Brown, Emma E J

OBJECTIVE: The purpose of this study was to explore factors associated with southern rural black women’ STI/HIV-related behaviors and their participation in prevention services. METHODS: This qualitative-descriptive study was conducted with 27 black women from two ruralNorth Central Florida counties. Participants were recruited through publicly displayed flyers and by word of mouth to participate in semi-structural, face-to-face interviews. Interviews were conducted during April and May 2001. Participants received $20 in cash at the completion of the 45 to 90 minute audiotaped interviews, which were transcribed verbatim. A codebook was developed to aide in the data analysis, and then the transcripts were hand coded. RESULTS: The participants identified seven structural factors (those associated with the interaction of the women with their physical environment), five socio-structural factors (those associated with the interaction of the women with an individual, a group, or their community), and five individual-level factors. A structural intervention model was developed from data derived from the interviews. CONCLUSION: STI/HIV prevention interventions designed to reduce structural and socio-structural barriers may be more effective than individual-level interventions in rural areas.

KEY WORDS: Black Women; Rural South; Qualitative Method; Structural Intervention Model; STI/HIV.

The southern region of the United States has the highest rate of chlamydia, gonorrhea, primary and secondary syphilis in the country (Centers for Disease Control and Prevention [CDC], 1997), with HIV also increasing in southern rural areas. Increasing sexually transmitted infection (STI) rates are especially significant, as STIs facilitate HIV transmission at least two to five fold (Sorvillo, Smith, Kerndt, & Ash, 2001) and HIV/AIDS is the leading cause of death among Black women aged 25 to 44 (CDC, 2000).

HIV/AIDS is a public health problem in rural Florida, where the epidemic has disproportionately impacted Blacks. It is estimated that 65,000-100,000 Floridians are living with HIV Throughout Florida, one (1) in 50 blacks have HIV, compared to 1 in 286 whites. In 1999, Black females comprised 75% of the HIV infections among women in Florida (Florida Department of Health [FDOH], 1999).

Cumulative data through 1998 indicated that 5,825, or 9%, of AIDS cases were reported from rural counties in Florida. Of Florida=s 67 counties, 46 are classified as rural, which is defined as areas with a population density of less than 100 individuals per square mile. From the number of AIDS cases reported from rural counties declined by only 24%, while the number of cases reported from urban counties declined by 44%, suggesting that HIV prevention is not reaching rural areas. In rural Florida, Black females comprise 64% of HIV cases among rural female cases. The AIDS rate for all rural counties in Florida is 20.4 per 100,000, which exceeded that of 40 U. S. states (FDOH, 1999). The data collection site was in North Florida, which has the largest number of rural counties in the state.

Numerous circumstances and behaviors place rural Blacks at risk of STIs (Hu, Fleming, Mays, & Ward, 1994; Neal, Fleming, Green, & Ward, 1997; Schable, Chu, & Diaz, 1996; Womack, et al., 1997). One in particularly is the use of crack cocaine; a public health problem that is frequently associated with an increased sexual-related risk for STI/HIV among southern rural Blacks (Behnke, et al., 1997; CDC, 1998; Cobb, et al.,1997; Weatherby, et al., 1997). These behaviors include unprotected sex (oral, vaginal and anal) sex with multiple partners, and sex with partners in exchange for drugs or money (Weatherby, et al., 1997). Heterosexual acquired STIs and HlV is also increasing among rural black women who do not use drugs (CDC, 1998; 2002). Researchers have developed frameworks to differentiate and define levels or types of environmental or structural factors which influence HIV and other health behaviors among primarily urban populations (Blankenship, Bray, & Merson, 2000; Des Jarlais, 2000; Fullilove, Green, & Fullilove, 2000; Parker, Easton, & Klein, 2000; Rotheram-Borus, 2000; Shriver, Everett, & Morin, 2000; Sumartojo, et al., 2000; Taussig, Weinstein, Burris, & Jones, 2000; Wohlfeiler, 2000).

