (PA, NA)

Individual’s opinion on the scientific focus of the workshops (PA, NA)

Individual’s report of things they learned from the workshops (PA, NA) and the extent to which they have been able to retain that information (PA)

Personal impact, if any, from the workshop, including changes to one’s views or perspective (PA, NA), and changes to the ways the individual conducts their duties in the church and the community, if applicable (PA)

Examples of ways in which the individual has used the information from the workshop, if any, and perceived responses from others toward the individual’s use of knowledge or skills gained from the workshop (PA)

Examples of how the information may be applied to the individual’s current work in the church and in the community, if applicable, and the extent to which the individual plans to utilise the information moving forward (NA)

Examples of observed changes in the individual’s church or community that the individual attributes to the workshop (PA)

Potential impact of the knowledge and skills from workshops on the individual’s church and community (NA)

Barriers – both experienced and perceived – to utilising the knowledge and skills from workshops, and ideas to address those barriers (PA, NA)

Suggested improvements to the workshop, including information, materials, other resources, and audience (PA, NA)

Field interviews were conducted in Lusaka, Livingstone, and the Copperbelt Province during May through July 2016. Before data collection, interview guides were reviewed for clarity by a Zambian colleague. Purposive sampling was used to recruit participants based on the sampling frame. New attendee participants were recruited directly from Trusted Messenger workshops conducted in 2016. Some prior workshop participants were recruited in this process, as several were repeat attendees that attended a workshop both in 2016 and previously between 2006 and 2015. Following the sampling frame, other prior attendees randomly selected from registration records of workshops in 2006 through 2015 were contacted via telephone, provided with an explanation of the study and invited to participate.

Participants chose the interview site (e.g. churches, employment offices, cafés, residences). Informed consent was obtained, and the interviewer collected basic demographic information. Interviews were audio-recorded with consent of the participant. One participant declined to have audio recording of the interview, but allowed written notes. Upon completion, participants were provided with refreshments, transportation reimbursement if applicable, and a modest thank-you gift. After each interview, the interviewer recorded summary notes and behavioural observations.

Data analysis was iterative. Interviews were transcribed verbatim and imported into Dedoose (2016) for organisation, coding, and analysis. Preliminary descriptive memos were made while listening to the interviews, and subsequent descriptive and analytic memos were made while reading the transcripts. A codebook was developed using deductive and inductive methods. Deductive codes were developed based on the research objectives and topics in interview guides. Inductive codes were crafted from ideas that emerged from the memos and during repeated transcript reading and analysis. The interviewer coded the transcripts, which were periodically checked, co-coded and discussed by research team members for consistency and agreement. Code outputs were used for detecting overarching themes which researchers discussed and situated in the context of Zambian sociocultural norms, engagement with religious leaders and objective of the research.

Results

Thirty-four individual, in-depth interviews were conducted (Table 2). Twenty-two participants first engaged with Trusted Messenger between 2009 and 2015, and 12 in 2016. Their sociodemographic characteristics included a range of age (22 to 76 years) and leadership roles such as pastors, deacons, musicians, teachers, and youth workers (Table 2). Participants identified as Christian. More women than men were either unable to be reached via telephone or declined to participate. Four women and one man self-disclosed that they were HIV-positive. Researchers identified six major themes of Trusted Messenger impact on Zambian religious leaders with regards to HIV and AIDS.

Table 2. Sociodemographic characteristics from in-depth interviews.

Sociodemographic	Sample (n = 34)
Sex	N	%
Male	20	58.8
Female	14	41.2
Age in years
18–33	6	17.6
34–49	12	35.3
50–65	12	35.3
66+	4	11.8
Residence
Urban	28	82.4
Peri-Urban	3	8.8
Rural	3	8.8
Church role
Clergy (Pastor or Minister)	20	58.8
Non-Clergy (Laity Officer)	14	41.2
Geographical location
Lusaka	14	41.2
Livingstone	9	26.5
Copperbelt	11	32.3
First workshop attendance
2016	12	35.3
Prior to 2016	22	64.7

Anticipating: The prospect of knowledge

Almost every participant reported a desire for knowledge as their primary motivation to attend. This desire stemmed from what they described as a dearth of comprehensive, accurate HIV-related knowledge in their communities, common barriers (e.g. financial) to educational opportunities, and the belief that action against HIV must be based on correct information. The prospect of a workshop that promised free, accurate, in-depth, science-focused HIV-education came as a welcomed and relevant opportunity.

