Culturally Responsive Sexual and Reproductive Health Education to Address HIV Risk Among African-Born Immigrant Women

Abstract

Objective

African-born immigrants (ABIs) represent a growing demographic in the United States, constituting nearly half of the foreign-born Black population. They face distinct health challenges, with ABI women experiencing disproportionately high rates of HIV incidence. A critical factor contributing to this health disparity is limited sexual and reproductive health (SRH) literacy. The primary objective of the study was to pilot and evaluate an intervention that employed a culturally responsive, community-led approach to sexual and reproductive health (SRH) education for HIV prevention among ABI women.

Methods

The community-based sexual and reproductive health education was implemented using the African Women Making Healthy Choices (AWMHC) curriculum which consists of 10 modules, delivered across 6 sessions. Sessions were facilitated by AB women and combined didactic and interactive learning elements. The primary outcomes measured were HIV-related health literacy and self-efficacy in protective sexual health behaviors. Ten ABI women were recruited through community-based organizations. Demographic and questionnaire data were summarized using frequencies and proportions. Changes in knowledge and perception of risk associated with HIV were assessed using paired t-tests.

Results

Among the 10 study participants, significant improvements were observed in HIV/SRH knowledge following the intervention, with mean scores increasing from 6.4 to 8.2 out of 10 (p<0.05). Additionally, participants demonstrated enhanced self-efficacy in multiple domains, including condom use negotiation, sexual violence reporting, and healthcare provider engagement. Assertiveness items showing the largest gains related to knowing how to report sexual violence and how to request exams and ask questions of a healthcare provider, each increasing from 6 to 10 affirmative responses.

Conclusion

The findings suggest that culturally tailored SRH education interventions can effectively enhance HIV-related knowledge and self-efficacy among ABI women. Addressing SRH literacy gaps - particularly around fertility, condom use, and sexual rights - appears to be a promising strategy for reducing HIV disparities in this population. The community-led delivery model, grounded in African cultural values, was central to participant engagement and may serve as a replicable framework for scaling up SRH programming with ABI communities. Additional research is warranted to evaluate the intervention’s long-term impact on behavioral outcomes.

Keywords

african immigrant women HIV disparities sexual and reproductive health HIV prevention community health

Background

Historical Trends of Immigration

African-born immigrants (ABIs) in the United States (U.S.) have one of the fastest growth rates compared to other immigrant groups. The U.S. Census Bureau data indicates that the numbers have approximately doubled each decade since 1970.¹ The first two decades of the 21st century saw a dramatic increase of ABIs in the U.S. While there were approximately 600,000 African-born Black residents in 2000, this number more than tripled to reach 2 million by 2019, representing a 246% increase.¹ This significant growth changed the composition of America’s foreign-born Black community - whereas African-born individuals previously made up less than a quarter (23%) of foreign-born Black residents in 2000, they came to represent nearly half (42%) of this population by 2019.²

Most ABIs in the U.S. originate from sub-Saharan Africa. From 2010 to 2018, the sub-Saharan African population in the U.S. increased by 52 percent, which was significantly higher than the overall foreign-born population growth rate of 12 percent.³ Minnesota is one of the states with the largest population of ABIs, who are mostly from sub-Saharan Africa. As of 2015 – 2019, Minnesota was the residence for 6% of sub-Saharan ABIs in the U.S.³ The increasing ABI population in Minnesota has prompted new challenges and unmet needs for this particularly vulnerable group of immigrants. One issue of great concern is that of HIV incidence rates.

HIV in African-Born Immigrants in Minnesota

In 2023, ABIs constituted 3% of the State population, but accounted for 10% of the new cases of HIV diagnosed.⁴ In this population. ABI women were even more disparately affected, as they accounted for 23% of newly diagnosed HIV cases among women, by race/ethnicity.⁴ This incidence rate represents an improvement in trends as ABI women have accounted for as high as 54% of all new diagnoses among women in MN, in 2015⁵; which data informed the community-based efforts being reported.