HIV-related structural factors are defined as barriers to, or facilitators of, an individual’s HIV prevention behaviors. Changes in structural factors that protect individuals from becoming infected with diseases are interventions (O’ Leary & Martins, 2000). Structural interventions are aimed at modifying the social, cultural, organizational, economic, political and/or legal environments and community systems in which people live (Sumartojo, 2000). To date, a few researchers have identified structural factors associated with HIV care or treatment of rural populations (Chang-Yit, Lippert, & Thielges, 1992; Graham, et al.; James, 1995; Helms, 1993; Moon, Vermund, Tong, & Holmberg, 2001; Sowell, et al., 1997), but considerably fewer structural STI/HIV prevention studies have been conducted among rural populations (Cohen, Scribner, et al., 2000; Cohen, Farley, et al., 2000; Thomas, Earp, & Eng, 2000). The current study was conducted to add to the body of knowledge pertaining to STI/HIV prevention strategies for rural minorities.



This qualitative descriptive study was designed to explore and characterize the structural and socio-structural factors that influence rural black women’s STI/HIV-related behavior and their participation in STI/HIV prevention services through in-depth qualitative interviews. A secondary purpose was to develop a STI/HIV intervention model.

Subjects and Setting

The author conducted interviews with 27 respondents in her research office, which was located in an adjacent urban county. The inclusion criteria for participation in this study were (1) gender, female; (2) race, Black or African-American; (3) age, between 18 and 55 years; (4) sexual act status, sexually active with males or males and females; and (5) residential location, residence in one of two North Florida rural counties.


Data collection instruments consisted of a demographic data sheet and an in-depth interview guide. Items on the interview guide were either developed by the author or adapted from existing qualitative interview guides (Sobo, 1995). The interview guide comprised of seven sections: (a) an icebreaker, (b) socialization, (c) sexual situation, (d) sexual relationships, (d) HIV and relationship, (e) sexual harassment/violence, and (f) experience with STI/HIV service participation. Each section began with a broad, open-ended request for information and was followed with more specific, probing questions.


Approval to conduct the study was secured from the Institutional Review Boards of the University of Central Florida and the University of California at San Francisco. To access a diverse sample, potential respondents were recruited by flyers and personal contact at local churches, businesses, and “juke joints”, structures similar to bars where people socialize on the outside as much as on the inside. The recruiter discussed the study’s purpose and the protocol with potential participants. Upon arriving at the data collection site, each participant received written informed-consent forms and a demographic data sheet, which they or the interviewer read and completed. The interviews were 45-90 minutes in length. All participants received $20 for participating while 18 received transportation to and from the data collection site because they lacked personal transportation.

Data Analysis

Interviews were transcribed verbatim from the audiotapes and verified against the audiotapes for accuracy. Revisions were made as necessary. Data collection and analysis to develop the codebook were simultaneous and ongoing. Categories, themes and concepts were inductively derived from the data. The final analyses of the interviews were accomplished with the aide of the WordPerfect software program and hand coding.


Twenty-seven women participated in the study; however, the audio taped from one interview was inaudible, resulting in a final sample of 26. The mean age was 34.7 with a range of 18-55 years and the mean educational level was 11.3 with a range of 7-15 years. Seventy-four percent of the participants, were divorced, separated or never married while 26% were married or living with a male partner. Ninety-six percent had sex with males only, while 4% had sex with males and females. Interviews were conducted to the point of saturation, which was the point at which the respondents provided no additional information. Saturation was achieved with the 25 interview.

Several structural, socio-structural and individual-level factors related to STI/HIV prevention emerged from the interview data; however, this article focuses solely on structural and socio-structural factors. The author developed a model from these data. See Figure 1. Socio-structural factors are defined in this study as factors associated with the interaction of a person with his or her social environment, be it an individual, a group, or a community. Structural barriers appearing to influence rural Black women in STI/HIV-related behaviors and their participation in preventive health services were: limited job options, a lack of transportation, limited personal resources, limited public resources, an increased availability of drugs in the community, and limited condom accessibility. Socio-structural barriers included social isolation, negative social norms of carrying condoms, a perceived lack of confidentiality at public-health agencies/familiarity with staff at public health agencies, and relationships with individuals involved in the drug culture. Select excerpts from the interviews, with minor editing for readability, will be presented to highlight these major concepts. The author chooses to let the respondents’ voices “speak for themselves” without undue interpretation.

