Drug (Ab)use research among Rural African American males: an integrated literature review.

Little is known about the cultural norms and prevalence of drug use and abuse among rural African American males. Rural drug use research among males tends to focus on Native American, white, or diverse racial/ethnic samples of adolescents and, to a much lesser extent, white adult males, with almost no targeting of African American males. Therefore, an extensive search of published literature on drug use among rural African American males was undertaken to identify and summarize the published research related to drug use among this population, with the ultimate goal of delineating research gaps warranting future investigation. Findings revealed that most studies focused on adolescents and children, often using national data sets, and were descriptive. Those that targeted adults frequently analyzed demographics for respondents who were rural, male, and/or African American, although all three characteristics were usually not reported in combination. Of these studies, the percentage .of African American males varied, usually being the largest minority subgroup but still a relatively small percentage of each sample. Results specific to rural African American adult males are rarely reported in these studies. Recommendations for the direction of future drug use research among rural African American males are offered, and research gaps are identified.

Keywords: rural, African American male, drug (ab)use, integrated literature review

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The integrative literature review presented here examines and summarizes published research in an effort to derive comprehensive conclusions from the separate studies related to substance abuse among rural African American males. Since most of the research studies differ in their objectives, targeted population, and design and were primarily descriptive (either qualitative or quantitative), this analysis was based on the approach developed by Bland, Meurer, and Maldonado (1995). Four of the five phases of a nonstatistical meta-analysis recommended by Bland and colleagues were used to select the articles included in the review: (1) literature retrieval, (2) literature coding, (4) annotation of high-quality references, and (5) synthesis of the major findings of each study. The third phase, rating of the articles for quality, was omitted since the authors deemed it appropriate to include all of the limited studies published that met the inclusion criteria pertaining to the topic. It is also the authors' position that the state of the investigation of substance abuse among this subgroup has not advanced in the United States to the stage at which empirical, randomized clinical trials are the "gold standard" by which to gauge quality research.

REVIEW OF THE LITERATURE

Rural drug use research among males tends to focus on Native American (i.e., Ellis, 2003; Wallerand, Okamoto, Miles, & Hurdle, 2003), white (i.e., Trudeau, Lillehoj, Spoth, & Redmond, 2003; Zavela, Battistich, Gosselink, & Dean, 2004), or diverse racial/ethnic samples of adolescents (i.e., Albrecht & Amey, 1996; Allen & Page, 1994; Cronk & Sarvela, 1997; French & Picthall-French, 1998; Hodge, Cardenas, & Montoya, 2001; Redmond, Spoth, Shin, & Hill, 2004; Scheer, Borden, & Donnermeyer, 2000; Smith et al., 2004; Wills, Gibbons, Gerrard, & Brody, 2000). To a much lesser extent the focus has been on white adult males (Booth & Kirchner, 2001), with almost no targeting of African American adult males (Brown, Hill, & Giroux, 2004).

From research findings of the criminal justice system, it can be extrapolated that rural African American males, like their urban counterparts, are disproportionately incarcerated because of drug use or drug-related crimes. African Americans were almost twice as likely as whites to be incarcerated in state prisons in 1996, with about 40% of all African Americans being incarcerated for drug-related offenses (Ditton & Wilson, 1999). Although the prevalence of drug use among African American, Hispanic, and white Americans is comparable, African Americans were found to be more than 20 times more likely than whites to be incarcerated due to a drug-related offense. In addition, drug-related emergency room visits, deaths due to drug overdose, and HIV infections related to injection drug use are higher among African Americans than among whites (Drucker, 1999).

Drug and alcohol use has become increasingly prevalent in rural areas, with crack cocaine now being a common drug of choice for African Americans (Brown et al., 2004; Hays, Farabee, & Patel, 1999). In addition, a recent study by McAuliffe and Dunn (2004) revealed that southern states in the United States have the highest percentage of African Americans in comparison to other states, while having low-to-moderate levels of drug and alcohol abuse and also very low levels of drug treatment services. Yet, rural African American males are often "hidden" from social and health care agencies, with limited access to these services, especially if they lack insurance. This leaves the criminal justice system as the primary avenue of exposure to services for many rural African American males. Researchers attempting to access the target population within the criminal justice system are likely to encounter many recruitment barriers, including lack of trust. Perhaps these access barriers explain in part the scant amount of drug-related research conducted with rural African American males. Therefore, the purpose of this integrated literature review was to identify and summarize the published research related to drug use among rural African American adult males, with the ultimate goal of identifying research gaps warranting future investigation.

