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CORK Bibliography: Rural

87 citations. January 2009 to present

Prepared: September 2011

Ahmad A; Khalique N; Khan Z. Analysis of substance abuse in male adolescents. Iranian Journal of Pediatrics 19(4): 399-403, 2009. (12 refs.)

Objective: Substance abuse in adolescents may also be a marker to other harmful life styles. This study aims to find out the prevalence, pattern and sociodemographic risk factors of substance abuse in male adolescents. Methods: This study examined 390 male school children aged 10-19 yrs in the rural and urban areas of district Aligarh, Uttar Pradesh, India. Data was analyzed by SPSS -10. Findings: Substance abuse was prevalent in 13.3% of adolescents of whom 96.1% were using various forms of tobacco and 3.8% were taking alcohol. While there was statistically significant association between the substance abuse and the age group of adolescents and size of their families, variables such as religion, socioeconomic status, place of residence were not associated with substance use. Most of the students reported initiation of substance use at 14 yrs of age due to peer pressure. Conclusion: Peer educators would be a useful strategy for communication with adolescents to counter peer pressure. The prevention and control measures should be started at primary education level.

Bailey BA; Cole LKJ. Rurality and birth outcomes: Findings from southern Appalachia and the potential role of pregnancy smoking. Journal of Rural Health 25(2): 141-149, 2009. (44 refs.)

Context; Rates of preterm birth (PTB) and low birth weight (LBW) vary by region, with disparities particularly evident in the Appalachian region of the South. Community conditions related to rurality likely contribute to adverse birth outcomes in this region. Purpose: This study examined associations between rurality and related community conditions, and newborn outcomes in southern Appalachia, and explored whether pregnancy smoking explained such associations. Methods: Data for all births in a southern Appalachian county over a 2-year period were extracted from hospital records. Findings: Data were available for 4,144 births, with 45 different counties of residence. Babies born to women from completely rural counties, on average, weighed 700 g less, were 1.5 inches shorter, and were born over 3 weeks earlier than less rural infants. In addition, these babies were 4.5 times more likely to be LBW, 4 times more likely to be PTB, and 5 times more likely to be admitted to the neonatal intensive care unit (NICU). Effects were also found for per capita income, poverty rate, and unemployment rate, all of which were associated with rurality. Some, but not all of the association was explained by elevated rates of pregnancy smoking. Conclusions: Babies born to women residing in rural and economically depressed counties in southern Appalachia are at substantially increased risk for poor birth outcomes. Improving these outcomes in the rural South will likely require addressing access to health services and information, health care provider retention, transportation services, employment opportunities, and availability of public health services including smoking cessation assistance.

Benson P. Tobacco talk: Reflections on corporate power and the legal framing of consumption. Medical Anthropology Quarterly 24(4): 500-521, 2010. (67 refs.)

This article examines how North Carolina tobacco farmers think about the moral ambiguities of tobacco business. Drawing on ethnographic research with tobacco farmers and archival research on the tobacco industry, I specify the core psychological defense mechanisms that tobacco companies have crafted for people associated with the industry. I also document local social, cultural, and economic factors in rural North Carolina that underpin ongoing rural dependence on tobacco despite the negativity that surrounds tobacco and structural adjustments. This article contributes to our knowledge about tobacco farmers and tobacco farming communities, which is important for tobacco-control strategies. I reflect on ethical and economic paradoxes related to the rise of corporate social responsibility in the tobacco industry, where an official legal framing of consumption, focused on informed adult consumer autonomy and health education, is promoted to undermine more robust public health prevention efforts.

Berends L. The emergence of a specialist role in rural alcohol and drug service delivery: Lessons from a review in rural Victoria, Australia. Drugs: Education, Prevention and Policy 17(5): 603-617, 2010. (23 refs.)

Aim: Perspectives on rural alcohol and other drug (AOD) service provision were explored. Methods: A mixed methods approach included a document review, service monitoring data, regional group fora with AOD and other health providers (109), semi-structured interviews with stakeholders from health, policy and research (53), and interviews with rural AOD services users (21). Findings: Alcohol is the main drug used by people in rural Victoria, followed by cannabis and then heroin. Services are allocated within a unit cost funding model and distributed on a regional or statewide basis. AOD treatment is dominated by outpatient therapy, outreach and rural withdrawal. Pharmacotherapy and residential rehabilitation are in short supply. Distance, stigma, and confidentiality concerns are barriers to treatment. Recruiting and retaining workers is difficult. The system continues to develop; secondary consultations and networking strategies increase capacity in other care systems. Hospital involvement in AOD treatment varies according to other health demands. Conclusions: Many aspects of the rural AOD service provider's role enhance service delivery by extending reach and capacity. This occurs through AOD models, such as outreach, as well as strategies for working with other systems that include networking and secondary consultation. While there is task diffusion beyond traditional understandings of AOD treatment, the service delivery role may be understood as specialist in its own right. Recognition of this role as specialist may support staff recruitment and retention, while building potential for career pathways.

Booth BM; Curran G; Han X; Wright P; Frith S; Leukefeld C et al. Longitudinal relationship between psychological distress and multiple substance use: Results from a three-year multisite natural-history study of rural stimulant users. Journal of Studies on Alcohol and Drugs 71(2): 258-267, 2010. (44 refs.)

Objective: Substance use is associated with poor mental health, but little is known regarding how use of multiple substances is associated with mental health, particularly longitudinally, in community studies. This article examines this issue in a large (N = 710), natural-history study of rural stimulant (cocaine and/or methamphetamine) users in three states. Method: Respondent-driven sampling recruited recent (past-30-day) stimulant users in three counties each in Arkansas, Kentucky, and Ohio. Participants were interviewed every 6 months for 3 years. Mental health was measured by the Brief Symptom Inventory, and prior 6 months' substance use was measured for 17 possible substances. Data analysis used generalized estimating equations for longitudinal data with the Global Severity Index of the Brief Symptom Inventory as the dependent variable at each interview and substance use as predictor variables measured by number of substances used in the past 6 months and, separately, the 17 individual substances, adjusting for use of substance-use treatment, demographics, and recruitment site. Results: On average, both Global Severity Index score and use of many substances declined over the course of study. Global Severity Index score was significantly associated with (a) greater number of substances used in the past 6 months (p <.0001) and (b) use of crack cocaine, methamphetamine, and nonprescription use of prescription painkillers and tranquilizers. Conclusions: Multiple and specific substances appear to incrementally increase psychological distress. Users of cocaine and methamphetamine are present in rural areas; these associations with poor psychological health raise concerns regarding availability of local treatment services for individuals with mental-health problems, as well as substance abuse.

Bottorff JL; Carey J; Mowatt R; Varcoe C; Johnson JL; Hutchinson P; Sullivan D; Williams W; Wardman D. Bingo halls and smoking: Perspectives of First Nations women. Health & Place 15(4): 1014-1021, 2009. (46 refs.)

The purpose of this study was to examine bingo halls as a frequent site for exposure to secondhand cigarette smoke for First Nations women in rural communities. Thematic analysis of interviews with key informants, group discussions with young women, and observations in the study communities revealed that smoky bingo halls provided an important refuge from everyday experiences of stress and trauma, as well as increased women's risk for addiction, marginalization, and criticism. The findings illustrate how the bingo economy in isolated, rural First Nation communities influences tobacco use and secondhand smoke exposure, and how efforts to establish smoke-free bingos can be supported.

Boulos DNK; Loffredo CA; El Setouhy M; Abdel-Aziz F; Israel E; Mohamed MK. Nondaily, light daily, and moderate-to-heavy cigarette smokers in a rural area of Egypt: A population-based survey. Nicotine & Tobacco Research 11(2): 134-138, 2009. (19 refs.)

Understanding tobacco use among nondaily and light daily cigarette smokers is needed because they are dissimilar from other smokers and may require specific prevention efforts. We compared three groups of adult male smokers in rural Egypt: light daily and nondaily smokers versus moderate-to-heavy daily smokers. Data were obtained from a household survey in 2003 in six randomly selected villages in the Nile Delta region of Egypt. There were 7,657 adult participants, of whom 48.6% were male and 51.4% were female. Among them, 1,401 males (37.6%) and 5 females (0.1%) were self-identified as current cigarette smokers; further analysis focused on males. We restricted data analysis to those who reported a stable pattern of 3+ years of smoking. There were 42 nondaily smokers. Daily smokers were subdivided into two groups: light daily smokers (who smoked no more than 10 cigarettes/day; n = 223) and moderate-to-heavy daily smokers (who smoked at least 11 cigarettes/day; n = 769). We found statistically significant differences between these groups on nearly every measure: nondaily smokers tended to be younger and unmarried, but they also had higher levels of education and professional occupations compared with the other smokers. Nondaily and the light daily smokers were more likely than moderate-to-heavy smokers to be planning to quit and to have self-efficacy for quitting, and they were less likely to be smoking in the presence of their wife and children at home. Further understanding of nondaily and light daily smokers may aid in tailoring specific interventions.

Bourke L; Humphreys J; Lukaitis F. Health behaviours of young, rural residents: A case study. Australian Journal of Rural Health 17(2): 86-91, 2009. (21 refs.)

To analyse self-reported health behaviours of young people from a rural community and the factors influencing their behaviours. Interviews were conducted with 19 young people, 11 parents and 10 key informants from a small rural Victorian community, asking about teenage health behaviours and the factors influencing these behaviours. Young people ate both healthy and unhealthy foods, most participated in physical activity, few smoked and most drank alcohol. The study found that community level factors, including community norms, peers, access issues and geographic isolation, were particularly powerful in shaping health behaviours, especially alcohol consumption. Smoking was influenced by social participation in the community and national media health campaigns. Diet and exercise behaviour were influenced by access and availability, convenience, family, peers and local and non-local cultural influences. The rural context, including less access to and choice of facilities and services, lower incomes, lack of transport and local social patterns (including community norms and acceptance), impact significantly on young people's health behaviours. Although national health promotion campaigns are useful aspects of behaviour modification, much greater focus on the role and importance of the local contexts in shaping health decisions of young rural people is required.

Brown RA. Crystal methamphetamine use among American Indian and White youth in Appalachia: Social context, masculinity, and desistance. Addiction Research & Theory 18(3): 250-269, 2010. (57 refs.)

Rural areas and American Indian reservations are hotspots for the use of crystal methamphetamine ('meth') in the United States, yet there is little ethnographic data describing meth use in these areas. This study draws upon 3 years of ethnographic work conducted with American Indian and White youth in Appalachia during the height of the meth epidemic. First, I show how crystal meth filled a functional niche in the lives of many young men, alleviating boredom and anomie linked to recent socioeconomic changes and changing labor opportunities, and intersecting with local understandings of masculinity and forms of military identity. Here, ethnographic and interview data converge to illustrate how social role expectations, recent socioeconomic change, and meth's pharmacological properties converge to create vulnerability to meth use in Appalachia. Next, I draw upon two American Indian narratives of desistance. These youth described recently severed social relationships and acute feelings of social isolation during the initiation of meth use. Both also described dramatic close calls with death that facilitated their eventual desistance from use, involving repaired social relationships and the establishment of new lives and hope. Comparisons with meth use in other populations and regions, including men who have sex with men in urban environments, suggest that similar motivations and contextual factors may influence meth use across diverse cultural and regional contexts. Recent interventions targeting the pathogenic aspects of masculine role socialization and ethnographic evidence on the role of social networks in desistance suggest both avenues and caveats for intervention.

Carlo G; Crockett LJ; Wilkinson JL; Beal SJ. The longitudinal relationships between rural adolescents' prosocial behaviors and young adult substance use. Journal of Youth and Adolescence 40(9): 1192-1202, 2011. (58 refs.)

While many adolescents and young adults experiment with substances (e.g., alcohol, cigarette smoking, marijuana), recent research suggests that rural youth and young adults may be more at risk for substance use than their urban counterparts. This study was designed to examine the longitudinal relationships between rural adolescents' prosocial behaviors and substance use in young adulthood. Furthermore, we examined the potential mediating effects of adolescent substance use, academic investment, and delinquency. Rural youth (N = 531; 263 girls) were surveyed in grades 10-12 (Time 1; M age = 16.17; SD = .91) and again in early adulthood (Time 2). Measures of prosocial behaviors, substance use, academic investment, and deviant activities were assessed at Time 1. At Time 2, measures of marijuana use, cigarette smoking, and getting drunk were administered. Overall, the findings showed that rural adolescents who frequently exhibit prosocial behaviors are less likely to engage in substance use in young adulthood than those who exhibit relatively low levels of prosocial behaviors. These findings indicate that prosocial behaviors may have positive health consequences, establishing behavioral trajectories that lead to lower levels of risky health behaviors in adulthood in rural populations.

Carlson RG; Sexton R; Wang JC; Falck R; Leukefeld CG; Booth BM. Predictors of substance abuse treatment entry among rural illicit stimulant users in Ohio, Arkansas, and Kentucky. Substance Abuse 31(1): 1-7, 2010. (23 refs.)

Illicit drug use in the rural United States is increasingly common, yet little is known about drug users' treatment-seeking behaviors. This study identifies predictors of substance abuse treatment entry over 24 months among 710 illicit stimulant users in rural areas of Ohio, Arkansas, and Kentucky. Active users of powdered cocaine, crack cocaine, and/or methamphetamine (MA) were recruited using respondent-driven sampling. Participants completed structured interviews at baseline and follow-up questionnaires every 6 months for 24 months. Data were analyzed using the Cox proportional hazards model. The paper is informed by the Anderson-Newman Model. Overall, 18.7% of the sample entered treatment. Ohio or Kentucky residence, perceived need for substance abuse treatment, higher Addiction Severity Index (ASI) legal problem composite scores, prior substance abuse treatment, and tranquilizer use were positively associated with treatment entry. Nondaily crack cocaine users and marijuana users were less likely to enter treatment. The findings can help inform rural substance abuse treatment program development and outreach.

Cole J; Logan TK. Nonmedical use of sedative-hypnotics and opiates among rural and urban women with protective orders. Journal of Addictive Diseases 29(3): 395-409, 2010. (112 refs.)