Findings from a preliminary study conducted as a community-based participatory needs assessment, pointed to gender-specific socio-cultural factors as key drivers of HIV transmission and unique barriers to HIV care for ABI women.⁶ These included domestic/intimate partner violence; gender-biased stigma; discriminatory cultural beliefs and normative values/expectations based on gender; unprotected sex with husbands who maintain sexual relationships with other men; gender discordance in provider-patient healthcare encounters (preference for female provider); and sexual/reproductive health illiteracy. Of these factors, there was emphasis on limited sexual and reproductive health education as a major issue that had intersection with most of the other factors identified. Poor understanding of sexual and reproductive health was attributed to cultural norms that consider conversations about sex inappropriate, particularly for female members of the community.

HIV and Sexual & Reproductive Health Knowledge

Sexual and reproductive health (SRH) literacy has been associated with more accurate self-assessment of HIV infection risk and shown to influence subsequent sexual behavior.^7,8 This relationship aligns with the Health Belief Model’s theoretical framework, which proposes that health-related behaviors are shaped by individuals’ beliefs about health problems, their perceived risk and susceptibility, their assessment of benefits and barriers to recommended actions, and their confidence in their ability to implement these recommendations.⁹ Therefore, limited sexual and reproductive health literacy may lead to inaccurate HIV risk perceptions among ABI women, increasing their vulnerability when combined with other risk factors. A community-based sexual and reproductive health educational intervention was strongly recommended as a strategy to address HIV risk in this population.

The primary objective was to pilot and evaluate an intervention that employed a culturally responsive, community-led approach to sexual and reproductive health (SRH) education for HIV prevention among ABI women. The study assessed two key outcomes: HIV-related health literacy (specifically, increased knowledge and understanding); and self-efficacy regarding protective sexual health behaviors.

Methods and Materials - The Pilot

This was a single-cohort, pre-post pilot study examining the feasibility and preliminary efficacy of a culturally responsive, community-based sexual and reproductive health (SRH) educational intervention for HIV prevention among African-born immigrant (ABI) women in Minnesota. The study employed a community-engaged approach, with community members as active partners in both curriculum development, intervention design and program delivery.

Inclusion Criteria

To be a part of the study, participants had to be female, 18 years and older, self-identify as born in Africa (1^st generation immigrant) or daughter to parent(s) of African origin, English-speaking, able to read and write in English, and resident in the state of Minnesota. Sexual orientation was not considered in recruitment.

Recruitment and Enrolment

A sample of 10 African-born immigrant (ABI) women who met stated criteria were recruited through community-based organizations and social networks using fliers. At the first session held in the conference facility/community center located in a Church, the purpose of the study was stated and the expectations of participants described. The women were encouraged to ask questions and seek clarification before informed consent was obtained from each participant. Consenting participants then filled out a demographic sheet and a pre-intervention survey.

The Curriculum

The community-based sexual and reproductive health education was implemented using the African Women Making Healthy Choices (AWMHC) curriculum which consists of 10 modules (see Table 1.). The AWMHC curriculum was developed by a team of five AB women who adapted and augmented a conventional curriculum - the Becoming a Responsible Teen (BART) - used primarily in HIV prevention for African American youth.¹⁰ Adaptation by the curriculum design team was facilitated by first developing a framework based on African cultural beliefs and values – the African Queens Health Education Wheel. The process has been described in detail in a previous publication.¹¹

Table 1.

