The rise of synthetic opioids, such as oxycodone and fentanyl, has precipitated increases in overdose‐related deaths, and this concerning trend is not solely due to the opioid crisis (
1,
2). Concomitantly, the rise in methamphetamine use, its co‐use with opioids, and lethal adulteration with fentanyl have had deleterious consequences (
3,
4). While fatal overdose rates fell in Non‐Hispanic White individuals, overdose‐related mortality rates increased in Hispanic and Non‐Hispanic Black male‐identifying individuals. Treatment is also less accessible, with individuals in Non‐Hispanic Black communities accessing care for mental health or substance use disorders at one‐half to one‐third the rate of Non‐Hispanic White individuals (
5,
6). Barriers include: (1) psychoeducational gaps; (2) structural racism; (3) dearth of culturally competent care; (4) less comfort with seeking treatment due to historical harms perpetrated in medical settings; (5) greater exposure to social determinants of health; and (6) living in underresourced settings (
7,
8,
9).
To address these barriers, community‐based engagement is being utilized to reduce inequities via health education, access to services (i.e.,—COVID vaccinations and testing), and providing culturally competent care (
10,
11,
12,
13,
14,
15,
16). Churches have a strong history of psychological and social support for people living in communities of color, and leaders occupy a position of trust and confidence (
17). In addition to medical illness, community‐based programs have addressed mental health concerns including depressive and substance use disorders (
15). The development of interventions is critical in order to address barriers to accessing care for mental health and substance use disorders for individuals in communities of color (
18). Addressing these issues may include customized interventions which are designed in collaboration with community members and delivered in the context of the community (
19).
When considering interventions for increasing compassion and enhancing knowledge surrounding stimulant‐use disorders, video‐based interventions are a promising option. People with substance use experience anticipated negative responses from family members, the perception of seeking healthcare as a weakness, discrimination, and (for parents) fears of being reported to child protective services (
20,
21,
22,
23). Video interventions have been shown to increase health literacy amongst African‐American communities, increase community engagement and trust in the healthcare system (
24,
25), and are lower‐cost and more easily disseminated compared to other interventions (
26,
27).
The American Heart Association (AHA)'s EmPOWERED to Serve (ETS) program seeks to dismantle structural racism within healthcare and to achieve health equity for all. This team has built relationships with church leaders in Black and Hispanic communities over several years, and has a collaborative process for co‐creation of online health lessons in accordance with community‐partnered participatory research including but not limited to: establishing memoranda of understanding with community leaders, compensation for church participation, conducting focus groups to revisit prior work and plan for future projects, engaging with community leaders about structural racism, circumventing barriers to intervention uptake, modifying dissemination strategies, and meeting needs not covered by current projects (
28,
29,
30,
31). Topics include cardiovascular health, diabetes, nutrition, exercise, mental health, and substance use. These health lesson packages contain multimedia educational tools, intended to facilitate open and honest conversations amongst community members. Churches within communities of color hold an established role in economic development and civic advocacy. The purpose of this study is to determine the effectiveness of a video intervention administered by community leaders to increase knowledge about substance use and compassion for individuals with substance use disorders, and to encourage action toward reducing stimulant misuse in communities. Following co‐creation of the videos and assessment questions as well as train‐the‐trainer sessions, faith‐based leaders presented this health lesson in their own communities. This aspect of the implementation strategy becomes very important as we engage in discussions on health‐related topics which are sensitive and thus difficult to discuss. We hope that this psychoeducational video available free‐of‐charge will provide additional groups with the necessary information to seek out high‐quality mental healthcare, in addition to providing basic care for those around them. We further hope that our data encourage other organizations to perform similarly low‐cost, high‐yield interventions to assist communities of color during this substance use crisis.
METHODS
Theoretical Framework
As mentioned previously, our work is guided by a community‐based participatory research framework. We also employed interpersonal contact theory in including a pastor with lived experience with substance misuse in the video intervention. The pastor had served a similar faith‐based community to those of our partners. Interpersonal contact theory suggests that exposure to individuals with problems that are stigmatized may reduce stigma, and this framework has been extraordinarily useful in prior work to reduce HIV‐related stigma in faith‐based communities (
32,
33).