Structural Factors

The structural factors the respondents implied influenced their use of STI and HIV prevention services, and STI/HIV behaviors are described below.

Limited job options. Several women viewed not having a job as a struggle. The following statements are indicative of this view:

“Okay, well right now. Well by me being eighteen years old, even though I have a GED, it’s kinda hard to get a good job without having a college education or whatever. So right now basically, you know, the money that I do make either goes towards bills or food.”

“…right now I’m in a financial struggle trying to find a job. I’m a CNA and most of the jobs I got were 3 – 11 pm and I need day shift… it’s hard for me to pay daycare and then get the $400 whatever and pay my bills with ’em [only $400 dollars]. I’m in a financial struggle right now as we speak.”

Other women made general comments about the lack of job opportunities and suggested that reasons for the situation centered on living in a rural area:

“I can’t get anywhere and it’s [the town] too small, the businesses are all family run. You know you can’t really get no job so you go out of town and get it.” “…it’s like here in north Florida and work. I mean living out there [away from the county seat] where I live, you know with the prison system and everything. To me it’s like, who you know and who you are in getting a job. So it’s like if you don’t know anybody it’s hard to get a job or, you know, If you don’t know the right people.”

Lack of transportation. A lack of transportation has long been seen as a barrier to accessing health care in rural areas. However, some women in the current study implied that a lack of transportation was a barrier to their social life, due to classism, and limited their job options as well. An 18-year-old expounded on the classism aspect of not having transportation, stating:

“When people don’t see you all dressed up or you don’t have a car, they make, they say, they kinda overlook you. If they got a car, whatever, they wanta be better than you.”

Another respondent talked about what effect not having transportation had on securing health care and emotional support, by stating:

“Well there may not be any accessibility in these rural areas, I mean, for AIDS [services] because I’m talking from experience. Because I know a couple people right in ______ ______ (rural county) who’ve have it (AIDS) and the facilities are not there for them. They can’t come, I mean if you don’t have a car, transportation, for treatment. Not so much treatment, but just emotional support, it is, it’s difficult. I watched a neighbor try to commit suicide because she just didn’t have support.”

Other women related a lack of job opportunities with not having transportation, as well as with living in a small town. They expressed a sense of hopelessness with words similar to these:

“Because I mean, I can’t get anywhere and its [the town] too small, the businesses are all family run. You know you can’t really get no job so you go out of town and get it. Sometimes you don’t have the transportation. And so I wish I could move. I mean, it just, it don’t make no sense how it is.”

“They don’t have good jobs here, so you have to take what you can get. And then transportation and stuff like that, they don’t have transportation. The only way you can get to somewhere is if you are on welfare, something like that.”

Limited public resources. Rural residents typically have limited access to health care services, including prevention services, due to geographical distance, limited public transportation, a lack of Medicaid or private insurance, or inadequate personnel staff in health care agencies (Chang-Yit et al., 1992; Graham et al., 1995; Heckman et al., 1996; Helms, 1993; McKinney, 1998; Sowell et al., 1997). Respondents in this study were no exception. Nineteen of the twenty-five women interviewed did not have health insurance. Of the six with insurance, three were on Medicaid and three had private insurance obtained through their jobs.

Limited personal resources. Many of the women expressed concern about their financial situation. Three women recalled how their financial circumstances led to specific hardships:

“There was a situation (sigh) concerning my home. They were going through foreclosure, trying to foreclose. Um, the financier got in touch with someone that was supposed to help me. I think I was really trying to be taken advantage of because I was a Black woman.”

“Um, I have some issues, you know. Um, being a single B well, not really single, but separated from my husband. All the burdens of my bills are on me. It’s a struggle, it’s a struggle.”

