The Spoken Word Project: Using Poetry in Community Dialogue and Mobilization for HIV Prevention

By: Malika Roman Isler, Guarav Dave, Heather L. Jones, Doris Stith, Tiarney Richwood, Turquoise Griffith, Leslie Atley, and Giselle Corbie-Smith

Abstract

        Spoken word, a form of performance poetry, is a promising approach to HIV/AIDS awareness and prevention, as it has the potential to encourage dialogue among and within communities and address concerns regarding the social stigma present in rural communities. The purpose of this study is to describe the development and implementation of the Spoken Word Project (SWP), an HIV/AIDS pilot intervention in rural North Carolina designed to improve HIV-related attitudes and self-efficacy and decrease stigma through the use of performance poetry. Spoken word is a collaborative effort between residents of two rural counties in North Carolina and Project GRACE (Growing, Reaching, Advocating for Change and Empowerment), a community-based participatory research collaboration aimed at reducing health disparities in African American communities. The project included 15 adult and youth participants. Results indicated that spoken word has the ability to build upon local resources, generate community reflection, and engage a broad spectrum of performers and audiences. Our findings also showed that the effect of stigma and limited community conversations about HIV in rural communities can be abated through the use of spoken word.
        Of all U.S. regions, the South has the highest rates of HIV diagnoses — 23.8 per 100,000 (Reif, Whetten, Osterman, & Raper, 2006); and 64% of people living with AIDS in rural areas reside in Southern states (Reif & Whetten, 2012). As these rural areas continue to disparately experience the burden of HIV/AIDS, limited community conversations about HIV severely hamper prevention efforts (Hovey, Booker, & Seligman, 2007; Lichtenstein, 2005; McEwan, Bhopal, & Patton, 1991)). The social challenges of HIV stigma, fear, and denial impede the delivery of prevention messages and efforts to mobilize communities most in need of intervention (Darrow, Montanea, & Gladwin, 2009; Foster, 2007). Prevention efforts in rural communities are further challenged by prevalent poverty that is linked to less HIV-related knowledge and a tendency to stigmatize those affected by the condition (Des Jarlais, Galea, Tracy, Tross, & Vlahov, 2006; Foster, 2007; Hovey, Booker, & Seligman, 2007). In 2010, a report released by the White House Office of National AIDS Policy further described stigma as adversely impacting willingness to be tested for HIV, to disclose their serostatus to sex partners, and adherence to antiretroviral therapy among people with HIV/ AIDS. The report recommended strategies to reduce stigma, which included community engagement to support people with HIV/AIDS and developing new public health approaches to HIV prevention (White House Office of National AIDS Policy, 2010). One such innovative approach, performance poetry, holds promise to raise awareness about HIV/AIDS, foster dialogue among communities, and overcome the social stigma present in rural communities.
        Poetry, along with other artistic forms of expression, has a rich history as a tool for community mobilization and has the potential to provide an innovative approach to dismantling social challenges (Niba & Green, 2005). Performance poetry, a form of poetry often performed as a dramatized monologue in the presence of an audience, provides a platform to transcend stigma and marginalization associated with HIV/AIDS, both of which are significant challenges to rural HIV prevention (Pietrzyk, 2009). In addition, the use of performance poetry can have both individual and community level benefits. Performers often report a sense of individual empowerment and self-healing from the process of self-reflection and sharing of their life experiences (Chung, Corbett, Boulet, Cummings, Paxton, McDaniel, Mercier, Franklin, Mercier, Jones, Collins, Koegel, Duan, Wells, & Glik, 2006; Des Jarlais et al., 2006; Valente & Bharath, 1999). For the audience or broader community, performance poetry encourages dialogue around HIV; dispels stigma by encouraging community-wide empathy and social responsibility; and creates opportunities to discuss strategies for communities to engage in HIV prevention (Moyo, 2010). In addition to stimulating community interest in socially relevant issues, performance poetry also promotes peer-topeer camaraderie and social relationships through critical reflection and exchange of ideas. This in turn encourages greater community mobilization and cohesion around an issue of importance (Pietrzyk, 2009; Valente & Bharath, 1999). For both performers and communities, performance poetry serves as a vehicle to disseminate information, dispel misinformation and myths that may be common to a local setting, and provide educational messages about transmission and protective barriers (Hovey, Booker, & Seligman, 2006; Lichtenstein, 2005; Moyo, 2010; Pietrzyk, 2009).
        Performance poetry is well suited for communicating messages within African American communities (Banks-Wallace, 2002). Oral traditions in U.S. black communities have a long history as intergenerational vehicles of expression, from slavery through the Harlem Renaissance, to the Civil Rights movement and current popular culture (Ashe, 2002). Performance poetry, colloquially referred to as spoken word, combines elements of music and literary expression that can appeal to audiences of varying ages, literacy levels, and socioeconomic classes. Given the ability of spoken word to attract large crowds (Chung et al., 2006; Valente & Bharath, 1999) and reach broad audiences at once, this art form circumvents many of the resource challenges that may be present in rural communities. In addition, the process of developing and delivering performance poetry is closely aligned with participatory approaches to addressing health in underserved communities. Developing spoken word within communities builds upon the local expertise and experience, and supports communities in generating local solutions to improving health. Performers who are in and of the community increase the impact of performance poetry, as audiences are more likely to identify with the performer and their message. In addition, in studies with youth poets, students identified with the performers and their experiences based upon similarities in age (McEwan et al., 1991). By building upon local community assets, the development and delivery of poetry builds collective self-efficacy to address HIV/AIDS, and creates a sustainable network to reinforce de-stigmatization and ongoing positive local change. The local investment and enactment of performance poetry promotes long-term sustainability that is similarly seen with other creative and participatory media methods, such as photovoice (Yonas, Burke, Rak, Bennet, Kelly, & Gielen, 2009).
        While performance poetry effectively engages individuals and communities in social and health issues, few examples exist in the literature around methods to use it for HIV prevention in rural communities. Here, we describe the development, implementation and evaluation of SWP, an HIV/ AIDS pilot intervention in rural North Carolina that aimed to improve HIV-related attitudes and self-efficacy and decrease stigma through the use of performance poetry.