METHODS

Four methods were used to retrieve research articles pertaining to drug use among rural African American males. Since the aim was to identify all research, both descriptive and empirical studies were included. Only the studies generated from targeting adult males and focusing on drug abuse (including alcohol) were selected.

The first search technique was an in-depth, computer-based literature search of ten databases: Academic Search Premier, CINAHL, Pre-CINAHL, Health Sources, Nursing/Academic Edition, Medline, PsyclNFO, PsycArticles, Sociological Abstracts, and Social Science Database. MeSH terms were entered under the keyword, abstract, and title options. The MeSH terms were: "drug use," "substance use," "African American," "black," "male," "men," "rural," and/or "non-urban" in various combinations. The searches were limited to the years "1985-2005," "English language," "adult age groups," "peer reviewed publications," and "articles." After locating no studies that targeted rural African American adult males only, the search was broadened to include studies targeting rural adult males of any race/ethnicity including rural African Americans, even if the percentages of rural African American males was small. Nine research articles were selected based on the following criteria: they addressed at least two of the categories of interest, one being "African American/ black" and the other being either "substance/drug abuse," "rural," or "male."

Second, the authors searched the bibliography #SP 210-B titled "African American Alcohol and Drug Use, Published 1990+" generated by the Alcohol and Drug Abuse Institute (ADAI) of the University of Washington (http://depts.washington. edu/adai/lib/bibs/sp_210b.htm). Two studies were generated using this method; however, one was a duplicate article.

Third, a search was conducted via EBSCOhost under the "author" search option for invited presenters at a National Institute on Drug Abuse (NIDA) meeting held December 7-8, 2004, titled "Drug Abuse Research in Rural Communities: Current Knowledge and Future Directions." Presenters were invited based on their expertise and experience in substance abuse research with rural populations. The names of presenters who were not National Institute of Health (NIH) employees were entered into the database by one of the authors, who determined if the manuscripts were research-focused. One study was secured from the author search.

Fourth, the reference sections of articles selected by the previous methods were canned for articles meeting the inclusion criteria. One study was located using this method.

All the articles retrieved using these four methods were again screened using additional inclusion criteria before being included in the present review. These second-level inclusion criteria were: (1) substance abuse focus, (2) at least 20% of the sample being rural, (3) at least 20% of the sample being male, and (4) at least 10% of the total sample being African American. A total of eleven articles met the first and second level of inclusion criteria (see Table 1). Of these eleven studies, seven used samples in which African Americans comprise less than half the sample, six included special populations, and five had samples in which less than half were rural participants. Several authors of the published studies had collaborated on two or more publications, which may indicate that the number of separate studies is even smaller. In addition, some published studies used the same or similar samples, national databases, or sites.

Nineteen studies were excluded from the review because they targeted adolescents (i.e., Albrecht & Amey, 1996; Allen & Page, 1994; Cronk & Sarvela, 1997; French & Picthall-French, 1998; Hodge et al., 2001); had insufficient numbers of rural subjects (Booth et al., 2005), males (Boyd, Phillips, & Dorsey, 2003) or African Americans (Herz & Murray, 2003; Simons, Oliver, Gaher, Ebel, & Brummels, 2005); or did not present separate findings for rural African American males (Booth, Curran, & Han, 2004; Booth & Feng, 2002).

The narrative summaries presented will include only those studies of adult males under the subheadings Studies of Rural African American Males and Studies Including Rural and/or African American Males. Summaries include brief descriptions of the sample, duration of the study, the objective(s), key results, and conclusions as presented by the researchers, as well as conclusions about the studies by the authors of this review. When findings are not presented for the target population of rural African American males, results most pertinent to this target population (i.e., findings for rural males or findings for urban African American males) are presented.

RESULTS

STUDIES OF RURAL AFRICAN AMERICAN MALES

Of these three studies, the researchers of one focused on alcohol only, while the other two investigated drugs other than alcohol. All studies in this section included both males and females, but findings specific to males are presented. One study was a focus group, one was an ethnography, and the other was a descriptive study. The two qualitative studies used primary data collection, and the latter used a secondary national data set.

