Rural Southeastern United States Research Articles

Concurrent partnering and condom use among rural heterosexual African-American men

Background Limited research has targeted HIV risk among heterosexual African-American men in the rural south-eastern United States. A cross-sectional survey was administered to 538 men to assess HIV knowledge, attitudes towards HIV testing and sexual risk behaviour. Fifty-one percent reported consistent condom use in the past 3 months. Monogamous men reported more consistent condom use (t=3.47, d.f.=536, P<0.001). In concurrent partnerships, condom use was inversely related to age (adjusted odds ratio (AOR)=0.98, 95% confidence interval (CI)=0.95-0.998, P=0.03) and increased with the number of female partners (AOR=1.49, 95% CI=1.26-1.76, P<0.001). African-American HIV prevention outreach should include focus on concurrent partnering in rural settings.

Gender integration of a core content area teacher/athletic coach in the rural southeastern United States

Research on the occupational socialization of teachers and coaches has largely centered on physical education teachers and rarely on teachers from core content areas (i.e. English, foreign language, mathematics, science and social studies) who also coach athletics. The primary purpose of this single-case study was to explore the socialization of a first-year, core content area teacher/athletic coach at a small high school in the rural southeastern United States. Various qualitative techniques were utilized during data collection, while data analysis consisted of a system of open, axial and selective coding. Four themes emerged and were viewed through the lens of teacher identity. Themes include gender and opportunity; interactions within the school culture; teaching and coaching expectations; and interrole conflict and complementarity. Findings from this study hope to shed light on the need for further research on core content area teacher-coaches, while adding to the existing literature on females in the coaching profession and the roles of academics and athletics in rural areas.

Race and Wildfire Risk Perceptions among Rural Forestland Owners in North-Central Florida

The southern United States is susceptible to wildfire, from its climate, growing seasons, lightning frequency, and decades of fire suppression. With much known about wildfire's biophysical risks, less is understood about sociodemographic obstacles, including race, income, and education. Blacks in the rural southeastern United States are typically among the most marginalized Americans and least likely to have sufficient knowledge about resource protection. Because disaster preparedness has been shown to vary by sociodemographic status and race, this study focused on race and wildfire prevention by rural forestland owners in north-central Florida. Results show that while Whites were more aware of existing resources, they were less likely to incorporate preventative measures. In contrast, Blacks earned lower incomes and utilized their land less, but were more likely to manage and live on their land. We conclude that wildfire mitigation programs may be more effective when they work to connect absentee rural land owners to their land.

Sustained reduction in tuberculosis incidence following a community-based participatory intervention.

Rates of latent tuberculosis infection (LTBI) and tuberculosis (TB) disease are elevated in the rural southeastern United States and among US- and foreign-born Black residents. To prevent TB and reduce TB transmission, community-based strategies are essential. To describe a community-based participatory intervention for improving the detection and treatment of LTBI and TB and reducing TB incidence. In rural Florida, we carried out a community educational TB campaign from 1997 to 2000, including presentations at community events, a media campaign and working with local community groups to develop culturally appropriate prevention messages. The campaign was implemented concurrently with a population-based LTBI survey. The annual TB incidence rate in the intervention area decreased from 81 per 100 000 in 1994-1997, to 42/ 100 000 in 1998-2001, and to 25/100 000 in 2002-2005 (P = 0.001). This decrease was not observed in communities where the intervention was not implemented. There was no decrease in the TB incidence rate ratio between Blacks and non-Blacks in either region during the study period. We conclude that community participation in LTBI screening and TB education was associated with a substantial reduction in TB rates. Although the TB incidence rate ratio did not decrease between Blacks and non-Blacks, TB incidence fell in all racial groups.

Development of the Rural Active Living Perceived Environmental Support Scale (RALPESS)

Evidence supports the role of physical and social environments in active living, including perception of environment. However, measurement of perceived environments in rural settings is lacking. This study describes the development of the Rural Active Living Perceived Environmental Support Scale (RALPESS). Premised on social ecological and cognitive perspectives, 85 initial items were generated through a literature review and a mixed-methods investigation of "activity-friendly" environments. Items were organized by resource areas--town center, indoor and outdoor physical activity areas, schools, churches, and areas around the home/neighborhood--and submitted for expert panel review. In 2009, a revised questionnaire was disseminated to adolescents, parents, public school staff, and older adults in 2 rural southeastern United States counties. Principal component analysis with varimax rotation was used to explore factor structure (n = 542). The final analysis yielded 33 items with 7 factors: 1) church facilities, 2) town center connectivity, 3) indoor areas, 4) around the home/neighborhood, 5) town center physical activity resources, 6) school grounds, and 7) outdoor areas. The RALPESS is a valid, internally consistent, and practically useful instrument to measure perceptions of rural environments in the context of physical activity across the lifespan. Confirmatory factor analysis is recommended to validate factor structure.

