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CORK Bibliography: Rural

103 citations. January 2007 to present

Prepared: June 2009

Allareddy V; Peek-Asa C; Yang JZ; Zwerling C. Risk factors for rural residential fires. Journal of Rural Health 23(3): 264-269, 2007. (18 refs.)

Context and Purpose: Rural households report high fire-related mortality and injury rates, but few studies have examined the risk factors for fires. This study aims to identify occupant and household characteristics that are associated with residential fires in a rural cohort. Methods: Of 1,005 households contacted in a single rural county, 691 (68.8%) agreed to participate. One household with missing information on a reported fire was excluded from the analysis. We used logistic regression to examine the independent association of occupant and household characteristics with reported fires, controlling for years lived in the residence. We also examined the association between the occurrence of previous fires and the adoption of safety measures. Findings: A total of 78 (11.3%) households reported a residential fire. Occupant characteristics that were associated with significantly higher odds of reported fires included the presence of an occupant with alcohol problems (OR = 1.82, 95% CI = 1.01-3.28) and being married (OR = 2.11, 95% CI = 1.14-3.91). Rural farm households were associated with significantly higher odds (OR = 1.72, 95% CI = 1.01-2.93) of reporting a fire when compared to residences in towns, after controlling for all other occupant and household characteristics. The presence of a fire extinguisher (OR = 2.00, 95% CI = 1.10-3.64) was the only fire safety measure that had a statistically significant association with reported fire. Conclusions: Rural farm households report higher incidences of fire when compared to households located in towns. Experiencing a fire is not associated with an increased likelihood of adopting safety measures to prevent injuries once a fire has started.

Baca CT; Alverson DC; Manuel JK; Blackwell GL. Telecounseling in rural areas for alcohol problems. Alcoholism Treatment Quarterly 25(4): 31-45, 2007

The prevalence of alcohol problems is roughly equal in urban and rural communities. In rural areas, however, treatment options for people with problem drinking tend to be limited at best. One way to reach rural populations is to deliver alcohol counseling services via telephone or interactive televideo links, called telecounseling in this paper. Telecounseling can overcome not only the geographic barriers to treatment, but also concerns with confidentiality and stigma, which may be particularly salient in small rural communities. This approach to service delivery may be particularly important in areas with large rural and frontier regions. This paper reports on current use of common long-distance methodologies, their strengths and limitations.

Bean MK; Mitchell KS; Speizer IS; Wilson DB; Smith BN; Fries EA. Rural adolescent attitudes toward smoking and weight loss: Relationship to smoking status. Nicotine & Tobacco Research 10(2): 279-286, 2008. (30 refs.)

Perceptions that smoking contributes to weight loss are widespread among youth. We examined the association between weight loss and smoking to determine whether supportive attitudes were associated with smoking status and whether this is a particular problem in rural areas. High school students (N=730) completed a survey assessing smoking-related characteristics and behaviors. Attitudes assessed included perceptions of whether weight concerns were the reasons others smoke and personal beliefs about tobacco's effect on weight gain. Smoking status was categorized as never (44%), experimental (42%), and current (14%). Multinomial logistic regressions investigated relationships between attitudes and smoking, adjusting for weight goals, gender, ethnicity, parent/peer smoking, and body mass index. Both attitudinal measures were associated with smoking (p<.05). Nonsmokers and experimental smokers were more likely than current smokers to believe that people smoke to lose weight. Although current smokers were less likely to report that others smoke for weight control, they believed they would gain weight if they quit. Conversely, nonsmokers and experimental smokers were less likely to believe they would gain weight if they do not smoke compared with current smokers. Thus personal attitudes differ from attitudes toward others with respect to weight loss and smoking. Moreover, endorsement of these attitudes can reliably distinguish current versus experimental smokers and may help better clarify the transition to current smoker. Because weight concerns are a significant factor in youth smoking, these issues should be included in intervention efforts, particularly in rural communities where smoking rates are higher and age at initiation is earlier.

Best CM; Sun K; de Pee S; Sari M; Bloem MW; Semba RD. Paternal smoking and increased risk of child malnutrition among families in rural Indonesia. Tobacco Control 17(1): 38-45, 2008. (24 refs.)

Objective: To determine whether paternal smoking is associated with an increased risk of child malnutrition among families in rural Indonesia. Methods: The relation between paternal smoking and child malnutrition was examined in a population-based sample of 438 336 households in the Indonesia Nutrition and Health Surveillance System, 2000-2003. Main outcome measures were child underweight (weight-for-age Z score <-2) and stunting (height-for-age Z score <-2) and severe underweight and severe stunting, defined by respective Z scores <-3, for children aged 0 59 months of age. Results: The prevalence of paternal smoking was 73.7%. The prevalence of underweight and stunting was 29.4% and 31.4%, and of severe underweight and severe stunting was 5.2%, and 9.1%, respectively. After adjusting for child gender, child age, maternal age, maternal education, weekly per capita household expenditure and province, paternal smoking was associated with an increased risk of underweight (odds ratio (OR) 1.03, 95% confidence interval (CI) 1.01 to 1.05, p=0.001) and stunting (OR 1.11, 95% CI 1.09 to 1.13, p < 0.001) and severe underweight (OR 1.06, 95% CI 1.01 to 1.10) p=0.020) and severe stunting (OR 1.12, 95% CI 1.08 to 1.16, p < 0.001). Conclusions: Paternal smoking is associated with an increased risk of child malnutrition in families living in rural Indonesia.

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.

Boyd MR; Baliko B; Cox MF; Tavakoli A. Stress, coping, and alcohol expectancies in rural African-American women. Archives of Psychiatric Nursing 21(2): 70-79, 2007. (51 refs.)

African-American women report less alcohol and other drug (AOD) use compared with Caucasian women. However, health care professionals cannot afford to dismiss AOD use as a significant problem for some African-American women. Although we know much more about AOD problems in women in general, we still lack information on AOD disorders and associated factors among rural African-American women. This article focuses on examining rural African-American women (n = 142) with and without AOD disorders on the following variables: stressors, uplifts, coping, and alcohol expectancies.

Bradley AC; Baker A; Lewin TJ. Group intervention for coexisting psychosis and substance use disorders in rural Australia: outcomes over 3 years. Australian and New Zealand Journal of Psychiatry 41(6): 501-508, 2007. (29 refs.)

Objective: Outpatient group interventions have been shown to be efficacious in reducing substance use among people with psychosis. This is the first Australian studyto report on the effectiveness of such interventions provided in a rural area by mental health and drug and alcohol clinicians, with follow up over 3 years. The primary aim was to investigate whether an open-ended weekly outpatient group intervention, consisting of motivational interviewing (MI) and cognitive behaviour therapy (CBT), was effective in reducing substance use and improving symptomatology and general functioning among people with psychosis. Method: This was a service evaluation project, with clinician-administered ratings made for four retrospective 3 monthly baseline observations and up to 12 3 monthly post-recruitment observations. Results: Thirty-nine participants entered the group intervention, with an average attendance of 28.51 sessions (SD=24.61). Compared to a baseline period of 1 year, the group intervention was associated with significant improvements in substance use, symptomatology, treatment non-compliance, overall functioning and unscheduled service use. A median split according to treatment group attendance indicated that there was no difference in improvement profiles on a factor reflecting overall severity among those who attended fewer (mean = 10.63) versus more sessions (mean = 45.50), but there was a sharper reduction in the use of acute mental health services among those who attended more sessions. Conclusions: Significant change in functioning (including substance use and symptomatology) can occur within the context of a regular but relatively short outpatient group intervention, delivered in addition to usual treatment. However, extended group attendance over a 1 year period may be further associated with prevention of relapse and less unscheduled service use.

Brems C; Johnson ME; Warner TD; Roberts LW. Exploring differences in caseloads of rural and urban healthcare providers in Alaska and New Mexico. Public Health 121(1): 3-17, 2007. (46 refs.)

Objectives: Although it is commonly accepted that rural healthcare providers face demands that are both qualitatively and quantitatively different from those faced by urban providers, this conclusion is based largely on data from healthcare consumers and relies on qualitative work with small sample sizes, surveys with small sample sizes, theoretical reviews and anecdotal reports. To enhance our knowledge of the demands faced by rural healthcare providers and to gain the perspectives of healthcare providers themselves, this study explored the caseloads of rural providers compared with those of urban providers. Method: An extensive survey of over 1500 licensed clinicians across eight physical and behaviourat healthcare provider groups in Alaska and New Mexico was undertaken to explore differences in caseloads based on community size (small rural, rural, small urban, urban), state (Alaska, New Mexico) and discipline (health, behaviourat). Results: Findings indicated numerous caseload differences between community sizes that were consistent across both states, with complex case presentations being described most commonly by small rural and rural providers. Substance abuse, alcohol use, cultural diversity, economic disadvantage and age diversity were issues faced more often by providers in rural and small rural communities than by providers in small urban and urban communities. Rural, but not small rural, providers faced challenges around work with prisoners and individuals needing involuntary hospitalization. Although some state and discipline differences were noted, the most important findings were based on community size. Conclusions: The findings of this study have important implications for provider preparation and training, future research, tailored resource allocation, public health policy, and efforts to prevent 'burnout' of rural providers.

Brown CH; Guo J; Singer LT; Downes K; Brinales JM. Examining the effects of school-based drug prevention programs on drug use in rural settings: Methodology and initial findings. Journal of Rural Health 23(Supplement S): 29-36, 2007. (37 refs.)

Context: Although there have been substantial advances in knowledge about drug prevention over the last decade, the majority of school-based drug prevention studies have been conducted in urban settings: There is little knowledge about the effectiveness of such programs when they are implemented in rural populations. Purpose: To examine the prevention effects of school-based drug prevention programs implemented in rural populations. Methods: Mixed model or 2-level meta-analysis of trials based on school-based drug prevention programs that included rural populations. A total of 182 trials were coded for urbanicity of schools and 22 separate trials were selected for the analysis conducted in this paper. A total of 435 distinct analyses were examined from these 22 trials: Findings: We found a modest but consistent beneficial impact of drug prevention programs on later use as well as level of use. Regarding later drug use, the largest impact was on those who were not using at baseline and those exposed to an interactive program; the results were much larger for marijuana and other drugs compared to alcohol or tobacco, while inhalant use was less affected than other drug categories. Regarding, level of use, the impact was greatest 6 months after the trial ended, with diminishing effects thereafter. Conclusions: Evidence exists for a small but systematic beneficial effect of drug prevention programs in rural settings. It is likely that these programs have produced a mild reduction in new use of substances' but have had little impact on those already using substances.

Brown EJ; Smith FB; Hill MA. HIV risk reduction in rural African American women who use cocaine. Women & Health 46(2-3): 77-97, 2007. (31 refs.)

Research has demonstrated associations between cocaine use and sexually transmitted infections (STIs), including Human Immunodeficiency Virus (HIV). More research has been conducted among the sub-population of women, with less focus on rural African American women. Investigation of the social context that influences rural African American women's behavior that places them at risk for STI/HIV has received limited attention. The results of one component of the comprehensive Study presented here focused on perceived STI/HIV risk reduction strategies of U.S. southern rural African American women who used cocaine. This ethnographic study of 30 rural African American women using cocaine was conducted over four years. Researchpondents described HIV risk reduction strategies and their motives for using them. Condoms were used more with casual partners (80%) than primary partners (16%) and with partners who were less known, less trusted, young, or physically or sexually "dirty." Condoms were also used to prevent pregnancy (60%) more than to prevent STI/HIV (40%). HIV testing patterns varied, as did the motives for seeking testing. The sexual behavior of the women in this Study exposed them to increased risk of STI/HIV. Although many perceived that they were using sexual risk reduction strategies, these strategies were not scientifically sound risk reduction strategies. Consequently, their exposure to STI/HIV continued as they used ineffective strategies both in assessing partner risk and in implementing risk reduction behaviors.

Chen X; Stanton B; Li X; Fang X; Lin D. Substance use among rural-to-urban migrants in China: A moderation effect model analysis. Substance Use & Misuse 43(1): 105-124, 2008. (37 refs.)

Background: Substance use represents a public health challenge in China. The rapidly growing rural-to-urban migrants, currently numbering 88 million, may be especially vulnerable to substance use. Methods: Levels of and risk factors for substance use were examined among 3,752 rural-to-urban migrants using cross-sectional data collected in 2002 in China. A moderation effect modeling analysis was applied to examine interactions of workplace with income and income with depression in predicting substance use. Results: Respondents (41.7% females) were 18 to 30 years of age ( mean = 23.3, SD = 3.5) with an average of 4.26 years of migratory experience. The nine work-places for migrants were construction companies, restaurants, barber shops/hair salons, stalls/small shops, massage parlors, factories, night clubs, hotels, domestic services. The 30-day smoking rate was 10.5% for females and 56.5% for males; the 30-day alcohol intoxication rate was 16.8% for females and 36.7% for males; and lifetime use of illegal drugs was 1.8% for females and 1.6% for males. Hair salons and massage parlors were associated with increased levels of substance use for both sexes; construction companies and night clubs were associated with more substance use among females. Differences in levels of substance use by workplace were associated with differences in income and depression, but the effect was neither linear nor homogenous. Conclusions: Substance use is prevalent among rural-to-urban migrants, especially among female migrants. Workplace, income, and depression are associated with substance use interactively. Tailored substance use prevention is needed to target high-risk workplaces with specific efforts devoted to female migrants.

Cicero TJ; Dart RC; Inciardi JA; Woody GE; Schnoll S; Munoz A. The development of a comprehensive risk-management program for prescription opioid analgesics: Researched Abuse, Diversion and Addiction-Related Surveillance (RADARS (R)). Pain Medicine 8(2): 157-170, 2007. (31 refs.)

