Obstacles and Options to Faith-Based HIV Service Delivery to Low-Income Inner City Residents

HIV Risk and Poverty

Research suggests that residential location may be an important variable in HIV rates (Aral, 2008; Rothenberg, 2007). Murray, Kulkarni, and Michaud (2006) found that neighborhood levels of economic well-being were highly correlated with the occurrence of HIV. Risk is magnified by the inability of poor residents to form sexual relationships outside of their communities. Consequently, if low-income residents do not engage in high-risk behaviors themselves, racial segregation increases the likelihood of having a high-risk partner (Rothenberg, 2007). In one study, having a partner who had concurrent partnerships was a risk factor for heterosexual HIV transmission among Blacks who were otherwise at low risk (Adimora et al., 2006). Other research suggests that poverty and low sex ratios are associated with low marriage rates, and married people have lower rates of concurrent partnerships than unmarried people (Adimora & Schoenbach, 2005).

Incarceration may play another critical in role in increasing HIV risk among inner city Blacks. More than 12% of Black men ages 25 to 29 years are in jail or prison (Mauer, 2008). Incarceration directly affects sexual networks by physically removing men from partnerships (Adimora & Schoenbach 2005). The partner who is left behind loses the financial, social, and other supports of the incarcerated partner and may seek other partners (Aral, Adimora, & Fenton, 2008). The shortage of Black men promotes partner concurrency as well as partnering between women with low-risk behaviors and men with high-risk behaviors, such as substance use, particularly intravenous drug use, which plays an important role in the spread of HIV and other sexually transmitted infections (STIs) in the Black community (Adimora et al., 2003, 2004). Women involved in multiple concurrent sexual partnerships are at increased risk of spreading STIs (Adimora et al., 2002; Adimora et al., 2003; Adimora et al., 2005). In empirical studies, people who had concurrent partnerships were more likely to transmit Chlamydia (Potterat et al., 1999) and syphilis (Koumans et al., 2001) than were those who did not.

The Black Church

The National Congregations Study reports that 19% of congregations (regardless of denomination) located in the cities of the United States are concentrated in high-poverty neighborhoods (Chaves, 2009). Growing numbers of policy makers, including CDC, believe that the congregations located in poor neighborhoods possess resources and capacity to support local residents. They talk of religion and the faith factor as solutions to many social ills. They advocate using tax revenue to implement faith-based initiatives to save the inner cities. There is an assumption that because urban churches are in closer proximity to the problems, they can work from the bottom up, helping communities one by one, claiming whole blocks and neighborhoods for transformation (Cimino, 2011). If this is true, the presence of Black churches in poor and oppressed neighborhoods is critical in responding to the HIV epidemic.

Since enslavement (Frazier, 1996; Nelsen & Nelsen, 1975) through the civil rights movement of the 1950s and 1960s (Morris, 1984; Pattillo-McCoy, 1998) to civic participation and local organizing of the 1990s (Pattillo-McCoy, 1998), the Black church has been a vital institution in the Black community. Throughout the 20th century, the church has promoted education, business, and political activism within the Black community (Lincoln & Mamiya, 1990; Morris, 1984; Nelsen & Nelsen, 1975; Pattillo-McCoy, 1998). Given its historical and continuing roles within the Black community (Freedman, 1993), the church is an ideal setting in which to offer health promotion activities for the Black community. Such activities are warranted because Blacks have lower life expectancies, are less likely to have health insurance, make fewer primary care visits, and have lower birth weights and higher infant mortality rates compared with Whites (CDC, 2013). In fact, several studies have found that the church can be an important conduit through which to inform marginalized communities about preventive care and that the Black church, because of its ethic of service to others, is particularly well suited for health promotion (Chatters, Levin, & Ellison, 1998).