“Well, it’s hard. It’s really hard. I don’t, I don’t have no job. I have to get money the best way I can. And I’m not saying that I go out and do this and that for it, but by the help of the Lord. My mother she helps me a lot. I have a sister that help me and my father, he helps me sometime. But other than that, I have to get my money the best way I can.”

Increased availability of drugs. Drugs appear to be increasingly more available in rural areas, as noted by several respondents. The following quotes highlight the drug situation of the interview settings:

“It’s not a very fast paced place, but like everywhere else stuff do filter in; you know the drugs and what have you.”

“Well, the streets and there are drugs out there and all.”

“Um, like most of my friends that I did have right now they’re on drugs, they’re doing their own thing”

Limited condom accessibility. Social norms of the rural South still oppose the widespread, public distribution of condoms due to the belief that it will increase sexual promiscuity. A recent survey of HIV prevention activities in Florida during the year 2000 indicated that outreach programs including condom distribution were scant in Florida’s rural counties; only two programs were documented (personal communication, Ricko Turner; Florida Bureau of HIV/AIDS; July 20, 2001). Within the data collection site, free condoms were obtainable at only two public health departments. The hours of operation at both agencies were 8 a.m. to 5 p.m.; the hours of operation for STI and HIV clinics were less than eight hours per week. This practice could have serious negative consequences given Cohen and colleagues (1996) findings that access to free condoms was associated with increased condom use.

Socio-Structural Factors

Five socio-structural factors were identified as barriers for this group of women. Again, socio-structural factors, as defined in this research, are factors associated with the interactions of a person with his or her social environment, whether another individual, a group or a community.

Social isolation. Many women reported having no, or a very limited, social network. One respondent implied that classism was a contributing factor to her small social network.

Res: When people don’t see you all dressed up or you don’t have a car, they all say, they kinda overlook you. If they got a car, whatever, they wanta be better than you.

Int: Does it mean, does it limit your social contact because you are one of the people without, as opposed to someone that has these things?

Res:Yeah, when it comes to people that I would deal with. You understand what I’m saying? And because the ones that are either in the same boat that I am in [have few material things] or a little bit better off [have a few more material things, but not a car or money to buy extra clothes] you know, they probably wouldn’t be the people that I would talk to anyway. Because you know some people feel like because they don’t have nothing, they can be nothing. You understand what I’m saying? And by me not having nothing, that don’t change the person that I am.

A sparse population in rural environments enhances the notion that there is a lack of confidentiality or that “everyone is going to know my business.” The women were asked to discuss their network of friends with whom they could discuss personal/sensitive issues, such as HIV. Many said they had no or a very small social network. Yet, social isolation for some of the other women seemed more related to their distrust of others, women in particular, rather than the sparse population density of the rural area:

“Well, really, um about the only person I really talk to, the one that I think would keep my business confidential, is the girl that I’m living with right now. . . . Because I done been through this [friends who are not friends] before. I know, uh, how that goes. So really I don’t talk too much to people no more, because I don’t want my business spread all over the County.”

“Well, really tell you the truth, I really don’t have very many [friends] because it’s like back stabbing. Um, like most of my friends that I did have right now they’re on drugs, they’re doing their own thing, so it’s not really like a close bond . . .. I have like one true friend and I don’t see her very often. We talk on the phone and stuff [trouble, gossip or confusion], but that’s about it.”

“I really don’t have many friends, you know. They like to keep up a lot of stuff [trouble, gossip or confusion]. I try to be by myself.”

“There’s one person, one female, that I feel I could probably tell my most closest, you know deepest, most personal secrets to, confide in, and you know, feel confident in that, that it would be kept confidential, just one. Although, then there is my mother and sister. This person, if it was something that I didn’t want my mother and sister to know about, would be the person I would tell.”

Negative social norms around carrying condoms. A novel finding of this study was women expressing their discomfort with keeping condoms in locations where they might be discovered by others. This finding merits reporting, even though only two women expressed their discomfort with this issue. One was concerned that her nieces and nephews would find her condoms; while the other was concerned that anyone looking in her purse might find them.