Objective. Beginning in the late 1990's a marked increase in abuse of OxyContin(R) emerged, which led to the development and establishment of a proactive surveillance program to monitor and characterize abuse, named the Researched Abuse, Diversion and Addiction Related Surveillance (RADARS(R)) System. The main goal of RADARS(R) was to develop proactive, timely and geographically sensitive methods to assess the abuse and diversion of OxyContin(R), along with a number of other Schedule II and III opioids with the aim of using this information to guide risk reduction interventions. Thus, its major focus was the detection of abuse of OxyContin(R) and other commonly prescribed opioid analgesics at the three-digit ZIP code level across the country utilizing a number of different detection systems. Methods. The detection systems selected were: (1) Quarterly-surveys of drug abuse experts who are knowledgeable about cases of prescription drug abuse; (2) Surveys of law enforcement agencies that detect diversion of prescription drugs; and (3) Poison Control Center reports of intentional misuse or abuse of prescription opioids. Collectively, the three systems provide overlapping coverage of over 80% of the nation's 973 three-digit ZIP codes. Results. Preliminary results indicate that prescription drug abuse is prevalent nationwide, but it seems to be heavily localized in rural, suburban and small urban areas. Our results also indicate that hydrocodone and extended and immediate release oxycodone products are by far the most widely abused drugs in the country, but the abuse of all prescription opioids seems to have grown over the 14 quarters since the inception of RADARS(R). Conclusion. The next step in these studies is to develop regionally specific, risk-minimization strategies, which is the goal of all risk-management programs. If successful, RADARS(R) will serve as a prototype of such programs for any new drug approved thathas measurable abuse potential.

Cicero TJ; Surratt H; Inciardi JA; Munoz A. Relationship between therapeutic use and abuse of opioid analgesics in rural, suburban, and urban locations in the United States. Pharmacoepidemiology and Drug Safety 16(8): 827-840, 2007. (38 refs.)

Purpose: The goal of these studies was to determine the relationship between prescribed use of opioid analgesics and their non-medically related use (abuse) at a regional level across the country. Methods To gather information about prescription drug abuse, we asked 233 drug abuse treatment specialists to provide us Quarterly reports on the number of cases of prescription opioid analgesic abusers who used opioid analgesics to get high in the past 30 days. Results and Conclusions We found that there was a very strong correlation between therapeutic exposure to opioid analgesics, as measured by prescriptions filled, and their abuse. There were, however, geographical loci that represented outliers in which abuse was disproportionately high relative to therapeutic use (> 95th percentile), most of which were in very small urban, suburban, and rural areas. The rank order of abuse shows that buprenorphine products, extended release (ER) oxycodone and methadone are the most intensely abused prescription opioid analgesics, with hydrocodone the least abused, when the data are corrected for degree of exposure, i.e., cases/1000 persons filling a prescription. If, on the other hand, one uses the number of cases/100000 population, hydrocodone ranked as high as ER oxycodone and all other drugs grouped together at very low levels of abuse. Since the latter conclusion ignores therapeutic exposure, we conclude that the rate of abuse of highly efficacious opioid analgesics is best expressed as cases of abuse/1000 persons filling a prescription, which yields the best possible estimate of the risk-benefit ratio of these drugs.

Conroy E; Kimber J; Dolan K; Day C. An examination of the quality of life among rural and outer metropolitan injecting drug users in NSW, Australia. Addiction Research & Theory 16(6): 607-617, 2008. (29 refs.)

This article aims to explore the relationship between quality of life (QOL) and health-related behaviours among rural and metropolitan injecting drug users (IDU) using a new scale developed specifically for use with IDU.One-hundred and sixty-four rural and 96 metropolitan IDU from seven different NSW Area Health Services were interviewed using a cross-sectional survey, including the Injection Drug Use Quality of Life (IDUQOL) scale. The mean domain-based IDUQOL score was 59.4 (SD 22.3). The life areas most commonly selected by participants as important in determining their QOL were family, health, money, housing and partnerships. Rural participants were less likely to choose housing compared to those from the metropolitan areas, but were more likely to select independence. Rural participants also gave a lower mean rating to money (33.1 vs. 47.0) and to partnerships (53.8 vs. 71.1), suggesting differences in the composition of QOL among rural and metropolitan IDU. Compared to metropolitan participants, rural participants had a lower domain-based QOL score (56.1 vs. 64.5). No association was found between QOL and health-related behaviours such as drug use or sexual and injecting practices. IDU subjective assessment of QOL is mediated by a range of factors. Disparity between rural and metropolitan IDU appears to be influenced by non-health related areas such as partnerships and money, highlighting the need for a more holistic approach to the management of substance use problems.

Cox LS; Cupertino AP; Mussulman LM; Nazir N; Greiner KA; Mahnken JD et al. Design and baseline characteristics from the KAN-QUIT disease management intervention for rural smokers in primary care. Preventive Medicine 47(2): 200-205, 2008. (61 refs.)

Objective. To describe the design, implementation, baseline data, and feasibility of establishing a disease management program for smoking cessation in rural primary care. Method. The study is a randomized clinical trial evaluating a disease management program for smoking cessation. The intervention combined pharmacothetapy, telephone counseling, and physician feedback, and repeated intervention over two years. The program began in 2004 and was implemented in 50 primary care clinics across the State of Kansas. Results. Of eligible patients, 73% were interested in study participation. 750 enrolled participants were predominantly Caucasian, female, employed, and averaged 47.2 years of age (SD = 13.1). In addition to smoking, 427 (57%) had at least one additional major risk factor for cardiovascular disease (diabetes, hypertension, high cholesterol, heart disease or stroke). Participants smoked on average 23.7 (SD = 10.4) cigarettes per day, were contemplating (61%) or preparing to quit (30%), were highly motivated and confident of their ability to quit smoking, and reported seeing their physicians multiple times in the past twelve months (Median=3.50; Mean=5.48; SD=6.58). Conclusion. Initial findings demonstrate the willingness of patients to enroll in a two-year disease management program to address nicotine dependence, even among patients not ready to make a quit attempt. These findings support the feasibility of identifying and enrolling rural smokers within the primary care setting.

Cupertino AP; Richter KP; Cox LS; Nazir N; Greiner KA; Ahluwalia JS et al. Smoking cessation pharmacotherapy preferences in rural primary care. Nicotine & Tobacco Research 10(2): 301-307, 2008. (25 refs.)

Pharmacotherapy is a critical adjunct to smoking cessation therapy. Little is known about relative preferences for these agents among smokers in primary care settings. In the context of a population-based clinical trial, we identified 750 smokers in primary care practices and independent of their readiness to quit offered them a free treatment course of either bupropion or transdermal nicotine replacement (TNR). Smokers opting for pharmacotherapy completed standardized contraindication screens that were reviewed by the patient's primary care physician. Most participants (67%) requested pharmacotherapy. Use of pharmacotherapy was positively associated with higher nicotine dependence and readiness to quit. Of the smokers requesting pharmacotherapy, 51% requested bupropion and 49% requested TNR. Choice of bupropion was related to no history of heart disease and no previous use of bupropion. Although potential contraindications to treatments were identified for 21.7% of bupropion and 6.6% of TNR recipients, physicians rarely felt that these potential contraindications precluded the use of these agents. When cost is removed as a barrier, a large proportion of rural smokers are eager to use smoking cessation pharmacotherapy, especially agents that they have not tried before. Although some comorbid conditions and concurrent drug therapies were considered contraindications, particularly to bupropion, physicians rarely considered these clinically significant risks enough to deny pharmacotherapy.

Draus PJ; Carlson RG. Change in the scenery: An ethnographic exploration of crack cocaine use in rural Ohio. Journal of Ethnicity in Substance Abuse 6(1): 81-107, 2007

Though still largely perceived as an "inner city" drug, crack cocaine has become increasingly available in many areas of the United States. However, little research has been conducted on the phenomenon of crack cocaine use outside of urban areas. This paper draws on qualitative interviews with 50 recent and former crack-cocaine users to explore patterns of use and distribution in three counties in rural Ohio. The findings show that variable patterns of crack use previously documented among urban crack users are evident in rural areas as well, though these are modified by the context of the rural small town. It is postulated that local social networks are the primary means by which these patterns are both transmitted and translated. Implications of these exploratory findings and possible directions for future research are discussed.

Dunn MS; Goodrow B; Givens C; Austin S. Substance use behavior and suicide indicators among rural middle school students. Journal of School Health 78(1): 26-31, 2008. (26 refs.)

BACKGROUND: This study provides a descriptive profile of substance use behavior and the prevalence of suicide indicators (thought about, considered, and planned) among rural middle school students and examines the association between substance use and suicidal indicators among middle school students participating in the Coordinated School Health Program in a rural state. METHODS: During April and May 2004, 10,273 middle school students completed the middle school Youth Risk Behavior Survey. RESULTS: This study found that a large percentage of students had initiated substance use behavior, with the greatest number of students having tried cigarettes (40.9% females and 42.7% males), followed by alcohol use (37.2% females and 41.3% males). Additionally, suicidal ideation and behavior were prevalent. Significant associations were found between substance use and suicidal ideation and behavior among middle school students. CONCLUSIONS: Prevention programs for adolescent suicide should be implemented during the middle school years and should focus on preventing substance use given its relationship to suicide.

Dunn MS; Ilapogu V; Taylor L; Naney C; Blackwell R; Wilder R et al. Self-reported substance use and sexual behaviors among adolescents in a rural State. Journal of School Health 78(11): 587-593, 2008. (40 refs.)

BACKGROUND: Research finds a strong association between substance use and risky sexual behavior but more needs to be known about this relationship. Few studies have examined this relationship among rural sixth- to eighth-grade students. As such, the purposes of this study were to provide a descriptive profile of rural sixth- to eighth-grade students' substance use behavior and sexual activity and to examine the relationship between substance use behaviors and sexual activity. METHODS: Participants consisted of a convenience sample of 10,273 middle school students (sixth to eighth grade) attending 10 public schools in rural Tennessee. The middle school Youth Risk Behavior Survey was administered to these students during April and May 2004. RESULTS: Analysis found that a large percentage of students had tried cigarettes, alcohol, and inhalants. Additionally, it was found that sexual intercourse had been initiated by 18.8% of females and 25.4% of males. Of those students who reported ever having had sexual intercourse, 75% had reported the use of cigarettes and alcohol. In addition, approximately 50% of those students reported marijuana and inhalant use. CONCLUSIONS: The results suggest that substance use behavior has a relationship with the likelihood of initiating sexual activity. Additional longitudinal research with this population will be needed for explaining whether these select substance use behaviors are probable risk factors predisposing young rural adolescents to report engaging in sexual behaviors or a result of other factors.

Duran BG; Wallerstein N; Miller WR. New approaches to alcohol interventions among American Indian and Latino communities: The experience of the Southwest Addictions Research Group. Alcoholism Treatment Quarterly 25(4): 1-10, 2007

This introduction presents a bi-directional approach to developing alcohol interventions for American Indians, Latinos, and rural populations, which recognizes the need to translate knowledge from evidence-based practice to diverse minority communities, as well as to learn from the healing knowledge that emerges from the communities themselves. The overarching paradigm of Community Based Participatory Research is presented which emphasizes addressing health disparities through partnering with communities and building on their strengths. The articles in this volume are an outgrowth of the Southwest Addictions Research Group (SARG), which was founded to promote interventions with these populations through supporting the career development of investigators of color. Articles discuss investigator-piloted interventions and other cultural dimensions which support effective behavioral and preventive services for diverse populations.

Edwards RW; Stanley L; Plested BA; Marquart BS; Chen J; Thurman PJ. Disparities in young adolescent inhalant use by rurality, gender, and ethnicity. Substance Use & Misuse 42(4): 643-670, 2007. (39 refs.)

Inhalant use is of increasing concern as rates appear to be rising among young adolescents and gender differences narrowing. Data from 20,684 Mexican American and White non-Hispanic seventh- and eighth-grade males and females from the Western United States and 15,659 African American and White non-Hispanic seventh- and eighth-grade males and females from states in the southeastern United States collected via in-school surveys from 1996 to 2000 were analyzed using a variety of statistical techniques including multilevel modeling. Questions addressed in the study included: Does inhalant use vary by level of rurality? What effect does the ethnic composition of the community have on inhalant use and does this effect differ by an individual's ethnicity? Do males use more inhalants than females and does the level of use by males and females differ by individual ethnicity, ethnicity of the community, or level of rurality? Do males and females of different ethnicities initiate inhalant use at different ages? Limitations of the study and implications of findings for prevention are discussed and areas of future research are suggested. This study was funded by the National Institute on Drug Abuse.

Falck RS; Wang J; Carlson RG. Health status of illicit stimulant drug users in rural Ohio. Journal of Psychoactive Drugs Supplement 4: 401-405, 2007. (17 refs.)

The SF-8 health survey was used to assess the physical and mental health status of a community sample of not-in-treatment, illicit stimulant drug-using adults (n = 249) living in rural Ohio. Physical health status scores indicative of poor health were present in 30.5% of the sample. Poor physical health was associated with older age (OR = 1.06; 95% C.I. = 1.02-1.11), chronic disease (OR = 2.24, 95% C.I. = 1.14-4.40), and frequent opioid use (OR = 3.14, 95% C.I. = 1.16-8.50). Poor mental health status scores were present in 63.9% of the sample. Men were less likely (OR = 0.25, 95% C.I. = 0.11-0.53), and Whites more likely (OR = 3.97, 95% C.I. = 1.56-10.13), to have poor mental health scores. Frequency and type of drug use had no measurable effect on mental health status. Physical and mental health problems are likely to be pervasive among nonmedical drug users in rural areas.

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.

Fromme K; Corbin WR; Kruse MI. Behavioral risks during the transition from high school to college. Developmental Psychology 44(5): 1497-1504, 2008. (23 refs.)