Congregation‐Level Participation
The ETS Program at the AHA, has formed partnerships over several years with multiple faith‐based institutions serving Black and Hispanic communities. During this project, the team had connected with 12 churches (located in California, Georgia, Louisiana, Maryland, New York, Puerto Rico, and Wisconsin) serving Black and Hispanic communities. Content was designed by a team at the University of Colorado School of Medicine and the ETS group at AHA in collaboration with church partners, funded via a subaward from a SAMSHA grant via the American Academy of Addiction Psychiatry and the Opioid Response Network. Twelve churches participated in design, feedback process, and dissemination of this health lesson on stimulant use disorders, with six participating in the pre‐ and post‐questions.
To discuss the needs of congregations with respect to substance use psychoeducational materials, the AHA hosted a set of five focus groups, with 11 church partners opting to co‐lead the groups with AHA staff. Fifty individuals attended across the focus groups. During the focus groups, our team engaged with leaders to identify important topics for health lesson videos (as has been the practice in developing other health lesson videos in the context of our multi‐year partnerships with the churches and their leaders). The health lesson content and assessment questions were created based on community feedback from prior health lessons and in collaboration with church leaders. Train‐the‐trainer sessions were conducted with ETS staff and community leaders. During the focus groups and Zoom meetings throughout the year, the team discussed question content, incorporating partner feedback on question content as well as the number and type of questions that church leaders felt were appropriate for their communities. We also discussed the history of research in communities of color, soliciting feedback from church partners about how we offer the opportunity to participate in the assessment of the educational intervention in a way that would be congruent with church community culture and practices. To specifically test the effect of this customized video, questions were developed internally (as in prior studies (
13,
34)) with congregation leadership utilizing a Likert scale or multiple‐choice format to minimize study burden for congregants. Additionally, although the program initially had intended to only use an electronic survey, after careful discussion with church leaders regarding potential barriers to participation, we also utilized paper surveys with lock boxes (similar in appearance to ballot boxes). This format enabled more individuals to respond to the surveys and was culturally acceptable to communities. Importantly, though focus groups had been consistently part of the team process, this was the first time that a more formal assessment was implemented.
Train‐the‐trainer sessions were conducted with ETS staff to orient leaders to health lesson modules, and to answer questions prior to them conducting local events within their communities (lesson plans are available
here). Congregational leaders were able to present the video program (accessible
here) in their preferred format (i.e.,—virtual vs. in‐person) to their congregants. Due to ongoing COVID‐19 related restrictions as well as to offer more options to reach congregants, churches did a combination of virtual, in‐person, and hybrid presentations. Churches implemented the trainings during Sunday School, within church services, during family game nights, in the context of food bank events, or during in‐person or virtual workshops. Overall, church leaders found multiple ways to disseminate and to implement the materials beyond formalized settings, including on social media, display via church websites, as well as one church creating a live faith‐based play regarding substance use, and training actors using the materials to give them insight into the issues that people with substance misuse face.
Congregant‐Level Participation
During an event, congregations presented the opportunity for congregants 18 years of age or older to participate in the de‐identified pre‐/post‐video survey either via REDCap HIPAA‐compliant web‐based data collection platform (
35) or via paper surveys, which were preferred by most congregants. Five identical pre‐ and post‐questions, along with self‐reported demographic questions, were posed to participants as well as a sixth item during the post‐survey (see below) which invited congregants to share anything else with the ETS team regarding their thoughts and feelings about the video. Participants completed the pre‐video questions, followed by viewing the psychoeducational video, and immediately afterward they completed the post‐video questions. Three questions (#1–3) were attitudinal, and two (#4–5) were knowledge‐based.
1.
It is hard to have compassion for people using substances. (pre‐post)
2.
I feel comfortable talking to someone who may have a substance use disorder. (pre‐post)
3.
A substance use disorder is a medical illness. (pre‐post)
4.
Which chemical in the brain is most affected by stimulants? (pre‐post)
5.
What are some changes in the way someone looks or acts that may be related to stimulant or methamphetamine use? (pre‐post)
6.
Is there anything else you would like to share? (post‐survey only)
For the attitudinal questions, the anchors were as follows: strongly agree, agree, neutral, disagree, and strongly disagree. For the knowledge‐based question number 4, there was one correct answer (dopamine). For the knowledge‐based question number 5, the question response was scored correct if individuals selected “all of the above,” which included all signs of methamphetamine use listed as answer options.
Data Entry and Analysis
The study was approved by the Colorado Multiple Institutional Review Board with exempt status due to the de‐identified nature of the data. All surveys were completed on the day the video intervention was disseminated. Church leaders opted for a combined virtual REDCap web‐based platform (
35) available through the Colorado Clinical and Translational Sciences Institute and paper‐based implementation for pre‐ and post‐surveys, to allow congregants to experience more comfort with the survey format. For paper surveys, completed forms were placed in lock boxes and sent to the ETS team, with double data entry to ensure accuracy. Any discrepancies were reviewed and reconciled by the data processing team (B.B., K.H., A.C., A.K.O.).