Asking Mom: Formative Research for an HPV Vaccine Campaign Targeting Mothers of Adolescent Girls

Vaccination against the types of human papillomavirus (HPV) that cause about 70% of cervical cancers is approved for use in girls and women between 9 and 26 years of age and recommended routinely in 11–12-year-old girls. This article reports on the systematic theory-based formative research conducted to develop HPV vaccine messages for a campaign targeting racially diverse mothers of nonvaccinated 11–12-year-old girls in rural Southeastern United States. A consortium of 13 county health departments concerned about high rates of cervical cancer in their region relative to state and national averages initiated the campaign. The research examined behavioral determinants for vaccination decisions as well as mothers’ reactions to message frames and emotional appeals. On the basis of focus groups and intercept interviews (n = 79), the authors demonstrated how preproduction message research and production message testing were used to develop messages that would motivate mothers of preteen girls. Core emotional truths that emerged were a mother's instinct to protect her daughter from harm and to embrace aspirations for her daughter's future. Mothers also reacted more positively to text about preventing cervical cancer than about preventing HPV, a sexually transmitted disease. Mothers preferred message concepts with photos of minorities and Caucasian mothers and daughters.

Perspectives of Nurse Practitioners on Health Care Needs Among Latino Children and Families in the Rural Southeastern United States: A Pilot Study

The purpose of this study was to explore perspectives of nurse practitioners on health care needs among Latino children and families in the rural Southeastern United States. This qualitative research used semi-structured interviews with seven nurse practitioners (NPs) practicing in the rural southeastern part of North Carolina. Flanagan's critical incident technique was used to describe the experiences of NPs providing health care for Latino children and parents. Data analysis indicates that the most commonly reported illnesses by Latino children are upper respiratory infections and asthma, followed by otitis media, obesity, anemia, pneumonia, leukemia, and tumors. Barriers to health care for children included language and cultural differences, lack of access to care (e.g., lack of insurance, cost, and transportation), and health illiteracy/low education level of parents. The findings also suggest that Latinos are preserving their traditional health practices when treating their children's illnesses, such as through use of foods, hot/cold items, herbs, coin on "belly button," traditional juices, healing bracelets, and evil eye. The findings of the study imply the need to incorporate culturally sensitive care when providing care for Latino children and parents.

HIV-Disclosure, Social Support, and Depression Among HIV-Infected African American Women Living in the Rural Southeastern United States

This cross-sectional study examined the relationships between social support, HIV disclosure, and depression among 340 rural African American women with HIV disease living in the southeastern United States. Three aspects of social support (perceived availability of support, sources of available support, and satisfaction with available support) were measured along with HIV disclosure and depression. Perceived availability of support (p < .0001), sources of support (p = .03), satisfaction with support (p = .003), and HIV disclosure (total and to children; p = .05 and .04, respectively) were significantly and inversely correlated with depression. Perceived availability of support and satisfaction with support mediated the relationship between HIV disclosure and depression. If confirmed in longitudinal studies, these findings have implications for designing and implementing interventions supporting African American women with HIV disease in disclosing their HIV status appropriately, particularly to their children. In long run, appropriate self-disclosure may help decrease depression and improve quality of life among HIV infected African American women living in limited resource settings.

A Qualitative Study of the Barriers and Facilitators to Retention-in-Care Among HIV-Positive Women in the Rural Southeastern United States: Implications for Targeted Interventions

Retention in HIV medical care has been recognized as critical for long-term favorable clinical outcomes among HIV-positive patients. However, relatively little is known about specific factors related to HIV medical care adherence among HIV-positive women in rural areas in the United States, where the epidemic is rapidly growing among minorities and women. The objective of the current study was to assess barriers and facilitators to HIV clinic visit adherence among HIV-positive women in the rural southeastern region of the United States. Forty HIV-positive women were recruited from four outpatient clinics providing services to HIV-positive patients residing in 23 predominately rural counties in Alabama. Four focus groups were conducted ranging from 5 to 16 participants each. Content analysis was used to analyze and interpret the data. Data coding and sorting was conducted using QRS NVivo 8 software. Participants were predominately African American (92.3%) ranging in age from 29 to 69 years (mean = 46.1 years). On average, participants reported living with HIV for 8.8 years. Factors that impacted participants' ability to maintain clinic visit appointments included personal, contextual, and community/environmental factors that included: patient/provider relationships, family support, access to transportation, organizational infrastructure of the health care facility visited and perceived HIV stigma within their communities. The current study highlights the myriad of retention-in-care barriers faced by HIV-positive women living in rural areas in the southeastern United States. Innovative multilevel interventions that address these factors are sorely needed to increase long-term retention-in-care among HIV-positive women residing in rural areas.