Brown, Hill, and Giroux's (2004) study objective was to assess perceptions of factors contributing to the initiation and continuation of drug use, particularly cocaine use among African Americans, with possible interventions. A formative focus group study was conducted with 19 rural and small-city African Americans (10 males and 9 females) who used cocaine. Key results revealed five contributing factors related to crack use and three major cessation strategies. Male respondents expressed particular concerns about the need to relate to other African American men in recovery. They also viewed jobs, transportation, home, and family as important in cessation efforts. The researchers concluded that effective drug prevention programs in southern African American cocaine users should be community-based, personalized, and culturally relevant, with gender- and race-based strategies.

The authors of this review conclude that, although both genders were included, findings from rural African Americans who use drugs are just a beginning for further study focusing only on males. The emphasis on treatment strategies is particularly important.

Sexton, Carlson, Siegal, Falck, Leukefeld, and Booth (2005) were primarily interested in understanding the potential barriers and pathways to the diffusion of methamphetamine use among African Americans in the rural South. The African American sample of 34 was drawn from a larger sample of 86. Of this subgroup 61% were males with an age range of 18 to 52 years (mean age = 33). Females ranged in age from 18 to 55 years (mean age = 38). Fourteen (41%) had some experience with methamphetamine. Of the 14 reporting use, eight were men and six were women. The key findings were that those involved in methamphetamine use, manufacture, and sales were predominantly white. Barriers to diffusion within the African American community were perception of its long-term effect, concern about the ingredients and drug manufacturing process, and especially perceptions about the hazards of the environment. In addition, problems associated with purchasing methamphetamine were perceived as a barrier. The pathways to use were attributed to methamphetamine being substituted for powder cocaine without the person's knowledge, using methamphetamine when crack was unavailable, being introduced to methamphetamine by a white significant other (usually a female), and involvement in a predominantly white social network. Key findings associated with sustained use were a "hyperness" effect, craving, and perception of low cost. The researchers concluded that rural African Americans use methamphetamine in spite of barriers. They suggested that methamphetamine use by African Americans has the potential to increase as African American/white interactions increase.

The authors of this review conclude that there is a potential for continued diffusion of methamphetamine into the African American community in the South. African Americans who are introduced to the drug are supplied with the drug by outsiders, particularly whites, who in turn introduce it to other African Americans.

Herd (1995) focused on residence and alcohol use among African Americans. The sample was comprised of 1,947 African Americans, a subset of a national survey of 5,221 adults. The objective of the study was to explore regional differences in drinking patterns of African Americans by studying the effects of migration and residence at different points in life in relation to drinking behavior and social context. Although specific questions about residence were asked that distinguished rural from urban subjects, statistics were not reported for the number or percentage of rural or male participants. Instead, residence was categorized into "wet" or "dry" areas and primarily reported in this manner, with a few references to rural or urban residence. Key findings indicated that current or lifetime residence in a "wet" area or lifetime residence in an urban area was associated with increased drinking. Gender differences for African American men were attributed to age and the indirect influence of norms, home drinking environment, and bar attendance. The researcher concluded that region and urbanization affect drinking patterns of African American males and females differently. Males were more affected by influences on drinking norms and home environment (both significant predictors of the quantity and frequency of drinking) and bar behavior. Increased bar attendance and increased drinking were both associated with lifetime residence in an urban area and current or lifetime residence in a "wet" area. Those who grew up in "dry" areas attended bars less often and drank less, regardless of current residence. In contrast, those who migrated from rural to urban areas drank less than those who remained in rural areas. Age was negatively correlated with drinking for men, but not for women. The researcher recommended further study of these influences by race and gender.

The authors of this review conclude that this study offers findings relevant to African American male drinking patterns, although both genders were included. Clearer findings on "indirect influences" and additional studies focusing on the specifics of the broader areas identified would be useful.

STUDIES INCLUDING RURAL AND/OR AFRICAN AMERICAN MALES

Of the eight studies in this category, one was a medical record review, six were descriptive studies, and one was an intervention study. Two of the eight used secondary data sets.