Methods
Study Background
        The SWP is a collaborative effort between residents of Edgecombe and Nash Counties of NC and Project GRACE (Growing, Reaching, Advocating for Change and Empowerment), a community based participatory research (CBPR) collaboration aimed at reducing disparities in health in African-American communities. Conversations with community partners in Project GRACE highlighted the need to raise social consciousness and awareness about HIV in the local community, increase individual and collective self-efficacy to prevent HIV/AIDS, facilitate dialogue about HIV, and decrease stigma towards HIV in the local community. Both Edgecombe and Nash counties have three-year HIV disease rates above the state average; Edgecombe at 31.4 and Nash at 17.4 cases per 100,000 (North Carolina Department of Health and Human Services, 2013). In response, Project GRACE and local community members engaged adolescents and adults, who had participated in an HIV prevention intervention, in the SWP. The institutional review board of the University of North Carolina at Chapel Hill approved this study.

Recruitment and Data Collection
        We recruited adolescents and adults who: 1) self-identified as African-American, 2) were living in Edgecombe or Nash counties, and 3) were youth ages 10–17 years or caregivers at least 18 years of age. Recruitment postcards were sent to all eligible participants who had previously participated in another HIV prevention project, and consent was obtained before the project began. The SWP consisted of two phases: spoken word training and spoken word performances.