For a few participants, the hope of knowledge acquisition simply for the sake of one’s own learning was reason enough to attend. One non-clergy leader engaged because she was ‘interested in learning more about the biological aspect of HIV’ (female, age 18–33, Lusaka). For others, clarification of pre-existing knowledge was wanted, as was the case for this clergy leader: ‘there’s been a lot of mysticism, you know, misinterpretation of things … so we needed to have correct information’ (male, age 34–49, Lusaka). For most religious leader participants, however, actionable knowledge was the driving force behind their participation: ‘If you’re not infected, you’re affected. If I don’t have that disease, it means where I’m working … within my community, there must be someone who is infected, to whom I should have that responsibility of helping out’ (male, age 34–49, Livingstone).

These excerpts illustrate the range of knowledge-related motivations to participate in the intervention – knowledge for knowledge’s sake, for clarification and for action.

Experiencing: A basis for understanding and action

Two core components of Trusted Messenger are its biological science perspective and emphasis on HIV testing. Most participants described the scientific content in positive terms, commenting on its utility in understanding HIV and AIDS. Numerous individuals specifically identified the depth of information as a useful and unique attribute.

One clergy leader placed her appreciation of the approach in context of other HIV workshops she had attended: ‘the advantage of this [workshop] is … we are biologically taught, unlike these lessons we use to get from other organizations … . With [Trusted Messenger], it’s deeper’ (female, age 34–49, Livingstone). Others discussed the implications regarding dissemination of information gained: ‘[Science] is the most important factor … . Where there is evidence, it’s easy for people to accept’ (male, age 50–65, Livingstone).

Few participants indicated problems understanding the science or conflict with religious doctrine. Those who did noted that further explanation by the facilitators clarified complex concepts. A non-clergy leader indicated that ‘[the facilitators] took time to … bring it to our level of understanding’ (female, age 50–65, Lusaka). Another described how the facilitators ‘were eager to explain things you don’t understand … you can ask them a thousand times’ (male, age 18–33, Lusaka). No one indicated that the science-based focus on HIV conflicted with their beliefs. Several participants, such as this clergy and non-clergy, indicated they could accept the insights from science when framed in Trusted Messenger as perceived orchestration by their god: ‘The owner of the science is God’ (male, age 34–49, Lusaka); ‘It’s also God that brought scientists. So … there was nothing wrong with the [scientific] approach’ (female, age 34–49, Lusaka).

That most workshops conducted between 2006 and 2016 provided on-site voluntary counselling and testing (VCT) was significant for several participants. Responses suggested that some would not have undergone VCT had the scientific content been lacking. An accurate understanding of HIV and AIDS-related illness via scientific knowledge encouraged and permitted them to test. A non-clergy leader reported that ‘it was just during that conference that … we gave ourselves willingly, even to go for HIV test, because we were now aware’ (female, age 50–65, Lusaka). One clergy leader recounted his personal experience with VCT at a workshop:

There was an emphasis to go and test for VCT on the same premises. I didn’t go myself because I’m scared. I didn’t want to know my status. I didn’t know what this would be to me. [The] second day, I risked myself … . I just felt I’d do well without that fear … . I said, ‘I must do it.’ And I did that because of the influence of the material. (male, age 50–65, Copperbelt)

These excerpts reflect the unique and comprehensible quality of the scientific content and demonstrate how obtaining a biological understanding of HIV and AIDS motivates religious leaders to undergo VCT. Quantitative results from follow-ups subsequent to the workshops agree with these excerpts about accessing VCT (Fuller & Goins, 2018).

Internalising: A broadening of perspectives

Several participants reported a variety of ways in which the scientific content prompted re-evaluation of pre-existing beliefs. One of the most common insights obtained was the incurability of HIV. A clergy leader explained: ‘I learned about the material which is found in the HIV virus, which is the RNA … and when that one mixes with DNA … it becomes difficult [to remove], and that's the reason why that disease cannot be cured’ (male, age 18–33, Copperbelt). Another clergy explained the importance of this information:

How the virus gets embedded in the cell – that actually tells you that, don’t you even bother that it will go away … . Because what bothers people sometimes is that they want it to go away, so they will go from church to church, they will see one pastor, one pastor to another – it’s because they want it to go away. (male, age 34–49, Lusaka)

Another clergy elaborated further: ‘when people are not taught and then they find that they are HIV-infected, they tend not to accept … and as a result they go into a denial state’ (female, age 34–49, Livingstone). Religious leader participants warned that such a denial state prevented treatment acquisition and adherence by People Living with HIV (PLWH). This implies that a science-focused understanding of the incurability of HIV infection would instead prompt PLWH to seek and receive treatment.