The transition from high school to college is an important developmental milestone that holds the potential for personal growth and behavioral change. A cohort of 2,245 students was recruited during the summer before they matriculated into college and completed Internet-based surveys about their participation in a variety of behavioral risks during the last 3 months of high school and throughout the 1 st year of college. Alcohol use, marijuana use, and sex with multiple partners increased during the transition from high school to college, whereas driving after drinking, aggression, and property crimes decreased. Those from rural high schools and those who elected to live in private dormitories in college were at highest risk for heavy drinking and driving after drinking.

Galliher RV; Evans CM; Weiser D. Social and individual predictors of substance use for Native American youth. Journal of Child & Adolescent Substance Abuse 16(3): 1-16, 2007. (29 refs.)

Substance abuse is a primary concern for youth worldwide and increasingly so for Native American Youth. Guided by theoretical models of the socialization of substance use in children and adolescents, we conducted a preliminary examination of socialization factors specific to Native American Youth. Strong, pro-social bonds with three primary socialization sources (family, school, and peer networks) were hypothesized to facilitate child self-efficacy and refusal skills and predict drug use. Participants were 84 Native American children between the ages of 9 and 11, living on or near a northern reservation. Structural path analysis results Indicated that self-efficacy was predicted from school bonding and peer social skills, while refusal skills were predicted from parent support/involvement and school bonding. Both self-efficacy and refusal skills predicted child drug use/experimentation. This preliminary study expands the limited research available for substance abuse prevention projects specific to rural, reservation-based Native American communities.

Garrity TF; Leukefeld CG; Carlson RG; Falck RS; Wang JC; Booth BM. Physical health, illicit drug use, and demographic characteristics in rural stimulant users. Journal of Rural Health 23(2): 99-107, 2007. (30 refs.)

Context: There is growing concern about illicit rural stimulant use, especially regarding methamphetamine use and its health consequences. Purpose: The present study describes associations between aspects of stimulant use and illness experience in rural areas, with additional focus on the role of demographic characteristics in these associations. Methods: The research participants were 710 stimulant drug users who were recruited from rural areas of Arkansas, Kentucky, and Ohio using Heckathorn's respondent-driven sampling method. Health was measured by self-reports of perceived health and extent of current, recent, and lifelong health problems. Drug use was measured with self-reports of type and frequency of use. Findings: Several associations were found between drug use and illness, controlling for demographics. Stimulant use pattern related significantly with the sum of health problems in the previous 6 months and the sum of lifetime illness diagnoses, after adjustment for demographic factors. Extent of illicit drug use in the past month and self-perceived drug and alcohol problems were associated with several measures of health. Conclusions: In this sample of stimulant users, methamphetamine use was associated with fewer recent medical problems than crack cocaine, combined crack and powder cocaine use, and use of all 3 of these stimulants. These results, across the 3 sites, suggest that prevalent assumptions about the methamphetamine "plague" and its negative health consequences must be viewed cautiously and examined with additional research.

Gfroerer JC; Larson SL; Colliver JD. Drug use patterns and trends in rural communities. Journal of Rural Health 23(Supplement S): 10-15, 2007. (8 refs.)

Context and Purpose: This study examines the prevalence of tobacco, alcohol, and illicit drug use among adolescents and adults in 3 types of counties: "rural" (nonmetropolitan counties with urban population 3 less than 20,000), "urbanized nonmetropolitan" (nonmetropolitan counties with urban population 20,000 or higher), and "metropolitan" (counties in metropolitan areas). Methods: Data from the 2002-2004 National Surveys on Drug Use and Health are used to compare residents of the 3 county types. Descriptive findings and a. multivariate model of marijuana use among adolescents are presented by county type. Findings: Past year illicit drug use is generally similar among adolescents in rural, urbanized nonmetropolitan, and metropolitan counties, except that Ecstasy use is higher among youth in metropolitan and urbanized nonmetropolitan counties than rural counties, while rural youth have a higher prevalence of stimulant and methamphetamine use than metropolitan youth: Gender; race/ethnicity, and family income functioned differentially across the 3 county types as predictors of youth marijuana use during the past year. Rural adults had generally lower rates of illicit drug use than: metropolitan adults, but adults in rural,and urbanized nonmetropolitan areas had higher rates of methamphetamine use than those in metropolitan areas: Rural youth had a higher prevalence of past month use of tobacco and alcohol. Rural adults had higher rates of tobacco use but lower rates of alcohol use. Conclusions: This study dispels the notion that substance abuse is only an urban problem and provides information useful in developing and implementing interventions that consider the unique characteristics of rural residents.

Gibbons FX; Reimer RA; Gerrard M; Yeh HC; Houlihan AE; Cutrona C et al. Rural-urban differences in substance use among African-American adolescents. Journal of Rural Health 23(Supplement S): 22-28, 2007. (16 refs.)

Purpose: To examine substance use differences among African-American adolescents living in rural and more urban areas in Iowa and Georgia and factors thought, to be related to those differences. Specifically, negative affect and perceived availability were examined as mediators of the relation between community size and alcohol, tobacco, and drug use. Methods: In-home interviews with the adolescents (Time 1: N = 897, Mean age = 10.5) assessed their use, perceived substance availability, and negative affect across 3 waves. Their parents' use was also assessed. Census data were used to determine community size (rural <= 2,500; urban >= 2,500). Findings: Perceived substance availability and use were both higher among the more urban adolescents. As expected, negative affect was a primary antecedent to use at each wave. Structural Equation Modeling indicated that the relation between population and use was mediated by perceived availability of the substances. Additional multigroup analyses indicated that the relations between negative affect and, use were significantly stronger among the urban adolescents at all waves. Conclusions: Results suggest that stress or negative affect is an important antecedent to use among African-American adolescents, especially when it occurs at an early age, but living in rural areas may be a buffer for both problems, in part, because exposure to this type of risk is lower in these environments.

Gpant J. Rural women's stories of recovery from addiction. Addiction Research & Theory 15(5): 521-541, 2007. (80 refs.)

In general, much has been written on women's patterns of drug use and the varying factors that impel them into addiction and subsequently into recovery. However, there is a paucity of information on rural Appalachian women and how they make meaning of their recovery processes. Drawing on data collected through informal interviews this article explicates dimensions of the various strategies 25 rural women develop and apply as they shift from using alcohol and/or drugs to their nonuse of such substances through a consideration of their self-change processes: the disgusted self, the aware self, the alternative self, and the stable self. Furthermore, with little access to treatment in this region, data show that participants compensated for that within their own cultural contexts: through the use of family, church, friends, work, school, and self-help institutions such as Alcoholics Anonymous and Narcotics Anonymous. I conclude with a discussion of the implications of these strategies for understanding rural women as they manage recovery processes.

Grant KM; Kelley SS; Agrawal S; Meza JL; Meyer JR; Romberger DJ. Methamphetamine use in rural midwesterners. American Journal on Addictions 16(2): 79-84, 2007. (27 refs.)

Methamphetamine use has been characterized as a "rural'' drug; however, little is known about rural methamphetamine use disorders (MUD). This study describes and compares characteristics of rural and urban patients with MUD. Rural study participants reported earlier first regular use of methamphetamine, more alcoholism, more intravenous use, and a greater number of cigarettes/day, and were more likely to report methamphetamine-related psychotic symptoms. Rural methamphetamine users report multiple factors that may contribute to medical and psychiatric complications and worsen their prognosis. This is of significant concern given the limited substance abuse, mental health, and specialty care available in most rural Midwestern communities.

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; Ostler T; Black J; Sheridan K; Kingery L. A child's-eye view of parent methamphetamine abuse: Implications for helping foster families to succeed. Children and Youth Services Review 29(1): 1-15, 2007. (28 refs.)

This report focuses on the experiences and perspectives of rural, Midwestern children aged 7-14 years who were involved with the public child welfare system because of their parents' methamphetamine abuse. Eighteen children participated in semi-structured, in-depth interviews focusing on their families of origin. Children reported exposure not only to their parents' and non-kin adults' methamphetamine and other substance abuse, but to a constellation of activities related to drug use or drug seeking behavior including violence within their homes and other criminal behavior. Children responded to the contexts in which they were reared in a variety of ways including accepting or actively resisting socialization messages that normalized substance abuse. The majority of children described involvement with law enforcement and child welfare as a "sad" and "scary" time in their families. Far from embracing their placement within safe and stable families, many children continued to express sadness, distress and resistance to legal and child welfare interventions even after months in foster care. Implications for facilitating the adjustment of children to foster care and beyond are discussed including providing foster parents with support and information about the contexts in which children have been reared and children's understanding of those contexts in order that they may interpret and respond to challenges that may emerge.

Hall JA; Smith DC; Easton SD; An H; Williams JK; Godley SH et al. Substance abuse treatment with rural adolescents: Issues and outcomes. Journal of Psychoactive Drugs 40(1): 109-120, 2008. (57 refs.)

This study compared the characteristics and treatment outcomes of rural adolescents with urban adolescents in substance abuse treatment programs in CSAT's Strengthening Communities for Youth (SCY) initiative. Using data from ten SCY programs nationally, the authors classified adolescents as rural or urban using Rural-Urban Commuting Area (RUCA) codes. We then evaluated changes in substance use frequency and substance-related problems at three, six, and 12 months after baseline assessments for the two sites that treated rural (n = 59) and urban (n = 345) youth in outpatient settings. Data were analyzed using a two-part mixed effects model for zero-saturated dependent variables. At treatment intake, rural youth exhibited greater problem severity on a number of substance abuse and mental health indices. From intake to the 12-month follow-up point, the percentages of both urban and rural youth who reported abstinence increased significantly. Both rural and urban youth also reported fewer problems due to substance use over time, but differences between groups were not consistent. Overall, treatment appears equally effective for both rural and urban adolescents. As few rural youth obtained treatment, we encourage funding agencies and treatment providers to consider innovative ways for providing services in rural areas and addressing gaps in primary prevention, early identification, and continuing care.

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.

Hartley D; Ziller EC; Loux SL; Gale JA; Lambert D; Yousefian AE. Use of critical access hospital emergency rooms by patients with mental health symptoms. Journal of Rural Health 23(2): 108-115, 2007. (15 refs.)

Context: National data demonstrate that mental health (MH) visits to the emergency room (ER) comprise a small, but not inconsequential, proportion of all visits; however, we lack a rural picture of this issue. Purpose: This study investigates the use of critical access hospital (CAH) ERs by patients with mental health problems to understand the role these facilities play in rural mental health needs and the challenges they face. Methods: Primary data were collected through the combination of a telephone survey and ER visit logs. Our sampling frame was the universe of CAHs at the time the survey was fielded. Key Findings: About 43% of CAHs surveyed operate in communities with no mental health services, while 9.4% of all logged visits were by patients identified as having some type of mental health problem. The most common problems identified were affective disorders, substance abuse, anxiety, and psychotic disorders. Only 32% of CAHs have access to on-site detoxification and 2% have inpatient psychiatric services, meaning that patients in need of these services typically must leave their communities to gain treatment. Conclusions: The lack of community resources may impact CAHs' ability to assist patients with mental health problems. Among those with a primary mental health condition, 21% left the ER with no or unknown treatment, as did 51% of patients whose mental health condition was secondary to their emergent problem. Patients in need of detoxification or inpatient psychiatric services often must travel over an hour to obtain these services, potentially creating significant issues for themselves and their families.

Havens JR; Oser CB; Leukefeld CG; Webster JM; Martin SS; O'Connell DJ et al. Differences in prevalence of prescription opiate misuse among rural and urban probationers. American Journal of Drug and Alcohol Abuse 33(2): 309-317, 2007. (15 refs.)

We compared the prevalence of prescription opiate misuse among 2 cohorts of felony probationers (N = 1525). Multiple logistic regression was utilized to determine the independent correlates of prescription opiate misuse among rural (n = 782) and urban (n = 743) probationers participating in an HIV-intervention study. After adjustment for differences in demographic and drug use characteristics, rural participants were almost five times more likely than their urban counterparts to have misused prescription opiates. The prevalence of prescription opiate misuse was significantly higher among the rural probationers; however, given the paucity of illicit opiates and relatively recent emergence of prescription opiates in rural areas, rural substance abuse treatment may be ill-prepared to treat prescription opiate misuse.

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. Prevalence of opioid analgesic injection among rural nonmedical opioid analgesic users. Drug and Alcohol Dependence 87(1): 98-102, 2007. (35 refs.)

Objective: The purpose of this study was to examine the prevalence and correlates of opioid analgesic injection (OAI) in a cohort of rural opioid analgesic users. Methods: Cross-sectional study of 184 participants from rural Appalachian Kentucky. Results: The majority of participants were male (54.9%), white (98.4%) and the median age was 30 years (interquartile range: 24-37). The self-reported lifetime prevalence of injection drug use (IDU) was 44.3%, with 35.3% of respondents reporting injection of oral opioid analgesic formulations. The prevalence of self-reported hepatitis C (HCV) was 14.8%, significantly greater than those not injecting opioid analgesics (1.7%) (p < 0.001). Receptive needle sharing, distributive needle sharing and sharing of other injection paraphernalia was reported by 10.5%, 26.3%, and 42.1% of those currently injecting, respectively. Conclusions: Opioid analgesic injection was more prevalent in this rural population than has been found in previous reports. This study suggests a rising problem with injecting among rural opioid users, a problem more typically associated with urban drug users. Educating injectors of opioid analgesics on safe needle practices is necessary in order to curb the transmission of HIV, HCV, and other infectious diseases. Further study on the longitudinal course of opioid analgesic injection in this population appears warranted.

Heil SH; Sigmon SC; Jones HE; Wagner M. Comparison of characteristics of opioid-using pregnant women in rural and urban settings. American Journal of Drug and Alcohol Abuse 34(4): 463-471, 2008. (25 refs.)