The African Women Making Healthy Choices (AWMHC) Curriculum


Module 1: Getting to Know Your Body [Female anatomy]
Module 2: Definitions of commonly used sexual health terms
Module 3: Understanding Reproductive Health
Module 4: Making Sexual Decisions and Understanding Your Values
Module 5: Skills Related to Unplanned Pregnancies & Avoiding Diseases
Module 6: Learning Assertive Communication Skills
Module 7: Practicing Assertive Communication Skills
Module 8: Personalizing the Risks (How Risky is this for me?)
Module 9: Spreading the Word
Module 10: Taking AWMHC with You

The curriculum was structured to be culturally responsive and yet flexible to accommodate variances between African cultures. The framework developed was also used in the implementation of the proposed project. This framework leverages the cultural significance of African women as central figures (“the core”) in their families and communities, where they serve as caregivers, educators, leaders, and pillars of support. By recognizing these traditional roles and values around communal well-being, the framework taps into women’s inherent motivation to take action on behalf of their children, families, and communities, even when faced with cultural barriers. The key message for promoting SRH education was then that being empowered with sexual health knowledge, as women, would enable them to, in turn, empower their families, friends, and broader community.

The Intervention

The first module of the African Women Making Healthy Choices curriculum was facilitated at the first session. The ten participants then reached a consensus on what days and times were convenient for subsequent sessions. Participants elected to have the remaining five sessions conducted over a weekend. A more convenient venue - a Mosque - was proposed; to which participants agreed. Each of the sessions lasted for 2-3 hours. After the first session (introductions, ice-breaker activities, getting-to-know “you”, laying down ground rules, and administering informed consent, module 1), the subsequent four sessions each covered two (2) modules from the AWMHC curriculum. Module 10 was covered in the final session, followed by the administration of the post-intervention survey (see Table 1.). Each session was facilitated by two AB women who were also members of the team that put together the AWMHC curriculum used for the intervention. Each session included didactic and interactive learning elements and allowed for questions which stimulated robust discussion. One of the investigators served as a participant observer – taking field notes and weighing in on the discussions. Meals were provided for participants and childcare as needed. Each participant was compensated with a $20 gift card per session.

Data Collection

Demographic information with no personal identifiers was obtained from each participant. A questionnaire (assessing sexual and reproductive health literacy, knowledge and perception of risk associated with HIV/STDs, and assertiveness) was administered pre- and post-intervention. The questionnaire was developed during the curriculum development process.

Data Analysis

The demographic and questionnaire data were summarized using frequencies and proportions. Changes in the outcome measures – knowledge and perception of risk associated with HIV/STDs, and assertiveness – were assessed using paired t-tests. For the knowledge-based questions, a score of one was assigned to each correct response to an item. Similarly, a point was given if a response was in the affirmative for statements regarding self-efficacy regarding sexual encounters. For change in knowledge, only data from the nine participants who completed both the pre- and post-evaluations were included in the data analysis.

Results

Demographic Information

Ten AB women participated in the pilot intervention. Participants’ demographic characteristics were cross-cutting and representative of diverse categories by age, marital status and educational attainment (see Table 2.)

Table 2.

Demographic Information

	Freq (%)
Age	Mean: 33.6
	Median: 30
	Range: 23 - 65
Marital status
Single	2 (20)
Married	7 (70)
No response	1 (10)
Educational attainment
High school	2 (20)
College	6 (60)
Grad school	1 (10)
No response	1 (10)
Sexually Active
Yes	7 (70)
No	3 (30)

Ten items were used to assess participants’ knowledge of HIV and sexual and reproductive health, using common myths (see Table 3). There was a significant increase in knowledge from pre-to post-intervention (p < 0.05). Nine of the 10 participants completed both the pre- and post-evaluation. A point was allocated for each correct response. The mean score was 6.4 pre-intervention (of potential max of 10) and 8.2 post-intervention (see Table 4).

Table 3.