Other salient shifts in perspective involved use of condoms and understanding the origin of HIV. Some participants acknowledged the common tendency in their religious institutions to ignore condom usage due to its perceived association with promiscuity. However, they noted that the Trusted Messenger explanation of condom use, as one of several options to avoid virus contact, provoked them to think differently. A non-clergy recounted how the intervention helped her to ‘understand that, yes, there are certain situations where people need [condoms] as an option … . The kind of mind-set I was stuck in – [Trusted Messenger] shifted me a little’ (female, age 34–49, Livingstone). A clergy noted that it ‘was incredible information that I needed … sex is part of our being, so, whether we like it or not, people will do it, so it’s better to make them know [about condoms] and be able to protect themselves’ (male, age 34–49, Lusaka). Despite inclusion of consistent correct condom use as a preventive measure, a few participants seemed unmoved. As reflected by this clergy, abstinence--with no mention of condoms--remained the most important prevention lesson: ‘[abstinence] is the solution to this calamity’ (male, age 50–65, Copperbelt).

Several intervention participants recalled the impact of learning about the origin of HIV through zoonotic transfer from primates (Sharp & Hahn, 2011) and about why the virus can only survive in, and thus is only transmitted by, a few bodily fluids. These participants described how Trusted Messenger dispelled myths about supernatural origins of HIV and how this revelation removed some of the stigma associated with what was previously viewed by some as divine judgment. This clergy explains:

Some time back, some pastors, whenever they see a patient or someone who is slim or thin in their church, the message on the pulpit will be – ‘the wages of sin is death.’ … So, these days, with these pastors who happen to come here [Trusted Messenger workshops], that message is no longer there. They know that HIV/AIDS is not punishment from God, but is just a disease, as any other diseases. (female, age 34–49, Livingstone)

One clergy indicated how his ‘fear of just being told ‘this one is HIV positive’ – that was taken away from me, because I now understood it’s just a normal disease’ (male, age 65+, Lusaka). Another was delighted that Trusted Messenger helped ‘people to see that this thing is not … witchcraft … . It’s just like any other disease’ (male, age 50–65, Copperbelt). Yet another expressed: ‘[Trusted Messenger] was actually telling us that, it’s not a curse … nobody deserves to get it. … that in itself was an incredible approach for me’ (male, age 34–49, Lusaka). Some participants came to appreciate implications of a scientific, rather than spiritual, understanding of HIV, such as this non-clergy:

One of the things I learned is the fact that, those people who are … you cannot judge because someone has HIV … . Even if they got the virus because they were promiscuous, they still need our support … . They need our moral support. They need our, you know, psychological support. We have to interact with them the same way we interact with everyone else. (male, age 18–33, Lusaka)

A clergy recounted his changed view:

The workshop has changed the way I look at HIV and AIDS itself … the way I look at an HIV negative person and the way I look at an HIV positive person is the same. Or the way that I look at a malaria patient and an HIV patient is the same … has just, like, helped open my mind. (male, age 18–33, Lusaka)

These excerpts demonstrate how in-depth science impacted participants intellectually and interpersonally to shift long-held beliefs about the virus, illness and PWLH that can contribute to HIV transmission and stigma. This shift has implications for both the infected and uninfected.

Externalising: The gospel of HIV and AIDS

Most participants provided examples of how they had acted on knowledge gained from attending a Trusted Messenger workshop. These centred on pastoral counselling, education and information dissemination (e.g. about HIV transmission, VCT) and providing support for PLWH. That religious leader participants took action with their personal/family, church, and community required some to forsake local customs that forbid discussion of sex between people of different statuses (e.g. age, gender). Some participants were more active than others, engaging in all three types of actions in all three contexts. The few Trusted Messenger participants who had not yet acted upon the knowledge were a subset of those who first participated in 2016. They indicated that they were devising plans to use the information.