Historically, research on opioid use during pregnancy has occurred in urban settings and it is unclear how urban and rural populations compare. We examined sociodemographic and other variables in opioid-using pregnant women seeking treatment and screened for participation in a multi-site randomized controlled trial. Women screened in rural Burlington, Vermont (n = 54), were compared to those screened in urban Baltimore, Maryland (n = 305). Rural opioid-using pregnant women appear to have some characteristics associated with better treatment outcomes (e. g., less severe drug use, greater employment). However, they may face additional barriers in accessing treatment (e. g., greater distance from treatment clinic).

Henry KL; Edwards RW; Oetting ER. Use of ephedra among rural-dwelling U.S. adolescents. Substance Use & Misuse 42(6): 949-959, 2007. (13 refs.)

Prior to 2004, ephedra had been readily available to adolescents. Due to reports that use of ephedra produced a number of serious adverse consequences, including death, sales of the compound became illegal in the United States on April 12, 2004. Data are presented from a random sample of 156,050 students in grades 7 through 12 from 185 rural communities across the United States who completed the Community Drug and Alcohol Survey. This study provides a valuable epidemiological benchmark of reported rates of lifetime prevalence of ephedra by adolescents living in rural America before the sale of the drug became illegal (data were collected between 1996 and 2001). While there were small regional, racial, and gender differences, rates of adolescent use were, in general, very low. The highest rates of ephedra use were found among youth using other drugs, particularly stimulants.

Henry KL; Smith EA; Caldwell LL. Deterioration of academic achievement and marijuana use onset among rural adolescents. Health Education Research 22(3): 372-384, 2007. (54 refs.)

This study utilizes discrete-time survival analysis to assess the effect of level of academic achievement (both contemporaneously and prospectively) and changes in academic achievement on initiation of marijuana use among rural adolescents in junior high school. In the sample under consideration, 36% of boys and 23% of girls initiated use of marijuana by the end of ninth grade. Consistent with our hypothesis, poor academic achievement is a salient predictor of initiation of marijuana use among both boys and girls. Both contemporaneous and lagged levels of achievement significantly predict initiation. In addition, change in academic achievement is an important predictor of initiation. That is, students who demonstrate a deterioration of their academic achievement over time are more likely to start using marijuana. Poor academic achievement and deterioration of academic achievement should be considered as risk factors for initiation of marijuana use among rural adolescents. Initiatives targeted at improving academic achievement and/or drug use prevention initiatives designed for poor achieving students may help to prevent initiation of marijuana use.

Hiller ML; Leukefeld CG; Garrity TF; Godlaski T; Schoeneberger M; Townsend M et al. Client outcomes from rural substance abuse treatment. Journal of Psychoactive Drugs 39(1): 59-68, 2007. (30 refs.)

Several national evaluations have been conducted since the late 1960s that have assessed the effectiveness of publicly-funded substance abuse treatment in the United States. These studies, however, have focused principally on urban-based treatment programs, and it is unclear whether findings from urban programs can be replicated in outcome studies of programs in rural areas. The current study, therefore, examined the treatment outcomes of clients admitted to one of several short-term inpatient or outpatient drug-free treatment agencies in rural Kentucky. Findings showed that treatment was associated with reductions in drug use and criminality during a six-month follow-up interval. Employment status also improved significantly, and health services utilization was reduced. The similarity between the current findings and findings from national outcome studies of urban-based treatment programs is discussed.

Hutcheson TD; Greiner KA; Ellerbeck EF; Jeffries SK; Mussulman LM; Casey GN. Understanding smoking cessation in rural communities. Journal of Rural Health 24(2): 116-124, 2008. (47 refs.)

Context: Rural communities are adversely impacted by increased rates of tobacco use. Rural residents may be exposed to unique communal norms and other factors that influence smoking cessation. Purpose: This study explored facilitating factors and barriers to cessation and the role of rural health care systems in the smoking-cessation process. Methods: Focus groups were conducted with smokers (N = 63) in 7 Midwestern rural communities. Qualitative analysis and thematic coding of transcripts was conducted. Findings: Three levels of pertinent themes-intrinsic, health-system resource, and community/social factors-were identified. Intrinsic factors facilitating cessation included willingness to try various cessation methods, beliefs about consequences of continuing smoking (eg, smoking-related illnesses), and benefits of quitting (eg, saving money). Intrinsic barriers included skepticism about resources, low self-efficacy and motivation for smoking cessation, concern about negative consequences of quitting (eg, weight gain), and perceived benefits of continued smoking (eg, enjoyment). Key health-system resource facilitators were pharmacotherapy use and physician visits. Resource barriers included infrequent physician visits, lack of medical/financial resources, limited local smoking-cessation programs, and lack of knowledge of existing resources. In terms of community/social factors, participants acknowledged the negative social impact/image of smoking, but also cited a lack of alternative activities, few public restrictions, stressors, and exposure to other smokers as barriers to cessation. Conclusions: Smokers in rural communities face significant challenges that must be addressed. A multilevel model centered on improving access to health care system resources while addressing intrinsic and community/social factors might enhance smoking-cessation interventions and programs in rural communities.

Jiang X; Li DG; Boyce W; Pickett W. Alcohol consumption and injury among Canadian adolescents: Variations by urban-rural geographic status. Journal of Rural Health 24(2): 143-147, 2008. (25 refs.)

Context: The impact of alcohol consumption on risks for injury among rural adolescents is an important and understudied public health issue. Little is known about whether relationships between alcohol consumption and injury vary between rural and urban adolescents. Purpose: To examine associations between alcohol and medically attended injuries by urban-rural geographic status using a representative national sample of Canadian adolescents. Methods: The study involved a secondary analysis of a national sample of Canadian adolescents aged 11-15 years (n = 7,031) from the 2001-2002 Health Behavior in School-Aged Children Survey. Respondents were classified into 5 geographic categories of rural-urban status. Multiple logistic regression was used to examine the magnitude and homogeneity of associations between drinking patterns and adolescent injuries across these 5 geographic groupings. Findings: Higher rates of alcohol consumption and adolescent injuries were observed in more rural areas. Alcohol consumption was significantly associated with higher risks for injury occurrence with evidence of a dose-related pattern of risk. Associations between alcohol consumption and injury were consistent by urban-rural geographic status. Conclusions: Misuse of alcohol is an important potential cause of injury. Adolescents whose lifestyle includes alcohol consumption experience higher risks for injury, and this association is observed consistently by urban-rural geographic status. Findings of this study emphasize a need to intervene with high-risk adolescents as a tertiary prevention strategy, irrespective of geographic background.

Jirapramukpitak T; Prince M; Harpham T. Rural-urban migration, illicit drug use and hazardous/harmful drinking in the young Thai population. Addiction 103(1): 91-100, 2008. (36 refs.)

Aims: Limited data are available about whether rural-urban migration, often characterized by exposure to urban life stress and a reduction in social network and support, can affect the prevalence of illicit drug use and hazardous/harmful drinking. The purpose of our study was to examine the prevalence of these risky behaviours among Thai young adults and to describe their association between their migration status and these outcomes. Design: A population-based cross-sectional survey. Setting: A representative sample of 1052 residents, aged 16-25 years (467 males and 585 females) in a suburban community of Bangkok in 2003 and 2004. Measurements (i) Exposures migration (defined as the occasion when a young person born in a more rural area moves for the first time into Greater Bangkok); and (ii) outcomes-illicit drug use was assessed with an anonymous self-report adapted from the Diagnostic Interview Schedule (DIS) and hazardous/harmful drinking with Alcohol Use Disorder Identification Test (AUDIT). Findings: The results showed that 10.9% (82 males and 17 females) had illicit drug use and 24.3% (179 males and 62 females) hazardous and harmful drinking. In multivariate analysis, rural-urban migration was not associated with illicit drug use, whereas hazardous/harmful drinking was associated independently with being late migrants, who moved at the age of 15 or older. Conclusions: Illicit drug use and hazardous/harmful drinking were common among young Thais. The potential effect of migration on hazardous and harmful drinking identified in this study may be helpful for the design and implementation of preventive measures.

Kaholokula JK; Braun KL; Santos JI; Chang HK. Culturally informed smoking cessation strategies for Native Hawaiians. Nicotine & Tobacco Research 10(4): 671-681, 2008. (38 refs.)

former and current smokers for the purpose of developing a culturally informed smoking cessation program. Ten focus groups with a total of 52 Native Hawaiian men and women were convened in a rural community in Hawai'i. Thematic analysis of focus group transcriptions resulted in the identification of 11 strategies and 23 supports for and 13 barriers to smoking cessation that were categorized into social, psychological, physical, political, economic, behavioral, and spiritual factors. Native Hawaiian former smokers (compared with current smokers who had tried to quit) found social, psychological, and physical factors helpful in supporting smoking cessation and remaining smoke free. They also reported having used more behavioral and religious/spiritual strategies to quit smoking compared with current smokers. The stories of former smokers also spoke to the importance of family and their religion/spirituality in quitting. Consistent with the findings from other studies, multiple factors were implicated in smoking behavior, suggesting that a multicomponent strategy may be beneficial for addressing the social, psychological, and physical factors related to smoking that we observed in our sample of Native Hawaiians. We also recognize that religion/spirituality is an integral part of Native Hawaiian culture and that church-based support of smoking cessation may help those Native Hawaiians for whom religion/spirituality is an important source of inspiration and guidance.

Kauffman RM; Ferketich AK; Wee AG; Shultz JM; Kuun P; Wewers ME. Factors associated with smokeless tobacco cessation in an Appalachian population. Addictive Behaviors 33(6): 821-830, 2008. (37 refs.)

Identifying factors associated with successful tobacco quit attempts may help in the development and targeting of effective cessation strategies. This paper aims to describe factors associated with smokeless tobacco (ST) cessation and compares the results to findings in the smoking cessation literature. Prospective data on 116 men aged 19 to 70 and participating in a ST cessation program were used to examine correlates of successful ST cessation at 1-year post-intervention. Controlling for age, level of education (p=0.002) and daily coffee consumption (p=0.005) had significant independent associations with successful cessation. No ST use variables were significant predictors of cessation success. In a multivariable logistic regression model three factors were significantly associated with cessation: education (p=0.010), coffee consumption (p=0.019), and age (P=0.029). Factors associated with successful ST cessation in this sample are consistent with predictors of smoking cessation reported in the literature. Based on its widespread use and the strength of its association with successful quitting, the role of caffeine consumption in ST cessation merits further study.

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.

Knudsen HK; Ducharme LJ; Roman PM. Controlled-release oxycodone admissions in public and private substance abuse treatment: Associations with organizational characteristics. Journal of Addictive Diseases 26(1): 41-50, 2007. (33 refs.)

Although non-medical use of controlled-release (CR) oxycodone is increasing, little is known about the substance abuse treatment facilities serving individuals dependent on this medication. This study examines the associations between the characteristics of treatment organizations and two dependent variables: any CR-oxycodone admissions and the number of CR-oxycodone admissions in the past six months. Face-to-face interviews were conducted with administrators of 363 publicly funded and 401 privately funded treatment centers in the US. Publicly funded non-profit organizations were less likely to have treated this population than government-owned, privately funded non-profit, and for-profit treatment centers. Some evidence indicated the availability of pharmacotherapies and detoxification services were associated with the dependent variables. Twelve-step programs were more likely to have treated oxycodone-dependent clients. Rural facilities treated significantly more clients than those in metropolitan areas. The high prevalence of CR-oxycodone admissions suggests the need for widespread training of treatment providers regarding treatment for CR-oxycodone dependence.

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.

Lambert D; Gale JA; Hartley D. Substance abuse by youth and young adults in rural America. Journal of Rural Health 24(3): 221-228, 2008. (29 refs.)

Purpose: Addressing substance abuse in rural America requires extending our understanding beyond urban-rural comparisons to how substance abuse varies across rural communities of different sizes. We address this gap by examining substance abuse prevalence across 4 geographic levels, focusing on youth (age 12-17 years) and young adults (age 18-25 years). Methods: The analysis is based on 3 years (2002-2004) of pooled data from the National Survey on Drug Use and Health. We measure rurality using a four-tier consolidation of the 2003 Rural-Urban Continuum Codes: urban, rural-adjacent, rural-large, and rural-small and medium. Findings: Rural youth have higher alcohol use and methamphetamine use than urban youth and the more rural the area, the higher the use. Rural young adults living in rural-large areas have higher rates of substance abuse than their urban peers; those living in the most rural areas have nearly twice the rate of methamphetamine use as urban young adults. Rural youth are more likely than urban youth to have engaged in the high-risk behavior of driving under the influence of alcohol or other illicit drugs. Conclusions: Higher prevalence rates, coupled with high-risk behavior, place rural youth and young adults at risk of continued substance use and problems associated with this use. Rural community infrastructure should be enhanced to support substance abuse prevention and intervention for these populations.

Leadbeater BJ; Foran K; Grove-White A. How much can you drink before driving? The influence of riding with impaired adults and peers on the driving behaviors of urban and rural youth. Addiction 103(4): 629-637, 2008. (31 refs.)

Aims: Following an ecological model to specify risks for impaired driving, we assessed the effects of youth attitudes about substance use and their experiences of riding in cars with adults and peers who drove after drinking alcohol or smoking cannabis on the youths' own driving after drinking or using cannabis. Design and methods Participants were 2594 students in grades 10 and 12 (mean age = 16 years and 2 months; 50% girls) from public high schools in urban (994) and rural communities (1600) on Vancouver Island in British Columbia, Canada; 1192 of these were new drivers with restricted licenses. Self-report data were collected in anonymous questionnaires. Regression analyses were used to assess the independent and interacting effects of youth attitudes about substance use and their experiences of riding in cars with adults or peers who drove after drinking alcohol or smoking cannabis on youth driving. Findings: Youth driving risk behaviors were associated independently with their own high-risk attitudes and experiences riding with peers who drink alcohol or use cannabis and drive. However, risks were highest for the youth who also report more frequent experiences of riding with adults who drink alcohol or use cannabis and drive. Conclusions: Prevention efforts should be expanded to include the adults and peers who are role models for new drivers and to increase youths' awareness of their own responsibilities for their personal safety as passengers.