The purpose of this study was to examine the prevalence and risk factors for lifetime nonmedical use of sedative-hypnotics and opiates among a sample of rural and urban women with recent partner violence victimization (n = 756). Nearly one third of the sample (32.8%) reported ever using illicit sedative-hypnotics or opiates. Nonmedical use of sedative-hypnotics and opiates was significantly associated with lifetime cumulative exposure to interpersonal victimization, rural Appalachian residency, past-year use of other substances and other substance-related problems, and lifetime unmet health care needs. Findings have implications for substance abuse prevention and treatment and victim advocacy programs.

Cox LS; Wick JA; Nazir N; Cupertino AP; Mussulman LM; Ahluwalia JS et al. Predictors of early versus late smoking abstinence within a 24-month disease management program. Nicotine & Tobacco Research 13(3): 215-220, 2011. (24 refs.)

Introduction: Standard smoking cessation treatment studies have been limited to 6- to 12-month follow-up, and examination of predictors of abstinence has been restricted to this timeframe. The KanQuit study enrolled 750 rural smokers across all stages of readiness to stop smoking and provided pharmacotherapy management and/or disease management, including motivational interviewing (MI) counseling every 6 months over 2 years. This paper examines differences in predictors of abstinence following initial (6-month) and extended (24-month) intervention. Methods: Baseline variables were analyzed as potential predictors of self-reported smoking abstinence at Month 6 and at Month 24. Chi-square tests, 2-sample t tests, and multiple logistic regression analyses were used to identify predictors of abstinence among 592 participants who completed assessment at baseline and Months 6 and 24. Results: Controlling for treatment group, the final regression models showed that male gender and lower baseline cigarettes per day predicted abstinence at both 6 and 24 months. While remaining significant, the relative advantage of being male decreased over time. Global motivation to stop smoking, controlled motivation, and self-efficacy predicted abstinence at 6 months but did not predict abstinence at Month 24. In contrast, stage of change was strongly predictive of 24-month smoking status. Conclusions: While the importance of some predictors of successful smoking cessation appeared to diminish over time, initial lack of interest in cessation and number of cigarettes per day strongly predicted continued smoking following a 2-year program.

Czech S; Shakeshaft AP; Byrnes JM; Doran CM. Comparing the cost of alcohol-related traffic crashes in rural and urban environments. Accident Analysis and Prevention 42(4): 1195-1198, 2010. (22 refs.)

Context: Existing studies have identified that, although to a lesser extent than individual factors such as males and young people, rural (compared to urban) communities represent a disproportionately high-risk of alcohol-related traffic crashes (ARTCs). To date, however, few studies have attempted to apply different costs to alcohol crashes of different severity, to provide more precise, and practically useful, data on which to base public health policy and intervention decisions. Objective: The aim of this study is to quantify the per capita prevalence and differential costs of alcohol crashes of different levels of severity to determine the extent to which urban and rural geographical areas may differ in the costs attributable to ARTCs. Design: A cross-sectional analysis of alcohol-related traffic crash and costs data from 2001 to 2007. Setting and participants: Data from New South Wales, Australia. Main outcome measures: Modified routinely collected traffic accident data to which costs relevant to alcohol crashes of different severity are applied. Results: Although the rate per 10,000 population of alcohol-related crashes is 1.5 times higher in rural, relative to urban, communities, the attributable cost is four times higher, which largely reflects that rural alcohol-fatalities are seven to eight times more prevalent and costly. Conclusions: Given that per capita alcohol-related fatal crashes in rural areas account for a disproportionately large proportion of the harms and costs associated with alcohol-related traffic crashes, the cost-effectiveness of public health interventions and public policy initiatives should consider the relative extent of ARTC-harm in rural versus urban communities.

Dake JA; Price JH; Ward BL; Welch PJ. Midwestern rural adolescents' oral sex experience. Journal of School Health 81(3): 159-165, 2011. (30 refs.)

BACKGROUND: This study examined the prevalence of oral sexual activity in rural Midwestern adolescents. We also examined the correlates of a series of risk behaviors with oral sexual activity. METHODS: A questionnaire based on the Youth Risk Behavior Surveillance System was distributed to 2121 rural middle and high school students in grades 6-12 across 5 rural counties in a Midwestern state. The schools within districts were stratified by grade level and a stratified random sample of schools was used (n = 49). RESULTS: A total of 2000 (94%) students completed the survey. The rural adolescents were: male (51%), White (85%), with an average age of 14.7 years (SD = 1.9). Overall, one-fourth (26%) of the students had engaged in sexual intercourse (8% of middle school and 39% of high school students). Slightly more than one-fourth of the students (29%) had engaged in oral sex (9% of middle school and 44% of high school students). Logistic regression was used to calculate adjusted odds ratios and found 3 risk behaviors were statistically significantly associated with oral sexual behavior: ever having had sexual intercourse (16.6 times more likely to engage in oral sex), having drunk alcohol in the past 30 days (2.2 times more likely), and having smoked 1 or more cigarettes in the past 30 days (2.0 times more likely). CONCLUSIONS: Oral sexual activity is an established component of many rural adolescents' sexual experiences. These findings have important implications for sex education programs targeted to rural adolescent youths.

Daniulaityte R; Falck R; Wang JC; Carlson RG; Leukefeld CG; Booth BM. Predictors of depressive symptomatology among rural stimulant users. Journal of Psychoactive Drugs 42(4): 435-445, 2010. (106 refs.)

This study examined sociodemographic and drug-related predictors of depressive symptoms among a rural, multistate sample of not-in-treatment stimulant drug users (n = 710). Participants were recruited using respondent-driven sampling in Ohio, Arkansas, and Kentucky. The Patient Health Questionnaire (PHQ-9) was used to measure symptoms of depression. Moderate to severe depressive symptomatology was reported by 43.0% of the sample. Cumulative logistic regression analysis showed that daily and nondaily crack use as well as the daily use of cocaine HCl increased the odds of depressive symptoms. Methamphetamine use had no significant association with depression. The daily use of marijuana, the illicit use of tranquilizers, light/moderate cigarette smoking, and injection drug use also increased the risk of depressive symptoms. Living in Kentucky or Ohio (compared to Arkansas), having unstable living arrangements, and being White, female, and older were related to higher odds of depressive symptoms. These results suggest that a host of drug and nondrug factors need to be considered when addressing depressive symptoms in stimulant users.

De Haan L; Boljevac T; Schaefer K. Rural community characteristics, economic hardship, and peer and parental influences in early adolescent alcohol use. Journal of Early Adolescence 30(5): 629-650, 2010. (51 refs.)

The study explores how differences in rural community contexts relate to early adolescent alcohol use. Data were gathered from 1,424 adolescents in the sixth through eighth grades in 22 rural Northern Plains communities, as well as 790 adults, parents, teachers, and community leaders. Multilevel modeling analyses revealed that community supportiveness, as perceived by adolescents, but not adults, was associated with less lifetime and past month alcohol use, and for past month use, this relationship was stronger than perceived peer drinking or parental closeness. Perceived peer drinking and parental closeness were not associated with past month use. Adolescents experiencing family economic strain did not report greater lifetime or past month use, but living in a disadvantaged community was associated with greater past month use. Relatively affluent adolescents reported greater past month use when living in a poor community than did poorer adolescents, highlighting relationship complexity between economic disadvantage and alcohol use.

Dobson A; McLaughlin D; Vagenas D; Wong KY. Why are death rates higher in rural areas? Evidence from the Australian Longitudinal Study on Women's Health. Australian and New Zealand Journal of Public Health 34(6): 624-628, 2010. (37 refs.)

Objective: Death rates in Australia are higher in rural than urban areas. Our objective is to examine causes of death of urban and rural women to gain insight into potential explanations for differences in mortality. Methods: Participants were a community-based random sample of women (n=12,400) aged 70-75 years when recruited in 1996 to the Australian Longitudinal Study on Women's Health. The main variables used were: area of residence classified according to the Australian Standard Geographic Classification (ASGC), survival to 31 October 2006, cause of death, selected risk factors. Results: The total number of deaths at 31 October 2006 was 2,803 and total number of women still alive was 9,597. Mortality was higher for women in rural areas overall (hazard ratio (HR)=1.09; 95% confidence interval (CI): 1.01-1.18) and for most major causes of death compared to urban women. In particular, death rates were substantially higher for lung cancer (HR=1.52; 95% CI: 1.03-2.25) and chronic obstructive pulmonary disease (COPD) (HR=1.83; 95% CI: 1.25-2.69). Nevertheless there were almost no differences among the groups for current smoking or smoking history. Prevalence of overweight and obesity was slightly higher and levels of physical activity lower among women in remote areas. Conclusion: There is little evidence that differences in mortality are due to the risk factors considered. Alternative explanations such as inequities in health services and environmental hazards should be considered. Implications: People in rural areas may suffer from a double disadvantage of poorer health services and exposure to health hazards that are less common in urban areas.

Fahy P; Croton G; Voogt S. Embedding routine alcohol screening and brief interventions in a rural general hospital. Drug and Alcohol Review 30(1): 47-54, 2011. (25 refs.)

Issues. Alcohol screening and brief intervention approaches (SBI) are strongly supported by evidence, but few health-care facilities have successfully introduced and sustained routine SBI. Approach. This paper describes the first 2 years of implementing SBI in an Australian rural general hospital. The SBI project aims were to universally screen presentations to Northeast Health Wangaratta (NHW), to provide brief interventions to people screening at medium risk of harm from drinking and enhanced referral for persons screening at high risk. Key Findings. In 2007 and 2008, the NHW SBI project conducted 11 079 screens for alcohol use disorders using the Alcohol Use Disorders Identification Screening Test screening tool. Eighty-five per cent of persons screened at low risk of alcohol-related problems, 11% at medium risk and 4% at high risk. Implications. Policy and planning bodies and hospital management's support and the appointment of a dedicated project worker are critical to successful SBI implementation. Conclusion. It is possible to establish a SBI service in a rural general hospital setting. The NHW SBI project broadened the focus from treatment of persons with severe dependency to detection, early intervention and prevention for the larger, more easily treated, cohort of persons drinking at hazardous/harmful but non-dependent levels. The challenge for any organisation is to maintain routine SBI deployment over the long term.

Farrell SP; Zerull LM; Mahone IH; Guerlain S; Akan D; Hauenstein E et al. Electronic screening for mental health in rural primary care: Feasibility and user testing. CIN: Computers Informatics Nursing 27(2): 93-98, 2009. (34 refs.)

Despite attention to prevention and screening for depression and alcohol use, Healthy People 2010 objectives continue to include goals to increase the detection of depression and decrease the rates of alcohol abuse. These problems remain significant. The overall goal of this study was to develop a computer-based electronic screening (eScreening) tool and determine the feasibility of implementing computer-based eScreening technology for rural visitors to a primary care clinic. The study called specifically for an electronic touch screen with voice prompts. This tool, called the eScreening tool, screens for alcohol abuse and depression among rural patients in a primary care setting. The screening was offered to rural adults who are not in acute distress and not at end of life, regardless of their stated reason for seeking medical care. Phase 1 of the pilot was used to determine the perceptions of nurses, other providers, and consumers regarding the acceptability and perceived usefulness of an eScreening tool. Phase 2 involved user testing of the eScreening tool. The longer term goals of the research program are to work with rural nurses to improve patient outcomes and develop interventions and for educational, consultation, and/or direct clinical care.

Gansky SA; Ellison JA; Kavanagh C; Isong U; Walsh MM. Patterns and correlates of spit tobacco use among high school males in rural California. Journal of Public Health Dentistry 69(2): 116-124, 2009. (39 refs.)

Objective: To assess patterns and correlates of spit [smokeless tobacco (ST)] use among high school males in rural California. Methods: An 18-item, self-administered questionnaire was used to assess ST use among young males in 41 randomly selected high schools in 21 rural counties in California. To ensure confidentiality, students were instructed to seal their completed questionnaire in an attached envelope prior to returning it to the questionnaire administrator. Results: Overall prevalence of ST use was 9.8 percent, significantly increasing with year in school from 5 percent among freshmen to 15 percent among seniors. ST use was highest among rodeo athletes at 42 percent compared with < 6 percent among nonathletes; ST use was significantly higher among smokers (32 percent) who were 2.5-30 times more likely to use ST compared with nonsmokers, depending on race/ethnicity as a result of a significant race/ethnicity x smoking interaction of degree/magnitude. In addition, students who believed there was no, or slight risk of, harm from ST use were significantly more likely to use ST than students perceiving moderate or great risk, depending on race/ethnicity (odds ratios 3.6-13). Among all ST users, 40 percent used ST on at least 5 days in the previous week, 80 percent of those reporting a brand used the brand Copenhagen, and 41 percent (189) used ST within 30 minutes of waking. Conclusion: Dental public health practitioners, scholars, and policy-makers need to promote dental health through organized community efforts targeting high school male subgroups in rural areas that are at risk for ST-associated adverse health effects.

Gruenewald PJ; Johnson K; Shamblen SR; Ogilvie KA; Collins D. Reducing adolescent use of harmful legal products: Intermediate effects of a community prevention intervention. Substance Use & Misuse 44(14): 2080-2098, 2009. (55 refs.)

Purpose: Preliminary results are presented from a feasibility study of a comprehensive community prevention intervention to reduce the use of inhalants and other harmful legal products (HLPs) among adolescents in three Alaskan frontier communities conducted in 2004-2007. The legal products used to get high include over-the-counter drugs, prescription drugs, and common household products. Community mobilization, environmental and school-based strategies were implemented to reduce access, enhance knowledge of risks, and improve assertiveness and refusal skills. Methods: Pre- and post-intervention survey data were collected from 5-7th grade students from schools in three communities using standardized instruments to assess knowledge, assertiveness, refusal skills, perceived availability, and intent to use. The intervention consisted of community mobilization and environmental strategies to reduce access to HLPs in the home, at school, and through retail establishments. In addition, the ThinkSmart curriculum was implemented in classrooms among 5th grade students to increase the knowledge of harmful effects of HLPs and improve the refusal skills. Data were analyzed using hierarchical linear models that enable corrections for correlated measurement error. Results: Significant increases in knowledge of harms related to HLP use and decreases in perceived availability of HLP products were observed. The environmental strategies were particularly effective in reducing the perceived availability of HLPs among 6th and 7th graders. Discussion: Although limited by the absence of randomized control groups in this preliminary study design, the results of this study provide encouragement to pursue mixed strategies for the reduction of HLP use among young people in Alaskan frontier communities.