Items Assessing HIV-Related Sexual and Reproductive Health Knowledge

Common myths in the community	No. of participants with correct responses
Common myths in the community	Pre-intervention	Post-intervention
Men cannot get HIV-AIDS when they have sex with a virgin. F	9	9
Women can become infertile when they are infected with a sexually transmitted disease. T	3	7
Men can become sterile when they are infected with a sexually transmitted disease. T	3	7
A woman can get pregnant the first time she has sex. T	5	8
A sexually active woman can get pregnant if she forgets to take her birth control pills for a few days. T	7	9
Birth control pills can help prevent sexually transmitted infections, including HIV-AIDS. F	7	9
Not having sex guarantees 100% that I will not be infected with HIV. F	7	7
Sexually transmitted infections will go away eventually if I don’t treat them. F	7	7
My chances of being infected with a sexually transmitted disease, including HIV-AIDS increases greatly if I have sex with more than one person. T	8	9
Condoms break easily. F	2	3

F– False statement. T– True statement.

Table 4.

Change in HIV-Related Sexual & Reproductive Health Knowledge

	Pre-intervention (n=9	Post-intervention (n=9
Mean	6.44	8.22
Std Dev	1.236	0.972
Mean Difference	1.778
t-statistic	-5.488
p-value	0.001

Self-Assessment of HIV Risk Perception and Prevention

For both pre- and post-evaluation, most of the participants responses were in the affirmative (“True”) with respect to knowledge about how to avoid getting infected with sexually transmitted diseases (including HIV), and behaviors that put one at risk for infection. Fewer participants reported being “embarrassed to buy condoms at the store”, following the intervention, while those who reported knowing “how to use condoms correctly” and “where to get condoms for free” doubled following the intervention (see Table 5.).

Table 5.

Self-Efficacy in Addressing HIV Risk Behaviors [N = 9]

	Responded “True”
	Pre-intervention	Post-intervention
I know how to avoid getting infected with sexually transmitted diseases.	8	9
I know how to say no to sex if my partner does not want to wear a condom.	7	9
* I would be offended if my partner wanted to use a condom with me because I am not a prostitute.	1	1
I know how to use condoms correctly to prevent HIV-AIDS.	4	8
I am embarrassed to buy condoms at the store.	4	2
I know where to get condoms for free.	3	6
I know what to do to be protected from HIV-AIDS.	8	9
I know of the behaviors that put me at risk of getting infected by HIV.	9	8 (1 “no response)

*Limiting factor to self-efficacy in addressing HIV risk.

Assertiveness

Fourteen items were statements intended to assess participants’ assertiveness. These statements were based on attitudes and knowledge associated with sexual health. Ten of the statements were protective, while four of the statements were associated with unsafe sex-related attitudes and practices. Before the intervention, three of the women agreed with the statement “I do not have to enjoy sex like men do.” Following the intervention, none of the women agreed with the statement. The most significant increases pre- and post-were with statements regarding how to engage with healthcare practitioners and make reports in cases of rape (see Table 6). For this component, we included only the 9 participants who completed both the pre- and post-evaluation. Assertiveness scores were higher post-evaluation, but not statistically significant (p=0.094).

Table 6.

Assertiveness - Attitudes and Knowledge Associated With Sexual Health

	Pre-eval [^N=9]	Post-eval [^N=9]
Item Statements	No, of respondents that indicated “True” for statement Frequency (%)
I know how to request exams and tests from my doctor.	6 (66.7)	9 (100)
I can ask my doctor questions about sex.	7 (77.8)	9 (100)
I know how to report a man forcing himself on me to my family, the community elders and/or police.	6 (66.6)	9 (100)
I know who to call and where to go if a man forces himself on me.	6 (66.6)	8 (88.9)
* It is wrong to report a man who has sex with a child to the family, the community or the police	1 (11.1)	0 (0)
I know my private body parts and how they function.	7 (77.8)	9 (100)
I know how to make healthy and wise decisions for myself.	8 (88.9)	9 (100)
* I do not have to enjoy sex like men do.	3 (33.3)	0 (0)
* When I say no to having sex, I actually mean yes.	1 (11.1)	1 (11/1)
I can decide when and how I want to have sex just like men do.	2 (22.2	0 (0)
* There is no risk in having a one-night stand (sleeping with a stranger once and never seeing him again).	1 (11.1)	1 (11.1)
Sexual rights are human rights. I know what my sexual rights are.	7 (66.7)	9 (100)
Rape is saying no to sex and having a man force himself on me.	8 (88.9)	9 (100)
Talking about sexually transmitted diseases makes my relationship with my partner better.	7 (77.8)	9 (100)

^One participant’s data excluded due to non-completion of pre-evaluation.