Spoken Word Training
        The materials for the SWP drew from curricula previously developed for photovoice projects and in consultation with spoken word poets. Training sessions were led by trained facilitators and co-facilitators selected by Project GRACE’s community partners. All facilitators were trained poets with prior experience in performance poetry. Additionally, we recruited four guest poets from diverse geographic regions, representing a range of performance styles and genres. The guest poets also served as a motivational force for participants in the poetry-forming process. Adolescents and adults participated in six three-hour sessions held at a local community hospital, one of the partners in Project GRACE. Transportation to and from the program was provided along with a $10 cash incentive for each of the six training sessions. Each session was designed to prepare participants to deliver a spoken word piece during a local showcase and a regional showcase on World AIDS Day.
        The training sessions employed Freire’s (1973, 1993) theory of critical consciousness to support individual and community understanding of the root causes of HIV/AIDS and in turn build selfefficacious behavior. We supported participants in matriculating through three stages: 1) apathy, where participants begin to care about the problem through discussion with facilitators, peers and trained poets, 2) social responsibility, where participants engaged with others directly affected by the social issue to gain a sense of empathy, and 3) action, where participants were armed with skills to produce influential change in their communities (Wallerstein & Berstein, 1998).
        Six session topics were chosen: (1) Introduction to Spoken Word; (2) What HIV/AIDS Means to Me; (3) How HIV/AIDS Has Affected My Community; (4) What My Community Can Do to Prevent HIV/AIDS; (5) Spoken Word — Putting It All Together; and (6) Community, advocacy, and spoken word (see Table 1).
        The first training session introduced participants to the performance poetry art form and how it can work as an advocacy and awareness tool within their communities. The next three sessions focused on eliciting participants’ local experiences with HIV and guided participants in creating their own spoken word pieces. The fifth session gave participants the opportunity to plan a showcase to feature each participant’s piece, using a video recording of a previous spoken word showcase as an example. The sixth session focused on advocacy and creating solutions for community issues through the use of poetry, and rehearsal for the showcase performances.
        During the first session, participants received a journal to record their thoughts and assignments, and to facilitate the writing process for the poetry. Each spoken word training session was designed and facilitated using WORD (Write, Our, Relating, Do), which is an adapted form of the SHOWED method that is commonly used in photovoice (Gubrium & Torres, 2013; Kubicek, Beyer, Weiss, & Kipke, 2012; Wang & Burris, 1994, 1997). WORD guides participants through a process of posing problems and critical thinking by using group dialogue and writing exercises. WORD answers these questions: What can we write down about what is happening in this community related to HIV? How does HIV relate to our lives and how does the issue make us and others feel? How can I explain my feelings to others in a way that they can related to my emotions about the issues surrounding HIV? How can I use spoken word to demonstrate what others can DO to improve HIV awareness and attitudes, decrease stigma, and promote community mobilization? Before starting the WORD process, each group listened to and experienced a performance poetry piece, presented by a guest poet. Following the WORD process, participants received a homework assignment to create their own poetry around the topics discussed during each session. To assist participants in developing the poetry pieces, the group engaged in a brainstorming session to generate words and ideas that could be used in their poetry. However, due to limited literacy in the adult class, the facilitator guided the group in the development of one group poem instead of individual poems. After the fifth session, each participant selected one of the pieces they developed during training to deliver during the showcases.

Spoken Word Performances
        The SWP participated in one local and one regional showcase for the participants to deliver their performance poetry pieces. For the local showcase, participants created an invitation list of community members, elected officials, family and friends. Based upon discussion during the training sessions, participants also decided on the color scheme, attire, decorations, and program for the showcase. Publicity for the showcase included a press release and advertisements in a local newspaper. On the day of the local showcase, participants completed a practice performance of their poems before performing live. The facilitators served as Mistresses of Ceremony introducing each poet (participant) and the title of their poem. Each poem was intended to raise awareness about HIV, dispel stigma, and advocate for change in the community around the issue of HIV. For the regional showcase, the SWP participants opened the program with their poetry pieces, followed by performances by a nationally renowned

Table 1. Section Spoken Word Training Components
Table 1. Section Spoken Word Training Components

motivational speaker, a national recording artist, and a national spokesperson.

Data Collection and Management
        Outcome evaluation. Participants in the SWP completed self-administered pre- and post-test surveys at the beginning and end of the entire training program. The survey included three domains: selfefficacy, attitudes and beliefs, and stigma. The 9-item collective/individual self-efficacy domain, which was comprised of items adapted from Chung, Jones, Corbett, Booker, Wells, and Collins (2009) and the study team, measured one’s ability to address the burden of HIV/AIDS within one’s community, both individually and collectively. Example items include, “I feel comfortable talking about HIV/AIDS” and “I feel that I have the ability to make change in my community.” The 13-item attitudes and beliefs domain, comprised of items adapted from Chung et al. (2009), measured one’s beliefs and attitudes about issues related to HIV/ AIDS. Examples from this domain include “I think HIV/AIDS is an important issue in my community” and “I think poetry is a better way to teach people than lecturing them about HIV/AIDS.” The 13- item stigma domain, comprised of items adapted from Chung et al. (2009) and Van Rie, Sengupta, Pungrassami, Balthip, Choonuan, Kasetjaroen, Strauss, and Chongsuvivatwong (2008), measured negative thoughts associated with HIV/AIDS. Examples from the stigma domain include “People with HIV/AIDS should not play with other people’s children” and “I view people with HIV/AIDS as unclean.” All the domain-specific responses were structured using a 5-point Likert scale (5=strongly agree to 1=strongly disagree).
        For the showcases, we asked all attendees to complete self-administered pre- and post-test surveys that included 7 items from the self-efficacy domain, 8 items from the attitudes and beliefs domain, and all 13 items from the stigma domain. Showcase responses also used a 5-point Likert rating scale (1=strongly disagree and 5=strongly agree).