Hays, Farabee, and Patel (1999) examined demographics and other characteristics of cocaine abusers admitted to a private hospital addictions unit. The sample consisted of the medical records of 65 patients with a diagnosis of cocaine abuse or dependence out of 667 admitted over an 18-month period. Key findings revealed that both African Americans and males were over-represented among the population of cocaine users. Of the two hypotheses relating to user's route of choice, the hypothesis that smoking cocaine is African American users' primary route of choice was supported. Conversely, African Americans were less likely to snort the drug (30% compared to 50% of whites) or inject it (11% compared to 21% of whites). Among men, only 12% reported intravenous use, compared to 25% of women. Duration of use was longer among both rural participants and men, although men used lesser amounts than women. No racial or rural-urban differences were found to be associated with a history of prior treatment, but those whose route of choice was smoking were more likely to have had treatment. The researchers concluded that most cocaine abusers also abuse other substances, limiting the extent to which findings can be generalized. They also noted that the concurrent diagnosis of mood disorders in only 17% of their study was lower than usual, perhaps indicating a recent decline in this dual diagnosis. However, seven such patients (14%) were males. Four were African Americans; only one was rural. The researchers also commented on a likely association of smoking with more severe dependence, expense, and violence. They expressed concern about the lack of information differentiating rural and urban cocaine abusers and the implications this may have for treatment, citing limited options for follow-up in rural areas, few Alcoholics Anonymous/Narcotics Anonymous programs, and the need for social work related to legal problems.

The current authors conclude that, because the number of rural African American males in the study could not be extrapolated from the tables or text presented, findings relevant to this target group were sometimes inconclusive. This occurred when results differed for rural participants, African Americans, or men and the combination was not presented.

Blazer, Crowell, and George (1987) conducted one of the earliest, largest, and most comprehensive descriptive studies of adult alcoholics. Of the 3,921 participants in this study, 41% were non-white, described as almost entirely African American (37% male; 51% rural). These researchers' objective was to determine rural-urban differences in the prevalence of alcohol abuse or dependence and whether other demographic factors explain such differences. For this NIMH Epidemiological Catchment Area program research (one of five areas studied), four counties in rural Piedmont, North Carolina, were designated as the rural site for the specific purpose of comparing rural-urban differences with urban Durham County. The researchers found alcohol diagnoses to be more common in rural areas and particularly significant for African Americans. Abstinence and the number of those never having been intoxicated was greater in rural areas, but some patterns of use were also greater, including morning drinking and daily consumption. Among rural African American males, the highest rate of alcoholism was among 45- to 64-year-olds, over twice that of other age groups. Researchers speculate about possible influences such as genetics and intermarriage; socioeconomic status with poverty, social isolation, and/or fewer protective factors for African Americans; migration back to rural areas with family ties at midlife; environmental differences or greater ease in functioning in a rural setting while drinking daily; and rural families complaining significantly more about drinking, which was one of a number of criteria used to diagnose alcohol problems in this study. The researchers concluded that factors related to rural/urban differences in alcohol abuse and/or dependence are too complex to be explained by geography alone, due to higher rates among men and African Americans.

The authors of this review conclude that these findings support the need for further research focusing on rural African American males.

Various co-morbidities were examined in several studies of polysubstance users in community, clinical, and criminal justice settings. Booth and Kirchner (2001) sampled 733 rural and urban drinkers in six southern states (67% male, 20% African American, 50% rural). They studied concurrent use of alcohol and other drugs among adults with the objective of identifying the correlates and outcomes of co-occurring cannabis use in rural and urban alcohol drinkers. The key findings were that the most common drug used with alcohol was cannabis, followed by cocaine and amphetamines. Twenty-one percent of the subjects using cannabis recently reported more problems associated with alcohol. These problems included more consumption, more physical, legal, and social consequences of drinking, and more psychiatric diagnoses, including panic disorders and antisocial personality disorders. Dual use was also significantly related to being single, unemployed, and without a high school education. No significant differences were found in any of the measures studied based on gender, race, or rural versus urban residence. The researchers concluded that cannabis use might be a marker for greater physical and psychological impairment in alcoholism. Whether cannabis is less benign than was thought and how much impairment is due to its effects versus other possible variables were topics recommended for further study.