Data were analyzed with IBM SPSS Statistics (version 28), specifying a significance level of p < 0.05, two‐tailed. Frequency and central tendency data were computed for self‐reported demographic data including age, race, ethnicity, gender identity, and the venues (congregation) where the person was exposed to the video intervention. For the pre‐ and post‐assessments, each Likert scale response item (#1–3) was compared post‐ versus pre‐video with Wilcoxon signed ranks tests and for the two knowledge questions (#4–5), proportions correct post‐ versus pre‐video were compared with McNemar's tests.
RESULTS
This stimulant use health lesson program was presented to a total of 18,193 individuals across the 12 congregations which participated in the dissemination of this content. Congregation participants ranged in size from 224 to 6325 individuals and half of these congregations participated in the surveys. Survey participation from the six churches included a convenience sample with a total of 73 electronic and 405 paper surveys, for a total 478 surveys in the final database. Completeness of data varied by question. Demographic and congregation (not identifiable) data are presented in
Table 1. Age was fairly evenly distributed, with 28% between 18 and 30 years of age, 27% between 31 and 50 years of age, 36% between 51 and 70 years of age, and 10% >70 years old. The majority of the congregants who participated identified as Black or African American (91%), not Hispanic or Latino (82%),
cis‐gender female (70%).
As an additional note on participation, the 18,193 individuals count all “lives touched by the materials.” This statistic reflects all individuals with whom the videos were shared, regardless of whether videos were viewed in a group setting. Pre‐ and post‐video surveys were primarily administered in more formal presentation contexts in which videos were viewed communally and then surveys were administered.
Attitudinal Questions
With respect to the attitudinal questions (
Table 2), for response item #1 (“It is hard to have compassion for people using substances.”), there was significant movement toward compassion post‐video (median) compared to pre‐video (median) (
Figure 1A,
Z = −4.64,
p < 0.001
N = 420), with more people strongly disagreeing with this statement. For response item #2 (“I feel comfortable talking to someone who may have a substance use disorder.”) (
Figure 1B,
Z = −1.21,
p = 0.23,
N = 408) and response item #3 (“A substance use disorder is a medical illness.”) (
Figure 1C,
Z = −1.59,
p = 0.11,
N = 407), responses did not change significantly.
Knowledge Questions
With respect to the knowledge questions (
Table 3), for Question #4 (“Which chemical in the brain is most affected by stimulants?”), there were more correct responses post‐ versus pre‐video (
Figure 2A, 90.2% vs. 57.9%, McNemar
2 = 101,
p < 0.001,
N = 366). For Question #5, (“What are some changes in the way someone looks or acts that may be related to stimulant or methamphetamine use?”), there were more correct responses post‐ versus pre‐video (
Figure 2B, 92.5% vs. 61.9%, McNemar
2 = 109,
p < 0.001,
N = 415).
DISCUSSION
A facilitated 10‐min video psychoeducational intervention regarding stimulant use was implemented across the ETS/church partner network serving primarily Black communities. This stimulant use health lesson program was presented to a total of 18,193 individuals across the 12 congregations which participated in the dissemination of this content. Congregation participation ranged from 224 to 6325 individuals, and half of these congregations participated in the surveys. On average, congregants' level of self‐reported compassion for people using substances as well as correct responses to knowledge questions improved following the video. Other attitudinal questions including sense of comfort with talking about substance use or the belief that substance use disorders are medical illnesses did not change following the video.
With respect to the first attitudinal question, (“It is hard to have compassion for people using substances.”), self‐reported compassion for people with substance use disorders significantly shifted post‐video toward greater self‐reported compassion. The word “compassion” (
com [with] and
pati [to suffer]) has been defined in the psychology literature as “a feeling of concern for another person's suffering which is accompanied by the motivation to help” (
36,
37). Compassion is related to but not synonymous with empathy; for instance, compassion has been suggested to be analogous to empathic concern, which describes the recognition of another person's pain or negative emotion and is a subcomponent of an empathic response (
38). We considered using a validated measure to assess change in congregants' perceptions but instead chose to develop questions in collaboration with partners as a valuable team‐building experience. Furthermore, in so doing, we could keep the assessment minimally burdensome to responders. In fact, according to a recent scoping review of measures to assess empathy and compassion, compassion is a difficult construct to assess due to multiple factors including social desirability bias and other factors, and there are few appropriately validated measures (
39). Compassion, however, is an important concept across multiple major religions, as well as within the medical field, and is associated with improved health outcomes (
40,
41). It is possible that including a Pastor from the community who spoke about his own lived experiences with substance use prior to entering the recovery process may have contributed to this process. Further, modeling of compassion and non‐judgment in the video may help to increase comfort in the community with seeking care.