Some participants’ initial recourse after the workshop was within their own homes. A clergy leader recounted: ‘In my own life, it has helped me share with my children … . It was taboo to talk to a daughter about sex and a thing like that, but now I can talk to them freely’ (male, age 65+, Lusaka). Some described branching out into their communities, such as this non-clergy: ‘In the community … I take them to clinics or hospital where they go to access the VCT … and they are thanking God because of the knowledge that I got from here’ (female, age 34–49, Livingstone). Several participants described incorporation of VCT discussions into pastoral counselling situations at church. A non-clergy doing premarital counselling reported:

Before the workshop, we were even afraid to mention or ask the couple, ‘Have you guys gone for HIV test?’ But after the workshop, the first time we meet them, that’s the message we hit them with, and we give them a timeframe … ‘Before the 10th [session], can we hear that you have been tested?’ (female, age 50–65, Lusaka)

Some of the most significant actions pertained to PLWH. A clergy recounted an event in which he reached out to an HIV+ woman mistreated by her neighbours:

After the second workshop, I, like, had time to sit her down and I said, ‘Don’t expect everybody to think the same about you, and don’t expect … everybody to act in the same way. The best you can do is … accept what your status is, and know that it is not, like, the end of it … .’ And I took time to talk to those that were around, like neighbours … . They raised certain questions, and I was able to provide them with the answers based on the knowledge that I acquired. (male, age, 18–33, Lusaka)

This and similar comments show how, once equipped with scientific knowledge about HIV, religious leaders fulfil their desire to contribute to the HIV and AIDS crisis across contexts and situations, utilising knowledge or actions they deem most relevant.

Embodying trust: Old roles, new realities

Numerous anecdotes painted religious leader participants as intermediaries who also connect their constituents with the medical system. A few participants noted that Zambian religious leaders had long been reluctant to assume such an advocacy role, especially regarding HIV. They attributed this reluctance to lack of knowledge and their perceived irrelevance to the HIV crisis. However, after their experience with Trusted Messenger, several found the impetus to engage confidently and willingly. One clergy explained:

Before this training, I personally thought maybe we, clergy, we’re not even supposed to know about these things, but since [Trusted Messenger] came … we can act different from what we used to act … . If we are to change the situation about HIV and AIDS, then we should work as a team – both in the church and with medical personnel (male, age 65+, Copperbelt).

Religious leader participants described multiple instances in which congregants or community members approached them, rather than healthcare professionals, to consult about health, including HIV-related issues. These participants instructed such individuals either to seek medical care at a hospital or to continue their medical treatment. One clergy recounted: ‘[Trusted Messenger] has helped me to try and guide people that are not well in their health to the clinic. Previously, I didn’t even have that knowledge, but I learned it from here’ (male, age 50–65, Livingstone). Another provided an instance with two congregants:

I’ve seen two members … . They came to me to ask me that, ‘Pastor, what can I do? … I went to VCT. They found that I’m positive.’ Then I told her that, sister, just continue what the doctor will tell you … . The same thing, another woman came, ‘Pastor, I went to the VCT, and they told me I must start taking that—.’ ‘Yes, just continue … . It will help’. (male, age 50–65, Livingstone)

Being properly equipped with knowledge did not only empower intervention participants, but it moved them into a state of empowerment, able to act anytime, anywhere, and with anyone. Such a state was reflected by several participants: ‘Whenever I see a situation I feel I can give help, I do it … because I’ve gone through a workshop’ (female, age 34–49, Livingstone); ‘Wherever I am, every time the matter arises, I deliver it to the people around me’ (male, age 34–49, Lusaka). Being properly equipped with knowledge also removed psychological barriers that may have otherwise inhibited participants’ actions. Specifically, Trusted Messenger conferred a sense of freedom on participants, as explained by this clergy: ‘An HIV workshop has to be freeing in the end. It has to set the minds of people free. They have to come out of [be relieved from] fear … and exactly that was the outcome’ (male, age 34–49, Lusaka). Some participants, such as this clergy, conveyed how this freedom persisted after workshop sessions:

[Trusted Messenger] just changed the mind-set of those who attended the workshop, because before that, people feared even to go for a test. But, after the workshop, people, they were free to go for test. Clergy, laity – they went there freely, without fear … . Testing and even talking about this HIV and AIDS … they are free. (male, age 50–65, Copperbelt)

These excerpts demonstrate how the possession of science-focused knowledge encouraged religious leaders to assume an integral role in others’ health plans through supporting medical treatment of HIV. They illustrate movement into a new state of empowerment and freedom for religious leaders and their constituents.