The Black Commuter Church

Today, social justice remains just as important as ever to the Black church—but the face of the community it serves has changed dramatically. Most researchers attribute the shift in church membership to population movement and economic decline (McRoberts, 2003; Trulear, 2001). When African Americans gained economic stability after desegregation, they began moving to more desirable neighborhoods in the suburbs and driving back to their previous neighborhoods for worship. Trulear (2001) found that many inner city Black congregants were middle-income and lived 10 miles or more from their church. Researchers define this type of church member as a “suburban commuter congregant” (Diamond, 1999; Indianapolis Family Life Clinic, 1958; Lopez, 2012; McRoberts, 2003; Schaller, 1962). Literature on the impact of commuter membership on the Black church and its surrounding community is nascent, but growing. McRoberts (2007) conducted a 4-year ethnography of four Philadelphia communities in which he found that suburban commuter congregations were often located close to city boundaries or where the population density is low, and that city commuter congregations were most likely to be located in neighborhoods with higher concentrations of poverty, less home ownership, African American residents, and decreasing populations. Further research suggests that suburban commuter congregations do not provide many social services to the broader community (Sinha, Hillier, Cnaan, & McGrew, 2007). These findings echo other ethnographic studies of low-income neighborhoods that conclude the churches in them are mainly commuter congregations that principally serve their own members (Laudarji & Livezey, 2000; Smith, 2001).

Some researchers suggest that this type of neighborhood gentrification can also provide opportunities for revitalization among declining congregations. A study of 30 congregations in New York found that revitalization resulted from gentrification in cases where congregations sought out and exploited niches in order to survive and meet the needs brought on by neighborhood change (Cimino, 2011). Lopez (2012) found that Black churches in Los Angeles have responded to the influx of Latino residents in a variety of ways. While some churches have relocated to the suburbs, others have chosen to build bridges to the Latino community by hiring a bilingual pastor, and others have redefined their mission to stay and serve their new community.

Historically, the Black church has played an important role in promoting health education in the Black community, such as diabetes management, heart disease reduction, breast cancer awareness, and dietary awareness to its members (Billingsley, 2002; Lincoln & Mamiya, 1990; Thomas, Quinn, Billingsley, & Caldwell, 1994). HIV prevention education, however, is not well addressed. According to the 2006-2007 National Congregations Study, 58% of religious congregations provide health-related services, but only 6% have programs that serve people who are affected or infected by HIV (Chaves, 2009). This statistic suggests that the church has neither an interest in nor the capacity to address HIV.

Understanding commuter congregations and their willingness and ability to provide HIV services to local residents is critical to addressing faith-based HIV service delivery. This article advances studies that have focused on a single congregation (Berkley-Patton, Moore, Hawes, et al., 2012; Reese, 2011) or were limited to single respondents within a church (Berkley-Patton et al., 2010; Cunningham, Kerrigan, McNeely, & Ellen, ., 2009) by identifying issues related to HIV service delivery using focus groups of clergy serving a diverse group of commuter congregations in urban communities. Unlike other studies focusing on a singular experience of HIV program implementation (Berkley-Patton et al., 2010), we sought to learn from the experiences of clergy who serve two disparate communities united by the church: middle-income commuter congregants and low-income community residents.

The specific objectives of this article are to (a) identify the need for HIV service delivery as perceived by clergy, (b) understand congregational receptivity to HIV service delivery as perceived by clergy, and (c) identify ways in which Black clergy with commuter congregations are addressing HIV issues among local residents. While the original project is a mixed-methods study inclusive of quantitative and qualitative data from local residents and faith leaders, the analysis presented in this article focuses solely on the focus-group interviews with faith leaders.

Design

This phase of the project utilized a qualitative approach to data collection. Qualitative methods are acknowledged for their ability to illuminate our understanding of the nuanced experiences of social context, including their ability to give voice to theological divergence (Root, 1992). This study employed an exploratory focus-group interview approach that allowed faith leaders to share their HIV experiences with their congregations and local community residents. Focus groups involve obtaining a cross-section of experiences on a particular topic. This method was selected for its capacity to explore social phenomena in a variety of contexts (Fraser, 2004).

Participant Recruitment

The recruitment team was composed of seven staff members, two community members, and eight graduate students. The study targeted faith leaders working in five zip codes in metropolitan Atlanta: 30310 (Pittsburgh), 30312 (Boulevard), 30314 (Vine City), 30315 (Lakewood), and 30318 (Bluff). Data for this study were collected via focus groups with faith leaders. A total of 16 faith leaders were recruited for the focus groups. These participants were recruited and screened for eligibility via snowball sampling. The faith leaders were eligible if their church was located within one of the five targeted zip codes. The Georgia State University Institutional Review Board approved this study. Informed consent was obtained from each participant prior to each focus group. At the end of each session, the participants received US$50 for their participation in the study.

