Servicemen's Perceptions of Male Sexual Assault and Barriers to Reporting During Active Component and Reserve/National Guard Military Service.

Despite growing recognition of the high rates of sexual violence experienced by men serving in the U.S. military, male victimization, specifically sexual assault in military (SAIM), is an understudied topic. We qualitatively describe servicemen's awareness and perceptions of male SAIM, and their understanding of common barriers to servicemen reporting sexual assault. Participants included Midwestern Active Component and Reserve and National Guard servicemen, actively serving or Veteran, who had returned from Iraq or Afghanistan deployments during Operation Enduring/Iraqi Freedom eras. Eleven focus groups were held with 34 servicemen (20 Reserve/National Guard and 14 Active Component). Qualitative analyses used inductive and deductive techniques. Servicemen reported a lack of awareness of male SAIM, a tendency to blame or marginalize male victims, and substantial barriers to reporting sexual assault. Reserve/National Guard participants emphasized barriers such as a perception of greater stigma due to their unique status as citizen-soldiers, an ethos of unit conformity and leadership modeling, and a lack of confidence in leadership and the SAIM reporting process. In contrast, Active Component servicemen emphasized the deployment location and sex of victim and perpetrator as key reporting barriers. Findings make an important contribution to the scant literature on risk and protective factors for male SAIM and servicemen's perceptions of sexual violence and assault reporting barriers by their service type and location. This work has implications for routine screening for sexual violence experiences of male service members and Veterans. Providers' knowledge of gender stereotypes regarding sexual assault, assault risks and experiences of deployed servicemen, and potential barriers to SAIM disclosure is vital for patient-centered care delivery. Additional research to address factors that influence post-SAIM care engagement of males is indicated.

Predictors of mental health and substance use disorder treatment use over 3 years among rural adults using stimulants.

Background: Persons using substances, living in rural communities, tend to underutilize mental health (MH) and substance use disorder (SUD) treatment compared with their urban peers. However, no studies have examined longitudinal predictors of MH and SUD treatment use among rural persons using stimulants. Methods: Data were collected through interviews conducted between 2002 and 2008 from a natural history study of 710 adults using stimulants and living in rural counties of Arkansas, Kentucky, and Ohio. Each study site recruited participants using respondent-driven sampling (RDS). Participants were adults, not in drug treatment, and reporting past-30-day use of methamphetamine, crack cocaine, or powder cocaine. Study participants completed face-to-face baseline assessments and follow-up interviews using computer-assisted personal interviews. Follow-up interviews were conducted at 6-month intervals for 3 years. Results: Our results show that being male, nonwhite, and having a prior lifetime history of MH or SUD treatment use were associated with lower odds of using MH and SUD treatment over time; having medical insurance and living in a state with potentially greater availability of MH and SUD treatment were associated with higher odds of using MH and SUD treatment over the 3-year period. Further, reporting greater legal problems and alcohol severity were associated with greater odds of using MH and SUD care, whereas greater employment problems was associated with higher odds of SUD but not MH treatment use. Conclusions: Findings from this study could be used to inform clinical and public health strategies for improving linkage to MH and SUD care in this population. Our findings also highlight the importance of having medical insurance as a potential facilitator to utilizing SUD care in this population and support the need for health care policies that increase the ability of rural adults who use stimulants to pay for such services.

Predicting Substance Use Patterns Among Rural Adults: The Roles of Mothers, Fathers, and Parenthood.

This study examined the role of parenthood and parental influences on substance use patterns for 710 stimulant users age 18-61 living in the rural Midwest and Mid-south U.S. Longitudinal growth analyses showed that a maternal history of drug use was associated with increased baseline drug use severity, lesser declines in severity, and greater plateau of drug use severity over time. Parental conflict was associated with lesser declines in drug use severity, and drug use severity declined more steeply for participants who were themselves parents. Participants with two parents having a history of alcohol use had a greater baseline severity of alcohol use, with paternal history of drug use associated with lower baseline alcohol use severity. These findings demonstrate the importance of identifying parental influences in evaluating adult substance use, and point to the inclusion of parents in efforts to prevent and treat substance use disorders.