Improving: Moving forward

Participants provided recommendations to enhance the intervention, some of which pertained to practicalities. Participants overwhelmingly appreciated the focus on science and the interactive components of workshops. They identified these as integral to comprehension of material and enjoyment of learning. Some participants suggested use of even more simplified English, as well as interpreter services and handouts in multiple dialects to accommodate individuals with less education and limited language skills during didactic portions. Others expressed appreciation of print materials of content provided as requested by initial workshop participants. Participants expressed that these helped them to better remember information and to more easily share it with others. Some suggested broadening the Trusted Messenger target audience. Many simply said that ‘everyone’ should be able to attend, which, as one clergy leader speculated, ‘may reduce or eradicate [HIV and AIDS] completely’ (male, age 50–65, Lusaka). Others specified particular groups to target. One of the most common was residents of rural communities due to their perceived lack of knowledge about HIV and AIDS. One non-clergy leader reflected: ‘In rural areas, they are the people who don’t know about this disease’ (female, age 50–65, Copperbelt). This stated perspective is noteworthy, given that HIV in Zambia is concentrated in urban areas (Chandang’oma, Chabwla, & Banda, 2014; Ministry of Health, 2017).

Another oft-recommended target group was youth due to a perceived high prevalence of sexual activity and PLWH. A non-clergy expressed a sense of urgency by noting: ‘a lack of knowledge, especially with us youth, it's slowly killing us … . A lot of youth have to be invited to [Trusted Messenger] so at least we get more knowledge’ (female, age 18–33, Lusaka). Even so, participants overwhelmingly agreed that religious leaders were an ideal target. One clergy stated ‘Everyone in religious leadership – they do need this … . We still have to find a way. We still have to bring them on board. We still have to engage them’ (male, age 34–49, Lusaka).

Trusted Messenger participants indicated that a barrier to success of the intervention stemmed from poverty. Several stated that poverty inhibited their ability to disseminate the information. One clergy stated: ‘You might know where the information is supposed to go, but how do you take it there? You need resources to move to certain areas, and you find … you do not have the resources’ (male, age 18–33, Lusaka). Others proposed that the knowledge provided held little relevance for the poor [such as those who live in shanty towns, compounds or slums].

Participants also discussed sustainability, with many expressing a desire for such workshops to continue in Zambia. A clergy explained: ‘I wish, God willingly, [Trusted Messenger should not stop coming to us’ (male, age 50–65, Livingstone). Others verbalised a wish for capacity-building, economic empowerment and intervention ownership, arguing that it would make in-depth HIV-information regularly accessible. Such would alleviate a perceived dependence on non-Zambian workshop implementers. This clergy explained: ‘When [Trusted Messenger] goes, that's the end. Now if … from people who are on the ground here, then you will empower them to help … . We need to be established’ (male, age 34–49, Lusaka). Reflecting the same sentiment, a non-clergy stated: ‘I think [Trusted Messenger] should … train some more leaders … so that, if [current implementers] are not around, at least we are able to depend on those other ones’ (female, age 18–33, Lusaka).

These excerpts illustrate a variety of adjustments that participants believe could enhance intervention outcomes. Participants articulated practical concerns, such as language and interpreter services as well as need for societal challenges, such as alleviating poverty.

Discussion

These results provide important insights into perceived effects of Trusted Messenger in Zambia. Findings from this participant sample indicate that the intervention stirs hope among religious leaders – hope that knowledge and better understanding of HIV may be channelled into relevant positive action. Science-focused understanding facilitates new learning and motivates individuals to undergo VCT and other behaviour modifications. Insights broadened participants’ views toward prevention of HIV infection or AIDS-related illness, and empowered participants to employ new knowledge in personal, social, and religious contexts. The intervention bridges health and theology for clergy and non-clergy leaders alike and fosters a redefinition of HIV, AIDS-related illness, self and reality. These findings indicate a need for continuing the Trusted Messenger approach in Zambia to benefit more individuals and their communities.