Haight W; Black J; Sheridan K. A mental health intervention for rural, foster children from methamphetamine-involved families: Experimental assessment with qualitative elaboration. Children and Youth Services Review 32(10): 1446-1457, 2010. (80 refs.)

This mixed method study describes the cultural adaptation, implementation and impact of a mental health intervention for individual rural children aged 7-17 from methamphetamine-involved families who are in foster care. Features of the culturally-shaped intervention include: 1) close collaboration with local professionals who provide the intervention over a seven month period; 2) provision of the intervention in and around children's homes; and 3) the use of local storytelling traditions in a narrative- and relationship-based intervention. As a group, children (N= 15) showed problematic levels of Childhood Behavior Checklist (CBCL) externalizing and total problem behaviors and symptoms of PTSD/dissociation during the pretest. Children were randomly assigned to an experimental group who received the intervention immediately (n = 8). or a wait-list control group (n = 7) who received the intervention at the end of the study. There was a significant interaction effect of time (pre and post test) and group on externalizing behavior with the trajectory of the experimental group improving while that of the control group worsened. Gains made by the experimental group were maintained over a seven month follow-up period. Comparative case studies, individual qualitative interviews and open-ended questionnaires provided rich elaboration of participants' experiences and illuminated complexities and challenges of the intervention.

Haight WL; Carter-Black JD; Sheridan K. Mothers' experience of methamphetamine addiction: A case-based analysis of rural, midwestern women. Children and Youth Service Review 31(1): 71-77, 2009. (28 refs.)

Engaging mothers who are abusing methamphetamine in services is an important goal for rural child welfare. Four rural, white, mothers in recovery from methamphetamine addiction described their life experiences through in-depth interviews. Three of the women grew up with parents who abused drugs, and all had experienced trauma as children and used other illegal drugs before methamphetamine. Mothers vividly portrayed the rapid loss of control that can occur with methamphetamine use, as well as the power of the addiction. They became "obsessed" with the drug and nothing was more important to them, not even the children whom they loved. They lost the ability to think "rationally," experienced serious lapses in judgment, lost motivation, and lived in a "fog." They described their illness as impacting their children's physical and psychological well-being including through exposure to domestic violence, adult substance abuse and other anti-social behavior, and loss of important relationships. They expressed concern that their children would abuse drugs. Women described recovery as possible only with significant external support, and they reported lasting physical, psychological and social side effects of their illness. Understanding mothers' experience of methamphetamine addiction can increase our awareness of this illness thereby reducing stigma and suggesting strategies for engaging them in intervention.

Haight W; Marshall J; Hans S; Black J; Sheridan K. "They mess with me, I mess with them": Understanding physical aggression in rural girls and boys from methamphetamine-involved families. Children and Youth Services Review 32(10): 1223-1234, 2010. (89 refs.)

This mixed method study examines the mental health and experiences of physical aggression in 41 children aged six to 14 years from rural families involved with methamphetamine misuse and the child welfare system. Each child was seen for a minimum of 3 h total by experienced clinicians on at least three sessions conducted at the child's home. Fifty percent of children scored in the clinical range (98th percentile and above) on externalizing and 26% on aggression scales of the Child Behavior Checklist (CBCL). More girls (75%) scored in the clinical range on CBCL externalizing behaviors than did boys (32%). During individual, semi-structured interviews, 17 children spontaneously produced 58 narratives of past physical aggression. These were primarily set at home and involved adults and the children themselves. Children primarily attributed physical aggression to anger and adult substance misuse, and described negative outcomes of the aggression. In contrast, a subgroup of girls with clinically significant levels of CBCL externalizing behaviors characterized their own physical aggression as appropriate retaliation with emotionally satisfying consequences. Many of these girls also scored in the clinically significant range on CBCL internalizing behaviors and total problems. Clinicians who collected the data expressed concern about these girls, in particular because they were ostracized from non delinquent peer groups, viewed others' continuing physical aggression against them as an inevitable part of their future, and described their own physical aggression as unavoidably driven by that violence. The perspectives of this subgroup of girls are elaborated through a case study of a physically aggressive 12-year-old. Implications for intervention are discussed.

Hall JA; Sarrazin MSV; Huber DL; Vaughn T; Block RI; Reedy AR et al. Iowa case management for rural drug abuse. Research on Social Work Practice 19(4): 407-422, 2009. (78 refs.)

Objective: The purpose of this research was to evaluate the effectiveness of a comprehensive, strengths-based model of case management for clients in drug abuse treatment. Method: 503 volunteers from residential or intensive outpatient treatment were randomly assigned to one of three conditions of Iowa Case Management (ICM) plus treatment as usual ( TAU), or to a fourth condition of TAU only. All were assessed at intake and followed at 3, 6, and 12 months. Results: Clients in all four conditions significantly decreased substance use by 3 months after intake and maintained most gains over time. However, the addition of ICM to TAU did not improve substance use outcomes. Conclusion: Overall, the addition of case management did not significantly improve drug treatment as hypothesized by both researchers and clinicians. Some results were mixed, possibly due to the heterogeneous sample, wide range of case management activities, or difficulty retaining participants over time.

Hamilton J; Noland MP; Riggs RS; Mullineaux DR. Factors related to adolescent drinking in Appalachia. American Journal of Health Behavior 34(2): 249-256, 2010. (35 refs.)

Objectives: To examine the relationships among parental monitoring, perceptions of peer drinking, and adolescent alcohol consumption. Methods: Tenth- and 12th-grade students (N=648) in a rural, Appalachian county were surveyed. Results: A binomial logistic regression revealed a composite of those who had perceptions that many peers drank, low parental monitoring, and no biological male guardian in the home were 8.496 times more likely to have ever been drunk. Other characteristics resulted in lower odds. Conclusions: Parental monitoring and perceptions of peer drinking were important predictors of drinking in this rural sample. Prevention efforts in school and at home should address both variables.

Hanson CL; Novilla MLLB; Barnes MD; Eggett D; McKell C; Reichman P et al. Using the rural-urban continuum to explore adolescent alcohol, tobacco, and other drug use in Montana. Journal of Child & Adolescent Substance Abuse 18(1): 93-105, 2009. (19 refs.)

The purpose of the study was to compare 30-day prevalence of alcohol, tobacco, and other drug use among twelfth-grade students in Montana across a rural-urban continuum during 2000, 2002, and 2004. The methods include an analysis of the Montana Prevention Needs Assessment (N=15,372) using multivariable logistic regression adjusting for risk factors, protective factors, and demographics variables. Findings revealed that adolescent substance use varies across the rural-urban continuum. Risk of cigarette, smokeless tobacco, and alcohol use increased in more rural counties while risk of marijuana, LSD, and any drug decreased in more rural counties. The specificity provided through use of such a classification scheme has important implications for designing effective drug-prevention programs across diverse settings.

Havens JR; Oser CB; Knudsen HK; Lofwall M; Stoops WW; Walsh SL et al. Individual and network factors associated with non-fatal overdose among rural Appalachian drug users. Drug and Alcohol Dependence 115(1-2): 107- 112, 2011. (43 refs.)

Background: Fatal overdoses involving prescription opioids have increased significantly in recent years in the United States - especially in rural areas. However, there are scant data about non-fatal overdose among rural drug users. The purpose of this study is to examine the prevalence and correlates of non-fatal overdose and witnessed overdose among rural Appalachian drug users. Methods: Rural drug users were participants in a longitudinal study of social networks and HIV transmission. An interviewer-administered questionnaire elicited information in the following domains: sociodemographic characteristics, drug use (including lifetime overdose and witnessed overdose), psychiatric disorders, HIV risk behaviors and social networks (support, drug and sex networks). Negative binomial regression was used to model the number of lifetime overdoses and witnessed overdoses. Results: Of the 400 participants, 28% had ever experienced a non-fatal overdose, while 58.2% had ever witnessed an overdose (fatal or non-fatal). Factors independently associated with a greater number of overdoses included having ever been in drug treatment, past 30-day injection of prescription opioids, meeting the criteria for post-traumatic stress disorder and/or antisocial personality disorder and having more members in one's support network. Conclusions: Rural drug users with history of overdose were more likely to have injected with prescription opioids - which is different from urban heroin users. However, the remaining correlates of non-fatal overdose among this cohort of rural drug users were similar to those of urban heroin users, which suggests current overdose prevention strategies employed in urban settings may be effective in preventing fatal overdose in this population.

Havens JR; Stoops WW; Leukefeld CG; Garrity T; Carlson RG; Falck R et al. Prescription opiate misuse among rural stimulant users in a multistate community-based study. American Journal of Drug and Alcohol Abuse 35(1): 18-23, 2009. (26 refs.)

Objectives: The purpose of the current analysis was to examine the factors associated with prescription opiate misuse among stimulant users from rural counties in Arkansas, Kentucky, and Ohio (N = 714). Methods: Multiple logistic regression was utilized to determine the independent correlates of recent (prior 6 months) prescription opiate misuse. Results: More than half of participants (53.2%) reported prescription opiate misuse in the previous 6 months. Other drug use (heroin, cocaine, methamphetamine, and marijuana) and anxiety (Adjusted Odds Ratio: 2.04, 95% Confidence Interval: 1.60, 2.59) were independently associated with prescription opiate misuse. Chronic pain and other health indicators were not associated with prescription opiate misuse after adjustment for covariates. Conclusions: Results indicate that illicit drug involvement and psychiatric symptoms may be driving the high rates of prescription opiate misuse among rural stimulant users. These findings have implications for the provision of treatment in resource-deprived rural areas.

Havens JR; Walker R; Leukefeld CG. Benzodiazepine use among rural prescription opioids users in a community-based study. Journal of Addiction Medicine 4(3): 137-139, 2010. (16 refs.)

Objectives: The purpose of this study was to examine both medical and nonmedical use of benzodiazepines among a community-based cohort of prescription opioid users. Methods: A total of 221 prescription opioid users from 2 rural Appalachian counties were recruited to participate in an interviewer-administered survey assessing sociodemographic characteristics, medical (source was valid prescription) and nonmedical (source other than prescription, such as dealer, friend, or family member) prescription drug use, illicit substance use, psychiatric disorders, and pain. Results: Almost all of the participants (92.8%) reported lifetime benzodiazepine use and two thirds were current users. Only 29.3% of the current users had a legitimate prescription for a benzodiazepine. Current users were significantly more likely than nonusers to report nonmedical use of a variety of prescription opioids and other illicit drugs. The major source of benzodiazepines was a dealer. Conclusions: A high rate of nonmedical benzodiazepine use was observed in this sample of prescription opioid users. Physicians should, therefore, be aware of the potential for nonmedical use of benzodiazepines. Implications for treatment and future research are discussed.

Havens JR; Young AM; Havens CE. Nonmedical prescription drug use in a nationally representative sample of adolescents: Evidence of greater use among rural adolescents. Archives of Pediatrics & Adolescent Medicine 165(3): 250-255, 2011. (44 refs.)

Objectives: To compare the prevalence of nonmedical prescription drug use among adolescents residing in urban, suburban, and rural areas of the United States and to determine factors independently associated with rural nonmedical prescription drug use among adolescents aged 12 to 17 years. Design: Cross-sectional, population-based survey. Setting: Noninstitutionalized residents in the United States. Participants: Participants included adolescents aged 12 to 17 years (N = 17 872), most of whom were residing in urban areas (53.2%), male (51%), and white (59%). Main Exposure: Living in rural compared with urban area. Main Outcome Measures: Nonmedical use of prescription drugs (pain relievers, tranquilizers, sedatives, and stimulants). Data were from the 2008 National Survey on Drug Use and Health. Results: Rural adolescents were 26% more likely than urban adolescents to have used prescription drugs nonmedically (adjusted odds ratio, 1.26; 95% confidence interval, 1.01-1.57) even after adjustment for race, health, and other drug and alcohol use. When examining the rural adolescents in particular, factors positively associated with nonmedical use of prescription drugs included decreased health status, major depressive episode(s), and other drug (marijuana, cocaine, hallucinogens, and inhalants) and alcohol use. Protective factors for nonmedical prescription drug use among rural adolescents included school enrollment and living in a 2-parent household. Conclusions: Rural adolescents were significantly more likely than urban adolescents to report nonmedical prescription drug use. However, these results suggest there are multiple potential points of intervention to prevent initiation or progression of use among rural adolescents including preventing school dropout, increased parental involvement, and increased access to health, mental health, and substance abuse treatment.

Hemovich V; Crano WD. Family structure and adolescent drug use: An exploration of single-parent families. Substance Use & Misuse 44(14): 2099-2113, 2009. (70 refs.)

Data from the 2004 Monitoring the Future survey examined a nationally representative cross-sectional sample of 8th to 12th grade adolescents in rural and urban schools from across the United States (N = 37,507). Results found that drug use among daughters living with single fathers significantly exceeded that of daughters living with single mothers, while gender of parent was not associated with sons' usage. This distinction in adolescent drug use between mother-only versus father-only households is largely overlooked in contemporary studies. Factors responsible for variations in sons' and daughters' usage in single-parent families have important implications for future drug prevention efforts.

Ho MG; Ma SJ; Chai WX; Xia W; Yang GH; Novotny TE. Smoking among rural and urban young women in China. Tobacco Control 19(1): 13-18, 2010. (19 refs.)