Este estudio analizó el papel que desempeñan la paternidad y las influencias de los padres en los patrones de consumo de sustancias de 710 consumidores de estimulantes de entre 18 y 61 años que viven en el Medio Oeste y Centro-Sur rural de Estados Unidos. Los análisis longitudinales de crecimiento demostraron que los antecedentes maternos de consumo de drogas estuvieron asociados con una mayor gravedad inicial de consumo de drogas, una menor disminución de la gravedad y una mayor estabilidad de la gravedad del consumo de drogas con el tiempo. El conflicto parental estuvo asociado con menos disminuciones de la gravedad del consumo de drogas y la gravedad del consumo de drogas disminuyó más abruptamente en los participantes que eran padres. Los participantes que tenían dos padres con antecedentes de consumo de alcohol tuvieron una mayor gravedad inicial de consumo de alcohol, con antecedentes paternos de consumo de drogas asociados con una menor gravedad inicial de consumo de alcohol. Estos resultados demuestran la importancia de reconocer las influencias de los padres a la hora de evaluar el consumo de sustancias de los adultos e indican la inclusión de los padres en los esfuerzos para prevenir y tratar los trastornos por consumo de sustancias.

Ethnic Minority Status and Experiences of Infertility in Female Veterans.

BACKGROUND: In the general population, infertility is increasingly prevalent in ethnic minority women; these women suffer longer and are less likely to access care. There is a paucity of data regarding the issue of race and infertility in the growing female military veteran population. MATERIALS AND METHODS: This cross-sectional observational study involved computer-assisted telephone interviews of 1,004 Veterans Administration (VA)-enrolled women aged ≤52 years. RESULTS: Racial minority veterans were more likely than white veterans to self-report infertility (24% vs. 18%), equally likely to report infertility evaluation (52% vs. 52%), and less likely to report receiving infertility treatment (31% vs. 63%). Differences in self-reported infertility (odds ratios [OR]: 1.50, 95% confidence interval [CI]: 1.02-2.22) and infertility treatment (OR: 0.32, 95% CI: 0.13-0.81) were retained after controlling for age, income, marital status, education, insurance, history of pelvic inflammatory disease, and lifetime sexual assault. While racial minority veterans were equally as likely as white veterans to be evaluated for infertility, white and racial minority groups reported different reasons for not seeking evaluation. CONCLUSIONS: Consistent with civilian studies, our data suggest that racial minority VA-enrolled female veterans are more likely to self-report infertility and less likely to receive infertility treatment. Future research should investigate whether these findings are consistent nationwide and regardless of VA enrollment, and if minority veterans have unique barriers to care. A better understanding of how the VA might improve awareness of infertility evaluation and treatment options, especially for racial minority veterans, is needed.

Alcohol use severity and age moderate the effects of brief interventions in an emergency department randomized controlled trial.

BACKGROUND: The primary aim of this study was to examine the efficacy of two motivational interviewing-based alcohol brief interventions (BIs) among adults presenting to an emergency department (ED). The secondary aim was to evaluate moderators of intervention effects. METHODS: Participants were 750 ED patients reporting recent alcohol misuse. Participants were randomly assigned to: 1) computer-delivered BI (Computer BI), 2) therapist-delivered BI with computer guidance (Therapist BI-CG), or 3) control. The BIs focused on reduction of alcohol use and risk behaviors. The outcome measure was trajectories of alcohol consumption (measured by the AUDIT-C) across baseline, 3-, 6- and 12-month follow-up assessments, analyzed using latent growth curve modeling. Moderation of intervention effect by gender, age, and baseline alcohol use disorder severity was examined. RESULTS: Across the full sample (40% males, mean age = 35.8, SD = 12.3), there was an overall reduction in alcohol consumption across 12 months. The main effects of the Therapist and Computer BI were not significant relative to control. Moderation analysis revealed that the impact of Therapist BI-CG, relative to control, was greater on reductions in alcohol consumption in participants with moderate to severe symptoms of alcohol use disorder compared to those with mild symptoms. The effect of the Computer BI on alcohol use, relative to control, was greater among younger participants compared to older participants. CONCLUSIONS: While no overall effect was shown, ED-based Therapist BI-CG with computer guidance may be effective among patients with moderate-severe drinking patterns, whereas Computer BIs may be more effective for younger participants.

Utilization of outpatient medical care and substance use among rural stimulant users: Do the number of visits matter?