Procedures

Two focus groups were conducted with faith leaders. Root (1992) recommends the use of familiar facilitators in research studies because such individuals can increase the comfort level of participants in the interview process, allowing them to share more personal and relevant information. The project director of the study facilitated the focus groups. The project director is a community-based social worker who is trained in, and has significant experience in, qualitative interviewing. The focus groups were conducted in the conference room of a local community-based organization in metropolitan Atlanta.

An interview script was developed to guide the focus-group process. This consisted of three phases: (a) the warm-up phase, (b) church and community description interview phase, and (c) and the wrap-up phase. The warm-up phase consisted of general introductions and an overview of the research goals, purpose, and objectives. During the second phase, the facilitator asked each participant to describe the community surrounding the church, community issues, congregational make-up, and experiences with HIV in the community and congregation. During the wrap-up phase, the facilitator attempted to address any participant concerns, thoughts, or questions regarding any aspect of the research study. Each focus group took approximately 2 hours. Each group was tape-recorded in order to ensure accuracy for transcription purposes.

Data Analysis

This study used paradigmatic analysis of narratives (Polkinghorne, 1995) to identify the common themes of experience within the narratives told by the clergy. Similar to other qualitative methods of inquiry, paradigmatic analysis attempts to organize qualitative data by viewing information as belonging to a concept or category (MacMath, 2009). This study used an inductive approach to data analysis. This means that meaning was derived from the data rather than imposed from a theoretical framework (Polkinghorne, 1995). Segments of the textual evidence were labeled with a term. These terms were then placed into groups based on similar thematic content related to the following research question:

Dedoose, a web-based mixed-methods software program, was used to organize, code, and analyze the focus-group transcripts data. In order to enhance the rigor of this study, initial codes were reviewed by a group of graduate research students in a different field (Public Health) who specialize in research with marginalized communities in metropolitan Atlanta. Triangulation methods, such as the interdisciplinary triangulation employed in this study, can help reduce subjectivity and bias (Root, 1992).

Participant Characteristics

Sixteen clergy participated in the focus groups. The faith leaders were predominantly male (75%) followed by female (25%). They ranged from age 27 to 64 with an average age of 52 years. All faith leaders identified as Black. A majority of the faith leaders were pastors (80%) followed by associate ministers (20%). The faith leaders all possessed master of divinity degrees and had been affiliated with their respective churches from 2 ½ years to 40 years with an average tenure of 15 years. Most of the churches were Baptist (33%) followed by non-denominational (20%). Additionally, one church from each of the following denominations was represented: Episcopal, Catholic, Church of God in Christ (COGIC), Full Gospel, Assembly of God, Pentecostal, and Methodist. Two ministers identified as gay and served predominantly African American Lesbian, Gay, Bisexual, and Transgender (LGBT) congregations. Two of the ministers did not have brick and mortar churches but rather operated street-based ministries that went directly into the community to provide food, clothing, and pastoral care. It should be noted that two of the ministers have campus ministries. Students who participate in college ministries are not traditional commuters in that they drive from home to church. While students are more likely to live on campus and in closer proximity to the church, they can be considered transient members of the church because their membership typically lasts the duration of their college enrollment. With the exception of the campus-based ministries, clergy said that between 50% and 80% of their members were commuters who traveled as far as 30 miles for church service. Because of the high percentage of commuter members, church members are disconnected from the day-to-day needs of the community.

Community Characteristics

The zip codes comprising the study area were once home to prominent members of the elite Black community. These zip codes are now defined as a ghetto poor neighborhoods based on the U.S. Bureau of the Census results of 2010 because more than 40% of its largely Black residents live below the poverty line. Specifically, census tract-level data report that the zip codes have an average poverty rate of 79%. The median income in the areas surveyed is US$4,999. Only 49% of homeowners report they occupy their homes and another 819 residents in the neighborhood are classified as renting homes owned by others (Gentry, Elifson, & Sterk, 2005). On average, 31.5% of the household income is spent on rent, which is higher than 26.4% for the United States overall and 25.8% for the state of Georgia (Sylvia, 2001; U.S. Census Bureau, 2010).