Process evaluation. In addition, SWP participants evaluated each training session. Participant responses were rated on a 5-point rating scale (1=very poor to 5=excellent). Following each training session, staff from the University of North Carolina at Chapel Hill, also members of Project GRACE, led a structured debriefing session with the facilitator and co-facilitator to discuss any process or emergent issues from the session. Debriefing sessions lasted no longer than 30 minutes. The sessions were recorded and transcribed verbatim. An independent reviewer crosschecked the transcripts to ensure accuracy. To ensure confidentiality, all identifying information was removed from the transcript. Immediately following the fifth youth session, we also conducted a focus group and gathered information about youth perceptions of the process and impact of the SWP experience. Focus group questions further explored the concepts included in the process evaluation (e.g. perception of the guest poets, likes and dislike about the program content and structure, and perceived benefits and barriers to SWP participation, etc.). The focus group session, which lasted approximately 45 minutes, was recorded and transcribed verbatim.

Data Analysis
        We used IBM SPSS Statistics 21© software for statistical analysis and reporting. The final sample excluded individuals if they had missing data. The participants’ demographic characteristics and self-reported information were described using frequencies, means and percentages. A paired-sample t-test was used to examine whether change in the self-efficacy, attitudes and beliefs, and stigma scores (pre to post) differs significantly from zero. All other data were summarized using descriptive statistics such as means, medians, proportions, and standard errors, with 95% confidence intervals. The statistical significance for all analyses was based on the conventional alpha level of significance of 0.05.
        For the debriefings and focus group, two team members reviewed the transcripts independently to familiarize themselves with the data, and identify conceptual patterns and groupings of the text, commonly referred to as themes (Braun & Clarke, 2006). The themes were shared with the research team, including the facilitators, for verification of the themes.

Results
Demographic Characteristics
        A total of 15 individuals (adult n = 7, 47%; youth n=8, 53%) participated in the spoken word training sessions. All participants were African Americans and more than half (n = 9) were males (see Table 2). The showcase attendees were primarily African American (77.8%) and most had at least some college-level education (64.4%).

Table 2: Demographic Characteristics of Participants* and Showcase Attendees
Table 2: Demographic Characteristics of Participants* and Showcase Attendees

Impact of SWP Training on Participants
        All 15 participants (100%) completed the overall pre-test survey and 14 participants (93.3%) completed the overall posttest survey. In general, participants in the SWP training demonstrated improvement in self-efficacy and reduced stigma towards HIV, while attitudes and beliefs remained relatively unchanged (see Table 3).

Table 3. Pre-Post Mean Differences in the Spoken Word Project, NC 2012 Participant Training Outcomes* (n=14)
Table 3. Pre-Post Mean Differences in the Spoken Word Project, NC 2012
Participant Training Outcomes* (n=14)

        The overall domain-specific mean for self-efficacy increased from 3.19 at pretest to 4.44 at posttest, though this difference was not statistically significant. However, two individual items in the self-efficacy domain showed statistically significant improvement — I know how to talk to my community about HIV/AIDS (p<0.05) and I think about how my surroundings are connected to HIV/AIDS in my community (p<0.05). For attitudes and beliefs towards HIV/AIDS, the overall domain-specific mean decreased from 4.21 at the pre-test level to 4.16 at the post-level, though the mean difference of -0.42 was not statistically significant. None of the mean ratings for individual attitude and belief items were different between pre and post-test surveys at a level of statistical significance. For stigma, the overall domain-specific mean decreased from 2.72 at the pre-test level to 2.46 at the post-test level, indicating an improvement in stigma scores. While the overall mean difference for stigma was not statistically significant, two individual items showed statistically significant resultsPeople with HIV/AIDS should not play with other people’s children and I would want to keep my distance from people with HIV/AIDS (p<0.05).