Rural substance users are less likely than their urban peers to use formal substance use treatment. It is therefore important to understand how the utilization of potentially more appealing care options, such as outpatient medical care (OMC), may affect substance use over time. This study sought to examine whether the number of OMC visits, after controlling for important covariates, was associated with days of alcohol, crack and powder cocaine, and methamphetamine use among a sample of rural stimulant users over a three year period. Data were collected from a natural history study of 710 stimulant users living in rural communities in Arkansas, Kentucky, and Ohio. Participants were adults, not in drug treatment, and reporting stimulant use in the last 30days. In terms of alcohol use, for participants with higher employment-related problems, having 3 or more OMC visits (relative to none) was associated with fewer days of alcohol use. The results for days of cocaine and methamphetamine use were mixed. However, we did find that for participants reporting at least one substance use treatment or mutual help care visit in the past 6-months, having 1-2 OMC visits (compared to none) was associated with fewer days of crack cocaine use. Regarding methamphetamine use, results showed that for participants without medical insurance, having 3 or more OMC visits (compared to none) was associated with significantly fewer days of methamphetamine use if they also reported greater than or equal to a high school education. The findings from this study may help us begin to understand some of the characteristics of rural drug users, who utilize OMCs, associated with reductions in substance use. These findings may help health care administrators better plan, coordinate, and allocate resources to rural OMCs to more effectively address substance use in this population.

Longitudinal associations between outpatient medical care use and substance use among rural stimulant users.

BACKGROUND: Negative views toward substance use treatment among some rural substance users and limited treatment resources in rural areas likely affect substance use utilization. It is therefore important to determine whether accessing healthcare options other than substance use treatment, specifically outpatient medical care (OMC), is associated with reductions in substance use. OBJECTIVES: We examined whether use of OMC was associated with reductions in substance use among rural substance users over a three-year period. We also explored whether substance user characteristics, including substance-use severity and related-problems, moderated this potential relationship. METHODS: Data were collected from an observational study of 710 (61% male) stimulant users using respondent-driven sampling. Participants were recruited from rural counties of Arkansas, Kentucky, and Ohio. RESULTS: We found a significant main effect of having at least one OMC visit (relative to none) on fewer days of alcohol, crack cocaine, and methamphetamine use over time. Fewer days of alcohol, crack cocaine, and methamphetamine use were reported in participants with at least one OMC visit (relative to those with none) among those reporting higher Addiction Severity Index employment and psychiatric severity scores, and low education, respectively. CONCLUSION: Our findings extend the results from prior studies with urban substance users to show that contact with an outpatient medical care clinic is associated with reductions in substance use over time among rural substance users with especially poorer functioning. These findings highlight the potential importance of OMCs in addressing unhealthy substance use in rural communities.

Factors Associated with Opioid Initiation in OEF/OIF/OND Veterans with Traumatic Brain Injury.

Objective: These analyses examined opioid initiation and chronic use among Iraq (OIF) and Afghanistan (OEF/OND) veterans with a new diagnosis of traumatic brain injury (TBI) in the Veterans Health Administration (VHA). Methods: Data were obtained from national VHA data repositories. Analyses included OEF/OIF/OND veterans with a new TBI diagnosis in 2010-2012 who used the VHA at least twice, had not received a VHA opioid prescription in the 365 days before diagnosis, and had at least 365 days of data available after TBI diagnosis. Results: Analyses included 35,621 veterans. Twenty-one percent initiated opioids; among new initiators, 23% used chronically. The mean dose was 24.0 mg morphine equivalent dose (MED) daily (SD = 24.26); mean days supplied was 60.52 (SD = 74.69). Initiation was significantly associated with age 36-45 years (odds ratio [OR] = 1.09, 95% CI = 1.01-1.17, P = 0.04), female gender (OR = 1.22, P < 0.001), having back pain (OR = 1.38, P < 0.0001), arthritis/joint pain (OR = 1.24, P < 0.0001), or neuropathic pain (OR = 1.415, P < 0.02). In veterans age 36-45 years, those living in small rural areas had higher odds of chronic opioid use (OR = 1.31, P < 0.0001, and OR = 1.33, P = 0.006, respectively) and back pain (OR = 1.36, P = 0.003). Headache/migraine pain was associated with decreased odds of chronic opioid use (OR = 0.639, P = 0.003). Conclusions: Prevalence of opioid use is relatively low among OEF/OIF/OND veterans with newly diagnosed TBI who are using VHA. Among those who initiated opioids, about 25% use them chronically. Prescribing was mostly limited to moderate doses, with most veterans using opioids for approximately two months of the 12-month study period.