Leukefeld C; Walker R; Havens J; Leedham CA; Tolbert V. What does the community say: Key Informant perceptions of rural prescription drug use. Journal of Drug Issues 37(3): 503-524, 2007. (43 refs.)

This article presents data from four groups of rural Key Informants-Community leaders, educators, health care providers and justice/law enforcement officials-to understand the nonmedical use and misuse of prescription drugs. Seventy key informants were purposively selected from two counties in Appalachian Kentucky. Key informants indicated that the nonmedical use of prescription drugs is complex and has historical roots. Two pathways, or entry points, into the nonmedical use and misuse of prescription drugs were identified: physical pain and recreational use. Data show trends with regard to drug use patterns, drug use education, involvement with the criminal justice system and the role of economics in the prescription drug use problem. Key Informants underscored a common theme that the rural prescription drug problem was fueled by a cultural acceptance of drug misuse. Recommendations are presented for services and research.

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).

Leyshon M. 'We're stuck in the corner': Young women, embodiment and drinking in the countryside. Drugs: Education, Prevention and Policy 15(3): 267-289, 2008. (86 refs.)

In this paper I extend our understanding of the ways in which young women in rural areas produce, negotiate and experience identity through an exploration of their drinking practices. Through a close ethnography of three groups of young women in the rural south west of England this paper shows how pubs, clubs, bedrooms and other informal spaces such as 'in the park' provide arenas of performance in which identities are constructed, negotiated and reproduced. In particular this paper explores the significance given by rural young women to their discursive drinking practices and the extent to which these practices lead to inclusionary and/or exclusionary experiences. Eschewing conventional notions of the body, by recognizing the body as malleable, porous and an unfinished product, subject to socially produced alteration, this paper teases apart the different lived experiences of rural young women by arguing that much of their behaviour in pub(lic) and private space(s) can be seen in terms of acts of spectacle, compliance and challenges to disciplinary frameworks. To illustrate this point I discuss how rural young women employ various embodied strategies to move between spaces to experiment with alcohol and alternative fernininities and 'do' gender, thereby contesting acceptable rural gender roles and expectations. Through shedding light on drinking practices, I reveal how this experimentation affects their sense of their body, femininity and belonging in the countryside.

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.

Martino SC; Ellickson PL; McCaffrey DE. Developmental trajectories of substance use from early to late adolescence: A comparison of rural and urban youth. Journal of Studies on Alcohol and Drugs 69(3): 430-440, 2008. (36 refs.)

Objective: This study investigated differences in the development of heavy drinking and marijuana use among students in urban and rural areas and assessed whether any such differences can be accounted for by locality differences in racial/ethnic makeup, social disorganization/low social bonding, feelings of despondency and escapism, and the availability of drugs. Method: Drawn from 62 South Dakota middle schools involved in a drug prevention field trial, participating students were assigned to a locality category based on the location of their seventh-grade school. Schools in metropolitan areas were distinguished from schools in nonmetropolitan areas. Schools in nonmetropolitan areas were further distinguished into those in micropolitan (medium and large towns) and noncore (rural areas without towns and with small towns) areas. We used latent growth curve analysis to model the influence of locality on the development of heavy drinking and marijuana use from ages 13 to 19 and to determine whether differences in development across locality were attributable to location-based differences in race/ethnicity, social disorganization/bonding, feelings of despondency and escapism, and alcohol and marijuana availability. Results: Heavy drinking increased at a faster rate among youth living in micropolitan areas compared with youth living in metropolitan areas. Marijuana use increased at a faster rate among youth living in metropolitan and micropolitan areas compared with youth living in noncore areas. Differences in the rate of change in heavy drinking were attributable to differences in the racial/ethnic composition of metropolitan and micropolitan areas. Differences in the rate of change in marijuana use were attributable to differences in residential instability and marijuana availability. Conclusions: This study underscores the diversity of drug use within rural communities, suggesting that living in a very rural area is protective against some forms of drug use but that living in a rural area that includes a medium or large town is not.

Minugh PA; Janke SL; Lomuto NA; Galloway DK. Adolescent substance abuse treatment resource allocation in rural and frontier conditions: The impact of including organizational readiness to change. Journal of Rural Health 23(Supplement S): 84-88, 2007. (15 refs.)

Context: Rural and frontier states are significantly affected by substance abuse and poverty. The; high rate of substance abuse coupled with high levels of dependence on state funded treatment systems places a burden on rural treatment systems and makes resource allocation a central planning issue. Purpose: The goal of this study was to combine substance abuse treatment need data with organizational readiness to change data to create a rank-ordered listing of residential treatment, providers to answer the following questions: Do program priority rankings change when organizational readiness to change is included in a need-based resource allocation algorithm? Methods: Three methodological procedures were used to determine program priority rankings among 14 residential adolescent treatment programs in 8 Wyoming counties: (2) a social indicators analysis of crime data, (2) synthetic estimates of substance-abuse treatment need, and (3) analysis of organizational change data from the directors 3 and staff at adolescent residential treatment programs: Findings: Program need rankings based on crime data and synthetic estimates of substance abuse treatment need shifted when organizational readiness to change data was added to, the algorithm: Conclusions: There is much to be gained from considering organizational readiness to change when selecting programs for funding: It plays a central: role in the successful diffusion of evidence-based practices within and among programs. Including this measure in the resource allocation process can help. planners identify programs that will be more apt to adopt a best practice. This is critical for making decisions about where to allocate scarce treatment resources.

Morris J. Characteristics and clinical practices of rural marriage and family therapists. Journal of Marital and Family Therapy 33(4): 439-442, 2007. (11 refs.)

This report presents a subset of data collected from the American Association for Marriage and Family Therapy (AAMFT) Practice Research Network project conducted in 2002. A sample of 47 clinical members of AAMFT who indicated they practiced in a rural community provided descriptive information on demographic characteristics, training, clinical practices, and treatment of substance abuse disorders. Similarities and differences with the demographic characteristics and practice patterns of the overall sample of 285 are discussed.

Northridge ME; Vallone D; Xiao HJ; Green M; Blackwood JW; Kemper SE et al. The importance of location for tobacco cessation: Rural-urban disparities in quit success in underserved West Virginia counties. Journal of Rural Health 24(2): 106-115, 2008. (41 refs.)

Context: Adults who live in rural areas of the United States have among the highest smoking rates in the country. Rural populations, including Appalachian adults, have been historically underserved by tobacco control programs and policies and little is known about their effectiveness. Purpose: To examine the end-of-class quit success of participants in A Tobacco Cessation Project for Disadvantaged West Virginia Communities by place of residence (rural West Virginia and the urban area of Greater Charleston). Methods: This collaborative program was implemented in 5 underserved rural counties in West Virginia and consisted of 4 intervention approaches: (1) a medical examination; (2) an 8-session educational and behavioral modification program; (3) an 8-week supply of pharmacotherapy; and (4) follow-up support group meetings. Findings: Of the 725 program participants, 385 (53.1%) had successfully quit using tobacco at the last group cessation class they attended. Participants who lived in rural West Virginia counties had a lower end-of-class quit success rate than those who lived in the urban area of Greater Charleston (unadjusted odds ratio [OR] = 0.69, 95% confidence interval [CI] = 0.48, 0.99), even after taking into account other characteristics known to influence quit success (adjusted OR = 0.58, 95% CI = 0.35, 0.94). Conclusions: Tobacco control programs in rural West Virginia would do well to build upon the positive aspects of rural life while addressing the infrastructure and economic needs of the region. End-of-class quit success may usefully be viewed as a stage on the continuum of change toward long-term quit success.

Office of Applied Studies, Substance Abuse and Mental Health Services Administration. The NSDUH Report. Illicit Drug Use by Race/Ethnicity in Metropolitan and Non-Metropolitan Counties: 2004 and 2005. (June 21, 2007). Rockville MD: Substance Abuse and Mental Health Services Administration, 2007. (6 refs.)

SAMHSA's National Survey of Drug Use and Health provides data on past month use of the following: any illicit drug, marijuana, and nonmedical use of prescription type drugs by race/ethnicity. This report also presents these by metropolitan status. Among whites and Hispanics: past month use of any illicit drug, marijuana, or nonmedical prescription drugs was lowest in non metropolitan areas than in any other area. Among blacks: past month use of any illicit drug or marijuana was lowest in non metropolitan areas than in any other area but nonmedical prescription drug use was highest in non metropolitan areas. Among American Indians/Alaska Natives: past month use of any illicit drug or nonmedical prescription drug use was lowest in large metropolitan areas than in any other area but marijuana use was lowest in non metropolitan areas.

Public Domain

Ogilvie KA; Moore RS; Ogilvie DC; Johnson KW; Collins DA; Shamblen SR. Changing community readiness to prevent the abuse of inhalants and other harmful legal products in Alaska. Journal of Community Health 33(4): 248-258, 2008. (46 refs.)

This paper presents results from an application of the Community Readiness Model (CRM) as part of a multi-stage community mobilization strategy to engage community leaders, retailers, parents, and school personnel in preventing youth use of inhalants and other harmful legal products in rural Alaska. The CRM is designed to assess readiness to address a single social problem, based on a limited set of key informant interviews. In this study, researchers conducted 32 baseline and 34 post-intervention community readiness assessment interviews in four rural Alaskan communities. These interviews with key informants from the communities were coded and analyzed using CRM methods to yield readiness scores for each community. The aggregate results were analyzed using hierarchical linear modeling (HLM), and the individual community scores were analyzed in the context of the overall study. Significant positive changes in community readiness were found across six readiness dimensions as well as for the overall readiness score. Variation in the degree of changes in readiness across the four communities is attributed to differences in the intervention's implementation. The implications of these results include the potential for CRM assessments to serve as an integral component of a community mobilization strategy and also to offer meaningful feedback to communities participating in prevention research.

O'Malley SS; Robin RW; Levenson AL; Wolf IG; Chance LE; Hodgkinson CA et al. Naltrexone alone and with sertraline for the treatment of alcohol dependence in Alaska Natives and non-natives residing in rural settings: A randomized controlled trial. Alcoholism: Clinical and Experimental Research 32(7): 1271-1283, 2008. (90 refs.)

Background: Access to specialty alcoholism treatment in rural environments is limited and new treatment approaches are needed. The objective was to evaluate the efficacy of naltrexone alone and in combination with sertraline among Alaska Natives and other Alaskans living in rural settings. An exploratory aim examined whether the Asn40Asp polymorphism of the mu-opioid receptor gene (OPRM1) predicted response to naltrexone, as had been reported in Caucasians. Methods: Randomized, controlled trial enrolling 101 Alaskans with alcohol dependence, including 68 American Indians/Alaska Natives. Participants received 16 weeks of either (1) placebo (placebo naltrexone + placebo sertraline), (2) naltrexone monotherapy (50 mg naltrexone + sertraline placebo) and (3) naltrexone + sertraline (100 mg) plus nine sessions of medical management and supportive advice. Primary outcomes included Time to First Heavy Drinking Day and Total Abstinence. Results: Naltrexone monotherapy demonstrated significantly higher total abstinence (35%) compared with placebo (12%, p = 0027) and longer, but not statistically different, Time to First Heavy Drinking Day (p = 0.093). On secondary measures, naltrexone compared with placebo demonstrated significant improvements in percent days abstinent (p = 0.024) and drinking-related consequences (p = 0.02). Combined sertraline and naltrexone did not differ from naltrexone alone. The pattern of findings was generally similar for the American Indian/Alaska Native subsample. Naltrexone treatment response was significant within the group of 75 individuals who were homozygous for OPRM1 Asn40 allele. There was a small number of Asp40 carriers, precluding statistical testing of the effect of this allele on response. Conclusions: Naltrexone can be used effectively to treat alcoholism in remote and rural communities, with evidence of benefit for American Indians and Alaska Natives. New models of care incorporating pharmacotherapy could reduce important health disparities related to alcoholism.

Ostler T; Haight W; Black J; Choi GY; Kingery L; Sheridan K. Case series: Mental health needs and perspectives of rural children reared by parents who abuse methamphetamine. Journal of the American Academy of Child and Adolescent Psychiatry 46(4): 500-507, 2007. (32 refs.)

Objective: This case-based, mixed-methods study was undertaken to understand the perspectives and mental health needs of rural children exposed to parental methamphetamine abuse. Method: Participants were 23 children involved with a state child protective agency because of parental methamphetamine abuse. A semistructured interview provided information on children's perspectives of their families. Information on children's mental health needs was obtained from the Child Behavior Checklist and Trauma Symptom Checklist. Case records and caseworker reports provided information on children's family experiences. Results: Children described emotional pain; few social resources for coping with emotions, problem solving, or talking about their experiences; and avoidant or passive coping skills. Sixty-five percent of children evidenced significant dissociative or posttraumatic symptoms on standardized assessments; 57% had other significant emotional and behavioral problems. Challenges to understanding children's perspectives included children's perceptions that talking about methamphetamine abuse was taboo and underreporting of significant symptoms on the Trauma Symptom Checklist. Conclusions: The high rate of mental health problems suggests the need for nontraditional strategies for services delivery in rural areas that are targeted toward these vulnerable children. Early identification and treatment of mental health problems should be a priority. Clinicians should be alert to the complexities in assessing children's mental health needs.

Ozer EJ; Fernald LCH. Alcohol and tobacco use among rural Mexican adolescents: Individual, familial, and community level factors. Journal of Adolescent Health 43(5): 498-505, 2008. (40 refs.)