The authors of this review conclude that these findings support the need for further research in these areas. Additional study may add to research on cannabis as a "gateway drug" to more serious substance abuse.

In another study rural/urban differences were found among 391 adults with a dual diagnosis of a major mental illness plus a substance abuse disorder (Mueser, Essock, Drake, Wolfe, & Frisman, 2001). This sample was taken from patients treated at mental health facilities in New Hampshire (rural sample, 57.5%) and Connecticut (urban sample, 42.5%). The total rural sample was 75.6% male but only 3.6% non-white, while urban patients were 71.7% minorities. The total number of African Americans was not specified. The objective of the study was to evaluate differences in patients living in rural and urban areas who have a dual-diagnosis of a severe mental illness and a co-occurring substance use disorder. Key results indicated that urban patients were more likely minorities, with greater homelessness, involvement with the criminal justice system, and use of cocaine. The increased rate of homelessness and criminal involvement was attributed to the use of cocaine rather than race, although African Americans showed greater cocaine use. Marijuana use disorders were also reported to be higher among African Americans than whites. Rural patients reported greater use of alcohol. The researchers concluded that urban patients needed more help and services to address their problems, given the type of substances abused and the need for residential and jail diversion programs.

The authors of this review conclude that this study seems to support the idea that the two populations are different, with urban patients having the greater need. However, there were more African Americans in the urban group, so further study is needed.

Three studies focused on differences between rural and urban samples from the Kentucky criminal justice system. Leukefeld and colleagues (2002) studied a sample of 655 males in four unidentified Kentucky state prisons (44.6% African Americans and 1.22% multiracial). Their objective was to assess the age of initial use of various drugs, comparing lifetime and past-year use among rural and urban prisoners. Key findings were only marginally statistically significant in terms of drug-use differences between incarcerated rural and urban drug users. Rural users were older at first use of marijuana and cocaine and had fewer years' use of cocaine, heroin, and hallucinogens, but more alcohol and sedative use. Due to the presence of significantly more urban than rural non-whites in the sample, race and ethnicity were controlled as the analysis developed. Researchers concluded that differences between rural and urban users were primarily in relation to the drugs of choice versus the extent of abuse. Rural and urban users were similar, with rural residence protective of the use of some drugs but risky for others. The researchers question why some use is greater in rural areas and what services are needed.

The authors of this review conclude that the hypothesis that rural residents are more protected from drug use was not supported, although some differences were found, particularly in drug choice. Further study to compare prisoners with the general population of rural African American males would add to the findings and help determine the extent to which they could be generalized.

Warner and Leukefeld (2001) studied rural/urban differences in treatment utilization as well as substance use, also in four unidentified Kentucky state prisons. Of the 337 male chronic drug abusers studied, 34% were rural and 8% were very rural (population with less than 2,500 residents outside of a census-defined urban area). African Americans comprised 41.4% of the total sample, 24.6% of the rural sample, and 10% of the very rural sample. The objective was to examine differences between urban and rural drug use patterns and treatment utilization among chronic drug abusers. Key findings indicated significant differences in rural and urban residents in both substance use and treatment utilization. Rural users showed significantly more drug use in both the 30 days prior and also over their lifetimes. They also reported significantly greater use of inhalants, hallucinogens, sedatives, amphetamines, opiates, and alcohol intoxication, but less use of cocaine than urban users. Among the rural and very rural sample, drug crimes accounted for 31.5% and 30% of their arrests respectively. Both the non-white and very rural respondents were significantly less likely to have been in treatment when race and duration of use were controlled. Among chronic users, drug abuse was more severe among those who were rural than those who were urban, with researchers recommending targeting this population for drug-related intervention during their incarceration. They concluded that the effects of being from a rural area are statistically significant in seeking treatment even after controlling for other variables. The importance of culturally appropriate education on the benefits of substance abuse treatment was emphasized along with the need for treatment within the criminal justice system.

The authors of this review conclude that this study strongly supports the need for targeting rural African American men specifically.