Criminogenic Needs, Substance Use, and Offending among Rural Stimulant Users.

There is a need to understand the determinants of both substance use and criminal activity in rural areas in order to design appropriate treatment interventions for these linked problems. The present study drew on a predominant model used to assess and treat offenders -- the Risk-Need-Responsivity (RNR) model -- to examine risk factors for substance use and criminal activity in a rural drug using sample. This study extends the RNR model's focus on offenders to assessing rural-dwelling individuals using stimulants (N=462). We examined substance use and criminal justice outcomes at 6-month (91%) and 3-year (79%) follow-ups, and used Generalized Estimating Equations to examine the extent to which RNR criminogenic need factors at baseline predicted outcomes at follow-ups. Substance use and criminal justice outcomes improved at six months, and even more at three years, post-baseline. As expected, higher risk was associated with poorer outcomes. Antisocial personality patterns and procriminal attitudes at baseline predicted poorer legal and drug outcomes measured at subsequent follow-ups. In contrast, less connection to antisocial others and fewer work difficulties predicted lower alcohol problem severity, but more frequent alcohol use. Engagement in social-recreational activities was associated with fewer subsequent arrests and less severe alcohol and drug problems. The RNR model's criminogenic need factors predicted drug use and crime-related outcomes among rural residents. Services adapted to rural settings that target these factors, such as telehealth and other technology-based resources, may hasten improvement on both types of outcomes among drug users.

Sexual assault in the US military: A comparison of risk in deployed and non-deployed locations among Operation Enduring Freedom/Operation Iraqi Freedom active component and Reserve/National Guard servicewomen.

BACKGROUND: To determine whether sexual assault in the military (SAIM) among active component and Reserve/National Guard servicewomen is more likely to occur in deployed or non-deployed locations; and which location poses greater risk for SAIM when time spent in-location is considered. METHODS: A total of 1337 Operation Enduring Freedom/Operation Iraqi Freedom era servicewomen completed telephone interviews eliciting socio-demographics, military and sexual assault histories, including attempted and completed sexual assault. RESULTS: Half of the sample had been deployed (58%). Overall 16% (N = 245) experienced SAIM; a higher proportion while not deployed (15%; n = 208) than while deployed (4%; n = 52). However, the incidence of SAIM per 100 person-years was higher in deployed than in non-deployed locations: 3.5 vs 2.4. Active component and Reserve/National Guard had similar deployment lengths, but Reserve/National Guard had higher SAIM incidence rates/100 person-years (2.8 vs 4.0). CONCLUSIONS: A higher proportion of servicewomen experienced SAIM while not deployed; however, adjusting for time in each location, servicewomen were at greater risk during deployment.

Feasibility and acceptability of shared decision-making to promote alcohol behavior change among women Veterans: Results from focus groups.

BACKGROUND: Although rates of unhealthy drinking are high among women Veterans with mental health comorbidities, most women Veterans with mental comorbidities who present to primary care with unhealthy drinking do not receive alcohol-related care. Barriers to alcohol-related treatment could be reduced through patient-centered approaches to care, such as shared decision-making. AIMS: We assessed the feasibility and acceptability of a telephone-delivered shared decision-making intervention for promoting alcohol behavior change in women Veterans with unhealthy drinking and co-morbid depression and/or probable post-traumatic stress disorder. METHODS: We used 3, 2-hour focus group discussions with 19 women Veterans to identify barriers and solicit recommendations for using the intervention with women Veterans who present to primary care with unhealthy drinking and mental health comorbidities. Transcripts from the focus groups were qualitatively analyzed using template analysis. RESULTS: Although participants perceived that the intervention was feasible and acceptable for the targeted patient population, they identified the treatment delivery modality, length of telephone sessions, and some of the option grid content as potential barriers. Facilitators included strategies for enhancing the telephone-delivered shared decision-making sessions and diversifying the treatment options contained in the option grids. Focus group feedback resulted in preliminary adaptations to the intervention that are mindful of women Veterans' individual preferences for care and realistic in the everyday context of their busy lives.

Correlates of three-year outpatient medical care use among rural stimulant users.