Table 4: Training Session Evaluation Outcomes — Mean Ratings* in the Spoken Word Project, NC 2012
Table 4: Training Session Evaluation Outcomes — Mean Ratings* in the Spoken Word Project, NC 2012

SWP Training Process Feedback
        On the training evaluation surveys, participants indicated that all sessions were either good or excellent (see Table 4). Specifically, sessions received a rating of 4 or higher, indicating that participants believed that sessions provided clear examples, facilitated a better understanding and application of spoken word in their performance poetry pieces, and facilitated better understanding of the journaling assignments. They also rated discussions during each session as helping them think through the issues [related to HIV/AIDS] (mean > 4.0) and felt that the facilitators/co-facilitators answered all their questions clearly, making the sessions enjoyable to attend (mean >4). After training session 6, participants reported that they were confident in carrying out their assigned tasks for the community during spoken word showcase exhibits (mean = 4.2).
        Participants offered positive feedback, as well as opportunities to improve the Spoken Word Program. Overall, youth participants appreciated the peer-to-peer learning environment. Youth participants noted, “I like being in an environment with people around my own age”, “My friends want to see me perform” and “It [spoken word training] builds your confidence”. Facilitators noted during debriefings that working in small groups gave both youth and adult participants an opportunity to receive constructive feedback on poetry efforts, to work together to brainstorm themes and ideas outlined during training sessions, and learn from each other’s poetry styles.
        Most of the participants had no previous experience performing spoken word. Facilitators noted the benefit of audio-video examples of previous showcases that “worked well and helped as a reference point.” For participants with limited exposure to spoken word, “asking them to come up with something they’ve never done is hard and asking them to decide how [to develop performance poetry} would have been an issue. The video was very helpful.” In addition, the diversity of guest poets enhanced the training experience as youth participants described the poets as “inspiring” and offering “different experiences to draw from”.
        Youth also described challenges to participation that included a desire for more incentive money, conflicts with the day of the week the sessions were held (six consecutive Saturdays), and the burden of completing evaluations. While engaging participants in the planning of the showcases was meant to foster ownership and empowerment for participants, some facilitators noted challenges with participant’s ability to plan a public event. Given the wide range of cognitive and literacy abilities of participants, facilitators observed opportunities to modify some of the language used in the training and the strategies used for delivering the information. Specifically, one facilitator noted difficulty among adult participants with lower functional literacy in developing spoken word and the need for more practical examples to support the adult’s creative process. Adults also needed more affirmation to be comfortable performing spoken word.
        Overall, facilitators noted that participation in the training and showcase experience helped youth participants with their performance poetry skills as “they recognized rhythm, rhyme, tone, sound, movement and discussed posture and how it can keep or lose your audience.” As a result of participating in the spoken word training, youth participants expressed that they “understand they have a voice in the community.”

Themes of Spoken Word Poetry
        The SWP participants developed a total of 36 poems during the spoken word training and chose 14 of those to perform for the showcase. Participants used poetry to cover a range of themes related to HIV. As part of the apathy stage of the SWP training, over half (8 out of 14) of the individuals described risk behaviors that contribute to risk for acquiring HIV; ranging from using “dirty needles” and having unprotected sex to not getting an HIV test and being unaware of one’s sero-status. Consistent with the “action” stage of the SWP training, most (6 out of 8) of these individuals also offered strategies to individuals to protect themselves from HIV infection by “being aware”, using clean needles, and practicing sexual abstinence. Half of the participants (7 out of 14) reflected the “apathy” stage of training through their focus on the personal experiences of people living with HIV/AIDS (PLWHA) and the impact of HIV on PLWHA’s significant others. Participants referred to the loss of friends who died from AIDS, the need for PLWHA to take pills every day, and even the pain of mothers seeing their children cope with living with HIV. One participant’s poem described the sexual risk behaviors that can lead to HIV infection, the personal awareness of becoming infected, and issued a warning to other members of the community to encourage others not to become infected:

I woke up this morning, happy as I could be,
not knowing that I had HIV.
It is something that I did not want to happen to me.
My mother warned me, “Son, be careful out there because of HIV,
it is easy to get,” but I did not listen.
I know the things that I didn’t do:
I know I got caught up with me using bad
needles that weren’t cleaned,
having sex with every woman that gave it
up free with no protection thinking that I
didn’t need it [protection].
Feeling bad and saying, “Man, it couldn’t have been me,
taking pills everyday though saying to myself, ‘What can I do?’”
I heard a voice say, “Pray, and I’ll pray for you.”
So remember, people, don’t do what I did!
Using needles that wasn’t cleaned.
Laying with every woman that give it up free.
If you do that, you won’t catch HIV.
Oh my God, it happened to me!