Logan, Walker, and Leukefeld's (2001) study of Kentucky partner violence arrestees included examining their substance use and comparing samples from rural, urban, and urban-influenced areas (a rural area in proximity to and influenced by an urban area). Their all-male sample of 1,112 was 22% rural (N = 246). African Americans comprised only 9% of the rural sample, but were 39% of the urban sample and 26% of the urban-influenced sample. The objective of the study was to examine similarities and differences in male domestic violence arrestees from urban, urban-influenced, and rural areas, including substance use as one factor. The key findings revealed that community context is critical. Rural men arrested for domestic violence had more significant psychological problems than urban or urban-influenced men, including greater use of alcohol, and also used psychoactive medications and "nerve pills." Among those who drank, rural males were also more likely to use prescription drugs. Researchers concluded that the problems of rural males were more significant and recommended that future researchers target the co-occurrence of domestic violence and substance abuse in rural populations. They also recommended more intervention in anger management and drug/alcohol treatment, especially in rural areas.

The authors of this review conclude that this study supports the need for further research of rural African American men. Findings were significant, but they mostly referred to the urban sub-sample because only 9% of the rural sub-sample was African American.

In the only intervention study in this category, Walton, Blow, and Booth (2001) compared participants from several urban/suburban treatment centers and a Veteran's Administration facility (N = 331; 58% male; 37.2% African American; rural not specified). The objective of the study was to explore gender and racial differences in psychosocial concerns of substance abuse treatment patients in relation to relapse prevention. Results indicated marked differences by race, but many of these differences disappeared with control of socioeconomic status and treatment-related variables such as drug of choice and resources. Although findings were not reported for rural African American males, researchers identified racial and gender differences in relapse-prevention needs. African American males had better coping skills than white males, but males of both races had poorer coping skills than females. African Americans reported greater resource needs than whites and were more often polysubstance abusers. Researchers anticipated that African Americans would need more help or skills to access resources. They concluded that men have the greatest need for relapse prevention and recommended alternative approaches that address diversity.

The authors of this review conclude that this study is important in that it targets the key goal in substance abuse: relapse prevention. Further study to clarify the relative importance of these variables is desirable.

DISCUSSION

An extensive search for published research on drug use among rural African American males yielded few studies on this specific topic, as most researchers targeted only one or two of these demographics in relation to drug use. Some analyses included a breakdown based on demographics with findings reported for respondents who were rural, male, and/or African American, although all three characteristics were usually not reported in combination for either demographics or findings. When findings specific to this target group were reported, they were often difficult to extrapolate and summarize consistently for this review because of the methods the researchers used to report the findings. For example, reporting the percentages of the samples who were male, African American, and/or rural often required the authors of this review to calculate these data from various sources within the articles. This suggests that the importance of this demographic (rural African American males) was not fully considered when the studies were designed or when the data were analyzed and reported. Other researchers have also indicated the need for further studies among rural African American males (Booth & Kirchner, 2001; Herd, 1995).

Several limitations were noted in the research reviewed. First, eight of the 11 studies included both genders. Second, rural and urban populations were sometimes combined in data reported by race and gender. Third, African Americans and whites were targeted in the majority of the studies. Fourth, in studies not limited to African Americans, this group was often a small percentage of the sample, even when they were the largest minority group represented. The small number of rural African American males included in many of the studies limits the extent to which the overall findings can be generalized to the targeted population.

The samples in six of the 11 studies were also from special populations, further limiting application to the general population of rural African American males. Three of these were arrestees or incarcerated males (Leukefeld et al., 2002; Logan et al., 2001; Warner & Leukefeld, 2001). Three were treatment populations, two with substance use disorders (Hays et al., 1999; Walton et al., 2001) and the third with a dual diagnosis of a major mental illness and a substance use disorder (Mueser et al., 2001).

The majority of data collection sites for the studies reviewed were limited to the South. Study sites were North Carolina, "six southern states," north Florida, Kentucky (four studies), Kentucky and Arkansas, and a national database used to examine migration influences, often from the South to the North. Only two study sites were outside the South, one in Michigan and one in New Hampshire and Connecticut. The fact that the South has a higher percentage of African Americans than other states (McAuliffe & Dunn, 2004) explains the regional concentration for this study.

Finally, the criteria for determining "rural" were not always described or defined consistently. Some terms were unclear (e.g., a "rural" study site described as "a large rural city," using non-metropolitan and rural interchangeably, and adding categories such as "urban-influenced" and "very rural").