Methods: A survey of 11 095 urban and rural women attending high school or college, aged 14-24 years, in 6 Chinese provinces was conducted. Ever-smoking (ES), current smoking, established smoking and intention to smoke frequencies were calculated. Bivariate analyses were conducted to identify possible correlates of smoking, and those found to be significant at the p = 0.1 level were included in a multivariate logistical regression model to obtain adjusted OR for correlates of ES. Results: ES prevalence was 20.1%, with urban female students (UFS) at 22.0% and rural female students (RFS) at 19.0% (p<0.01). Established smoking prevalence was higher among UFS than RFS (2.4% vs 0.9%, p<0.01). Similarly, current smoking prevalence was higher among UFS than RFS (4.2% vs 1.9%, p<0.01). The intention to smoke prevalence was higher among UFS than RFS (3.5% vs 1.7%, p<0.01). The majority were aware that smoking was harmful to health, but were less aware of specific diseases associated with smoking. ES was associated with awareness of cigarettes made for women (OR, 1.66, 95% CI 1.49 to 1.86) and thinking that they were less harmful than other cigarettes (OR 1.54, 95% CI 1.33 to 1.79). The strongest correlate of ES was low refusal self-efficacy (OR 6.35, 95% CI 5.32 to 7.57). Conclusions: This is the first report that having heard of women's cigarettes is a correlate of smoking among young Chinese women. ES among young Chinese women has increased in the last decade, and thus, specific prevention strategies need to be developed to prevent the tobacco epidemic from spreading among this vulnerable population.

Jafari S; Rahimi-Movaghar A; Craib KJP; Baharlou S; Mathias R. A follow-up study of drug users in Southern Iran. Addiction Research & Theory 18(1): 59-70, 2010. (26 refs.)

Iran has the highest rate of opium addiction per capita in the world. The aim of this study was to examine the outcome of substance use among a cohort of drug users living in a rural area in Southern Iran. A semi-structured interview was conducted at baseline and at each follow-up visit on 211 substance users. Of the total of 211 drug users, 145 were non-injection drug users (non-IDUs) and 66 were injection drug users (IDUs). The most common method of drug use among all participants was revealed to be opium smoking. Other methods of choice were injection drug use (IDUs) and opium ingestion among 31% and 20% of participants, respectively. From the total of 211 participants in this cohort, on average (SD), each drug user gave up drugs 3.2 (2.7) times over the study period. Among those who were non-IDUs at the base line visit (145), 17 (12%) were abstinent for more than 6 months compared to 9 of 66 non-IDUs (14%) at the end of the study. By the end of the study period, 9 of 145 non-IDUs switched to non-IDUs while I I of 66 IDUs (17%) switched to non-IDUs (chi-square = 5.78; p = 0.016). One main reason for a higher rate of transition among IDUs was mentioned by them as observing the deaths of several IDUs in their community that were a result of overdose.

John A; Barman A; Bal D; Chandy G; Samuel J; Thokchom M et al. Hazardous alcohol use in rural southern India: Nature, prevalence and risk factors. National Medical Journal of India 22(3): 123-125, 2009. (11 refs.)

Background. There Is a dearth of data on the hazardous use of alcohol in rural India. Methods. We examined the nature, prevalence and factors associated with hazardous use of alcohol among men in a rural community In southern India. We used stratified sampling to select subjects from the Kaniyambadi block and employed 'AUDIT', a standard instrument, to assess the use of alcohol. Results. The prevalence of life-time use, use In the past year and hazardous use of alcohol was 46.7%, 34.8% and 14.2%, respectively. Using Indian made foreign liquor (OR 20.51; 95% CI 8.81-47.75) and living In a village which brewed Illicit alcohol (OR 2.82; 95% CI 1.39-5.72) were risk factors for hazardous use while education (OR 0.39; 95% CI 0.21-0.72) was protective. These factors remained significantly associated with hazardous use after adjusting for age and education using logistic regression. Conclusion. The relationship between the availability of Illicit and commercial alcohol and Its hazardous use suggests the need for an alcohol policy which takes Into account health and economic Issues and also implements the law to prevent the negative Impact of problem drinking.

Johnson KW; Ogilvie KA; Collins DA; Shamblen SR; Dirks LG; Ringwalt CL et al. Studying implementation quality of a school-based prevention curriculum in frontier Alaska: Application of video-recorded observations and expert panel judgment. Prevention Science 11(3): 275-286, 2010. (50 refs.)

This study assesses the implementation quality of Think Smart, a school-based drug prevention curriculum that was designed to reduce use of harmful legal products (HLPs; e.g., inhalants and over-the-counter drugs), alcohol, tobacco, and other drugs among 5th- and 6th-grade students in frontier Alaska. Participating in the study were eight communities that took part in a larger randomized control trial to assess the short-term effects of the Think Smart curriculum. Video-recorded observations of the 12 core and 3 booster lessons were conducted in 20 classrooms. Ninety-five sessions were randomly selected from 228 usable videodiscs, and two pairs of researchers observed each video recording to code level of dosage, adherence to curriculum design, and teachers' delivery skills. Inter-rater reliability for all implementation quality measures was very high. An expert panel consisting of 16 scientists reviewed the results of the implementation study and concluded that the level of dosage and adherence to the curriculum design was at least as high as those yielded by similar studies. However, the panel assessed the delivery quality to be only marginal in comparison to results of other studies. The experts concluded that the implementation quality of the Think Smart curriculum was adequate even though the teachers' delivery skills were only marginal. A bootstrapping analysis, in which 1,000 samples were drawn for each implementation quality result, found the expert judgments to be reliable. The authors conclude that despite some limitations, video-recorded observations, as well as expert judgment, provide strong methodologies that should be considered for future implementation quality studies.

Kamal SMM; Islam MA; Abu Raihan M. Differentials of tobacco consumption and its effect on illicit drug use in rural men in Bangladesh. Asia-Pacific Journal of Public Health 23(3): 349-362, 2011. (23 refs.)

This study examined socioeconomic differentials of tobacco consumption and its effect on illicit drug use among rural men, extracting data from the 2004 Bangladesh Demographic and Health Survey. Overall, 58.4% of the respondents consumed tobacco either by smoking or chewing. Smoking bidi (33.9%) and cigarette (23.6%) were the most prevalent forms of tobacco use. The prevalence of illicit drug use was 3.5%. The predominant illicit drug used was ganja (2.3%). Socioeconomic and behavioral factors such as age, education, religion, marital status, premarital and extramarital sexuality, and having STDs were found to be significantly (P < .001) associated with tobacco consumption. Multivariate logistic regression analyses yielded significantly (P <.001) increased risk of illicit drug use for different forms of tobacco consumption, for young age, premarital and extramarital sexuality, and non-Muslims. Appropriate measures should be undertaken to prevent smoking and illicit drug use for a healthy Bangladesh.

Kavanagh D; Connolly JM. Mailed treatment to augment primary care for alcohol disorders: A randomised controlled trial. Drug and Alcohol Review 28(1): 73-80, 2009. (26 refs.)

Introduction and Aims. Remote delivery of interventions is needed to address large numbers of people with alcohol use disorders who are spread over large areas. Previous correspondence trials typically examined its effects as stand-alone treatment. This study aimed to test whether adding postal treatment to general practitioner (GP) support would lower alcohol use more than GP intervention alone. Design and Methods. A single-blind, randomised controlled trial with a crossover design was conducted over 12 months on 204 people with alcohol use disorders. Participants in an immediate correspondence condition received treatment over the first 3 months; those receiving delayed treatment received it in months 3-6. Results. Few participants were referred from GPs, and little intervention was offered by them. At 3 months, 78% of participants remained in the study. Those in immediate treatment showed greater reductions in alcohol per week, drinking days, anxiety, depression and distress than those in the delayed condition. However, post-treatment and follow-up outcomes still showed elevated alcohol use, depression, anxiety and distress. Greater baseline anxiety predicted better alcohol outcomes, although more mental distress at baseline predicted dropout. Discussion and Conclusions. The study gave consistent results with those from previous research on correspondence treatments, and showed that high levels of participant engagement over 3 months can be obtained. Substantial reductions in alcohol use are seen, with indications that they are well maintained. However, many participants continue to show high-risk alcohol use and psychological distress.

King G; Gilreath TD; Albert EH; Flisher AJ. Smoking among high school male students in rural South Africa. Journal of Substance Use 16(4): 282-294, 2011. (46 refs.)

Few studies examine smoking in rural areas of countries in Africa. This study examines the roles of families, community influences, and key sociodemographic factors and school-age smoking among adolescent boys in rural South Africa. A total of 1,116 black male students were included in this analysis. Descriptive analyses were conducted, and multiple logistic regression (MLR) models were developed to analyze outcomes. The dependent variables were lifetime smoking, recent smoking, and age of smoking initiation. Sociodemographic variables and students' perceptions of community, family, and school were employed as independent variables. MLR analysis revealed family structure and discipline were found to be significant predictors of adolescent male smoking behavior as well as age, number of household amenities, town and smoking behavior. Adolescents in developing countries are increasingly subjected to tobacco industry promotion and exploitation. The results show that males in rural South Africa are not isolated from the tobacco epidemic.

Korte JE; Hiott FB; Brady KT; Malcolm RJ; See RE. Distinctive characteristics of methamphetamine users presenting at public clinics: Steep rise in South Carolina, United States, 2000-2005. Drug and Alcohol Dependence 115(1-2): 9- 15, 2011. (38 refs.)

Background: Illicit methamphetamine use has risen dramatically over the last decade. We sought to examine methamphetamine use among individuals presenting for drug treatment in South Carolina, USA, to assess trends over time, correlates of methamphetamine use, and the relationship between methamphetamine use and functional/behavioral problems. Methods: Data from 2000 to 2005 were obtained from a state-wide network of substance abuse clinics. We examined time trends, and compared sociodemographic characteristics and problems with daily functioning (Axis IV and Axis V disorders) of methamphetamine users vs. other drug users. Results: Of 235,415 individuals presenting or being admitted to a clinic, 3526 reported illicit methamphetamine use. The prevalence of methamphetamine use as a presenting problem increased dramatically across the six-year period, especially in the rural Upstate region (0.4-6.1%). In comparison to other drug users presenting or admitted to treatment during this same time period, methamphetamine users were more likely to be female, between 20 and 40 years old, and non-Hispanic white ethnicity. In addition, more methamphetamine users had occupational (49% vs. 43%, p < 0.001) or economic problems (41% vs. 35%, p < 0.001), and problems with their primary support group (58% vs. 54%, p < 0.05). However, the prevalence of Axis IV and Axis V problems were not statistically different between the two groups. Conclusions: The rapid escalation of methamphetamine use in South Carolina and elsewhere highlights the need for longitudinal studies to better understand the etiology and characteristics associated with methamphetamine uptake and addiction, and to develop the knowledge base required for more effective prevention and treatment.

Kramer TL; Booth BM; Han XT. Two-year trajectory of stimulant use in 18-to 21-year-old rural African Americans. Substance Abuse 31(1): 12-23, 2010. (57 refs.)

Little is known about stimulant use trajectories of rural African American youth. The purpose of the present study is to explore substance use over 24 months in 98 African Americans, ages 18 to 21, who used cocaine or methamphetamine 30 days prior to baseline. The majority was male, unemployed, and had not graduated from high school. At baseline, almost half of the participants met criteria for abuse/dependence of cocaine-the primary stimulant used-which decreased to 25% by the final follow-up. Similar decreases were noted in rates of alcohol and marijuana abuse/dependence, although monthly use remained high. Participants reported minimal utilization of mental health or substance abuse services, but demonstrated significant improvements on physical and mental health measures. In summary, cocaine use declined, but other substances were used at high rates, suggesting a significant need for intervention services that address multisubstance use in rural areas.

Kramer TL; Han XT; Leukefeld C; Booth BM; Edlund C. Childhood conduct problems and other early risk factors in rural adult stimulant users. Journal of Rural Health 25(1): 50-57, 2009. (35 refs.)

Context: Understanding childhood risk factors associated with adult substance use and legal problems is important for treatment and prevention. Purpose: To examine the relationship of early substance use, conduct problems before age 15, and family history of substance abuse on adult outcomes in rural, stimulant users. Methods: Adult cocaine and methamphetamine users (N = 544) in rural Arkansas and Kentucky were interviewed. Data were analyzed using both bivariate analyses and multiple logistic and log-linear regression models, with dependent variables being any substance abuse/dependence, stimulant abuse/dependence, total number of arrests since age 18 and days incarcerated since age 18. Findings: One third reported 3 or more conduct disorder problems prior to age 15; half reported initiation of substances (excluding alcohol) before age 15; and 60% reported family history of substance problems. All 3 variables were associated with adult substance abuse/dependence but only the latter two were associated with stimulant abuse/dependence. Conclusions: This study highlights early risk factors for adult substance abuse/dependence among rural stimulant users.

Kulbok PA; Bovbjerg V; Meszaros PS; Botchwey N; Hinton I; Anderson NLR et al. Mother-daughter communication: A protective factor for nonsmoking among rural adolescents. Journal of Addictions Nursing 21(2-3): 69-78, 2010. (51 refs.)

Rural adolescent females are at-risk for smoking at rates nearly equal to those of boys, and girls are at increased risk for smoking related diseases, reproductive, and pregnancy problems. The purpose of this study was to investigate protective factors related to nonsmoking in African American (AA) and Caucasian American (CA) female adolescents residing in rural tobacco-producing counties in Virginia. This qualitative study targeted rural female adolescent nonsmokers and their parents because of the importance of promoting tobacco-free, healthy lifestyles into adulthood. Participants were 18 adolescent female nonsmokers 16-17 years of age (6 AA and 12 CA) and 10 mothers (5 AA and 5 CA). Semi-structured questionnaires based on a health behavior framework and communication theory guided four in-depth group interviews of female adolescents and two group interviews of mothers. Protective factors identified by youth and parent groups were: frequent and open communication about smoking dangers and risks, mothers' intentionality in messages about nonsmoking; repeated patterns of oversight of daughter's activities and friends; mothers' pride in their daughters; close knit family of support; and daughter's explicit desire not to disappoint their parents. Directions for future research include the nature and type of female adolescents' communication with parents and a parallel study of protective factors of tobacco-free rural male adolescents to design parent-child communication interventions for tobacco prevention.