        Two participants spoke directly to the stigma associated with HIV/AIDS, and one described the subsequent need for communities to “respect those with HIV.” Several participants incorporated faith principles as part of the coping experience for PLWHA, and described “God watching over those with HIV” and “His love and strength” helping PLWHA to cope. Interestingly, a couple of participants also noted the critical role of PLWHA in generating apathy by sharing their personal experiences with others, and demonstrating their stories of perseverance and survival. As part of their social responsibility, some participants also used their poetry to describe action steps that individuals within the community can take to promote HIV prevention (i.e. be a community spokesperson, get the word out, make your voices heard, do your research, be unified, etc.)
Spoken Word Showcase Outcomes
        We reached approximately 200 adults and youth through the national showcase, which took place on World AIDS Day in Raleigh, NC through sponsorship from Black Entertainment Television’s Wrap It Up Campaign. Overall 33 individuals completed the pre and posttests assessments. The self-efficacy of the showcase attendees to address the burden of HIV/AIDS in their community remained relatively unchanged from pre (4.41) to post (4.39) and the difference was not statistically significant. The attendees had very positive attitudes and beliefs towards HIV/AIDS with a mean rating of 4.52 at pre-test, which remained unchanged at the end of the showcase. In assessing stigma associated with HIV/AIDS, we found that the mean ratings decreased from 1.72 at the pretest level compared to 1.67 at the posttest level. While this mean difference was not statistically significant, the decrease in mean ratings suggests an overall improvement in attendee’s stigma associated with HIV/AIDS. None of the mean differences for domain-specific individual items were statistically significant.