IMPLICATIONS FOR RESEARCH

Further formative and epidemiological drug-related research is needed among rural African American males to help clarify the inconsistencies found in some of the studies reviewed. African Americans reported lower substance use than other racial/ethnic groups in some studies (Sexton et al., 2005), but higher substance use in others (Blazer et al., 1987). In discussing these differences in use reported by racial/ethnic groups, some researchers shed doubt on data indicating lower use rates among African Americans, even when their own findings were consistent with this trend. Researchers suggested under-reporting and offered various possible reasons why this may have occurred. Conflicting statistics such as higher rates of mortality and incarceration associated with drug use among African Americans further confuse this issue. Differences were also found in comparisons of rural and urban use, which appear at this stage of the research to be more related to the choice of drugs rather than the extent of use.

Although trends indicate an increase in drug-use studies among rural male populations, as indicated by 65% of the studies in this review having been conducted between 2000 and 2004, there is a need to expand the research to include studies that target rural African American males solely or to increase the percentage of the rural African American male population in studies of diverse racial/ethnic sub-samples.

Similarly, the need exists to increase studies of illicit drugs. Some of the studies reviewed were confined to the investigation of alcohol use or focused primarily on alcohol and prescription medication, which may indicate a more biased view of illicit drug use in rural areas. Perhaps one explanation for focusing on non-African American males and on alcohol may be related to the difficulty of recruiting African American participants who will acknowledge illicit drug use due to stigma and/or legal consequences. Self-report was usually the method of data collection, and trust issues are particularly sensitive with respect to questions about illicit drug use.

Conducting formative research to identify risk and resiliency factors associated with a given health behavior or to enhance knowledge of the acceptability and feasibility of a proposed prevention intervention is becoming standard practice among behavioral scientists. As scant substance abuse research has been conducted with rural African American males, the use of formative approaches (e.g., focus groups, qualitative individual interviews, participant observation, cross-sectional survey administration) is warranted. Very little is known about issues that contribute to the initiation, continuation, and cessation of drug use within this subgroup, and while what is known about urban African American males may seem generalizable to rural African American males, the soundness of such a generalization is questionable.

Another line of inquiry that warrants investigation is epidemiological research of the prevalence and type of drugs used by rural African American males. Although the findings of a few studies (Brown et al., 2004; Logan et al., 2001) indicate similar drug use (alcohol, marijuana, powder cocaine and crack, with limited use of heroin and methamphetamine), more studies are needed because the numbers of rural African American males comprised only a small percentage of the total sample, and drug use changes over time.

Using a mixed method (ethnographic with epidemiological) design has the potential to produce reliable data in greater quantity, because formative and/or ethnographic studies have been found effective in building trust and recruiting "hidden" subgroups. For example, such studies have been conducted with rural African American women (Brown, 2003), urban African American women (Sterk, Elifson, & Theall, 2000), urban Puerto Rican men (Robles et al., 2003), and urban African American males (Lifson, Thompson, Grant, Hilk, & Lorvick, 1998).

Finally, prevention intervention studies informed by formative research findings are needed to justify efforts to curb the increasing prevalence of both substance abuse and negative outcomes of substance abuse among this understudied subgroup. Pilot testing of prevention interventions for acceptability and feasibility as well as randomized clinic trials are appropriate.

CONCLUSION

It was difficult to draw definitive conclusions from the findings of the studies related to rural African American males, because most researchers did not focus solely on rural African American males or report findings specific for this subgroup in comparison to other racial/ethnic subgroups. Only three studies (Brown et al., 2004; Herd, 1995; Sexton et al., 2005) targeted African Americans only. The percentage of rural participants ranged from 22 to 100, with two studies targeting rural populations only and three targeting males only. The percentage of rural African American males was indicated in only two studies (Brown et al., 2004; Sexton et al., 2005). In addition, the majority of the studies reviewed were descriptive (qualitative or quantitative) and cross-sectional in design.

However, the findings permit four conclusions. First, similar to their urban counterparts, rural African American males' drugs of choice are either alcohol or cocaine (crack and powder). Second, polysubstance use in the form of alcohol, marijuana, and cocaine is common. Third, methamphetamine use is not yet prevalent among rural African American males. Fourth, rural African American males' access to drug treatment lags behind that of rural white males. In summary, the need for further research on drug use among rural African American males is apparent from this review of the limited research literature available on the topic.