Clergy said that local residents approach their churches daily for a variety of support services including food, clothing, transitional housing, literacy support, substance abuse counseling, domestic violence counseling, and burial assistance. One clergy said, “It’s a challenge to serve the community because the neighborhood went down because of the economy. A lot of people don’t have the necessities that they need to just to make it.” Clergy generally agreed that the level of poverty and lack of resources contribute to the high rate of violence in the community. One clergy said,

When you hear about the number of people that are killed on the weekend in the area, it kind of gives credence to what I’ve experienced. It’s dangerous. It’s dangerous. It’s especially dangerous for the homeless folks on the streets. Gangs prey on them in the community.

Clergy acknowledged that the churches and congregants are not immune to the community violence. Many clergy reported that their churches have been broken into and members’ cars have been vandalized. One clergy explained,

We thought that having a security system would help but sometimes that doesn’t even help either. They will steal your stuff out of the church. We’ve had our whole A/C system stolen out of our church. The area where we’re located is violent . . . there’s a lot of stuff that just goes on in that little area.

Commuter Congregations

With the exception of clergy with college-based ministries, all others stated that a majority of their members lived in the suburbs and commuted to church. Clergy estimated that their congregants lived approximately 10 to 50 miles away from the church. Several clergy suggested that the distance from the church disconnected church members from the issues of the community. One clergy member said, “I don’t think church members really identify with the community because they personally live in other areas.”

When asked why the churches remained in the inner city while their membership relocated to the suburbs, clergy explained that they felt invested in the community. One clergy simply said, “It’s painfully rewarding.” Several of the clergy had grown up in the community surrounding their church and others had built their churches from the ground up in the community. One pastor explained his commitment to the community:

I came to this church as a young, bright-eyed pastor. I learned rather quickly the pain of doing that. But after experiencing the rewards of having done so I’m glad I stayed. I can candidly say that we built in the community. We built a new building in the community. I didn’t want to be there but I had no choice but to be there. Because it was clear to me that if I left, who would stay? I grew up in public housing, so I identified very much with the community I was serving. It was painful because some of the very people we helped would steal from us. But we continued to help them. But it has been rewarding because I’ve watched the community change. I’ve seen the transition from what it was. And the other thing is that in our community, our church, when you mention our church, people say that’s a community church. They identify us as a church where you can get help. If you can’t have a funeral nowhere else, you can come here.

Other clergy also felt compelled to remain in the inner city because of the needs of the local residents. One clergy explained,

We’re finding out that there are less and less services available for residents, especially those with HIV and Hep C. While we minister to that group, getting them care is hard. That’s why I feel that the church will have to become a complex part of the community that we serve. If we don’t do something with the people that live there, I mean those that are really on the low end of the totem pole, then where are they going to go? Some of them have grandparents and family there. Their homes are about to fall down in disrepair. It’s just a horrible scene. If we have to bring our standards up . . . we can’t stay basic. Just basic health needs, just giving them a sandwich. We have to come up or we are going to lose a whole group of people.

When we explored the issue of HIV service delivery to local residents, four themes emerged: (a) Clergy see the need, but are not sure how to proceed; (b) prioritized sin; (c) push-back; and (d) niche ministries.

Clergy See the Need, But Are Not Sure How to Proceed

Participants indicated that HIV was a critical problem facing their communities. However, many did not feel they possessed the knowledge base to respond to the educational needs or the associated stigma.

I think the thing that kills people with HIV is that we have not educated them. I think pastors are afraid to talk from the pulpit about HIV. The reason I have got a lot of people, through God who strengthens me, comfortable in Vine City and English Avenue is because I’ve had researchers come through there and had sessions on HIV. One lady told the other lady “don’t touch me” because she thought maybe she could get it. But see we have to teach people and once people become educated on HIV and other diseases, they know how to protect themselves. I feel like if we are educated in our communities as well as our churches it’ll be a more comfortable position for everybody.

Specific to HIV needs,

Every time we tried to do something, our hands were tied because there was no money because a couple of mega churches get good grant writers. They hire the best grant writers and soak up all the money. And then you ask them to help you, and they just simply tell you “refer them to us.”

Several clergy were unclear about the myths and realities of HIV transmission. As a result, they had to work past their own lack of knowledge.