Levine SB; Coupey SM. Nonmedical use of prescription medications: An emerging risk behavior among rural adolescents. Journal of Adolescent Health 44(4): 407-409, 2009. (10 refs.)

Little is known about prescription medication abuse by rural youth. We surveyed 849 rural high school students and found that 34% reported lifetime nonmedical use of prescription medication higher than the 12% reported nationally. Boys and marijuana users had higher odds of nonmedical use of prescription medication than did girls or marijuana nonusers (odds ratio 1.9 and 3.8, respectively).

Li L; Zhang X; Levine B; Li GH; Zielke HR; Fowler DR. Trends and pattern of drug abuse deaths in Maryland teenagers. Journal of Forensic Sciences 56(4): 1029-1033, 2011. (29 refs.)

The Office of the Chief Medical Examiner of Maryland recorded a total of 149 drug abuse deaths of teenagers aged 13-19 years between 1991 and 2006. Of these deaths, 96 (64.4%) were caused by the use of narcotic drugs only, 29 (19.5%) by both narcotics and cocaine, four (2.7%) by both narcotics and methylenedioxymethamphetamine, six (4.0%) by cocaine only, and 14 (9.4%) by volatile substances (e.g., butane, Freon, nitrous oxide, and propane). The annual death rate from drug abuse for teenagers increased from 1.4 deaths per 100,000 population in 1991 to 2.7 deaths per 100,000 population in 2006 (chi-square test for time trend, p < 0.01). The increase in teenager drug abuse deaths occurred in 1999 and since has remained at a higher rate. Further analysis revealed that the increase in drug abuse deaths was attributable to a large degree to narcotic drugs, particularly heroin / morphine and methadone, and was confined to teenagers residing in the suburban and rural areas.

Ling PM; Haber LA; Wedl S. Branding the rodeo: A case study of tobacco sports sponsorship. American Journal of Public Health 100(1): 32-41, 2010. (89 refs.)

Rodeo is one of the few sports still sponsored by the tobacco industry, particularly the US Smokeless Tobacco Company. Rodeo is popular in rural communities, where smokeless tobacco use is more prevalent. We used previously secret tobacco industry documents to examine the history and internal motivations for tobacco company rodeo sponsorship. Rodeos allow tobacco companies to reach rural audiences and young people, enhance brand image, conduct market research, and generate positive press. Relationships with athletes and fans were used to fight proposed restrictions on tobacco sports sponsorship. Rodeo sponsorship was intended to enhance tobacco sales, not the sport. Rural communities should question the tradition of tobacco sponsorship of rodeo sports and reject these predatory marketing practices.

Ma X; Xiang YT; Cai ZJ; Li SR; Xiang YQ; Guo HL et al. Smoking and psychiatric disorders in the rural and urban regions of Beijing, China: A community-based survey. Drug and Alcohol Dependence 100(1-2): 146-152, 2009. (28 refs.)

Background: In China, there is limited information on smoking and its socio-demographic correlates in general, and in psychiatric patients in particular. The aim of this study was to determine the prevalence of lifetime, current mild, and heavy smoking, the socio-demographic correlates of current smoking, and its relationship with psychiatric disorders in the Beijing municipality, China. Methods: A total of 5926 subjects who met the study's entry criteria were randomly selected from the urban and rural areas of Beijing and interviewed using standardized assessment tools, including the collection of basic socio-demographic and clinical data. All subjects fully cooperated in the interviews and readily disclosed all of the information. Results: The prevalence of lifetime smoking was 35.9%: the rates for current mild and heavy smoking were 21.8% and 10.8%, respectively. An age of 24 years or above, male sex, married. divorced, separated or widowed marital status, relatively low level of education (less than college level), being employed, a relatively high monthly income (more than RMB500), rural abode, and having a psychiatric disorder were risk factors of current smoking. Both current mild and heavy smoking were significantly associated with alcohol dependence, and current heavy smoking was also associated with a history of a major depressive episode. Conclusions: The prevalence of smoking in the rural and urban areas of Beijing is unacceptably high. In addition to certain socio-demographic factors, smoking was associated with common psychiatric disorders. Nationwide surveys are warranted to further explore the prevalence of smoking in China. Effective strategies to reduce the high rate of smoking are also needed.

Mashita RJ; Themane MJ; Monyeki KD; Kemper HCG. Current smoking behaviour among rural South African children: Ellisras Longitudinal Study. BMC Pediatrics 11(e-article 58), 2011. (42 refs.)

Background: The use of tobacco products is the major cause of chronic diseases morbidity and mortality. Most smokers start the smoking habits from childhood and adolescent stages. Method: This was a cross-sectional study. A total of 1654 subjects (854 boys and 800 girls), aged 11 to 18 years, who were part of the Ellisras Longitudinal Study completed the questionnaire. Association between tobacco products use and habits, attitudes and beliefs were explored in this study. Logistic regression was used to estimate the association. Results: The prevalence of tobacco product use increases with increasing (4.9 to 17.1%) age among boys whereas girls do not smoke cigarette but only considerable number (1.0 to 4.1%) use home made tobacco products (pipe and snuff) among the Ellisras rural children. Parents and grand parents play a significant (about 50%) role in influencing smoking behaviour among the Ellisras rural children. Seeing actors smoking on TV shows was positively associated (p < 0.05) with smoking (OR = 2.3 95% CI (1.3-4.1 and OR = 2.3 95% CI 1.3-4.1 after adjusting for age and gender). However, women who smoke cigarette were significantly (p < 0.001) associated with success and success and wealth (OR = 2.8, 95% CI 1.5-5.2) even after adjusting for age and gender (OR = 2.9 95% CI 1.5-5.4). Conclusion: The usage of tobacco products was high among older boys. Girls did not smoke cigarette. This tobacco use behaviour mirrors the cultural norms and adult behaviour. The association of this tobacco used products with biological parameters will shed more light on the health of these children over time.

Mason WA; Kosterman R; Haggerty KP; Hawkins JD; Redmond C; Spoth RL et al. Gender moderation and social developmental mediation of the effect of a family-focused substance use preventive intervention on young adult alcohol abuse. Addictive Behaviors 34(6-7): 599-605, 2009. (39 refs.)

This study examined the long-term impact of Preparing for the Drug Free Years (PDFY) on young adult alcohol abuse disorder, addressing theory-based questions about how, and for whom. the program had its effects on the outcomes. Participants were 429 families of 6th graders enrolled in 33 rural schools located in the Midwestern United States. Schools were randomly assigned to conditions. Target adolescents (52% female) were interviewed periodically from age 11 to age 22; throughout adolescence, information was collected also from the youths' parents. Moderation and mediation analyses were conducted using regression analysis and structural equation modeling with covariates measured at baseline (age 11), mediators measured at posttest (age 12), and the outcome measured at the young adult follow-up (age 22). Results showed that PDFY reduced the rate of alcohol abuse among target young women, with evidence that this effect was mediated by increased prosocial skills. The rate of alcohol abuse among PDFY group men was not significantly different from that of control group men. Findings have implications for reducing the public health burden of alcohol abuse among young women.

Mason WA; Spoth RL. Longitudinal associations of alcohol involvement with subjective well-being in adolescence and prediction to alcohol problems in early adulthood. Journal of Youth and Adolescence 40(9): 1215-1224, 2011. (52 refs.)

Adolescent alcohol involvement is associated with numerous negative outcomes, but also appears to have positive correlates, including subjective well-being. Additional research is needed to understand these paradoxical findings. The current study examines alcohol use, adverse alcohol-related (and other substance-related) consequences, and subjective well being in adolescence, and prediction to problem alcohol use in early adulthood. Participants in this longitudinal study, which extended from age 11 to age 21, were 208 rural teens (109 girls) and their families. Covariates included early substance use, early conduct problems, early depressed mood, gender, and parent educational attainment. Structural equation modeling showed that subjective well-being at age 16 positively predicted increased alcohol use at age 18. Alcohol use was not a significant predictor of subjective well-being; however, alcohol use at age 18 positively predicted alcohol problems at age 21, even while controlling for earlier adverse consequences and other predictors. Results help to further elucidate both the negative and positive correlates of underage drinking, and support the value of delaying alcohol initiation.

Nasim A; Belgrave FZ; Corona R; Townsend TG. Predictors of tobacco and alcohol refusal efficacy for urban and rural African-American adolescents. Journal of Child & Adolescent Substance Abuse 18(3): 221-242, 2009. (69 refs.)

This study sought to determine the relative contributions of individual, family, peer, and community risk and promotive factors in explaining alcohol and tobacco refusal attitudes among 227 African-American adolescents (ages 12 to 17) from urban and rural areas. Hierarchical linear regression (HLR) results revealed differences in the predictive value of risk and promotive factors with respect to tobacco and alcohol refusal attitudes. Specifically, individual and peer risk factors were predictive of tobacco refusal attitudes among youths. Individual, peer, and family risk, and promotive factors were predictive of adolescents' alcohol refusal attitudes. Community factors were not significant predictors of youths' ability to refuse tobacco and alcohol, after controlling for more proximal influences. Future research should consider other psychosocial influences within an ecological framework that may account for additional variance in substance use altitudes among African-American adolescents.

Oser C; Leukefeld C; Staton-Tindall M; Duvall J; Garrity T; Stoops W et al. Criminality among rural stimulant users in the United States. Crime & Delinquency 57(4): 600- 621, 2011. (47 refs.)

Despite the increase in media attention on "meth cooking" in rural areas of the United States, little is known about rural stimulant use-particularly, the criminality associated with stimulant use. Data were collected from community stimulant users in rural Ohio, Arkansas, and Kentucky (N = 709). Findings from three logistic regression models indicate that younger stimulant users (M = 32.55, SD = 10.35), those with more convictions, and those who used crack frequently were significantly more likely to have been arrested for committing a substance-related crime, a property crime, or another crime in the 6 months before entering the study. Implications include the need for longitudinal studies to further understand rural stimulant use, as well as increased community and corrections-based drug abuse prevention and treatment interventions for stimulant users who live in rural areas.

Oser CB; Leukefeld CG; Tindall MS; Garrity TF; Carlson RG; Falck R et al. Rural drug users: Factors associated with substance abuse treatment utilization. International Journal of offender Therapy and Comparative Criminology 55(4): 567-586, 2011. (80 refs.)

The purpose of this study is to use a modified version of Andersen's Behavioral Model of Health Services Use to identify the correlates of the number of substance abuse treatment episodes received by rural drug users. Data were collected from face-to-face interviews with 711 drug users in rural areas of Ohio, Arkansas, and Kentucky. Descriptive analyses examine rural drug users' substance use histories and retrospective substance abuse treatment service utilization patterns. A negative binomial regression model indicated that selected predisposing, historical health, and enabling factors were significantly associated with the utilization of substance abuse treatment among rural drug users. Despite high levels of recent and lifetime self-reported substance use among these rural drug users, treatment services were underutilized. Future studies are needed to examine the impact of the health care system and characteristics of the external environment associated with rural substance abuse treatment in order to increase utilization among drug users.

Petrie DJ; Doran CM; Shakeshaft AP; Sanson-Fisher R. The relationship between risky alcohol consumption, crime and traffic accidents in Australian rural communities. Addictive Behaviors 35(4): 359-362, 2010. (20 refs.)

Aim: To estimate the alcohol-attributable crime and traffic accidents for rural communities in Australia, controlling for potential bias. Method: For 20 rural communities in New South Wales. Australia, crime and traffic accident data was obtained from police records along with risky alcohol use estimated from a postal questionnaire. The relationship between community levels of risky drinking and crime and traffic accidents that occur in alcohol-related times is analysed controlling for the underlying level of crime by using the rate of incidents that occur in non-alcohol-related times. Findings: For the 20 rural communities, it was estimated that risky alcohol use is likely to have attributed to between 1.4 and 7.7 common assaults per 1000 Population and between 0.6 and 1.8 serious traffic injuries or fatalities per 1000 population, every year. Conclusions: Rural communities in Australia are experiencing a sizeable amount of potentially avoidable harm due to risky alcohol use. Reducing the population levels of those drinking at risk of acute harm or improving the settings in which drinking takes place may have benefits for these communities, especially in terms of crime and traffic accidents.

Piercefield E; Archer P; Kemp P; Mallonee S. Increase in unintentional medication overdose deaths: Oklahoma, 1994-2006. American Journal of Preventive Medicine 39(4): 357-363, 2010. (19 refs.)

Background: During 1999-2006, rates of unintentional drug-related deaths increased 120% in the U.S. Purpose: This report describes demographics and trends of unintentional medication overdose deaths among Oklahoma residents to target prevention strategies. Methods: Oklahoma medical examiner data regarding fatal unintentional poisonings involving at least one prescription or over-the-counter medication during 1994-2006 and opioid retail sales data during 1997-2006 were analyzed during 2008-2009 to determine demographic-specific rates of overdose deaths and changes in 3-year mean death rates. Results: A total of 2112 fatal unintentional medication overdoses were identified (4.7 deaths/ 100,000 population) involving a median of two substances/decedent. The highest fatality rates occurred among men (5.9/100,000) and people aged 35-54 years (11/100,000). Crude overdose death rates increased sevenfold during the investigation period, peaking at 11/100,000 in 2006. Death rates increased more for women (ninefold) than men (sixfold); rates among residents of rural counties increased more (eightfold) than urban county rates (sixfold). Leading drug types involved in fatalities were opioids and anxiolytics. The individual drugs contributing most frequently included methadone (31%); hydrocodone (19%); alprazolam (15%); and oxycodone (15%). During 1997-2006, Oklahoma prescription opioid sales increased fourfold. Methadone was associated with the highest number of deaths per equianalgesic dose sold (23.3), whereas hydrocodone and oxycodone had the highest increases in deaths per equianalgesic dose sold (threefold increase each). Conclusions: Unintentional medication-related deaths are increasing in Oklahoma and often involve multiple substances. Substances most frequently contributing to deaths were prescription opioid analgesics. Prevention strategies should target people aged 35-54 years and emphasize the dangers of coingesting substances and misusing prescription pain medications.