*Negative attitudes associated with sexual health.

Discussion

Demographics

Most of the participants were married. While recruitment efforts did not target married women, it is likely that single women may have felt less comfortable enrolling in the study because being sexually active prior to marriage is frowned upon in African communities. Per cultural values, talking about sex outside marriage is often perceived as being indicative of promiscuity.¹² However, there have been community-based programs targeting adolescent girls and young women to educate them about sexual health and HIV risk,¹³ suggesting separate programming for single and married women respectively, when scaling up the current pilot. While the women were from different countries, the cultural backgrounds are sufficiently similar to accommodate single programming with success.

Debunking Myths About HIV and Sexual Health

In assessing knowledge, common myths heard in the community were used. The items that had the least correct response pre-intervention included “Women can become infertile when they are infected with a sexually transmitted disease” (3 correct), “Men can become sterile when they are infected with a sexually transmitted disease” (3 correct), and “A woman can get pregnant the first time she has sex” (5 correct). These items were all related to fertility, suggesting limited sexual and reproductive health literacy even though seven of the 10 participants had a college education. This further supports the premise of this study that HIV risk may be higher among ABI women because of their lack of sexual and reproductive health knowledge.⁶

The myth that persisted was that “Condoms break easily”, even following the intervention. While there is possibility of condom breaking, this is often associated with factors extrinsic to the condom including wrong method of use, doubling condoms, “fit”, using an expired condom, and contact with sharp objects.¹⁴ This may be an area for education in this community as there may be a prevalent belief that condoms are susceptible to breaking easily, which would then deter use despite the proven protective benefits, particularly in the prevention of HIV.^15,16

Knowledge Gaps

The items showing the largest pre-/post-evaluation improvements (from 6 to 10 participants responding in the affirmative) focused on knowing appropriate actions in specific situations. Two of these questions addressed responses to sexual violence without specifying the perpetrator. Some participants may have interpreted these through the lens of intimate partner violence, as many African cultures often do not acknowledge forced sexual relations within partnerships (e.g. marriage) as rape.¹⁷ Additionally, the significant stigma associated with sexual assault often prevents women from reporting due to shame. The intervention directly addressed these misconceptions by providing women with specific information about reporting options for sexual violence cases.

Other items showing substantial improvement (from 7 to 10 affirmative responses) were related to understanding sexual rights and reproductive anatomy. One of the sessions of the intervention specifically explained the female reproductive system anatomy and educated participants about their sexual rights. These knowledge gaps and the subsequent improvements following the intervention highlight the critical need for comprehensive sexual and reproductive health education in this population.

Strengths and Limitations

A notable strength of this intervention was the intentional concordance of identities, with African-born women serving as facilitators. This approach fostered trust and encouraged open dialogue, as facilitators also leaned into culturally aligned communication modes such as storytelling and use of idioms and proverbs. The informal, community-centered design of the sessions, including the use of familiar community spaces, provision of meals, and availability of childcare, further reduced participation barriers and created an accessible, welcoming environment for a population that may otherwise face significant logistical and cultural obstacles to engagement. Although formal feedback was not systematically collected, informal debriefing revealed that participants found the educational content to be valuable and empowering, and appreciated the safe, communal learning environment as a space for connection and mutual support.