Educate me on how to deal with sexually transmitted diseases. We believe in laying hands on people when we pray, so if I touch a person with HIV when we pray, can I get it? I had to get past the stigma of when people come up that have HIV because it’s big in our community and a lot of people are infected. But I can still pray for these people. I can still show them love and compassion. And I had to change my mind and my thinking on that as a pastor.

Clergy discussed how they judge the success of their ministry on the behavior of their congregants. Behavior that is incongruent with church theology makes clergy feel unsuccessful. Church doctrine serves as directives for congregants’ behaviors. Consequently, when congregants engage in unsanctioned behaviors, clergy feel a sense of responsibility. In this sample, some clergy are transitioning away from fundamental interpretations of scripture toward more progressive and inclusive doctrine. As they progress through the theological shift, the lines between appropriate and inappropriate behavior have become blurred. This transition sometimes leaves some clergy uncertain about how to respond to people living non-conforming lifestyles.

The church is conflicted about how to change how we deal with HIV. I think we change it by having opportunities to sit at a table and dialogue about it, and also realize that it’s not only happening at my church, but it’s happening at someone else’s church too. So now I’m not the sore thumb. Nobody wants to open up about having an alternative lifestyle. Nor do pastors want to admit that their congregants have alternative lifestyles. Because in their mind, they think that they aren’t reaching their goals. So we have to change that thinking. But yeah, you are still reaching your goal if you have people in your congregation that’s smoking crack. I know guys who come to church, hear a good sermon, and roll a joint before they get home.

Prioritized Sin

Prioritized sin was generally how clergy described how their congregants responded to HIV in the church and community. More conservative congregations were generally more accepting of people who were thought to have contracted the virus through heterosexual, monogamous relationships. People who lived “alternative lifestyles” (i.e., openly gay, substance users) were stigmatized and perceived as being less worthy of compassion and care.

I think there’s still a stigma and there’s willful ignorance. The congregation I serve is traditional, Apostolic Pentecostal Holiness, and there is a great amount of stigma about HIV. They prioritize sins. But homosexuality is rampant in our community and our congregation and I think pretty much it’s an open secret. One of our directors of outreach just passed away of HIV. For 15 years his family refused to acknowledge his HIV, they gave all kind of reasons why he was sick. These are open secrets I think. The stigma is why we won’t deal with it. I really wish we would deal with it because we’re centrally located in the Thomasville Heights and Norwood Manor community and we could really help. But there’s just a stigma and willful ignorance.

Another clergy member explained how sex related sins are generally perceived by congregants:

They hold sex sins high on the totem pole. They are the most dangerous and weightiest of sins. To me, it’s very obvious that we have LGBT persons in our congregation. But we just don’t want to consciously deal with it and we don’t want to consciously deal with our behavior or talking about it. It’s mindless and I hope that this doesn’t come knocking on my door because it’s at somebody else’s door. I think that the way some people read and interpret the scripture as conservatives or evangelicals, which the black church tends to be, they just tend to highlight that behavior as something to condemn and I don’t see it as something to condemn. One of the other ironies is some of the individuals engaged in that behavior, are some of the most vociferous critics. It’s ironic.

The themes in prioritized sin comprise a rather heterogeneous grouping associated with proximity to the virus. Several clergy members had personal experience with HIV (i.e., either through a family member or church member).

I have family members who have been HIV positive. I don’t know why so many people are so reticent to talk about it or acknowledge it. Most of us probably even know someone who is HIV positive now or has died from AIDS . . . I don’t know why we want to put our heads in the sand and deny that it exists when it’s right here in front of us, in the room with us, and at family gatherings.

Some theologically conservative clergy, however, continue to draw a hard line when HIV is contracted through same sex behavior.

We teach our people to love and we do love everybody. We love the person, but we preach against homosexuality. We don’t believe in homosexuality. We love the person, we treat the person good. We don’t embarrass the person . . . we put our arms around them, we go out with them, and talk with them. But I think that a line has to be drawn. We preach against it.

Push-Back

Push-back on HIV from congregation members was a common theme among clergy with older more traditional congregations. Clergy defined “Push-back” as a lack of support and tolerance for HIV conversations or activities by congregants. One clergy said,

It’s something that you want to address but you get pushback. You bring it up in ministry talks and people get quiet. Deadly quiet. Like pastor, don’t talk about that!