“He wanted to have sex and stuff so I guess I was just being lazy. I didn’t get up and dig them [condoms] out of the closet. But that was the only reason he got away with it [not using a condom], then. I don’t, I can’t keep them in the nightstand because I live with my sister and she has kids.”

“Well, I keep them [condoms] in my car, not my purse. I keep them not in my purse. You know sometime people might go in your purse. I keep them locked up in my car.”

Brown (1993) noted similar findings among southern white females attending college in a mid-sized city in North Central Florida. These students stated that female students who carried condoms were perceived by their peers, both male and female, as being promiscuous.

Perceived lack of confidentiality at public health. Many of the women perceived a lack of confidentiality at the local health department. Some discussed an incident that seemed to have a great impact on their perception: it was about a nurse from the local health department looking for a client whom the women implied had an STI:

“I don’t think he’d take it [an HIV test] in ________ __ _____[the rural town] . . . the nurses . . . tell why they are looking for you.”

“Them clinic people [at the local health department] don’t mind hunting you down. They’ll drop a line on you and let everyone know what you got. That is why I don’t go to the clinic.”

Other women expressed general concerns about a lack of confidentiality:

“Everything’s supposed to be confidential, but everything is not…I would go and get check [tested] and make sure that I was or wasn’t . . . in County . . . If you go up there on this day, then they know what you are going for . . . when I use to go nothing was confidential . . . they talk so loud, and everyone in the lobby heard.”

Oh, okay. Like in _____ ________ [the rural town] they, um, the nurses or whatever, they’ll come to your house. They all ride around asking people all over town, have they seen such and such. Sometimes they even tell them [the people that are talking with] why they are looking for you. That’s supposed to be confidential. They’ll tell why they are looking for you. And I think most people don’t want to go [to the health department] cause they feel like they [the staff at the health department] gonna tell their business.”

Familiarity with staff at public health agencies. Participants also discussed their general concern about staff working in local health care agencies being from the same rural area as the participants, themselves; suggesting that this situation caused some local residents to hesitate about accessing services.

“Everybody knew everybody and they talked too much about it [what occurred at the local health department] and their [the rural residents who accessed services as the health department] business got on the street and that’s why they go out of town [to access services] sometime.”

“Because it’s a small town, everybody knows your business. I mean most of the people who work in the health department are people who live in the general area. And in a rural town, everybody’s business is everybody’s business. A lot of it is just fear that it would get out. That you were there, were being tested.”

Relationship with person(s) involved in the drug culture. Several women in the study discussed their past or current addiction. One participant talked about her involvement in a relationship with a drug dealer:

“Uh huh. See he probably lay up with a different kinda people ’cause he stay on drugs. And I’m thinking about this junk cause he didn’t answer me. . . I’m just thinking, but that’s, I mean, it’s [her perceived HIV risk] probably like a moderate I’ll just say moderate now, not small, a moderate risk because I done been. I done heard different crack heads say what they’ll do to get “em a hit and he’s selling, so he may be doing those things. . . . he better not be.”

Other participants indicated that drug dealing was not a rare occurrence within the data collection sites:

“I know several people who are selling [drugs]. It’s a big thing in this area. He [her son who sells drugs] would never think of selling it to me. All the years I have been doing it [using drugs] and he has never seen me do it. I am always hiding or leaving from around here [where she lives] and going somewhere else. But he has never seen me do it… Basically everybody out there in the country is doing it [selling drugs]. By people [drug dealers] coming in and out there [to the county] by my house, that is just the trigger to me.”