This study adds significantly to the literature on engagement with faith-based organisations (FBOs) for effective HIV and AIDS prevention interventions in sub-Saharan Africa (SSA), an area of inquiry that is all too lacking (Lindgren et al., 2013; Olowu, 2015; Swidler & Watkins, 2017; Trinitapoli, 2009). It contributes to explicating impact of existing interventions, and addresses some major barriers that have hampered HIV-prevention efforts such as FBOs’ anti-condom and abstinence-only messaging (Banda, 2017; Mukuka & Slonim-Nevo, 2006; Piot, Kazatchkine, Dybul, & Lob-Levyt, 2009; Rankin et al., 2008), emphasis on spiritual, rather than antiretroviral therapy (ART) for PLWH (Endeshaw et al., 2017; Kenworthy, Thomann, & Parker, 2018; Wanyama et al., 2007), fear of VCT (Jurgensen, Tuba, Fylkesnes, & Blystad, 2012) and stigmatisation of PLWH (Alubo, Zwandor, Jolayemi, & Omundu, 2010; Ansari & Gaestel, 2010; Rankin, Brennan, Schell, Laviwa, & Rankin, 2005; Williams, Haire, & Nathan, 2017). Other qualitative work has addressed the ongoing role that stigma plays in preventing uptake of VCT among Zambians (Jurgensen et al., 2012). That Trusted Messenger was able to destigmatise and facilitate VCT uptake among intervention participants is an important contrast with attitudes about VCT.

Providing comprehensible scientific information to trusted religious leaders in established networks was the primary mechanism by which reported barriers were reduced and changes achieved. The Healthy Beginnings Initiative in Nigeria similarly has leveraged the influence and community access of religious organisations for implementing HIV intervention to increase VCT uptake and linkage to care in preventing mother to child transmission of HIV (Ezeanolue et al., 2013, 2015).

Participant perspectives indicate that biological information can be successfully conveyed to religious leaders, regardless of educational or scientific background. This seems to occur despite possible pre-existing bias against science from perceived conflicts with religious doctrine. Religious leaders absorbed relevant science insights related to their context and experiences and digested the information without significant misunderstanding or conflict with their core faith values. Many reported changes in attitude and actions that were precipitated by the science-focused insights. Some came to view condom use favourably and verbalised a willingness and desire to advise others to consider this option. An FBO-collaborative intervention in Malawi that also combined science and theology resulted in a similar change among religious leaders (Willms, Arratia, & Makondesa, 2011). Some participants came to view HIV as ‘just a virus’ rather than a supernatural reprimand for immorality. This has significant implications as focus on morality has been shown to increase stigma and inhibit testing and status-disclosure (Jurgensen et al., 2012; Olowu, 2015; Williams et al., 2017).

The results show that biological information can equip religious leaders to be relevant, knowledgeable and willing to act to better assist with health issues. Individuals spoke of how they and their colleagues had previously consigned themselves to a realm separate from HIV, leaving the subject to medical professionals. For some Trusted Messenger participants, this perception shifted. These religious leaders are aware of the problem, believe they should be part of the solution, and are seeking ways to do so. Participants described situations in which congregants and community members sought their consultation on health matters. Rather than condemnation for immorality or suggestions to utilise prayer instead of anti-retroviral therapy (ART), counsel from Trusted Messenger informed leaders included discussions about HIV-testing, suggestions to seek or continue medical care, and recommendations about condom use and ART. Such indicates that these religious leaders can and want to be empowered to address health issues including HIV. They can and will do so effectively if adequately equipped. As other researchers have noted, religious leaders must be ‘as evidence-based in practice as any other health-care provider’ (Summerskill & Horton, 2015). A Trusted Messenger core principle is engaging through science to equip participants such as those interviewed in this study. Research elsewhere in SSA has shown that congregants are more likely to engage in HIV-prevention behaviours when their religious leaders are equipped to discuss HIV and condom use (Lindgren et al., 2013; Múnoz-Laboy et al., 2011; Trinitapoli, 2009). Outcomes for congregants of leaders who participate in Trusted Messenger remain to be explored.

Theologically-compatible knowledge about HIV and AIDS, and possibly other illnesses, can empower religious leaders to engage confidently with others about health issues. Participants described feeling confident, equipped, and capable after attaining scientific understanding of HIV and AIDS. Trusted Messenger engagement prompted a redefinition of identity whereby clergy and non-clergy leaders perceived themselves as relevant players in the fight against HIV. Participants provided numerous examples of utilising what they learned in multiple domains. This outcome resembles those of other successful interventions in SSA that provide healthcare workers with specialised HIV-prevention training (Harrowing, 2009; Kaponda et al., 2009). In another effective intervention, Islamic religious leaders received specialised schistosomiasis-prevention training (Celone et al., 2016).