Outpatient medical care (OMC) settings are a care context in which effective management of unhealthy substance use can occur. However, no studies have documented rates of OMC use and characteristics of OMC use among rural substance users. This study sought to examine the rates and frequency of OMC use in a sample of rural drug users over a three-year period. We also explored characteristics of participants associated with use of OMCs over time. Data were collected from June 2005 to September 2007 from a natural history study of 710 stimulant users living in rural communities. Participants were adults, not in drug treatment, and reporting recent methamphetamine, crack cocaine or powder cocaine use. Between 34 and 39% of participants reported any use of an OMC over the three-year follow-up period, with a mean average number of visits ranging from one to two at each follow-up. Having medical insurance, reporting any use of substance use disorder-related care (including formal substance use treatment or mutual-help groups), and higher Addiction Severity Index (ASI) medical and psychiatric composite scores were associated with greater odds of any OMC use and higher frequency of OMC use over time. Being male and having higher ASI alcohol and drug composite scores were associated with lower odds of any OMC use and lower frequency of OMC use. Our findings support the importance of public health efforts to increase OMC use among male rural drug users and those with more severe drug and alcohol use, the important role(s) of Federally Qualified Health Centers and other OMCs in rural communities that serve those with low rates of health insurance, and the need for public health efforts to increase the use of OMCs among rural drug users not experiencing more severe medical or psychiatric health problems.

Lifetime Sexual Assault and Sexually Transmitted Infections Among Women Veterans.

OBJECTIVE: Women veterans report a high prevalence of sexual assault. Unfortunately, there are limited data on the reproductive health sequelae faced by these women. Our objective was to evaluate the association between completed lifetime sexual assault (LSA) and sexually transmitted infections (STIs) among a cohort of women veterans, adjusting for sexual risk behaviors. MATERIALS AND METHODS: We conducted a retrospective study among women veterans aged 51 years or younger who enrolled for care at two Veterans Administration (VA) healthcare sites between 2000 and 2008. Participants completed a telephone interview assessing reproductive health and sexual violence history. We compared the frequencies of past STI diagnoses among those who had and had not experienced LSA. We used logistic regression to assess the effect of sexual assault with history of an STI diagnosis after adjusting for age, sexual risk behaviors, and substance abuse treatment. RESULTS: Among 996 women veterans, a history of STIs was reported by 32%, including a lifetime history of gonorrhea (5%), chlamydia (15%), genital herpes infection (8%), and human papillomavirus infection (15%), not mutually exclusive; 51% reported LSA. Women with a history of LSA were significantly more likely to report a history of STIs (unadjusted odds ratio [OR] 1.91, 95% confidence interval [CI] 1.45-2.50; adjusted OR 1.49, 95% CI 1.07-2.08). CONCLUSIONS: Women veterans who have experienced LSA are at increased risk for lifetime STI diagnoses. To adequately address the reproductive health needs of the growing population of women veterans, STI risk assessments should include queries of military service and LSA histories.

A randomized controlled trial of brief interventions to reduce drug use among adults in a low-income urban emergency department: the HealthiER You study.

AIMS: To examine efficacy of drug brief interventions (BIs) among adults presenting to a low-income urban emergency department (ED). DESIGN: Randomized controlled trial on drug use outcomes at 3, 6 and 12 months. Participants were assigned to (1) computer-delivered BI (Computer BI), (2) therapist-delivered, computer-guided BI (Therapist BI) or (3) enhanced usual care (EUC-ED) for drug-using adults. Participants were re-randomized after the 3-month assessment to either adapted motivational enhancement therapy (AMET) booster or enhanced usual care booster (EUC-B). SETTING: Patients recruited from low-income urban emergency departments (ED) in Flint, Michigan, USA. PARTICIPANTS: A total of 780 ED patients reporting recent drug use, 44% males, mean age = 31 years. INTERVENTIONS: Computer BI consisted of an interactive program guided by a virtual health counselor. Therapist BI included computer guidance. The EUC-ED conditions included review of community health and HIV prevention resources. The BIs and boosters were based on motivational interviewing, focusing on reduction of drug use and HIV risk behaviors. MEASUREMENTS: Primary outcome was past 90 days using drugs at 6 and 12 months and secondary outcomes were weighted drug-days and days of marijuana use. FINDINGS: Percentage changes in mean days used any drug from baseline to 12 months were: Computer BI + EUC-B: -10.9%, P = 0.0844; Therapist BI + EUC-B: -26.7%, P = 0.0041, for EUC-ED + EUC-B: -20.9, P = 0.0011. In adjusted analyses, there was no significant interaction between ED intervention and booster AMET for primary and secondary outcomes. Compared with EUC-ED, Therapist BI reduced number of days using any drug [95% confidence interval (CI) = -0.41, -0.07, P = 0.0422] and weighted drug-days (95% CI = -0.41, -0.08, P = 0.0283). Both Therapist and Computer BI had significantly fewer number of days using marijuana compared to EUC-ED (Therapist BI: 95% CI = -0.42, -0.06, P = 0.0104, Computer BI: 95% CI = -0.34, -0.01, P = 0.0406). Booster effects were not significant. CONCLUSIONS: An emergency department-based motivational brief intervention, delivered by a therapist and guided by computer, appears to reduce drug use among adults seeking emergency department care compared with enhanced usual care.