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EMMA J. BROWN AND FRANCES B. SMITH

University of Central Florida

Orlando, Florida

Correspondence concerning this article should be directed to: Emma J. Brown, University of Central Florida, School of Nursing, College of Health and Public Affairs, P.O. Box 162210, Orlando, FL 32816-2210. Electronic mail: [e-mail].

Table 1
Demographics of the Studies by Author and Year of Publication;
Study Design; Total Sample; Percent Male, African American,
and Rural Location: and Drug Targeted

Author and Year          Study Design       Duration     Total N

Brown et al., 2004       Focus group        2 weeks         19
Sexton et al., 2005      Ethnography        8 months        14
Herd, 1995               Quantitative
                           descriptive      Not stated   1,947
Hays et al., 1999        Retrospective
                           medical record
                           review           18 months       65
Blazer et al., 1987      Quantitative
                           descriptive      6 months     3,921
Booth et al., 2001       Quantitative
                           descriptive      6 months       733
Mueser et al., 2001      Quantitative
                           descriptive      ~11 years      391
Leukefeld et al., 2002   Quantitative
                           descriptive      15 months      655
Warner et al., 2001      Quantitative
                           descriptive      15 months      337
Logan et al., 2001       Quantitative
                           descriptive      12 months    1,112
Walton et al., 2001      Intervention       Not stated     331

Author and Year          Study Design       % Male       % AA

Brown et al., 2004       Focus group         52          100
Sexton et al., 2005      Ethnography         66          100
Herd, 1995               Quantitative
                           descriptive      N/S          100
Hays et al., 1999        Retrospective
                           medical record
                           review            75           57
Blazer et al., 1987      Quantitative
                           descriptive       37           41
Booth et al., 2001       Quantitative
                           descriptive       67           20
Mueser et al., 2001      Quantitative
                           descriptive       75.6          3.6 rural
Leukefeld et al., 2002   Quantitative
                           descriptive      100           44.6
Warner et al., 2001      Quantitative
                           descriptive      100           34.6
Logan et al., 2001       Quantitative
                           descriptive      100            9 rural
Walton et al., 2001      Intervention        58           37.2

Author and Year          Study Design       % Rural      % RAAM

Brown et al., 2004       Focus group        100          52
Sexton et al., 2005      Ethnography        100          66
Herd, 1995               Quantitative
                           descriptive       37.3        UTC
Hays et al., 1999        Retrospective
                           medical record
                           review            38          UTC
Blazer et al., 1987      Quantitative
                           descriptive       51          UTC
Booth et al., 2001       Quantitative
                           descriptive       50          UTC
Mueser et al., 2001      Quantitative
                           descriptive       57.5        UTC
Leukefeld et al., 2002   Quantitative
                           descriptive       40.3        UTC
Warner et al., 2001      Quantitative
                           descriptive       42.4        UTC
Logan et al., 2001       Quantitative
                           descriptive       22          UTC
Walton et al., 2001      Intervention       N/S          UTC

Author and Year          Study Design       Drug Targeted

Brown et al., 2004       Focus group        Crack
Sexton et al., 2005      Ethnography        Methamphetamine
Herd, 1995               Quantitative
                           descriptive      Alcohol
Hays et al., 1999        Retrospective
                           medical record
                           review           Cocaine
Blazer et al., 1987      Quantitative
                           descriptive      Alcohol
Booth et al., 2001       Quantitative
                           descriptive      Marijuana and alcohol
Mueser et al., 2001      Quantitative
                           descriptive      AOD
Leukefeld et al., 2002   Quantitative
                           descriptive      AOD
Warner et al., 2001      Quantitative
                           descriptive      AOD
Logan et al., 2001       Quantitative
                           descriptive      Alcohol and prescriptions
Walton et al., 2001      Intervention       ATOD

Note: N/S indicates not specified. The authors calculated % male,
African American, and rural when not explicit. AA = African
American; RAAM = rural African American male; UTC = Unable to
calculate from data given; AOD = Alcohol and other drugs;
ATOD = Alcohol, tobacco, and other drugs.