Scientific information can empower network leaders not only to embrace a responsibility to effectively engage in health issues, but also to transgress cultural boundaries to the benefit of the greater good. Participants spoke of how the workshop conferred a feeling of freedom that dissolved communication-related gender and age barriers. Such cultural flexibility was sustained beyond the workshop as participants reported feeling empowered to discuss HIV and AIDS with anyone. That these religious leader participants report sidestepping of what may have otherwise been significant obstacles to intervention engagement holds promise for other faith networks in comparable contexts. The Trusted Messenger approach of providing in-depth science through engaging religious leader networks seems to effectively address some obstacles common to HIV-prevention efforts when working within faith networks in Zambia, and perhaps in other countries.

Several recommended adjustments may enhance participant experiences. Besides providing translators and multilingual print materials for more accurate understanding and sharing of content, better communication and more workshop opportunities could increase attendance to Trusted Messenger sessions as will be required to saturate leaders in a targeted area. Enhanced efforts to build capacity and to move ownership of intervention implementation to Zambian entities could confer independence and empowerment while increasing scope, broader community access and sustained use of scientific information (Brear, 2017; Summerskill & Horton, 2015; Thomas-Slayter & Fisher, 2011). Developing partnerships with relevant government agencies and local and international NGOs, educators and researchers will allow broader assessment of impact of Trusted Messenger and will contribute to its sustainability.

Limitations

We note several limitations of this qualitative study. First, the sample is a small subset of Trusted Messenger participants. Their experiences may not be generalisable to all attendees. While the research design used a strategy to capture a diverse set of participants, all perspectives may not have been captured. Moreover, some attendants’ contact information was no longer accurate, further limiting the number of possible participants. Second, given some cultural taboos about women speaking to men to whom they are not married, female participants may have been reluctant to speak openly to the male interviewer. Third, cultural hospitality and/or interviewer characteristics may have influenced participants to describe their Trusted Messenger experience positively and refrain from verbalising its shortcomings (Brear, 2017). The interviewer attempted to minimise this through emphasising confidentiality and the purpose of the study.

Implications and conclusion

Interventionists have long attempted to harness the power and influence of religious leaders in sub-Saharan Africa. Experiences reported here with Trusted Messenger, as well as the quantitative outcomes and theoretical framing to be reported elsewhere, suggest some new ways this might be accomplished. Religious leaders who have influence and access to community members can and should be trained to effectively address health issues. Perspectives expressed by intervention participants suggest that scientific knowledge conveyed through a collaborative network strategy can engage these influential leaders without compromising religious beliefs. The network setting is important to success. Further, these perspectives indicate that cultural barriers are not unmalleable and need not impede successful intervention implementation. Other collaborative interventions with measurable outcomes (Celone et al., 2016; Ezeanolue et al., 2015; Kaponda et al., 2009; Willms, Arratia, & Makondesa, 2011) are meeting a serious and urgent need in for sustained engagement of community leaders. These and approaches like Trusted Messenger must continue to be implemented effectively if global strategies to control HIV are to succeed.

The Trusted Messenger approach, that can be enhanced and adapted, holds promise as a relatively low-cost HIV-prevention intervention well-suited to religious leaders in SSA. Participants have found hope in its prospect and delivery. They have taken new-found biological science understanding to heart and act to disseminate it through word and deed. With some adjustments, we are hopeful that Trusted Messenger can confer similar benefits on other networks in Zambia, and perhaps in comparable contexts elsewhere. This study shows that science-focused education in the context of established religious leader networks can engage and empower these influential leaders as readily available gateways for addressing health issues in their families and communities.

Acknowledgements

We thank in Zambia officials of the African Methodist Episcopal Church and the Council of Churches of Zambia and the many community participants for their partnership. We are grateful to Tremel Goins, Jr for technical assistance provided.

Disclosure statement

J. M. Wiginton and E. J. King have no known conflict of interest with the paper content. A. O. Fuller has an active Conflict of Interest management plan through the University of Michigan Medical School.

ORCID

Elizabeth J. King http://orcid.org/0000-0001-8465-4607

Additional information

Funding

This work was funded by the African Studies Center, the International Institute, the Center for Research on Learning and Teaching and the School of Public Health-Department of Health Behaviour & Health Education at the University of Michigan.