Purpose: We investigated the contributions of individual, family. and community-level factors for explaining alcohol use and smoking among rural Mexican adolescents. Methods: As part of a national survey. 3922 adolescents and their mothers from 333 poor, rural communities in seven Mexican states provided cross-sectional data on family-level. socioeconomic, and psychosocial factors, and individual-level data on Substance use and psychological symptoms. Community standard of living was also assessed. Results: Generalized linear models adjusted for sampling design indicated that adolescents' use of alcohol was associated with being male. older, employment, and having a mother who used alcohol. Being from in indigenous family living in a majority-indignous community was associated with less alcohol use. Family income, family size, and community standard of living were not directly associated with adolescents' alcohol use. Current smoking was associated with being male, older, and more anxious, having a mother who smoked, and having a mother with higher educational attainment. Further analyses indicated patterns in which adolescents' alcohol use wits moderated by gender and ethnicity. Conclusions: Beyond the contribution of mate gender and age as risk factors, maternal substance use uniquely explained variability in alcohol and cigarette use among Mexican adolescents from rural communities. Indigenous ethnicity and living in majority-indigenous community settings appeared to confer protective benefits with respect to alcohol. These findings extend prior research in Mexico and in other countries that identify the combined importance of developmental contexts and individual-level factors for adolescent health.

Paulozzi LJ; Xi YL. Recent changes in drug poisoning mortality in the United States by urban-rural status and by drug type. Pharmacoepidemiology and Drug Safety 17(10): 997-1005, 2008. (40 refs.)

Purpose: This study was conducted to determine how the recently reported increase in drug poisoning mortality rates in the United States varied by degree of urbanization. Although drug poisoning is traditionally seen as an urban problem, evidence suggested that at least one component of the recent increase, deaths involving opioid analgesics, was increasing more rapidly in rural areas. Methods: The study compared age-adjusted unintentional and undetermined drug poisoning mortality rates between 1999 and 2004 from the National Vital Statistics System (NVSS) in each of six urban-rural categories. Results: Unintentional and undetermined drug poisoning mortality rates rose 62% from 1999 to 2004. Metropolitan county rates rose 51 %, an increase of 2.66/100 000, while nonmetropolitan county rates rose 159%, an increase of 4.81/100 000. By 2004, metropolitan and nonmetropolitan drug poisoning rates had roughly equalized. In the narcotic drug category, which included heroin, cocaine, and opioid analgesics, the most urban ("large central metro") counties increased only 16% while the most rural ("noncore, nonmetropolitan") counties increased 248%. Heroin rates did not increase significantly for any urban-rural category. Cocaine rate increases were largest in nonmetropolitan counties. Opioid analgesic rate increases ranged from a low of 52% in large central metro counties to an increase of 371% in nonmetropolitan, noncore counties. Conclusions: Prescription drugs have replaced heroin and cocaine as the leading drugs involved in fatal drug overdoses in all urban-rural categories. Fatal drug overdoses are no longer a predominantly urban phenomenon. National prevention efforts will have to shift to address nontraditional populations using nontraditional drugs.

Payne J. Women drug users in North Cumbria: What influences initiation into heroin in this non-urban setting? (review). Sociology of Health & Illness 29(5): 633-655, 2007. (162 refs.)

This paper reports on a qualitative study which has investigated female problem drug use in North Cumbria, a relatively isolated area of the UK. Cumbria is the second most sparsely populated county in England with some of the most beautiful countryside juxtaposed with areas of disadvantage, particularly in towns along the west coast. Previous research has focused on female city dwellers and less is known about the social and cultural context of drug use in non-urban settings. The reasons for women's drug use remain controversial but gender differences appear to emerge. One frequent explanation is the influence of male oppression but some studies describe women as active players in their initiation. Findings from North Cumbria challenge the conventional view of women being coerced into illicit drug use and present greater complexity. The data derived from semi-structured interviews account for the impact of curiosity and trust, motives often tempered by a range of complex personal circumstances. A known individual, usually male, was often present at initiation and this relationship appears pivotal. I discuss these factors and will call for prevention initiatives to recognise the gender-specific determinants of initiation into problem drug use.

Peterson GM; Northeast S; Jackson SL; Fitzmaurice KD. Harm minimization strategies: Opinions of health professionals in rural and remote Australia. Journal of Clinical Pharmacy and Therapeutics 32(5): 497-504, 2007. (16 refs.)

Background and objective: There is some evidence that the problem of illicit drug use (IDU) is increasing in rural areas of Australia. Lack of access to harm minimization (HM) strategies is potentially exacerbated by a shortage of health care facilities and health care professionals in rural areas. This study was conducted to determine barriers to implementation, access to, and success of HM strategies, as seen by health professionals presently working in rural Australia. Methods: Four hundred rural pharmacists Australia-wide and 425 doctors in rural Victoria and Tasmania were sent postal surveys to assess their opinions on the level of IDU in their area, the types of drugs commonly used, the adequacy of HM strategies and facilities, and the barriers faced by doctors, pharmacists and clients. Results: The overall response rate was almost 50%. Slightly less than half of surveyed health professionals felt that IDU was increasing in their area, with heroin perceived to be the most prevalent drug used in all States except Tasmania and the Northern Territory. Both methadone prescribers and dispensers believed the methadone maintenance programmes were highly valuable to the community, but not without problems (e.g. risk of overdose). A lack of time or staff was the greatest influence on doctors not participating in the methadone programmes, whereas safety concerns were prominent with pharmacists. The majority of doctors felt HM facilities were inadequate, with needle-syringe exchange being the most frequently nominated HM strategy lacking. Conclusion: Despite best intentions, there are still problems with HM strategies in these areas. Improving the number and expertise of health professionals in rural areas, and providing adequate support for them, would address some of these problems.

Poulin C; Boudreau B; Asbridge M. Adolescent passengers of drunk drivers: A multi-level exploration into the inequities of risk and safety. Addiction 102(1): 51-61, 2007. (43 refs.)

This study determined the individual-, neighbourhood- and provincial-level effects of rural residence, socio-economic status (SES), substance use and driving behaviours on adolescents' riding with a drunk driver (RDD). Multi-level study based on cross-sectional self-reported anonymous data from the Student Drug Use Survey in the Atlantic Provinces (SDUSAP) and Census Canada data, merged on the postal code of participating schools. The sample design of the SDUSAP was a single-stage cluster sample of randomly selected classes stratified by grade and region. The Atlantic provinces of Canada. A total of 12 990 students in junior and senior high schools, with an average age of 15 years, participated in the 2002 SDUSAP. The outcome variable was past-year RDD. The main individual-level independent variables were SES, rural residence, substance use and driving behaviours. The school-neighbourhood independent variables were the prevalence of heavy episodic drinking, driving under the influence of alcohol, driver's licence, highest level of educational attainment and low income. The prevalence of RDD was 23.3% in 2002. Among students in grades 9-12, lower family SES, rural residence, substance use and driving under the influence were found to be independent individual-level risk factors for RDD; having a driver's licence was found to be protective. At the provincial and school-neighbourhood levels, a high prevalence of driving under the influence of alcohol and low educational attainment were found to be independent risk factors for RDD after taking into account individual characteristics. This study provides evidence that inequities exist in the options for adolescents to be ensured of passenger safety, and that interventions aimed at decreasing the extent to which adolescents engage in riding with a drunk driver should be based on conceptual approaches that recognize ecological factors as well as individual-level susceptibility.

Puskar KR; Bernardo LM; Switala J; Chughtai RL. Adolescent substance use in rural America: Current profile. Journal of Addictions Nursing 19(3): 150-155, 2008. (23 refs.)

Adolescent substance use in rural America has changed over the past decade. The purpose of this article is to describe the current profile of alcohol and drug use in a sample of adolescents in rural Pennsylvania. A total of 193 students (average = 15.6 years, SD = .93) from three high schools in rural western Pennsylvania were surveyed. Alcohol was reported at the highest percentage of use (49%), followed by painkillers (30.6%), and marijuana (13.6%). No significant difference in substance use was found between males and females, except for marijuana use (x(2) = 4.293, p value = .042). The results of this study have implications for the development of health education programs.

Quintero GA; Lilliott E; Willging C. Substance abuse treatment provider views of "culture": Implications for behavioral health care in rural settings. Qualitative Health Research 17(9): 1256-1267, 2007. (57 refs.)

Mandates for culturally competent substance abuse and mental health services call for behavioral health providers to recognize and engage cultural issues. These efforts to incorporate culture typically focus on client culture, but provider views of culture can also influence the provision of services. Analysis of 42 semistructured interviews with behavioral health providers suggests that culture is considered by many to be an obstacle to help seeking and treatment of substance-abusing youth. Although some providers do not highlight cultural issues, others conceptualize culture in terms of (a) generalized Hispanic cultural attributes, (b) male-dominant gender roles, and (c) the culture of poverty. Recommendations for provider training on cultural issues focus on ways they might critically consider their ideas about culture.

Rayens MK; Hahn EJ; Langley RE; Zhang M. Public support for smoke-free laws in rural communities. American Journal of Preventive Medicine 34(6): 519-522, 2008. (18 refs.)

Background: There has been an upward trend in smoke-free laws in countries, states, and municipalities in recent years. However, these laws are more likely to be enacted in urban areas. The purpose of this study was to examine public opinion of smoke-free laws and to determine if there was a difference in support for these laws between urban and rural dwellers. Methods: A series of random-digit-dialed phone surveys was conducted in 2005-2006 with 3672 adult Kentucky residents living in rural and urban communities without smoke-free laws. In addition to demographics, respondents were asked whether they would support a local law prohibiting smoking in public places. Responses were weighted to adjust for an over-representation of women in the sample relative to the population. Logistic regression was used to test for a rural/urban difference in support; data analysis was conducted in 2007. Results: Respondents were primarily women, Caucasian, with at most a high school education, and nonsmokers; the average age was 49.3 years. About half lived in rural communities. More than half (59.6%) supported a local smoke-free law. Controlling for age, gender, ethnicity, education, and smoking status, there was a significant difference in the level of support for a smoke-free law between rural and urban respondents. Compared to urban dwellers, rural residents were more likely to support these laws (OR=1.21; 95% CI=1.03, 1.42). Conclusions: When controlling for demographic differences between groups, rural residents were more likely than those in urban settings to support a law for local smoke-free public places.

Schultz CG; Neighbors C. Perceived norms and alcohol consumption: Differences between college students from rural and urban high schools. Journal of American College Health 56(3): 261-265, 2007. (32 refs.)

Objective: The authors examined perceived norms and drinking among college students who attended high schools in rural and urban communities. Participants and Methods: Undergraduates (99 men and 85 women) who attended high schools in communities with populations ranging from less than 100 to more than 400,000 completed surveys assessing perceived norms and alcohol consumption. Results: Analyses revealed that students from smaller towns and in smaller high school graduating classes reported heavier drinking and that perceived norms were positively associated with drinking. Perceived norms were unrelated to population variables, and the relationship between perceived norms and drinking did not vary as a function of population variables. Results suggest that differences in drinking as a function of coming from more rural areas contribute to drinking behavior in college independently of perceived norms. Conclusions: College students may adjust to campus drinking norms relatively quickly, and longitudinal research would be useful in understanding this transition.

Seale JP; Guyinn MR; Matthews M; Okosun I; Dent MM. Vital signs screening for alcohol misuse in a rural primary care clinic: A feasibility study. Journal of Rural Health 24(2): 133-135, 2008. (15 refs.)

Context: Alcohol misuse is more common in rural areas, and rural problem drinkers are less likely to seek alcohol treatment services. Rural clinics face unique challenges to implementing routine alcohol screening and intervention. Purpose: To assess the feasibility of using the single alcohol screening question (SASQ) during routine nursing vital signs in a rural clinic, and to determine its effect on alcohol screening and intervention rates. Methods: Patient exit interviews were used to identify alcohol misuse and to measure changes in screening and intervention rates. Chi-square tests were used to compare rates of screening across study phases, while odds ratios from logistic regression analyses were used to quantify association between nurse screening and clinician intervention. Findings: Exit interviews were completed by 126 current drinkers (41 before vital signs screening implementation and 85 afterward). Screening rates for alcohol misuse rose from 14.6% at baseline to 20.0% (P = .027) after screening implementation. Clinician intervention rates among alcohol misusers rose from 6.3% to 11.8% (P = .039). Nurse screening increased the odds of clinician intervention (OR 1.47; 95% CI 1.10-1.95). Conclusions: Vital signs screening proved to be feasible in this rural clinic and produced modest but significant increases in alcohol screening by nurses and brief interventions by clinicians. Additional studies are needed to define effective strategies for further increasing these rates.

Sexton RL; Carlson RG; Leukefeld CG; Booth BM. Barriers to formal drug abuse treatment in the rural South: A preliminary ethnographic assessment. Journal of Psychoactive Drugs 40(2): 121-129, 2008. (60 refs.)

This article describes barriers to obtaining drug abuse treatment in the rural South using qualitative interviews conducted with 86 illicit stimulant users recruited in rural Arkansas and Kentucky between 2003 and 2005. Fifty-nine (69.0%) of the interviewees had never entered drug abuse treatment. Sixteen (19.0%) participants reported current perceived need for treatment, while seven (8%) were ambivalent about seeking it. Interview data suggest five interrelated categories of barriers to accessing drug abuse treatment: (1) geographical, (2) organizational, (3) economic, (4) social, and (5) psychological. The study findings can inform further examination of rural treatment barriers and have important implications for developing strategies to overcome these obstacles.

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.

Simmons LA; Havens JR. Comorbid substance and mental disorders among rural Americans: Results from the National Comorbidity Survey. Journal of Affective Disorders 99(1-3): 265-271, 2007. (44 refs.)