Providing Care for Migrant Farm Worker Families in Their Unique Sociocultural Context and Environment

This article highlights the Farm Worker Family Health Program's (FWFHP) strategies for providing care to migrant farm workers residing within a unique social and cultural context. The care provided by health professions students from a variety of disciplines extends and augments the work of the local migrant farm worker clinic that is pushed beyond capacity during peak growing and harvest times. Nursing's social responsibility to care for underserved populations is a guiding principle of the FWFHP and shapes how the work is translated into action. The FWFHP is a community-academic partnership that began in the rural southeastern United States in 1993. Challenges facing migrant farm worker families include access to health care, language, health literacy, housing and sanitation, family and community integrity, and workplace safety. The nursing practice strategies used to address these health challenges may be adapted to strengthen health programs serving other populations who live in poverty or reside in low-resource settings.

Optimizing Hypertension Management in Underserved Rural Populations

Rural populations across the United States have an increased likelihood of developing hypertension and diabetes, which are significant risk factors for cardiovascular disease (CVD), including stroke and myocardial infarction. Limited access to care due to geography or socioeconomic status significantly impairs control of hypertension in rural populations, resulting in poor health outcomes. Epidemiological studies suggest that the prevalence of uncontrolled hypertension and poor glycemic control are affected by race, increasing age, and residence in the rural southeastern United States. Optimization of the delivery of rural health care is needed to improve outcomes in patients with hypertension. New strategies such as programs targeting therapeutic inertia, home-based monitoring of blood pressure (BP), and Internet-based communication programs may significantly improve BP control rates among rural patients. Among hypertensive medications, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are recommended by consensus guidelines and may be particularly effective in rural, minority populations due to their secondary effects on decreasing CVD.

Relationships Between Stigma, Social Support, and Depression in HIV-Infected African American Women Living in the Rural Southeastern United States

This cross-sectional study examined relationships between HIV-related stigma, social support, and depression in a sample of 340 HIV-infected African American women living in rural areas of the Southeastern United States. Three aspects of social support (availability of different types of support, sources of support, and satisfaction with support) and two aspects of HIV-related stigma (perceived stigma and internalized stigma) were measured. Perceived availability of support (p < .0001), sources of support (p = .03), satisfaction with support (p = .003), perceived stigma (p < .0001), and internalized stigma (p < .0001) were all significantly correlated with depression. Social support variables were negatively correlated and stigma variables were positively correlated with depression. HIV-related perceived stigma and internalized stigma were found to mediate the effect of sources of available support on depression. Study findings have implications for designing and implementing interventions to increase social support and decrease HIV-related stigma in order to decrease depression among African American women with HIV disease.

The Virgin of Guadalupe in My Backyard

•Photographer Jayson Ming Triplett

Physical Activity, Metabolic Syndrome, and Overweight in Rural Youth

Research suggests significant health differences between rural dwelling youth and their urban counterparts with relation to cardiovascular risk factors. This study was conducted to (1) determine relationships between physical activity and markers of metabolic syndrome, and (2) to explore factors relating to physical activity in a diverse sample of rural youth. Data were collected from 4th, 6th, 8th, and 11th grade public school students in the rural Southeastern United States in the spring of 2002. Physiological data included anthropometrics, fasting glucose, lipids, hemodynamics, and skinfold measurements. Psychosocial data included parental support for physical activity, accessibility of physical activity facilities, and safety concerns for physical activity. Behavioral data included self-reported physical activity and sedentary behaviors. After adjusting for sex, race, and age, subjects with low level of physical activity were 3 times more likely to be positive for metabolic syndrome compared to those reporting a high level of physical activity. Subjects reporting a low level of physical activity were 2.4 times more likely to be overweight compared to subjects reporting a high level of physical activity. Students with high levels of physical activity were more likely to have parents who provided money for physical activity lessons and sports teams. Rural youth with low levels of physical activity participation were at increased risks for metabolic syndrome and overweight. Effective physical activity promotions addressing supports for physical activity are urgently needed in rural America.

African American Women's Experience of Infection With HIV in the Rural Southeastern United States

The design of effective behavioral interventions to prevent HIV infection among African American women requires a more complete understanding of the context and circumstances that precipitate infection with the virus. A descriptive study was designed to explore African American women's experiences of infection with HIV in the rural southeastern United States. Ten women living with HIV participated in interviews. All were infected through sex with a man or men; three had engaged in high-risk activities associated with HIV infection including sex trading; seven described themselves as at low risk for infection related to serial monogamy, no injection drug use, and no history of addiction. Participants reported that desire for intimacy coupled with inaccurate risk appraisal of sex partners contributed to their infection. These results provide insight into the role of intimacy in sexual risk taking. Inquiry into how women can be assisted to protect themselves in the context of intimate relationships may improve interventions to prevent HIV.