With respect to the knowledge questions, increases in rates of correct responses regarding neural mechanisms of substance use may help to reduce stigma (
42). With respect to the second knowledge‐based question regarding recognition of signs and symptoms of stimulant use disorder, the increase in correct responses suggests that families and individuals may be empowered to recognize substance misuse or use disorders within their communities. Although knowledge alone is far from a panacea for stigma reduction, education regarding the biological underpinnings of mental health issues may play a role in reducing stigma, particularly when employed in conjunction with narrative approaches such as community members sharing their lived experiences as a Pastor did in this video (
42).
By contrast, some of the question responses suggested that the video may not support change in certain aspects. For the second attitudinal item (“I feel comfortable talking to someone who may have a substance use disorder.”), there was no significant change in post‐video responses. These data are consistent with adult learning principles in that becoming comfortable talking about substance use with others is a skill, and would be unlikely to change with passive viewing of a video or watching a lecture, as has been learned in medical student education (
43). It is possible that more active learning techniques such as “real plays” or role plays within small groups could be more impactful, such as those incorporated in the new set of health lessons being implemented currently, which cover additional new topics including responding to emergencies and engaging with family and friends who are experiencing substance use (available
here). Furthermore, these skills may be more effectively taught with a longitudinal approach, as process‐based learning requires a series of educational experiences for individuals to achieve a sense of comfort in speaking with individuals with substance use disorders (
43). Although we are not suggesting teaching medical interventions to laypeople, we nonetheless utilize adult learning principles to design psychoeducational interventions for communities. Lastly, it is possible that people who have watched a video and gained more knowledge and more compassion for people with substance use disorders may feel like these conversations are now higher‐stakes, and they may be more aware of what they might not fully understand with respect to helping to support behavioral change in their friends and loved ones living with substance use.
For the third attitudinal item, regarding whether substance use is a “medical illness,” there are a few reasons why the video may not have impacted responses to this statement. One explanation could be that the phrasing of the question was confusing, as people might think about substance use disorders (as well as other mental health conditions) as more of a psychological or potentially a spiritual challenge, which was suggested by free‐text responses written on the paper surveys by a few participants next to this question as well as by prior literature (
44,
45,
46). The findings as they stand suggest that changes in belief (i.e.,—cognitive empathy or other cognitive processes) are more difficult to achieve in a one‐time intervention, and that significant change in people's beliefs about substance use may be more amenable to longitudinal approaches in communities where educational content and interactions are disseminated over time.
Limitations and Future Directions
Self‐report surveys are limited in certain ways including social desirability biases in addition to the assessment not being a proctored test. Further, we did not utilize validated instruments, but rather, developed this brief survey in collaboration with church partners, as this was the first time when such a formal assessment was performed, though focus groups have been consistently part of this program. In future we may consider the use of more extensive and validated scales to address longitudinal improvement in stigma about substance use (
47). Further, despite Spanish translations of surveys being available, the majority of respondents identified as African American; thus, our results are more applicable to this population.
Given that compassion and knowledge were easier to change based on these data compared to individuals comfort with having conversations about substance use, in the new modules regarding substance use which are currently being implemented by the churches (available
here), we incorporated experiential learning into our suite of health lessons with “real plays” and education about the spirit of motivational interviewing. These aspects of the newer training modules may better address the level of confidence in communicating with individuals about substance use concerns. Lastly, the change in self‐reported compassion following a relatively short video intervention underscores the importance of learning processes which are linked to affect, which would be important for development of future interventions. In some ways, the salience of learners' emotional experiences while they think about people living with substance use may help with the encoding of other important information, and may over time lead to additional inroads in terms of changes in both beliefs and behaviors related to substance use.
Our research suggests that presentation of a brief 10‐min educational video conducted by a trusted leader in the community, through the EmPOWERED to Serve network is feasible. Our results showed an increase in compassion and knowledge with this brief intervention. Further research would test mechanisms for engaging and empowering community members about substance use disorders.