Background: The purpose of this study was to examine whether rural inhabitants were more likely than urban inhabitants to meet the criteria for comorbid mental health and substance abuse or dependence disorders. Methods: Data were from the National Comorbidity Survey, and included 5185 (532=rural; 4653=urban) persons age 14-54 years of age who were interviewed using the Composite International Diagnostic Interview (CIDI). Logistic regression that accounted for the complex survey data and weighting scheme was utilized. Results: Participants residing in rural areas were more likely to meet the DSM-III-R criteria for past month alcohol abuse or dependence if they also met the diagnostic criteria for past month major depressive disorder or lifetime antisocial personality disorder, adjusting for age, race, gender, education and income. Similarly, rural participants were more likely to meet the criteria for comorbid drug abuse or dependence in the past month if they met the diagnosis for either past month major depressive disorder, generalized anxiety disorder or lifetime antisocial personality disorder, controlling for demographic characteristics. Rural residents with any current mental disorder also were less likely to seek treatment than their urban counterparts. Limitations: Data were collected in 1991 and do not capture changes in prevalence of comorbidities. Also, the small number of rural residents sampled resulted in small cell sizes for some comorbidities. Conclusions: Rural residents were significantly more likely to meet the criteria for substance disorders given they also met the criteria for a mental disorder, and those with any current mental disorder were less likely to seek treatment. Since the overall prevalence of these disorders does not differ between rural and urban inhabitants, findings suggest that rural persons may lack access to adequate treatment for their mental health disorders and subsequently may be self-medicating with alcohol and/or drugs.

Simons JS; Dvorak RD; Batten BD. Methamphetamine use in a rural college population: Associations with marijuana use, sensitivity to punishment, and sensitivity to reward. Psychology of Addictive Behaviors 22(3): 444-449, 2008. (42 refs.)

This study examined predictors of methamphetamine use in a 6-month prospective study of 2.270 rural young adults. Sensitivity to punishment (SP), sensitivity to reward (SR). and gender were exogenous Variables in an observed variable path analysis with 3 endogenous criteria: Time 1 (T1) marijuana use and methamphetamine use at T1 and Time 2 (T2). SP was negatively associated with marijuana use at T1. and this association was attenuated by SR. Mate gender was positively associated with marijuana use. T1 marijuana use and SR were positively, and male gender negatively. associated with T1 methamphetamine use. T1 methamphetamine use, T1 marijuana use, and SP were positively associated with T2 methamphetamine use. Methamphetamine use prevalence and the role of distal predictors and proximal indicators of drug involvement are discussed.

Spence RT; Wallisch LS. Alcohol and drug use in rural colonias and adjacent urban areas of the Texas border. Journal of Rural Health 23(Supplement S): 55-60, 2007. (20 refs.)

Context: Little is known about substance use and treatment utilization in rural communities of the United States/Mexico border. Purpose: To compare substance use and need and desire for treatment in rural colonias and urban areas of the border. Methods: Interviews were conducted in 2002-2003 with a random sample of adults living in the lower Rio Grande Valley of Texas, adjacent to the Mexican border: The present analysis compares responses from 400 residents of rural colonias to those of 395 residents of cities and towns in the same geographic region. Findings: While the prevalence of drug use and drug-related problems was similar in both areas, binge drinking and alcohol dependence were higher in rural colonias than in urban areas and remained so after taking demographic and neighborhood variables into account. An increase in illicit drug use and substance-related problems in rural but not urban areas was seen when comparing results from this study with those of a previous survey conducted in 1996. The percentage of adults in potential need of treatment and the percentage motivated to seek it were similar in both urban and rural areas. However, colonia residents were more likely than their urban counterparts to be recent immigrants and to have lower incomes and educational attainment, factors that can increase the barriers they face in getting needed services: Conclusions: Rural areas are "catching up" with urban areas in problematic substance use. Given the potential barriers to accessing treatment services in rural areas; efforts should be focused on reaching those residents.

Spoth R. Opportunities to meet challenges in rural prevention research: Findings from an evolving community-university partnership model. Journal of Rural Health 23(Supplement S): 42-54, 2007. (78 refs.)

Various rural prevention research challenges have been articulated through a series of sessions convened since the mid 1990s by the National Institutes of Health particularly the National Institute on Drug Abuse. Salient in this articulation was the need for effective collaboration among rural practitioners and scientists, with special consideration of accommodating the diversity of rural areas and surmounting barriers to implementation of evidence-based interventions. This paper summarizes the range of challenges in rural prevention research and describes an evolving community-university partnership model addressing them.: The model, entails involvement of public school staff 4 and other rural community stakeholders, linked with a scientists; by Land Grant University-based Extension system staff. Examples of findings from over 16 years of partnership-based intervention research projects include 3 those on engagement of rural residents, quality implementation of evidence-based interventions, and long-term community-level outcomes, as well as' factors in effectiveness of the partnerships. Findings suggest a future focus on building capacity for practitioner-scientist collaboration, and developing a network for more widespread implementation of the partnership model in a manner informed by lessons learned from partnership-based research to date.

Staton-Tindall M; Oser CB; Duvall JL; Havens JR; Webster JM; Leukefeld CG et al. Male and female stimulant use among rural Kentuckians: The contribution of spirituality and religiosity. Journal of Drug Issues 38(3): 863-882, 2008. (55 refs.)

This study describes gender-specific patterns of drug use among active rural stimulant users and examines religiosity and spirituality as factors that may be related to stimulant use among males and females. The study includes a sample of 225 active rural stimulant users from Kentucky who were recruited using respondent driven sampling and completed face-to-face interviews. Findings suggest gender specific patterns among active rural stimulant users, with females reporting more amphetamine use. In addition, bivariate findings indicate that there is an inverse relationship between spirituality, religiosity, and stimulant use (specifically methamphetamine and amphetamine use), particularly for males. However, when further examining this relationship in multivariate models controlling for age and race, few significant findings were noted for spirituality and religiosity in predicting gender-specific stimulant use patterns. These findings suggest that treatment interventions that incorporate spirituality and religiosity should not only be gender specific, but should also target clients differentially. Findings on the degree of reported spirituality and religiosity also suggest that religious and/or faithbased organizations could be utilized for drug use interventions for rural stimulant users.

Staton-Tindall M; Oser CB; Duvall JL; Havens JR; Webster JM; Leukefeld CG et al. Male and female stimulant use among rural Kentuckians: The contribution of spirituality and religiosity. Journal of Drug Issues 38(3): 863-882, 2008. (55 refs.)

This study describes gender-specific patterns of drug use among active rural stimulant users and examines religiosity and spirituality as factors that may be related to stimulant use among males and females. The study includes a sample of 225 active rural stimulant users from Kentucky who were recruited using respondent driven sampling and completed face-to-face interviews. Findings suggest gender specific patterns among active rural stimulant users, with females reporting more amphetamine use. In addition, bivariate findings indicate that there is an inverse relationship between spirituality, religiosity, and stimulant use (specifically methamphetamine and amphetamine use), particularly for males. However, when further examining this relationship in multivariate models controlling forage and race, few significant findings were noted for spirituality and religiosity in predicting gender-specific stimulant use patterns. These findings suggest that treatment interventions that incorporate spirituality and religiosity should not only be gender specific, but should also target clients differentially. Findings on the degree of reported spirituality and religiosity also suggest that religious and/or faithbased organizations could be utilized for drug use interventions for rural stimulant users.

Stillman F; Navas-Acien A; Ma JM; Ma SJ; Avila-Tang E; Breysse P et al. Second-hand tobacco smoke in public places in urban and rural China. Tobacco Control 16(4): 229-234, 2007. (18 refs.)

Objective: To assess airborne nicotine concentrations as an indicator of second-hand smoke (SHS) exposure in public places in both urban and rural areas of China. Design: Measurement of vapour-phase nicotine concentration using a common protocol in all locations. A total of 273 samplers were placed for 7 days in urban and rural areas of China, including Beijing and the capital city, and a county (rural) area of the following provinces: Sichuan (Chengdu/Mianzhu), Jiangxi (Nanchang/Anyi) and Henan (Zhengzhou/Xin'an). Setting: Samplers were placed in hospitals, secondary schools, city government buildings, train stations, restaurants and entertainment establishments (internet cafes, mahjong parlours and karaoke bars) in each location. Main outcome measure: The time-weighted average airborne concentration of nicotine (mg/m(3)) was measured by gas chromatography. Results: Airborne nicotine was detected in 91% of the locations sampled. Beijing had the highest nicotine concentrations in most indoor environments (median 3.01 mu g/m(3)) and Chengdu had the lowest concentrations (median 0.11 mu g/m(3)). Overall, restaurants and entertainment establishments had the highest nicotine concentrations (median 2.17 and 7.48 mu g/m(3), respectively). High nicotine concentrations were also found in government buildings and in train stations. Conclusions: The data collected in this study provide evidence that SHS exposure is frequent in public places in China. Environmental nicotine concentrations in China provide evidence for implementation and enforcement of smoke- free initiatives in public places in China and indicate the need for protecting the public from exposure to SHS.

Stoops WW; Tindall MS; Havens JR; Oser CB; Webster JM; Mateyoke-Scrivner A et al. Kentucky rural stimulant use: A comparison of methamphetamine and other stimulant users. Journal of Psychoactive Drugs Supplement 4: 407-417, 2007. (57 refs.)

Population based surveys suggest that methamphetamine use is increasing. However, little is known about stimulant use in rural areas. Given the lack of data regarding rural stimulant use, particularly methamphetamine use, and the continuing problems associated with stimulant drug use, the purpose of this study was to examine rural stimulant use in Kentucky. Of 225 rural stimulant-using participants surveyed, 76% (n = 170) reported lifetime use of methamphetamine. Rural methamphetamine users differed from other rural stimulant users on demographic characteristics, health, and drug use histories. These results suggest that differences exist between rural stimulant users and that clinicians may need to consider these differences when planning treatment and rehabilitation strategies.

Sturk H; Kavanagh D; Gallois C; King D; Turpin M; Kina R et al. Should mental health issues be addressed in primary care, and can it be done? Views of rural general practitioners in Queensland. Australasian Psychiatry 15(Supplement S): S90-S94, 2007. (16 refs.)

Objective: The aim or this paper was to examine self-efficacy and perceived appropriateness among rural general practitioners (GPs) in regards to screening and intervention for physical, lifestyle and mental health issues. Method: Fifty GPs from 25 Practices in eight rural Queensland towns completed a written survey designed for the study. Results: General practitioners rated opportunistic screening or assessment for smoking and for detection of relapse of mental disorders as the most appropriate, with even cardiovascular and diabetes risk falling behind these. Self-efficacy was highest for medical disorders for smoking assessment. It was significantly lower for alcohol, mental health issues, and addressing risks of physical disorder in people with mental disorders. Conclusions: High appropriateness ratings suggest that current strategies to boost self-efficacy of GPs in addressing mental health issues are timely.

Vik PW. Methamphetamine use by incarcerated women: Comorbid mood and anxiety problems. Women's Health Issues 17(4): 256-263, 2007. (34 refs.)

Objective. Methamphetamine's (MA) impact on psychiatric functioning is not well understood, especially among women. Efforts to understand MA's impact are complicated by the use of other drugs. The purpose of this study is to untangle the relative contributions of MA versus other drugs on psychiatric symptoms. Method. Incarcerated women (N = 100) completed diagnostic interviews and a symptom measure to establish psychiatric status. Findings. Nearly all women (83%) had lifetime dependence on :l drugs. The most common drug of dependence was MA (67%), followed by alcohol (32%), cannabis (19%), and cocaine (15%). Over half met lifetime criteria for an affective disorder (53%), and nearly half (46%) met lifetime criteria for an anxiety disorder. Lifetime dependence on MA and a nonstimulant drug was related to current psychiatric symptoms and lifetime mood and anxiety disorder. Lifetime mood and anxiety disorders were generally unrelated to recent MA use. Conclusion. Findings highlight the impact of MA use on psychiatric presentation among women. Results suggest that MA impacts psychiatric symptoms independent of lifetime psychiatric diagnoses. Of note was the high incidence of drug dependence and mood and anxiety disorders among this sample of incarcerated women from a rural state. Findings imply important treatment implications for women in prison settings.

Villarreal MI. Women and health disparities: Implications for treating Hispanic women in rural and urban communities. Alcoholism Treatment Quarterly 25(4): 91-110, 2007

Hispanic women with alcohol and other drug disorders present special needs and face unique challenges related to cultural norms and values particularly when seeking treatment. In particular, Hispanic women, with substance use disorders, may encounter culturally imposed barriers which may limit their ability to access and benefit from treatment. The author proposes a systemic approach to treating Hispanic women embedded within a traditional and rigidly patriarchal cultural context. Specifically, this paper proposes an adaptation of Community Reinforcement Approach and Family Training (CRAFT), an evidence based, efficacious treatment, which provides a family-oriented, approach to treating women with alcohol and other substance use disorders. CRAFT principles work with "concerned significant others" (CSOs) to aid a family member to seek treatment. By adapting CRAFT in ways that are syntonic with Hispanic culture, clinicians may be able to work with women who may otherwise not seek or enter treatment for substance use disorders. Ways to improve services for women are discussed. This article provides clinically oriented guidelines and suggestions for treating disenfranchised women who may otherwise go untreated. Lastly, the implications for treatment of Hispanic women are discussed in terms of adapting CRAFT as interventions that may help prevent serious health consequences faced by Hispanic women who develop substance use disorders.

Wallace C; Burns L; Gilmour S; Hutchinson D. Substance use, psychological distress and violence among pregnant and breastfeeding Australian women. Australian and New Zealand Journal of Public Health 31(1): 51-56, 2007. (23 refs.)

Objective: To identify the population prevalence and demographic characteristics of pregnant and/or breastfeeding Australian women who use licit and illicit substances and their experience of psychological distress and violence. Methods: Data from the 2004 National Drug Strategy Household Survey were used to determine the prevalence of substance use, psychological distress and violence experienced by pregnant and/or breastfeeding women. Results: A total of 976 pregnant and/or breastfeeding women were included. These women were significantly less likely than non-pregnant women to consume alcohol (47% vs. 85%) or any illicit drug (6% vs. 17%); however, there was no significant difference in tobacco smoking (20% vs. 25%). Self-reported psychological distress was significantly more frequent in the non-pregnant group (42%) than in the pregnant group, irrespective of substance use status. At a population level, pregnant and/or breastfeeding women were not at a heightened risk of psychological distress or violence. Discussion: These findings highlight the importance of targeting older, tertiary-educated and relatively affluent mothers and those living in regional areas for drug and alcohol education campaigns and treatment. Implications: Simplifying the National Health and Medical Research Council pregnancy-specific alcohol guidelines, improving clinician training, and increasing the availability of treatment options in rural and regional areas may assist in the identification, referral and provision of assistance to substance using pregnant/breastfeeding women.