Rey GN; Mora-Rios J; Sainz MT; Aguilar PM. An international perspective: Constructing intervention strategies for families in Mexico. Drugs: Education, Prevention and Policy 17(special issue): 193-202, 2010. (23 refs.)

In this article, the authors comment on the contribution of the Alcohol, Drugs and the Family research group to draw public and scientific attention to the suffering and needs of families coping with addiction problems. The article also describes the impact of the stress-strain-coping-support model and the 5-Step Method on the research, intervention and education domains in Mexico. Some of the limitations to positively influence public policy are underscored; these include the nature of the sociocultural context which favors the view of addictions as private problems that must be solved within the family. The experience of delivering the 5-Step Method to Mexican urban population and its adaptation to indigenous communities and web-based format are discussed as well. Overall, the development and implementation of the 5-Step Method in Mexico has been positive, as demonstrated particularly by a cost-effectiveness study carried out with indigenous communities. Based on this review, the scope and challenges for family intervention in Mexico are outlined considering: (1) the dissemination of the 5-Step Method in both the rural and urban contexts; (2) extensive training of family counsellors; and finally (3) policy making to fulfil the needs of families facing addictive problems.

Ruggiero KJ; Gros DF; McCauley J; de Arellano MA; Danielson CK. Rural adults' use of health-related information online: Data from a 2006 National Online Health Survey. Telemedicine and E-Health 17(5): 329-334, 2011. (38 refs.)

Objective: The objective of this study was to examine access and use of health-related information online in rural versus nonrural Internet users, using national data from the 2006 Pew Internet and American Life Project. Materials and Methods: A national telephone survey of 2,928 adults in August 2006 yielded a sample of 1,992 adults who use the Internet regularly. A structured interview was administered to assess frequency of Internet use and access and use of health-related information online. Results: Most Internet-using rural adults search for health-related information online; two-thirds seek information about specific medical problems and over half seek information about treatment. Three-fifths of rural adults surveyed stated that online health-related information affected the decisions they made in health maintenance and managing treatment of an illness. More than one-third reported being significantly helped by information they found, whereas one-fourth reported being confused. Comparisons between rural and nonrural Internet users suggested that rural users were more likely to seek information about smoking cessation (chi(2) [1, N = 1,990] = 7.91, p < 0.01) and mental health issues (chi(2) [1, N = 1,988] = 3.71, p = 0.05), less likely to seek information about a particular doctor or hospital (chi(2) [1, N = 1,983] = 15.49, p < 0.001), and more likely to report being helped (chi(2) [1, N = 1,534] = 5.24, p < 0.05)-but also confused (chi(2) [1, N = 1,592] = 9.83, p < 0.01)-by information they found. Conclusions: Rural Americans are increasingly using the Internet to acquire information about chronic disease, mental health, doctors, and treatment options. Priorities should include further development and rigorous evaluation of online resources to ensure high-quality, more direct tailoring of resources to rural families and development of tools to assist consumers in assessing the credibility of online information.

Schnarrs PW; Rosenberger JG; Satinsky S; Brinegar E; Stowers J; Dodge B et al. Sexual compulsivity, the internet, and sexual behaviors among men in a rural area of the United States. AIDS Patient Care and STDs 24(9): 563-569, 2010. (58 refs.)

Sexual compulsivity has been associated with higher frequencies of sexual behaviors that may increase risk for transmission of HIV and other sexually transmitted infections (STI). In a rural midwestern region where social and community resources for the sexual health of men who have sex with men (MSM) are relatively few, the patterns of partner-seeking and sexual behavior, and their relations to sexual compulsivity, may be different than findings from other assessments of men in urban centers. Using a community-based participatory approach (CBPR), data were collected from 309 men who were primarily white, identified as gay or homosexual, and had a mean age of 29.37 years (SD = 11.33), to explore relations between scores on a measure of sexual compulsivity and their sexual partner-seeking, drug and alcohol use, and sexual behaviors with men and women. The majority of men reported having engaged in sexual activity with men in the past 30 days. Those scoring higher than the sample mean (1.65 [SD = 0.66]) on the sexual compulsivity measure reported patterns of having sex with partners met online and having been the insertive or receptive partner in unprotected anal intercourse. Given the unique patterns of sexual partner-seeking in this area, interventions to decrease sexual risk-taking should take into account that the vast majority of men in rural areas are using the Internet to locate sexual partners, and prevention messages focused on rural contexts need to be tailored to include men who have a propensity for sexually compulsive behaviors. Additionally, interventions created for virtual spaces may be more sustainable with rural communities than traditional approaches to HIV/STI prevention.

Shannon LM; Havens JR; Mateyoke-Scrivner A; Walker R. Contextual differences in substance use for rural Appalachian treatment-seeking women. American Journal of Drug and Alcohol Abuse 35(2): 59-62, 2009. (20 refs.)

Objective: To examine differences in substance use among a sample of women entering treatment from rural Appalachian and non-Appalachian areas. Participants: A total of 2,786 women participating in state-funded substance abuse treatment programs statewide. Measures: Substance use measures were based on the SAMHSA CSAT Government Performance and Results Act (GPRA) gathering information on lifetime and past 12-month use of alcohol, marijuana, opiates, sedatives/tranquilizers, cocaine, and stimulants. Results: Women entering treatment in rural Appalachia had disproportionately high rates of opiate and sedative/tranquilizer use while methamphetamine, cocaine, marijuana, and alcohol were more prevalent for women in non-Appalachian areas. Conclusions: Women entering treatment in rural Appalachia were significantly more likely to report opiate and sedative/tranquilizer use compared to non-Appalachian women. In order to begin to understand the elevated rates of prescription drug abuse in rural Appalachian Kentucky, substance use must be considered within the context of demographic, geographic, social, and economic conditions of the region.

Shannon LM; Havens JR; Hays L. Examining differences in substance use among rural and urban pregnant women. American Journal on Addictions 19(6): 467-473, 2010. (52 refs.)

Substance use during pregnancy is a major public health concern. This study examined differences in substance use among pregnant women from rural and urban areas. Participants were 114 pregnant women entering a hospital-based inpatient detoxification unit primarily for Opiate Dependence who voluntarily agreed to a face-to-face interview. Substance use measures were based on the Addiction Severity Index gathering information about lifetime, past 12 months, and 30 days prior to admission. Rural pregnant women had higher rates of illicit opiate use, illicit sedative/benzodiazepine use, and injection drug use (IDU) in the 30 days prior to admission. Additionally, a greater proportion of rural pregnant women reported the use of multiple illegal/illicit substances in the 30 days prior to entering detoxification. More specifically, pregnant women from rural areas were 8.4 times more likely to report illicit opiate use, 5.9 times more likely to report IDU, 3.3 times more likely to report illicit sedative/benzodiazepine use, and 2.8 times more likely to report the use of multiple illegal/illicit substances in the 30 days prior to entering inpatient detoxification, after adjustment for socio-demographic characteristics (including education and income), pregnancy characteristics, physical and mental health indicators, and criminal justice system involvement. The increased rates of prescription opiate and benzodiazepine use as well as IDU among rural pregnant women are concerning. In order to begin to understand the elevated rates of substance abuse among rural pregnant women, substance use must be considered within the context of demographic, geographic, social, and economic conditions of the region.

Shidhaye R; Patel V. Association of socio-economic, gender and health factors with common mental disorders in women: a population-based study of 5703 married rural women in India. International Journal of Epidemiology 39(6): 1510-1521, 2010. (59 refs.)

Background: There are few population-based studies from low- and middle-income countries that have described the association of socioeconomic, gender and health factors with common mental disorders (CMDs) in rural women. Methods: Population-based study of currently married rural women in the age group of 15-39 years. The baseline data are from the National Family Health Survey-II conducted in 1998. A follow-up study was conducted 4 years later in 2002-03. The outcome of CMD was assessed using the 12-item General Health Questionnaire (GHQ-12). Due to the hierarchical nature and complex survey design, data were analysed using mixed-effect logistic regression with random intercept model. Results A total of 5703 women (representing 83.5% of eligible women) completed follow-up. The outcome of CMD was observed in 609 women (10.7%, 95% confidence interval 9.8-11.6). The following factors were independently associated with the outcome of CMD in the final multivariable model: higher age, low education, low standard of living, recent intimate partner violence (IPV), husband's unsatisfactory reaction to dowry, husband's alcohol use and women's own tobacco use. Conclusions: Socio-economic and gender disadvantage factors are independently associated with CMDs in this population of women. Strategies that address structural determinants, for example to promote women's education and reduce their exposure to IPV, may reduce the burden of CMDs in women.

Shuaib F; Foushee HR; Ehiri J; Bagchi S; Baumann A; Kohler C. Smoking, sociodemographic determinants, and stress in the Alabama Black belt. Journal of Rural Health 27(1): 50-59, 2011. (54 refs.)

Purpose: In the Alabama Black Belt, poverty is high, and the educational level is low. Studies have found increased tobacco use among individuals exposed to high levels of stress. Few studies have been conducted in this region to measure smoking status, its sociodemographic determinants, and how smoking status relates to stressful environmental conditions. Methods: A cross-sectional questionnaire survey of 1,387 individuals. Findings: Approximately 25% of the respondents currently smoked cigarettes. Females were less likely to smoke compared to males (OR, 0.29; 95% CI, 0.23-0.38). Blacks were less likely to smoke cigarettes compared to whites (OR, 0.64; 95% CI, 0.43-0.95). Compared to individuals who were employed, participants who were unemployed or retired had increased odds of smoking (OR, 1.68; 95% CI, 1.15-2.20). The odds of being a current smoker were increased in the presence of moderate level stress (OR, 2.06; 95% CI, 1.38-3.07) or when there was a high level of stress (OR, 2.21; 95% CI, 1.47-3.31). Smoking was associated with increased odds of having a moderate level (OR, 2.06; 95% CI, 1.38-3.08) and a high level of stress (OR, 2.21; 95% CI, 1.47-3.32). Females who reported moderate to high levels of stress had increased odds of being smokers compared to males. Interaction between gender and stress showed deviation from additivity. Conclusion: Our findings suggest a high rate of cigarette use in the area. Increased stress levels appear to predispose females more than males to cigarette smoking. The implications of this association may guide interventions targeted at reducing smoking and its complications.

Spoth R; Trudeau L; Guyll M; Shin C; Redmond C. Universal intervention effects on substance use among young adults mediated by delayed adolescent substance initiation. Journal of Consulting and Clinical Psychology 77(4): 620-632, 2009. (61 refs.)

In this article, the authors examine whether delayed substance initiation during adolescence, achieved through universal family-focused interventions conducted in middle school, can reduce problematic substance use during young adulthood. Sixth-grade students enrolled in 33 rural midwestern schools and their families were randomly assigned to 3 experimental conditions. Self-report questionnaires provided data at 7 time points for the Iowa Strengthening Families Program (ISFP), Preparing for the Drug Free Years (PDFY), and control groups through young adulthood. Five young adult substance frequency measures (drunkenness, alcohol-related problems, cigarettes, illicit drugs, and polysubstance use) were modeled as distal outcomes affected by the average level and rate of increase in substance initiation across the adolescent years in latent growth curve analyses. Results show that the models fit the data and that they were robust across outcomes and interventions, with more robust effects found for ISFP. The addition of direct intervention effects on young adult outcomes was not supported, suggesting long-term effects were primarily indirect. Relative reduction rates were calculated to quantify intervention-control differences on the estimated proportion of young adults indicating problematic substance use; they ranged from 19% to 31% for ISFP and from 9% to 16% for PDFY.

Stickley A; Razvodovsky Y. Alcohol poisoning in Belarus: A comparison of urban-rural trends, 1990-2005. Alcohol and Alcoholism 44(3): 326-331, 2009. (35 refs.)

Aim: The aim of this study was to investigate the occurrence of alcohol poisoning in urban and rural regions of Belarus in the post-Soviet period. Methods: All-age male and female alcohol-poisoning mortality and population data were obtained for the years 1990, 1995, 2000 and 2005 for urban and rural regions of Belarus. These data were subsequently recalculated into three age categories and directly standardized. Poisson regression models were used to assess relative changes in rural-urban alcohol-poisoning rates across time. Results: Although extremely high in comparative terms in 1990, alcohol-poisoning rates had nevertheless risen considerably amongst men and women in all age groups in both urban and rural regions by 2005. In rural regions, the rise was continuous while amongst the urban population a small reduction was recorded in 2000 after a comparatively larger rise in 1995. By 2005, although alcohol-poisoning rates were significantly higher amongst rural men and women, the levels of acute alcohol mortality were nevertheless extremely high in nearly every age group in both urban and rural locations. Conclusions: It is probable that both the level and pattern of alcohol consumption in conjunction with the increasing use of illegal alcohol underlie the extremely high alcohol-poisoning rates in contemporary Belarus, and the growing rural-urban divergence in alcohol-poisoning mortality observed in recent years. Immediate action is now required to improve the poor social and economic conditions underpinning extreme levels of acute alcohol mortality, as well as to increase the provision of alcohol treatment services, especially in rural areas.

Stoops WW; Dallery J; Fields NM; Nuzzo PA; Schoenberg NE; Martin CA; Casey B; Wong CJ. An Internet-based abstinence reinforcement smoking cessation intervention in rural smokers. Drug and Alcohol Dependence 105(1/2): 56-62, 2009. (43 refs.)

The implementation of cigarette smoking abstinence reinforcement programs may be hindered by the time intensive burden placed on patients and treatment providers. The use of remote monitoring and reinforcement of smoking abstinence may enhance the accessibility and acceptability of this intervention, particularly in rural areas where transportation can be unreliable and treatment providers distant. This study determined the effectiveness of an Internet-based abstinence reinforcement intervention in initiating and maintaining smoking abstinence in rural smokers. Sixty-eight smokers were enrolled to evaluate the efficacy of an Internet-based smoking cessation program. During the 6-week intervention period, all participants were asked to record 2 videos of breath carbon monoxide (CO) samples daily. Participants also typed the value of their CO readings into web-based software that provided feedback and reinforcement based on their smoking status. Participants (n=35) in the Abstinence Contingent (AC) group received monetary incentives contingent on recent smoking abstinence (i.e., CO of 4 parts per million or below). Participants (n=33) in the Yoked Control (YC) group received monetary incentives independent of smoking status. Participants in the AC group were significantly more likely than the YC group to post negative CO samples on the study website (OR=4.56; 95% CI=2.18-9.52). Participants assigned to AC were also significantly more likely to achieve some level of continuous abstinence over the 6-week intervention compared to those assigned to YC. These results demonstrate the feasibility and short-term efficacy of delivering reinforcement for smoking abstinence over the Internet to rural populations.