The study had several limitations. First, it utilized a small sample size as this was primarily a pilot study designed to assess feasibility. Second, the research relied on knowledge assessment and risk perception measures as proxies rather than direct behavioral observations. While this approach has limitations, it’s worth noting that perception of risk has been established in previous research as a significant factor that influences health-related behaviors. Finally, the study employed a convenience sampling method - participants were not necessarily individuals at risk of HIV infection, and the majority college-educated - which may limit the generalizability of findings to higher-risk populations and those less educated Additionally, the predominance of married participants may have influenced responses, engagement with the curriculum, and interpretation of HIV/SRH risk, as relationship status and sexual context often shape how ABI women perceive and discuss sexual health. Findings may therefore not also be generalizable to single or unmarried ABI women.

Implications for Practice

The findings from this pilot study have implications for healthcare providers, community health educators, and public health practitioners working with ABI women. The persistence of the belief that condoms “break easily”, even after the intervention, points to the need for targeted, community-engaged, skills-based educational strategies that go beyond didactic instruction. Incorporating hands-on condom demonstration and role play into community-based sessions can address not only knowledge gaps but also self-efficacy for correct and consistent use of condoms. These strategies should be delivered within culturally responsive conceptual frameworks such as the African Queens Health Education Wheel, utilizing community health workers whose cultural backgrounds and values are aligned with this priority population. Approaches should also consider separate programming for those who are single, to provide an environment where they do not feel judged. The improvements in assertiveness, particularly regarding reporting sexual violence and engaging healthcare providers, suggest that community-based interventions that leverage relational trust, trainer-trainee cultural concordance, and safe learning spaces, can increase self-efficacy in limiting risk associated with sexual behavior and advocating for self. Community-engaged approaches should therefore be encouraged.

The significant pre-intervention deficits in fertility-related knowledge, despite most participants having college degrees, demonstrate that formal education alone does not confer SRH literacy, especially in populations that have been historically discouraged from having discussions around sexual health. Clinical encounters therefore represent an underutilized opportunity for SRH education. Healthcare providers serving ABI women should be equipped to integrate culturally sensitive SRH counseling into routine visits, thus normalizing conversations about reproductive anatomy, contraception, and the consequences of sexually transmitted diseases.

Conclusion

The findings suggest that culturally tailored SRH education interventions can effectively enhance HIV-related knowledge and self-efficacy among ABI women. Addressing SRH literacy gaps appears to be a promising strategy for reducing HIV disparities in this population. Subsequent studies should consider enrolling larger samples and accounting for differences in participants’ relationship status and whether or not they are sexually active, through purposive stratification or targeted subgroup programming, to more precisely capture how these contextual factors influence SRH learning and perception of HIV risk. Additional research is also warranted to evaluate the intervention’s long-term impact on behavioral outcomes.

Footnotes

Acknowledgement

We acknowledge the contributions of the women who facilitated the educational sessions and all the participants.

ORCID iD

Olihe Okoro

Ethical Considerations

This study was reviewed and approved by the University of Minnesota Institutional Review Board. IRB ID: STUDY00000620.

Consent to Participate

Written informed consent was obtained from all the study participants.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was funded by the lead author’s startup funds.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The participants of this pilot study did not give written consent for their data to be shared publicly, so due to the sensitive nature of the research supporting data is not available.*

Author Biographies

Olihe Okoro is an associate professor at the University of Minnesota, College of Pharmacy, Duluth. As a social and behavioral scientist, and a community-engaged researcher, Olihe has years of experience working collaboratively with African Immigrant and African American communities and patient populations to investigate root causes of health disparities and implement community-based health interventions. Olihe’s work continues to contribute to enhancing health and healthcare for these underserved populations, towards the goal of achieving health equity for all.

Shanasha Whitson has been the Executive Director of Community Partnership Collaborative 2.0 since 2017, a health HUB organization that helps communities improve their social determinants of health through social, civic, spiritual, medical, mental, financial and physical health programming. Shanasha is a Licensed Alcohol and Drug Counselor, holds a Community Health Worker certificate, and has graduate degrees in Organizational Management and Communications, and in Counseling Psychology. Shanasha has been a community organizer and community researcher for over 10 years. She also moonlights as a therapist, a job she has done for the past 20 years.

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