Developing an Integrated Violence Prevention for Men and Women in Treatment for Substance Use Disorders.

Rates of past-year partner and non-partner violence perpetration (VP) in substance use disorder (SUD) treatment samples exceed 50%, with studies showing rates of past-year VP exceeding 70% when considering violence occurring with either intimate partners or non-partners. However, SUD treatment programs typically do not include VP prevention interventions, and the few studies examining the impact of SUD interventions on VP have focused exclusively on partner VP. This study summarizes results of a randomized controlled pilot study of an Integrated Violence Prevention Treatment (IVPT) designed to address VP across partner and non-partner relationships as well as predictors of post-treatment VP. Participants were men (70%) and women (30%) in SUD treatment reporting past-year VP who were randomized to either IVPT or a control condition. The IVPT involved a Motivational Interviewing session targeting interpersonal conflicts, followed by five cognitive-behavioral therapy sessions focusing on VP prevention skills. The control condition included a session including a videotape and discussion of anger management, followed by five psycho-educational sessions common for SUD settings. Results showed that VP (total, partner, and non-partner) and cocaine use significantly decreased between baseline and 3-month follow-up for both conditions, and the IVPT group showed a significant decline in alcohol use. Analyses focusing on VP during follow-up revealed that baseline cocaine use and drinking during the follow-up predicted post-treatment VP. Together, these findings suggest that IVPT is a promising intervention (feasible, appears to impact drinking, an important factor related to violence) but that additional continuing care approaches may be indicated to sustain positive outcomes.

The Relationship Between US Military Officer Leadership Behaviors and Risk of Sexual Assault of Reserve, National Guard, and Active Component Servicewomen in Nondeployed Locations.

OBJECTIVES: To determine if military leader behaviors are associated with active component and Reserve-National Guard servicewomen's risk of sexual assault in the military (SAIM) for nondeployed locations. METHODS: A community sample of 1337 Operation Enduring Freedom and Operation Iraqi Freedom-era Army and Air Force servicewomen completed telephone interviews (March 2010-December 2011) querying sociodemographic and military characteristics, sexual assault histories, and leader behaviors. We created 2 factor scores (commissioned and noncommissioned) to summarize behaviors by officer rank. RESULTS: A total of 177 servicewomen (13%) experienced SAIM in nondeployed locations. Negative leader behaviors were associated with increased assault risk, at least doubling servicewomen's odds of SAIM (e.g., noncommissioned officers allowed others in unit to make sexually demeaning comments; odds ratio = 2.7; 95% confidence interval = 1.8, 4.1). Leader behavior frequencies were similar, regardless of service type. Negative leadership behavior risk factors remained significantly associated with SAIM risk even after adjustment for competing risk. Noncommissioned and commissioned officer factor scores were highly correlated (r = 0.849). CONCLUSIONS: The association between leader behaviors and SAIM indicates that US military leaders have a critical role in influencing servicewomen's risk of and safety from SAIM.

Acceptability of HIV Testing Sites Among Rural and Urban African Americans Who Use Cocaine.

African Americans (AAs) who use cocaine in the Southern region of the U.S. have a relatively high risk of HIV and need for HIV testing. Among this group, those residing in rural areas may have less favorable opinions about common HIV testing sites, which could inhibit HIV testing. We examined rural/urban variations in their acceptability of multiple HIV testing sites (private physician clinic, local health department, community health center, community HIV fair, hospital emergency department, blood plasma donation center, drug abuse treatment facility, and mobile van or community outreach worker). Results from partial proportional odds and logistic regression analyses indicate that rural AA who use cocaine have lower odds of viewing local health departments (OR = 0.09, 95 % CI = 0.03-0.21), physician offices (OR = 0.19, 95 % CI = 0.09-0.42), and drug use treatment centers (OR = 0.49; 95 % CI = 0.30-0.80) as acceptable relative to their urban counterparts. The findings have implications for further targeting HIV testing toward AAs who use of cocaine, particularly those residing in the rural South.