Swaim RC; Stanley LR. Rurality, region, ethnic community make-up and alcohol use among rural youth. Journal of Rural Health 27(1): 91-102, 2011. (39 refs.)

Purpose: As the most widely used substance among adolescents in the United States, alcohol remains a critical public health issue. The majority of research in this area has focused on individual-level variables. This study examined the contextual effects of rurality, geographic region, and community ethnicity in the prediction of alcohol use among adolescent youth. Method: Participants were 7th-12th grade students from a sample of 260 rural communities across the United States, with oversampling for predominantly Mexican American and African American communities. The total sample comprised 213,225 students. Multilevel modeling was used to estimate both individual and contextual effects for use of alcohol and getting drunk. Findings: Those living in more rural communities were somewhat more likely to have used alcohol and gotten drunk than their less rural counterparts. Consistent with a trend toward a narrowing gender gap across a number of substances, gender differences in alcohol use were not large, except in the South. A minority in a community, eg, a white student in an African American community, had greater risk for alcohol use and getting drunk. Conclusions: Models of alcohol use among rural youth that include only individual-level variables are likely to result in misleading results. While students from varying levels of rurality may not differ substantially from one another, geographic region and minority status within communities are likely to interact with individual-level variables, resulting in unique patterns of alcohol use and getting drunk.

Thomas D; Johnston V; Fitz J. Lessons for Aboriginal tobacco control in remote communities: An evaluation of the Northern Territory 'Tobacco Project'. Australian and New Zealand Journal of Public Health 34(1): 45-49, 2010. (18 refs.)

Objective: To evaluate a Northern Territory (NT) government-led pilot 'Tobacco Project' in six remote communities. Methods: Monthly surveys of staff, semi-structured interviews with staff and community members, observation of the delivery of tobacco control interventions, review of Project documents, and monitoring of tobacco consumption using sales (or wholesale orders) of tobacco. Results: There was a substantive amount of tobacco control activity delivered in three of the Project communities. In two of these locations, the majority of work was primarily driven and undertaken by resident staff. Overall, most of the Project's efforts related to community education and awareness-raising. There was variable impact of the Project on tobacco consumption across the six communities. More tobacco control activity was consistently associated with a greater reduction in tobacco consumption. An important predictor of local activity was the presence of strong community drivers. A significant obstacle to the Project was the lack of new resources. Conclusions: Despite the minimal impact of this Project on tobacco consumption overall, there was a consistent association between on-the-ground tobacco control activity and reductions in tobacco consumption. Implications: New initiatives will not only need to provide new funding, but identify and then support local staff, who are central to improving local tobacco control activity and so reducing smoking and smoking-related illnesses and deaths.

Thomas JL; Renner CC; Patten CA; Decker PA; Utermohle CJ; Ebbert JO. Prevalence and correlates of tobacco use among middle and high school students in western Alaska. International Journal of Circumpolar Health 69(2): 168-180, 2010. (38 refs.)

Objectives. Tobacco use is the leading cause of preventable death in the United States and contributes to increased incidence, morbidity and mortality from cancer, heart disease, stroke, complications of pregnancy and respiratory illness. Tobacco use rates are highest among American Indians and Alaska Natives. This study examined the prevalence and correlates of tobacco use among youth residing in rural western Alaska. Study design. Data were analysed from the 2003 Youth Risk Behavior Survey (YRBS) administered to a regional sample of adolescents attending school in western Alaska. Methods. Data were analysed from 260 middle school (52% female, 87% Alaska Native) and 258 high school (48% female, 93% Alaska Native) students. Results. Among middle school students, 39% reported current use of ST, 24% reported cigarette smoking and 50% reported current use of any tobacco product. On multivariate analysis, independent correlates of current use of any tobacco were Alaska Native ethnicity (p=0.002) and ever use of marijuana (p<0.001). Among high school students, 38% reported current ST use, 43% reported cigarette smoking and 60% reported current use of any tobacco product. Independent correlates of current use of any tobacco were increasing age (p=0.007), ever use of marijuana (p<0.001), current use of marijuana (p=0.005) and reporting a suicide attempt within the past 12 months (p=0.003). No significant gender differences on tobacco use emerged for middle or high school students. Conclusions. This study documents the high tobacco use rates among youth residing in western Alaska, with over half of the adolescents reporting tobacco use. Developing interventions to promote tobacco use prevention and cessation is an essential step towards reducing tobacco-related health disparities in this rural population. Expanded efforts are needed to address tobacco use among youth residing in this region of Alaska.

Valentine G; Holloway SL; Jayne M. Generational patterns of alcohol consumption: Continuity and change. Health & Place 16(5): 916-925, 2010. (63 refs.)

In most contemporary western societies there is growing concern about rising levels of alcohol consumption, particularly by young people, even in countries, such as France, which have previously been assumed to have 'sensible' drinking cultures Recent popular and policy debates about British drinking cultures have hinted at a shift in generational attitudes towards alcohol, as well as patterns of consumption. Previous intergenerational studies of work and care have found that in particular historical periods different normativities develop, reflecting both social and economic conditions. In this paper, we draw on a research project about alcohol consumption conducted in an urban and rural area - including intergenerational interviews with case study families - to identify the different normativities in terms of attitudes towards and consumption of alcohol experienced by three cohort generations in their youth. The paper then goes on to explore the patterns of both change and continuity that are evident in the interviewees' experiences. The conclusion reflects on drivers of intergenerational change and associated health policy implications.

Van Hout MC. Differentiated normalization and drug transitions among rural youth in Ireland. Drugs: Education, Prevention and Policy 18(2): 124-131, 2011. (36 refs.)

Prevalence surveys in Ireland indicate an increased trend of youth drug use with rural areas reporting comparable drug availability and prevalence of use in urban settings (Currie, C., Nic Gabhainn, S., Godeau, E., Roberts, C., Smith, R., & Currie, D. (Eds.). (2008). Inequalities in young people's health: HBSC international report from the 2005/2006 survey. Copenhagen: WHO Regional Office for Europe). Few studies have explored the contexts and meaning of drug use on rural youth transitions in terms of increased drug prevalence, recent influx of rural drug activity, normative tolerance of recreational drug consumption and fragmentation of traditional rural communities. Qualitative interviews were conducted with 220 young people (15-17 years), and 78 service providers in a rural area of Ireland, in order to yield contextualized narratives of their experiences of drug use and achieve a wider exploration of processes, drug transitions and realities of rural youth. The thematic analysis of the research described varied pathways, attitudes and typologies of rural youth drug use, ranging from abstinent, recreational and moderated to maturing out. The research suggests support for a 'differentiated' normalization theory (Shildrick, T. (2002). Young people, illicit drug use and the question of normalisation theory. Journal of Youth Studies, 5, 35-48) in terms of consumerist and normative rural youth drug use transitions in their negotiation of risk within integrating rural and urban dichotomies. In conclusion, it is recommended that drug education programmes need to situate localized rural drug taking behaviours within a wider understanding of rural community life.

Vander Weg MW; Cunningham CL; Howren MB; Cai XY. Tobacco use and exposure in rural areas: Findings from the Behavioral Risk Factor Surveillance System. Addictive Behaviors 36(3): 231-236, 2011. (40 refs.)

Evidence suggests that those residing in rural areas may be disproportionately affected by the health burden of tobacco use.. The present study examined tobacco use, self-reported exposure to tobacco smoke, and policies regarding public smoking according to area of residence, using data from the 2006 and 2008 Behavioral Risk Factor Surveillance System. Results indicated that, relative to those from suburban and urban locations, adults residing in rural areas were significantly more likely to smoke cigarettes (22.2% versus 17.3% (suburban) and 18.1% (urban), p<.001) and to use smokeless tobacco (p<.001). Rural residents were also more likely than those living in suburban and urban areas to report that someone had smoked in their presence during the past seven days both at home (p<.001) and at work (p<.001). Finally, rural participants reported policies that afforded less protection from tobacco smoke both at home and in the workplace. These findings suggest that those living in rural areas are at increased risk for tobacco-related illness due to both their own tobacco use and exposure to others' cigarette smoke.

Walsh MM; Langer TJ; Kavanagh N; Mansell C; MacDougal W; Kavanagh C et al. Smokeless tobacco cessation cluster randomized trial with rural high school males: Intervention interaction with baseline smoking. Nicotine & Tobacco Research 12(6): 543-550, 2010. (34 refs.)

Adolescent males in rural areas use smokeless tobacco (ST). We assessed the efficacy of a school-based nurse-directed ST intervention among rural high school males. Study high schools were randomly selected from a public high school list of California rural counties. Consenting high schools were stratified by school size and randomly assigned within strata to intervention or no-intervention groups. After gaining parental consent, male students completed baseline and 1-year follow-up questionnaires. The intervention included peer-led educational sessions and an oral exam by the school nurse who also provided brief tobacco cessation counseling. We used binary generalized estimating equation (GEE) models accounting for clustering within schools to test no difference between groups after adjusting for year in high school using both completers only and multiple imputation for those lost to follow-up. Subgroup analyses assessed Baseline Factor x Group interaction in GEE models. Twenty-one rural counties (72%), 41 randomly selected high schools (56%), and 4,731 male students (50%) participated with 65% retention. Nonsmoking ST users in the intervention group were significantly more likely to stop using ST at follow-up than those in the no-intervention group; there was no intervention effect among baseline ST users who also smoked. A higher percentage of baseline nonsmoking ST users reported smoking at follow-up than baseline non-ST-using smokers who reported using ST. A school-based nurse-directed ST cessation program was efficacious among rural nonsmoking ST-using high school males. The potential program reach holds significant public health value. Baseline ST use facilitated smoking at follow-up.

Webster JM; Dickson MF; Duvall JL; Clark DB. Rural and urban differences in Kentucky DUI offenders. Journal of Addiction Medicine 4(3): 186-190, 2010. (26 refs.)

Objectives: Recent national data suggest that the prevalence of driving under the influence (DUI) is higher in rural areas than in more urbanized areas of the United States. However, little is known about rural DUI offenders, particularly those living in very remote areas. This study was conducted to examine the similarities and differences between rural and urban DUI offenders. Based on recent research, it was expected that few differences would be found between rural and urban DUI offenders. Methods: This study examined a total of 21,135 substance abuse assessment records for persons convicted of DUI in Kentucky and who concluded treatment in 2005. Assessment records included demographic characteristics, Alcohol Use Disorders Identification Test scores, Drug Abuse Screening Test scores, and the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision substance use disorder checklist. Beale codes based on county of residence were used to create comparison groups. Results: Positive, and statistically significant, associations were found between rurality and Drug Abuse Screening Test scores, Diagnostic and Statistical Manual of Mental Disorders Fourth Edition substance abuse and dependence disorders, and rates of education/treatment noncompliance. Alcohol Use Disorders Identification Test scores were negatively associated with rurality. Conclusions: The study suggests that the problem severity among DUI offenders may be greater in rural areas. Given the lack of treatment services in rural areas, practitioners may face greater challenges in assessing and providing appropriate treatment for this group of DUI offenders, which may put them at greater risk for continued impaired driving.

Webster JM; Oser CB; Mateyoke-Scrivner A; Cline VD; Havens JR; Leukefeld CG. Drug use and criminal activity among rural probationers with DWI histories. International Journal of Offender Therapy and Comparative Criminology 53(6): 717-730, 2009. (33 refs.)

The present study examined whether ever being arrested for driving under the influence (DUI) was associated with higher levels of substance use and criminal activity in a sample of 800 probationers. Lifetime and 30-day histories of substance use and criminal activity were compared across three groups of probationers from rural Kentucky: those with a single DUI arrest, those with two or more DUI arrests, and those with no DUI arrests. A larger percentage of probationers with a DUI arrest reported lifetime and 30-day substance use than non-DUI offenders in almost all drug and alcohol categories. Higher prevalence of criminal activity was limited primarily to the multiple DUI arrest group. Findings add to the literature on rural substance abusers and indicate that DUI may be used as a marker to help identify opportunities for targeted substance abuse interventions.

Webster JM; Pimentel JH; Harp KLH; Clark DB; Staton-Tindall M. Substance abuse problem severity among rural and urban female DUI offenders. American Journal of Drug and Alcohol Abuse 35(1): 24-27, 2009. (25 refs.)

Objectives: Although there has been an overall decline in the rates of driving under the influence (DUI) over the past two decades, this decrease has not occurred uniformly across all groups of DUI offenders. For example, the proportion of female DUI offenders has significantly increased. Furthermore, DUI arrest rates remain higher in less populated areas of the country. The present study examines indicators of problem severity among female DUI offenders across graduated levels of rurality. Methods: A total of 19,094 substance abuse assessment records from females convicted of DUI between 2002 and 2006 in Kentucky were examined. Beale codes were used to define the extent to which the county of conviction was rural. Results: Rurality was significantly and positively associated with multiple DUI offenses, being underage, drug problems, prevalence of DSM-IV-TR substance dependence and abuse criteria, being referred to substance abuse treatment rather than an education only intervention, and referral noncompliance. Blood alcohol concentration and alcohol problems were inversely related to rurality. Conclusion: The study suggests that problem severity among female DUI offenders may be greater in rural areas and could produce challenges for practitioners who assess and treat rural female DUI offenders.

Weiss S. Cross-addiction on campus: More problems for student-athletes. Substance Use & Misuse 45(10): 1525-1541, 2010. (61 refs.)