Clergy suggest that congregants do not think HIV is an issue that affects them personally. As a result, there is no need to discuss it. One clergy who came from a church with a successful HIV ministry explained his challenge:

Yeah I get pushback. I do. I served a congregation in Northeast Ohio for 13 years and we had a thriving HIV/AIDS ministry primarily because a woman who contracted HIV/AIDS from her husband. She started the ministry and she was very personable. I haven’t been able to gain any traction with an HIV ministry in Atlanta. I get pushback whenever I talk about it. People clam up. We have a health ministry, but they don’t want to deal with HIV. We have health fairs. We don’t want to talk about HIV. We don’t want to talk about getting tested.

Another clergy member gave another example from his experience with an HIV infected member of his congregation:

I really value HIV as a ministry. About 15 years ago, a member of my congregation disclosed his HIV status. I told him that he had an excellent opportunity to help me do what I want to do, but he was very reluctant. And he essentially said to me “I’m telling you, but I’m not even telling my family.” And I think not only is there a stigma in the congregation, but I think it’s sometimes from the infected person.

Niche Ministries

Niche ministry is where some churches have developed specific approaches to address HIV in their local community. Some of the niche HIV ministries target LGBT communities, college students, and sex workers.

My congregation is predominately African American, gay, and lesbians. Many of the gay men found their way to our congregation as a result of being diagnosed and then being ousted from their ministering churches. So the ministry was actually developed by these brothers who actually needed to create a space not only for their own support, but also support of other brothers within the church and without the church that would need to not only garner support around emotional support but also support around resources, support around treatment, etc.

College campus-based ministries also experienced success in working with the surrounding community. Some clergy explained that the college congregations were often composed of diverse students—privileged, poor, gay, heterosexual, urban, rural, and so on. Several clergy felt their fringe existence on the college campus made them more cohesive as a group.

Some of my students grew up in the Episcopal Church and very privileged. Their grandparents and great grandparents went to college. And then I have other students who are first generation who are really struggling to make ends meet, who are working and going to school part time, who are living in boarding houses behind the college. So there is some mix of very wealthy kids and very poor kids who are trying to interact together. And I think probably the thing that brings them together most is a feeling of isolation from the larger group on campus. So I often think that I minister to the misfits or I minister to the gay kids, or to the kids who are really poor, or to the kids who have often been considered so elite that they don’t have any grounding or connection with the majority of the students. So it is a ministry to the misfits who all kind of come together.

Another church does street ministry with sex workers.

We have “Princess Night” where we go out on Fulton Industrial area and take the ladies a rose. We talk to her and try to get her off the street. If we are effective that night in getting her off the street, then we put her up in a facility up in a whole other city. Then we try to either get her treatment or if she’s not from this area, we try get her back to her home.

Non-Denominational

Becoming a non-denominational church was viewed by several of the clergy as an effective strategy for circumventing conservative church doctrine and serving niche populations. One clergy member said, “Denomination separates more churches and divides more people so I just lean toward non-denominational. I’m able to reach more people that way.” Another clergy member explained,

I think that marginalization that the church creates makes me people fell less than and causes them to practice unhealthy behavior. And only drives them to those communities and areas that end up causing them to be HIV positive or causes them to caught up in STDs or drug addiction and all these other things. But I think if we open up that road of love to everybody, I think that we will find that our churches and our communities will improve in the quality of life significantly.

One clergy member discussed how becoming a non-denominational church improved their ability to reach youth in the community:

I think the church struggles when it has a certain type of doctrine, and it’s kind of difficult. Like in my case, we had a pastor for 40 some odd years and he passed. Now we have a young man that came in and we have a totally different ministry now. It’s more progressive. It’s more in tune with what’s going on in the community of young people.

Clergy identified several holistic ways HIV education could be incorporated into sermons, Christian education, and workshops.

We can educate but it takes everybody—not only the pastor of the church. It takes the staff and folks at home. We should teach classes as a congregation, that’s what I would try to do. I try to teach classes to the congregation, I try to say things over the pulpit about HIV that they could think about when they leave the church. Also we teach marital classes. I think education is the best policy that we can incorporate into our churches about HIV and all these diseases. I found that helps and gives them what they need if they’re going be sexually active. I try to tell them what they need to do and I find that it works.