The Criminal Justice Experience of African American Cocaine Users in Arkansas.

BACKGROUND: African Americans are incarcerated at rates much higher than other racial and ethnic groups in the United States. OBJECTIVES: We sought to qualitatively explore the relationships between ongoing involvement in the criminal justice system and continued drug use in a population of urban and rural African American cocaine users in a southern state. METHODS: Semi-structured qualitative interviews were conducted among African American cocaine users in Arkansas between 2010 and 2012. Participants resided in both rural (two counties located in the eastern Arkansas Mississippi delta region) and urban (the county including the capital city of Little Rock) areas. RESULTS: Numerous important themes emerged from participants' narratives, including chronic involvement with the criminal justice system (being a "career criminal"), continued access to drugs while incarcerated, relapse, and reincarceration and lack of access to effective drug treatment. Conclusion/Importance: The themes which emerged from our data speak to the collective experience that many substance using populations in the United States face in dealing with the criminal justice system. Our findings highlight the need to better, more holistic ways of engaging African American substance users in community based substance use treatment and supportive services.

Associations Between Religiosity, Perceived Social Support, and Stimulant Use in an Untreated Rural Sample in the U.S.A.

BACKGROUND: Religiosity and perceived social support (SS) may serve as protective factors for more severe substance use in adults. OBJECTIVES: This study sought to examine whether aspects of religiosity and SS are associated with longitudinal reductions in stimulant use over three years in an untreated sample of rural drug users. METHODS: Respondent-driven sampling was used to recruit stimulant users (N = 710) from Arkansas, Kentucky, and Ohio. Follow-up interviews were conducted at 6-month intervals for 36 months. RESULTS: Our bivariate findings indicate that higher religiosity was associated with lower odds and fewer days of methamphetamine and cocaine use. After controlling for covariates, higher religiosity was associated with fewer days of crack cocaine use, but more days of methamphetamine use among a small sample of users in the two final interviews. Higher SS from drug-users was also associated with higher odds and days of methamphetamine and powder cocaine use, while higher SS from nondrug users was associated with fewer days of methamphetamine use. CONCLUSIONS/IMPORTANCE: Our bivariate findings suggest that higher levels of religiosity may be helpful for some rural individuals in reducing their drug use over time. However, our multivariate findings suggest a need for further exploration of the potential effects of religiosity on longer-term drug use, especially among those who continue to use methamphetamine and/or remain untreated. Our findings also highlight the potential deleterious effect of SS from drug users on the likelihood and frequency of methamphetamine and powder cocaine use over time among untreated rural drug users.

The Role of Social Capital in African Americans' Attempts to Reduce and Quit Cocaine Use.

BACKGROUND: Research examining substance users' recovery has focused on individual-level outcomes while paying limited attention to the contexts within which individuals are embedded, and the social processes involved in recovery. OBJECTIVES: This paper examines factors underlying African American cocaine users' decisions to reduce or quit cocaine use and uses practice theory to understand how lifestyle changes and shifts in social networks facilitate access to the capital needed to change cocaine use patterns. METHODS: The study, an in-depth analysis of substance-use life history interviews carried out from 2010 to 2012, included 51 currently not-in-treatment African American cocaine users in the Arkansas Mississippi Delta region. A blended inductive and deductive approach to data analysis was used to examine the socio-cultural and economic processes shaping cocaine use and recovery. RESULTS: The majority of participants reported at least one lifetime attempt to reduce or quit cocaine use; motivations to reduce use or quit included desires to meet social role expectations, being tired of using, and incarceration. Abstinence-supporting networks, participation in conventional activities, and religious and spiritual practices afforded access to capital, facilitating cocaine use reduction and sobriety. CONCLUSIONS: Interventions designed to increase connection to and support from nondrug using family and friends with access to recovery capital (e.g., employment, faith community, and education) might be ideal methods to reduce substance use among minorities in low-income, resource-poor communities.