Data on 503 students from rural and urban areas were collected from January 2009 to October 2009 to test for cross-addiction of alcohol dependency with disordered gambling among college athletes and nonathletes. To test for alcohol dependency, the Michigan Alcohol Screening Test (MAST) was employed, while the South Oaks Gambling Screen (SOGS) was utilized to assess gambling behaviors. Athletes had higher frequencies of cross-addiction. For athletes there was a correlation between scores on the MAST and SOGS. Limitations related to data collection are discussed. Recommendations for further research directed toward the development of programs geared to assist students are given.

Wu JQ; Yang TZ; Rockett IRH; Xing R; Karalic S; Li YY et al. Nicotine dependence among rural-urban migrants in China. BMC Public Health 11(e-article 296), 2011. (25 refs.)

Background: The complex mechanism of nicotine dependency makes it challenging to evaluate dependence or progress towards dependence. The aim of this study was to estimate nicotine dependence levels and identify determinants of dependence among Chinese rural-urban migrants. Methods: Multi-stage systematic sampling was used to select 4,198 rural-urban migrants aged 18 years or older from three metropolises in China. A structured questionnaire was administered during face-to-face interviews. Nicotine dependence among participants was assessed by means of the six-item Mandarin Chinese Version of the Fagerstrom Test for Nicotine Dependence (CFTND). Determinants of dependence were analyzed using multivariate analysis of variance (MANOVA). Results: Among 4,198 participants, estimated current, daily, and occasional smoking rates were 28.3%, 21.2%, and 7.1%, respectively. The CTFND score for the 894 daily smokers was 3.39(SD: 2.32). MANOVA showed that work type, age at first migration, length of migration, and number of cities ever lived were associated with nicotine dependence. Conclusion: A migratory lifestyle is associated with nicotine dependence. Results could inform the design of tobacco control programs that target Chinese rural-urban migrant workers as a special at-risk population.

Wunsch M; Nakamoto K; Behonick G; Massello W. Opioid deaths in rural Virginia: A description of the high prevalence of accidental fatalities involving prescribed medications. American Journal on Addictions 18(1): 5-14, 2009. (30 refs.)

In rural Virginia, drug overdose deaths increased 300% from 1997 to 2003. Polydrug deaths predominate (57.9%) in this review of 893 medical examiner cases. Prescription opioids (74.0%), antidepressants (49.0%), and benzodiazepines (39.3%) were more prevalent than illicit drugs. Two-thirds of decedents were 35-54 years old; 37% were female. When compared to western Virginia metropolitan cases, polydrug abuse was more common, specific medication combinations were found, the death rate per population was higher, and fewer illicit drugs were detected. These rural prescription overdose deaths differ from urban illicit drug deaths, suggesting the need for different strategies in prevention, treatment, and intervention by clinicians and policymakers.

Yang T; Wu J; Rockett IRH; Abdullah AS; Beard J; Ye J. Smoking patterns among Chinese rural-urban migrant workers. Public Health 123(11): 743-749, 2009. (31 refs.)

Objectives: To estimate smoking prevalence and identify correlates of smoking initiation among rural urban migrant workers. Study design: Subjects were 4198 rural-urban migrant workers, aged 18 years and older, residing in three Chinese cities. Methods: Participants were identified through multistage quota sampling. They were asked about their migration history, pre-migration and post-migration smoking status, employment and home life. Analyses were conducted using Chi-squared test and multiple logistic regression. Results: Overall, smoking prevalence was higher subsequent to migration (28.4%) compared with before migration (20.8%) (P < 0.01). Initiation of daily smoking was associated with gender [ odds ratio (OR) 0.02]; high school or greater education (OR 0.48; vs elementary school or lower); having a monthly personal income of 1000-1999 Yuan (OR 2.60), 2000-2999 Yuan (OR 3.08) or >= 3000 Yuan (OR 4.04) (vs <500 Yuan US$ 1 = 7.5 Yuan); and history of migration to three cities (OR: 1.65) or four or more cities (OR 2.80) (vs one city). Initiation of occasional smoking was only associated with gender (OR 0.11). Solitude was the primary situational trigger for smoking initiation. Conclusions: A migratory lifestyle is associated with smoking initiation. Findings could inform the design of tobacco control programmes that would target Chinese rural-urban migrant workers as a special population.

Yang TZ; Abdullah ASM; Mustafa J; Chen B; Yang XZ; Feng XX. Factors associated with smoking cessation among Chinese adults in rural China. American Journal of Health Behavior 33(2): 125-134, 2009. (32 refs.)

Objectives: To examine the factors associated with smoking cessation among adult Chinese males in rural China. Methods: The data were collected by face-to-face Interviews at the respondents' household using interviewer-administered questionnaires. Results: The factors associated with quitting were being residents of Guiyang, having received junior or high school education, being unmarried, being a farmer or other job holder, smoking fewer than 20 cigarettes per day, starting smoking late, smoking for shorter duration, and having a high mean score on hedonism seeking. Conclusions: Several predictors of successful quitting were identified that could help improve smoking cessation programs in China. The findings also have implications for the need for future surveys on the quitting process among rural Chinese.

York NL; Rayens MK; Zhang M; Jones LG; Casey BR; Hahn EJ. Strength of tobacco control in rural communities. Journal of Rural Health 26(2): 120-128, 2010. (29 refs.)

Purpose: This study aimed to: (a) describe the Strength of Tobacco Control (SoTC) capacity, efforts and resources in rural communities, and (b) examine the relationships between SoTC scores and sociodemographic, political, and health-ranking variables. Methods: Data were collected during the baseline preintervention phase of a community-based randomized, controlled trial. Rural counties were selected using stratified random sampling (n = 39). Key informant interviews were employed. The SoTC, originally developed and tested with states, was adapted to a county-level measure assessing capacity, efforts, and resources. Univariate analysis and bivariate correlations assessed the SoTC total score and construct scores, as well as their relationships. Multiple regression examined the relationships of county-level sociodemographic, political, and health-ranking variables with SoTC total and construct scores. Findings: County population size was positively correlated with capacity (r = 0.44; P < .01), efforts (r = 0.54; P = .01), and SoTC total score (r = 0.51; P < .01). Communities with more resources for tobacco control had better overall county health rankings (r = .43; P < .01). With population size, percent Caucasian, tobacco production, and smoking prevalence as potential predictors of SoTC total score, only population size was significant. Conclusions: SoTC scores may be useful in determining local tobacco control efforts and appropriate planning for additional public health interventions and resources. Larger rural communities were more likely to have strong tobacco control programs than smaller communities. Smaller rural communities may need to be targeted for training and technical assistance. Leadership development and allocation of resources are needed in all rural communities to address disparities in tobacco use and tobacco control policies.

Young AM; Havens JR; Leukefeld CG. Route of administration for illicit prescription opioids: A comparison of rural and urban drug users. Harm Reduction Journal 7(e-24), 2010. (68 refs.)

Background: Nonmedical prescription opioid use has emerged as a major public health concern in recent years, particularly in rural Appalachia. Little is known about the routes of administration (ROA) involved in nonmedical prescription opioid use among rural and urban drug users. The purpose of this study was to describe rural-urban differences in ROA for nonmedical prescription opioid use. Methods: A purposive sample of 212 prescription drug users was recruited from a rural Appalachian county (n = 101) and a major metropolitan area (n = 111) in Kentucky. Consenting participants were given an interviewer-administered questionnaire examining sociodemographics, psychiatric disorders, and self-reported nonmedical use and ROA (swallowing, snorting, injecting) for the following prescription drugs: buprenorphine, fentanyl, hydrocodone, hydromorphone, methadone, morphine, OxyContin (R) and other oxycodone. Results: Among urban participants, swallowing was the most common ROA, contrasting sharply with substance-specific variation in ROA among rural participants. Among rural participants, snorting was the most frequent ROA for hydrocodone, methadone, OxyContin (R), and oxycodone, while injection was most common for hydromorphone and morphine. In age-, gender-, and race-adjusted analyses, rural participants had significantly higher odds of snorting hydrocodone, OxyContin (R), and oxycodone than urban participants. Urban participants had significantly higher odds of swallowing hydrocodone and oxycodone than did rural participants. Notably, among rural participants, 67% of hydromorphone users and 63% of morphine users had injected the drugs. Conclusions: Alternative ROA are common among rural drug users. This finding has implications for rural substance abuse treatment and harm reduction, in which interventions should incorporate methods to prevent and reduce route-specific health complications of drug use.

Yun EH; Kang YH; Lim MK; Oh JK; Son JM. The role of social support and social networks in smoking behavior among middle and older aged people in rural areas of South Korea: A cross-sectional study. BMC Public Health 10(78), 2010. (58 refs.)

Background: Although the number of studies on anti-smoking interventions has increased, studies focused on identifying social contextual factors in rural areas are scarce. The purpose of this study was to explore the role of social support and social networks in smoking behavior among middle and older aged people living in rural areas of South Korea. Methods: The study employed a cross-sectional design. Participants: included 1,057 adults, with a mean age of 60.7 years, residing in rural areas. Information on participants' tobacco use, stress, social support, and social networks was collected using structured questionnaires. The chi-square test, the t-test, ANOVA, and logistic regression were used for data analysis. Results: The overall smoking prevalence in the study was 17.4% (men, 38.8%; women, 5.1%). Overall, stress was high among women, and social support was high among men. Smokers had high levels of social support (t = -2.90, p = .0038) and social networks (t = -2.22, p = .0271), as compared to non-and former smokers. Those in the high social support group were likely to be smokers (AOR = 2.21, 95% CI 1.15-4.26). Women with moderate social ties were less likely to smoke (AOR = 0.18, 95% CI 0.05-0.61). Conclusion: There was a protective role of a moderate social network level among women, and a high level of social support was associated with smoking behaviors in rural areas. Findings suggest the need for a comprehensive understanding of the functions and characteristics of social contextual factors including social support and social networks in order to conduct more effective anti-smoking interventions in rural areas.

Zhou L; Conner KR; Phillips MR; Caine ED; Xiao SY; Zhang RL et al. Epidemiology of alcohol abuse and dependence in rural Chinese men. Alcoholism: Clinical and Experimental Research 33(10): 1770-1776, 2009. (25 refs.)

Background: Several national and regional epidemiological studies in China have reported increases in the prevalence of alcohol use disorders over the past 3 decades. Methods: This cross-sectional study conducted in 2007 identified 11,884 male subjects aged 18 to 60 years using multi-stage randomized cluster sampling methods in 2 rural communities in China and interviewed 9,866 of them. Current and lifetime alcohol use disorders were assessed with a semi-structured diagnostic interview. Results: The age-standardized prevalence of current (lifetime) alcohol abuse and alcohol dependence in Hunan were 1.8% (4.8%) and 4.7% (8.6%) respectively, and those in Henan were 7.6% (11.8%) and 8.7% (10.8%). Higher age (55 to 60) and lower education were risk factors for alcohol dependence in Hunan while middle age (35 to 44), currently married, and higher education and higher income were risk factors in Henan. Conclusions: Alcohol abuse and dependence are no longer uncommon disorders among rural men in China. Unlike most western reports, alcohol dependence shows higher prevalence than abuse. There are significant differences in the prevalence of alcohol use disorders and the socio-demographic profile of affected individuals in the 2 different regions of the country.

Zhou LA; Conner KR; Caine ED; Xiao SY; Xu LY; Gong Y et al. Epidemiology of alcohol use in rural men in two provinces of China. Journal of Studies on Alcohol and Drugs 72(2): 333-340, 2011. (24 refs.)

Objective: Alcohol use in China has substantially increased during the last three decades. The objectives of this study were to examine the sociodemographic patterning of alcohol consumption and to explore the relationship between (a) heavy drinking and frequent acute intoxication and (b) type of alcohol consumed. Method: A cross-sectional survey of 18- to 60-year-old men in Hunan and Henan Provinces in 2007 used multistage, randomized clustered sampling to identify 11,884 subjects; 9,866 (83.0%) of them were interviewed. Results: The weighted prevalence of 3-month drinking was 61.4% in Hunan and 68.2% in Henan. Among current drinkers, the median daily consumption of pure alcohol in Hunan and Henan were 16.5 ml and 17.9 ml, respectively; 16.6% in Hunan and 22.3% in Henan met criteria for heavy drinking (average daily pure alcohol consumption >= 50 ml); and 3.0% in Hunan and 7.3% in Henan reported frequent intoxication. Adult men with lower education in Hunan and those with higher family incomes in Henan were more likely to engage in heavy drinking; those who were unmarried in Hunan and those with higher incomes in Henan were more likely to be intoxicated frequently. In both provinces, those who consumed distilled spirits were at higher risk for heavy drinking and frequent intoxication. Conclusions: The majority of rural adult men in both provinces drink alcohol and a substantial minority -- particularly those who consume distilled spirits -- are heavy drinkers and report more frequent acute intoxication. The consumption of distilled spirits may be a useful target of intervention to reduce the prevalence of heavy drinking and the experience of intoxication.

Ziller EC; Anderson NJ; Coburn AF. Access to rural mental health services: Service use and out-of-pocket costs. Journal of Rural Health 26(3): 214-224, 2010. (28 refs.)

Purpose: To examine rural-urban differences in the use of mental health services (mental health and substance abuse office visits, and mental health prescriptions) and in the out-of-pocket costs paid for these services. Methods: The pooled 2003 and 2004 Medical Expenditure Panel Surveys were used to assess differences in mental health service use by rural and urban residence and average per person mental health expenditures by payer and by service type. Findings: Study findings reveal a complicated pattern of greater need among rural than urban adults for mental health services, lower rural office-based mental health use and higher rural prescription use, and no rural-urban differences in total or out-of-pocket expenditures for mental health services. Conclusions: These findings raise questions about the appropriateness and quality of mental health services being delivered to rural residents. Lower mental health spending among rural residents is likely explained by lower use of psychotherapy and other office-based services, but it may also be related to these services being delivered by lower-cost providers in rural areas. Findings suggest that an approach focusing on reducing underinsurance for all health services among rural residents may help to reduce unmet mental health needs among the rural privately insured.