A Prevalence Study of Faith-based Healing in the Rural Southeastern United States

Although prayer and other spiritual practices are common among residents of the rural south, the use of faith-based healers (FBH), or healers who use prayer as their primary healing modality, has not been explored in this population. Secondary data analysis from a random digit dialing telephone survey of rural adults in eight southern states. Our overall response rate was 51% and 193 subjects (4.1%) had seen an FBH practitioner within the previous year. FBH use was significantly more common among younger respondents (OR 7.21, 95% Ci 2.00, 25.94), women (OR 1.49, 95% CI 1.03, 2.14), those reporting poorer health (OR 1.83, 95% CI 1.19, 2.83), and those who believed in avoiding physicians (OR 1.82, 95% CI 1.24, 2.67). A relationship between FBH use and delayed or foregone medical care, and cost as a barrier to obtaining care was not statistically significant after controlling for other factors. Prevalence of FBH use is low, but is significantly related to younger age, female gender, poorer health status, barriers to medical care and devaluing medical care. Clinicians may consider exploring FBH usage with their younger, female patients, and those in poorer health. Policy makers should consider how FBH usage is related to various indicators of health care services demand, utilization and access.

Evaluating Treatment Outcomes for African American and White Clients Receiving Treatment at a Community Mental Health Agency in the Rural South

The present study examines the relationship between race and treatment outcomes among clients receiving services at a community mental health agency in the rural southeastern United States. A nonprobabilistic sample of clients completed the BASIS-32, a self-report summated rating scale, at an initial assessment and a series of three follow-up assessments conducted at 3-month intervals. The data were analyzed using a hierarchical linear model (HLM) consisting of an individual growth model and a between-client model examining possible differences in growth trajectories attributable to race, diagnosis, socioeconomic status, and gender. Clients’ symptomatology remained stable or decreased during the study period. Of the demographic variables examined, only diagnosis was significantly related to variation in treatment outcomes. No racial differences in treatment outcomes emerged. Although the findings must be considered preliminary, they do suggest that community mental health agencies can effectively respond to various ethnic, cultural, and racial groups by providing appropriate and individualized services.

Concurrent sexual partnerships among African Americans in the rural south.

To investigate concurrent sexual partnerships among heterosexual African Americans, 18 to 59 years old, in rural North Carolina. Household interviews with persons randomly selected from the NC driver's license file were conducted to identify overlap among the 3 most recent sexual partnerships. Concurrency prevalence in the past 5 years was 53% (men) and 31% (women). Most (61%) respondents believed that a recent partner had had a concurrent partnership. Multivariate analysis revealed strong associations between concurrency and male gender, being unmarried, age of sexual debut, and incarceration of a sex partner. Concurrent partnerships may increase rates of heterosexual HIV among blacks in the rural Southeastern United States. Future research should examine the context that supports this network pattern.

Concurrent partnerships among rural African Americans with recently reported heterosexually transmitted HIV infection.

To investigate concurrent sexual partnerships among African Americans in North Carolina with recently reported heterosexually transmitted HIV infection. Population-based case series of persons with newly reported HIV infection. Household interviews concerning sexual and other risk behaviors for HIV transmission were conducted among African Americans, 18-59 years old, who had been reported to the state health department within the preceding 6 months as having heterosexually acquired HIV infection. Dates of sexual partnerships were analyzed to identify concurrency among the 3 most recent partnerships. Concurrency prevalence in the past 1 and 5 years, respectively, was 45 and 63% for men and 37 and 58% for women. Most respondents (87%) believed that a recent partner had had a concurrent partnership. Multivariate analysis revealed associations between concurrency and male gender, youth, crack cocaine smoking, and incarceration of a sex partner. Concurrent partnerships likely accelerate heterosexual HIV transmission among blacks in the rural southeastern United States. Future research should examine the socioeconomic context that supports this network pattern.

What Influences a Woman to Choose Vaginal Birth After Cesarean?

To discover what influences women in the decision to deliver via vaginal birth after cesarean (VBAC). Descriptive and qualitative, influenced by principles of phenomenology and using content analysis to describe the lived experiences of women who choose VBAC. Women were recruited from a postpartum unit in a hospital in the rural southeastern United States. Five women who had delivered via VBAC within 2 to 4 months before the study. The major influences that affect a woman's decision to choose VBAC are described. The dominant themes found were the woman's sense of control in the decision-making process; physician encouragement for VBAC; and delivery type outcome advantages, incorporating physical and emotional factors. Women are influenced by internal and external factors in their decision to choose VBAC. Their choices come from their personal experiences and should be encouraged by health care providers during all aspects of the childbearing process.