Wallace AE; West AN; Booth BM; Weeks WB. Unintended consequences of regionalizing specialized VA addiction services. Psychiatric Services 58(5): 668-674, 2007. (27 refs.)

Objective: From 1995 to 2000 the Department of Veterans Affairs (VA) dramatically reduced addiction treatment funding and regionalized specialized services to urban centers. By using New York State as an example, this study examined whether regionalization disproportionately affected rural versus urban veterans' use of VA and non-VA inpatient addiction services. Methods: By using a comprehensive data set of VA and non-VA hospitalizations for 294,748 VA enrollees who were residents of New York State from 1998 to 2000, this study examined admission rates for addiction treatment to VA and non-VA centers to determine how rates differed between rural veterans and urban veterans. Results: Between 1998 and 2000 rural veterans obtained 67% of their inpatient addiction care from the VA, compared with 54% for urban veterans (p <. 001). Compared with 1998 levels, the odds ratios of admission to VA facilities for inpatient detoxification fell for both rural and urban veterans to .80 in 1999 and .65 in 2000 (both p < .05). Although odds ratios of non-VA inpatient admission for addiction treatment were stable over time for urban veterans, those for rural veterans fell from 1998 values, falling to .76 in 1999 (not significant) and .62 in 2000 (p < .001) for detoxification and to .66 in 1999 (not significant) and .51 in 2000 for rehabilitation (p < . 05). Odds ratios for urban veterans' admission to VA facilities for rehabilitation fell to .51 in terms of 1998 rates in 1999 and .38 in 2000, but rural veterans' odds ratios fell more, to .31 and .16, respectively (p < .001 for all). Conclusions: In New York regionalization of VA addiction services disproportionately affected rural veterans. Rural veterans experienced concurrent reductions in VA and non-VA inpatient addiction services. The VA and other health care policy makers should consider the potential unintended consequences to rural populations of resource reallocation.

Wang JC; Falck RS; Li L; Rahman A; Carlson RG. Respondent-driven sampling in the recruitment of illicit stimulant drug users in a rural setting: Findings and technical issues. Addictive Behaviors 32(5): 924-937, 2007. (19 refs.)

Increasingly, respondent-driven sampling (RDS) is being applied to study not-in-treatment users of illicit drugs. Although RDS has been successftilly applied in recruiting active users in densely-populated, metropolitan areas, its utility with hidden populations in rural areas has yet to be determined. This study critically evaluates the sample of not-in-treatment, illicit stimulant drug users (n = 249) recruited from the application of RDS in three rural counties in west-central Ohio. The findings of this study largely support the results of earlier studies in urban areas and suggest that RDS is a useful method of sampling hidden drug using populations in less densely populated rural areas. Some limitations of RDS are also discussed.

Webster JM; Mateyoke-Scrivner A; Staton M; Leukefeld C. Rurality and criminal history as predictors of HIV risk among drug-involved offenders. Substance Use & Misuse 42(1): 153-160, 2007. (24 refs.)

The current study examined rurality and criminality as predictors of the lifetime HIV risk behaviors of 661 male, drug-abusing state prisoners. HIV risk behaviors included the number of lifetime sex partners, the number of lifetime drug injections, the number of times had sex with an injection drug user, and the frequency with which a condom was used. Regression analyses showed that criminality was related to the number of lifetime injections, whereas rurality was related to fewer lifetime sex partners and less frequent condom use. A rurality by criminality interaction for sex with an injection drug user was found. Specifically, those from rural areas who had more extensive criminal histories reported relatively high numbers of sex partners who were ID Us. Results are discussed in the context of rural and criminal justice interventions for HIV risk behavior.

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.

Wood SA. Health care services for HIV-positive substance abusers in a rural setting: An innovative program. Social Work in Health Care 47(2): 108-121, 2008. (16 refs.)

Agencies that deliver health care services to HIV-positive substance abusers living in rural areas of the United States face particular treatment challenges and barriers to care. Rural consumers of HIV/AIDS health care-related services identified long travel distances to medical facilities, lack of transportation, lack of availability of HIV-specific medical personnel, a shortage of mental health and substance abuse services, community stigma, and financial problems as leading barriers to access to care. This article discusses barriers to care for rural HIV-positive substance abusers, and challenges for rural health care providers. In addition, it presents a case study of Health Services Center, a model program that has devised innovative practices in the delivery of health care services to HIV-positive substance abusers in rural northeastern Alabama.

Wright PB; Stewart KE; Fischer EP; Carlson RG; Falck R; Wang JC et al. HIV risk behaviors among rural stimulant users: Variation by gender and race/ethnicity. AIDS Education and Prevention 19(2): 137-150, 2007. (43 refs.)

We examined data from a community sample of rural stimulant users (n = 691) in three diverse states to identify gender and racial/ethnic differences in HIV risk behaviors. Bivariate and logistic regression analyses were conducted with six risk behaviors as dependent variables: injecting drugs, trading sex to obtain money or drugs, trading money or drugs to obtain sex, inconsistent condom use, multiple sex partners, and using drugs with sex. Controlling for state, income, age, heavy drinking, and type of stimulant used, men had lower odds than women for trading sex to obtain money or drugs (adjusted odds ratio [AOR] -0.4, confidence interval [CI] = 0.28-0.59; p < .0001), greater odds than women for trading money or drugs to obtain sex (AOR = 44.4, CI = 20.30-97.09; p < .0001), greater odds than women of injecting drugs (adjusted odds ratio (AOR =1.6, CI = 1.11-2.42; p =.01), and lower odds than women of using condoms inconsistently (AOR = 0.6, CI = 0.35-0.92; p =.02); African Americans had lower odds than Whites of injecting drugs (AOR =.08, CI = 0.04-0.16; p < .0001), greater odds than Whites for trading sex to obtain money or drugs (AOR = 1.7, Cl = 1.01-2.85; p =.04) and for trading money or drugs to obtain sex (AOR = 2.9, CI = 1.53-5.59; p =.001), and greater odds than Whites of using drugs with sex (AOR = 3.9, CI = 1.47-10.09; p =.006). These findings indicate HIV prevention efforts should be tailored to address gender and racial/ethnic differences in risk behaviors among rural stimulant users.

Wu B; Mao ZF; Rockett IRH; Yue Y. Socioeconomic status and alcohol use among urban and rural residents in China. Substance Use & Misuse 43(7): 952-966, 2008. (38 refs.)

The association between socioeconomic status (SES) and current regular alcohol use was examined separately for urban and rural residents of Hubei, China, using the third Chinese National Health Service Survey conducted in 2003. A probability sample of 15,609 respondents, ages 15 through 101 years, was selected from the study base. Alcohol use was a dichotomized variable (current regular users vs. others). Multivariate analyses incorporated four SES indicators: income, education, occupation, and house size. Investigation of status discrepancy indicated that income was positively associated with the likelihood of current regular alcohol use, whereas education was negatively associated. For both urban and rural residents, likelihood of current regular alcohol use was smallest for those in the highest education and lowest income category. Further research, which factors in quantity and frequency, is needed to understand how alcohol use among Chinese urban and rural populations impacts their health.

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.

Wunsch MJ; Nakamoto K; Goswami A; Schnoll SH. Prescription drug abuse among prisoners in rural southwestern Virginia. Journal of Addictive Diseases 26(4): 15-22, 2007. (24 refs.)

Non-medical-use of prescription medications is on the rise across the U.S., particularly in rural areas. In this study of 233 prisoners and probationers in southwestern Virginia, we add to an emerging profile of individuals abusing prescription medications. In this retrospective review of 2000-2004 augmented Addiction Severity Index data, those abusing prescription medications reported increased illicit drug and alcohol abuse, poly-drug abuse, psychiatric problems, and arrests for property crimes. Forty percent reported abuse of OxyContin((R)), a drug implicated in a number of deaths in this region. Compared to non-users, OxyContino((R)) users were younger, more likely to be female, and more likely to abuse benzodiazepines, methadone, cocaine, and heroin. Longevity of abuse of these other drugs belies suggestions that OxyContino was acting as a "gateway" drug leading naive users into addiction and risk of death.

Yan AF; Chiu YW; Stoesen CA; Wang MQ. STD-/HIV-related sexual risk behaviors and substance use among US rural adolescents. Journal of the National Medical Association 99(12): 1386-1394, 2007. (47 refs.)

Objectives: The present study aims to examine the relationship between substance use and HIV/sexually transmitted disease (STD)-related sexual risk behaviors among a national sample of sexually active adolescents in rural settings. Methods: Participants included 9th-12th grade rural adolescents (N=5,745) who completed the 2003 national Youth Risk Behavior Survey. The independent variables were six substance use behaviors, including alcohol, marijuana, tobacco and cocaine use. The dependent variables were unprotected sex and the number of recent sexual partners. Universityariate and multivariate logistic regression models were examined. Results: Smoking >= 3 days during the past 30 days was associated with unprotected sex. Alcohol or drug use before lost sexual intercourse, having ever used marijuana, having ever used cocaine and drinking alcohol during the past 30 days were associated with having multiple sexual partners. Conclusions: Results from the current study highlighted the need to provide youth with increased STD/HIV prevention knowledge in rural areas. Our finding confirmed that in order to achieve more effective STD/HIV prevention among high-risk substance-abusing youth, more intensive and better-tailored efforts will be needed to promote sexual risk reduction.

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.

Yannessa JF; Reece M; Basta TB. HIV provider perspectives: The impact of stigma on substance abusers living with HIV in a rural area of the United States. AIDS Patient Care and STDS 22(8): 669-675, 2008. (49 refs.)

Recent literature has documented growing concerns related to access to HIV care services for rural individuals living with both HIV and a dual diagnosis of substance abuse. Previous research has investigated issues from a client perspective, but limited research has investigated provider perspectives of rural issues surrounding HIV and substance abuse. The purpose of this qualitative study was to examine issues that impact the ability of care providers to create sustainable linkages to care for dual diagnosed individuals who live in rural areas. In-depth interviews were conducted in late 2005 with 39 HIV service providers at 11 agencies that provided HIV-related services to individuals in rural areas of a Midwestern state in the United States. Findings suggest multidimensional stigma in the medical referral network as the leading factor that presents challenges to service providers in rural areas. The service providers reported verbal stigma in the form of insults, a loss of role/respect, and a global loss of resources such as poorer quality health care or no health care provided. The stigma is conceptualized in four themes: (1) staff of medical referral sources stigmatizing against rural dual-diagnosis clients, (2) physicians stigmatizing against rural dual-diagnosis clients, (3) medical specialists stigmatizing against rural dual-diagnosis clients, and (4) client-perceived stigma. These themes were expressed equally among all of the providers, regardless of geographic location, type of HIV-related organization, or job title.

Yen CF; Yang MS; Chen CC; Yang MJ; Su YC; Wang MH et al. Effects of childhood physical abuse on depression, problem drinking and perceived poor health status in adolescents living in rural Taiwan. Psychiatry and Clinical Neurosciences 62(5): 575-583, 2008. (38 refs.)

Aims: The aim of the present study was to investigate the magnitude and independence of the effects of childhood physical abuse on adolescent depression, problem drinking and perceived poor mental health in Taiwanese indigenous and non-indigenous adolescents living in rural areas controlling for individual and familial characteristics. Methods: A sample of adolescents was randomly selected from junior high schools in the rural areas of southern Taiwan. The associations between childhood physical abuse and adolescent depression, problem drinking and perceived poor health status were examined on univariate and multivariate logistic regression. Results: Of the 1684 adolescents who completed the questionnaires, 374 (22.2%) reported that they had experienced physical abuse in childhood. Controlling for individual and familial factors, childhood physical abuse significantly increased the risk of depression, problem drinking and perceived poor health status in the present sample of adolescents on multivariate logistic regression. Conclusions: History of childhood physical abuse should be elicited from adolescents in treatment for depression, alcohol abuse or physical discomfort of unknown etiology. This finding may be of clinical benefit in terms of the design and implementation of intervention.

Zule WA; Costenbader E; Coomes CM; Meyer WJ; Riehman K; Poehlman J et al. Stimulant use and sexual risk behaviors for HIV in rural North Carolina. Journal of Rural Health 23(Supplement S): 73-78, 2007. (17 refs.)

Context: While literature exists on sexual risks for HIV among rural populations, the specific role, of stimulants in increasing these risks has primarily been studied in the context of a single drug and/or racial group. Purpose: This study explores the use of multiple stimulants and sexual risk behaviors among individuals of different races and sexual identities in rural North Carolina. Methods: In-depth interviews were conducted with 41 individuals in 3 rural North Carolina counties between June 2004 and December 2005. Interviews were audiotaped, transcribed and reviewed for accuracy. Edited interviews were imported into Atlas.ti and askSam for analysis. Findings: Along with marijuana, stimulants-including powder cocaine; crack, and methamphetamine-were the most frequently used illicit drugs in these counties. Powder cocaine use was more closely associated with white participants, crack with African Americans, and both were more commonly used by female participants: Participants reported 3 overlapping behaviors involving stimulant use that may be associated with increased risk of HIV infection: engaging in sex while using drugs, sex trading and group sex. Nearly half of participants reported engaging in group sex activity. Conclusions: HIV risk through injection appears to be low in these rural counties. However, nearly all study participants reported some form of sexual risk behavior that may increase transmission of HIV and other sexually transmitted infections. Further research is warranted focusing on the nexus between substance abuse and risky sexual behaviors.