Discussion
        The purpose of the SWP was to facilitate community conversations about HIV/AIDS, to improve self-efficacy, attitudes, and beliefs about HIV, and to reduce stigma within a rural community. Participant representatives and other stakeholders guided the development of the SWP components thereby enhancing shared norms, common values and desire to address a mutual need — HIV prevention. This pilot relied on existing community resources and strengths by recruiting poets, facilitators and co-facilitators for the training sessions from within the community. We built upon the inherent social relationships and experiences within a rural community by involving community members, academic researchers, community organizations and local public officials in supporting community dialogue and decreasing stigma around a significant health concern identified by members of this community: HIV/ AIDS.
        Artistic forms of expression have often been used to identify issues of concern to a community and their use has the potential to lead performers, as well as their audiences, through a process that promotes social change (Fliegel 2005). The participants in the SWP appeared to move through the process of critical consciousness, which has been described as a process through which marginalized individuals interpret their social conditions and consider ways in which they could respond that might facilitate change (Freire, 1973, 1993). As demonstrated in other community interventions that utilized creative forms for expression, through poetry, performers in the SWP were able to engage with the issue of HIV in their communities and both performers and their audience were able to reflect on their role in addressing it (Gray, Oré de Boehm, Farnsworth, & Wolf, 2010).
        The demonstrated effect of the Spoken Word Project is similar to other applications of CBPR and the arts. For example, researchers using photovoice have successfully created “voice” among rural populations to tell their stories in their own words, and shifted participant roles from learners to teachers in their communities (Gubrium & Torres, 2013; Kubicek et al., 2012; Wang & Burris, 1994, 1997). The use of narratives and the transition of community members to leaders is necessary to bridge communication with local policymakers who develop governance for HIV prevention and treatment services. For both showcases, participants invited and shared their perspectives with influential people to whom they might not normally have access. Previous research has also suggested that poetry, in particular, can be a powerful means to allow groups that have been marginalized to express their perspectives and engender empathy for their concerns (Nyamathi, Slagle, Thomas, Hudson, Kahilifard, Avila, Orser, & Cuchilla, M. 2011).
        The SWP demonstrated benefits for both participants and the local community by improving some aspects of self-efficacy among participants and reducing HIV-related stigma among both participants and showcase attendees. These findings indicate that performance poetry may be an effective vehicle to raise awareness about HIV and support individuals to take action to address HIV associated stigma in their communities. The preliminary effectiveness of the SWP rested in its ability to effectively train local youth and adults to deliver messages using an innovative, culturally relevant, and sustainable approach. Consistent with this idea, others have shown that HIV interventions that are interactive by design, including those employing small groups and community-level engagement, have been shown to be the most effective in facilitating behavioral change and risk reduction (Albarracin et al. 2005).
        In addition to local performers, a contributing factor to the success of this intervention included the participation of the facilitators and co-facilitators, who were trained poets and selected by GRACE community partners. Other studies demonstrate that community-engaged interventions tend to be more successful when the facilitators share characteristics, such as age, ethnicity, and other demographic factors, with participants and target consumers, as was the case with the SWP (Crepaz et al., 2006). In addition, community-based interventions often face the challenge of sustainability (Minker, 2005); however, by building a cadre of local spoken word trainers and performers, SWP helped to create a local resource for continued community conversations to support HIV prevention and further reduce the local stigma surrounding HIV.
        Despite the overall success of SWP, there were some limitations. First, we experienced significant challenges with collecting data during the course of the showcases. In order not to disrupt the flow of the arrivals, only attendees who visited the project table during the pre-show exposition had the opportunity to complete the pre and post assessments. In addition, participants that arrived close to the start of the showcase or late were unable to participate in data collection. This logistical challenge limited our ability to determine effects of the SWP among attendees. Second, self-efficacy, attitudes and beliefs among showcase attendees completing the pre and posttest surveys were relatively high at pretest, which left little room for improvement (i.e., ceiling effect). It is also possible that attendees who self-selected into data collection may be more interested in and sensitive to the issues surrounding HIV within this rural community. Completion of the pre and posttest survey among a broader range of attendees may have presented a better understanding of community measures prior to and after participation in a spoken word showcase. In addition, we recruited the participants from a previous HIV prevention study — Teach One Reach One project. As a result, spoken word participants began the training with largely favorable attitudes and beliefs towards HIV/AIDS at the pre-test level, here again a possible ceiling effect. Future applications of spoken word in community settings will need to ensure participation by individuals that represent a broader cross-section of the community.
        While the SWP was designed as an intergenerational training, facilitators noted challenges to developing performance poetry that were specific to adult participants. The opportunity to stimulate dialogue around HIV/ AIDS prevention is clearly beneficial across all age groups; however, youth in this setting may feel more comfortable using the arts to facilitate community conversations. In addition, both counties have fewer residents with at least a high school education than is reported for the state overall (84.1% compared to 77.9% and 81.9%, respectively), which may explain some of the challenges with literacy that we encountered with adult participants. We felt it was important to make sure all voices were heard and made modifications to help individuals translate their ideas into individual written pieces. Given the strength of performance poetry as an oral art form, it may be particularly important that future programs employ activities and assignments that rely less on written formats (i.e., use of audio recording, videos, etc.) so that those most affected by health inequities can participate fully.
        Performance poetry builds upon local context and resources, generates community reflection and mental imagery regarding a health issue, and engages a broad spectrum of performers and audiences. Our findings show that the effect of stigma and limited community conversations about HIV in rural communities can be abated through the use of spoken word. As a form of performance poetry, spoken word provides channels of communication and benefits for those directly engaged in training and those who attend performances. As a strategy that leverages local experiences and capacity, performance poetry is a promising approach to raise HIV awareness, promote community conversations, and improve stigma in rural African American communities.

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About the Authors

        Malika Roman Isler is an assistant professor in the Department of Social Medicine, School of Medicine at The University of North Carolina at Chapel Hill. Tiarney Ritchwood is a postdoctoral research associate at the Center for Health Equity Research at The University of North Carolina at Chapel Hill. Guarav Dave is the administrative director of the North Carolina Translational and Clinical Sciences Institute at the Center for Health Equity Research at The University of North Carolina at Chapel Hill and evaluation chair of the Southeast Genetics Regional Collaborative. Heather L. Jones is a medical student at the School of Medicine at The University of North Carolina at Chapel Hill. Doris Stith is the executive director of the Community Enrichment Organization in Rocky Mount, NC. Turquoise Griffith is a former master’s student at The University of North Carolina at Chapel Hill. Leslie Atley is the project coordinator at Project Grace and social clinical research specialist at the Cecil G. Sheps Center for Health Services Research at The University of North Carolina at Chapel Hill. Giselle CorbieSmith is a professor in the Department of Medicine and Center for Health Equity Research at The University of North Carolina at Chapel Hill.

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