Heckman, Somlai, Kelly, Stevenson, & Galdabini., (1996) indicated that rural areas are typically burdened by weak economic systems with high levels of unemployment and poverty. Unemployment, poverty, and weak economic systems are even more evident in southern rural minority communities. Southern rural minorities typically have limited access to health care services, including prevention services, due to geographical distance, limited, or no public transportation, and limited access to health insurance coverage. Thus, HIV and AIDS have a devastating impact on the familiar, social, and economic systems of these communities. Additionally, the effect of being jobless is far-reaching for rural Black women, who often are the primary breadwinners for their families. Unemployment and under-employment among the women in the current study was the norm. Likewise, data from this study revealed the existence of other structural barriers, as well. A lack of public transportation and limited private transportation were a major concern for the majority of participants. Other barriers directly associated with not having access to transportation were limited job options and a lack of access to health care. There were two indirect consequences of not possessing transportation: not possessing health insurance, since most rural Blacks acquire such coverage through their employment, and lacking personal financial resources.

Four structural barriers (limited job options, lack of transportation, limited public resources and limited personal resources) appeared to be pronounced for these participants. Another structural factor was the increased presence of illicit drugs in the rural counties that comprised the data collection site. While the respondents did not relate the increasing presence of drug trafficking in their communities to a lack of job opportunities, it is logical to assume that one phenomenon influences the other. The respondents identified five socio-structural factors, which the investigator classified as barriers to participating in STI/HIV prevention services and the practicing of safer sexual behavior. Sparse populations in rural environments enhance the notion that there is a lack of anonymity and confidentiality or that “everyone is going to know one’s business.” This may influence rural residents to not publicly acknowledge engaging in activities associated with a negative stigma, such as HIV risk behavior (sexual behavior or drug use). It may also hinder their participation in prevention activities associated with these stigmas, such as HIV testing at health departments or community-based organizations.

Respondents expressed their reluctance to participate in STI/HIV prevention services at local health-care agencies. Their reluctance appeared to be associated with both structural and socio-structural reasons, such as a familiarity with staff at local public-health agencies and a perceived lack of confidentiality at these agencies. Many respondents recalled similar experiences of a breach in confidentiality while receiving services at their local health department. While one cannot attest to the accuracy of these narratives, it is evident that they influence the health-seeking behavior of many of the respondents, who implied that they were hesitant to seek STI or HIV prevention services at public clinics. This finding has a major implication for STI/HIV prevention, since the majority of the respondents did not have health insurance coverage or the private funds to pay for prevention services from private health care providers.

There were two factors associated with condoms use: One was the structural factor of limited condom accessibility and the other was the socio-structural factor of a negative social connotation with carrying condoms. Condoms were accessible for free at only two public health agencies and by purchase at private businesses, such as convenience stores, drug stores, and department stores. Even when condoms were available, respondents stated that the location where they kept their condoms (locked in a car and hidden in a closet) were not readily accessible when the condoms were needed. Hiding condoms appeared to be related to the discomfort the women felt in having others discover that they possessed condoms. These condom-related findingshave serious implications for prevention strategies. For example, a number of studies (Eiser & Ford, 1995; Gielen, Faden, O’Campo, Kass, & Anderson, 1994) find a relationship between condom carrying and condom use among adult samples. Even when such a relationship is not present, as found by DiClemente and colleagues (2001), the question remains: How does one discuss the need to use condoms if one is not comfortable with the act of possessing them in the first place?

A final socio-structural factor was that of social isolation. Most of the respondents said that the social network with which they could discuss sensitive issues, such as STI/HIV or drug use, was limited to one or two friends. Many, though viewing family members as an extension of their social network, at the same time expressed reluctance to talk with their family about such sensitive issues. They provided spontaneous reasons for their limited social networks, with the primary reasons being past negative experience of being betrayed by a friend, a general distrust of women, and the consequences of living in a rural area where nothing is kept confidential. Most prevention interventions integrate some aspects of changing negative/unsafe social norms for positive/safer ones. The implication is that socializing processes may enhance prevention intervention strategies. The need in rural areas may be to initiate strategies that will broaden a positive social network of rural black women.


Clearly, socio-culturally relevant, regionally specific, and theoretically based STI/HIV prevention intervention research among southeastern rural Blacks is needed. The acceptability and feasibility of structural interventions, rather than individualized interventions, is more likely among these populations, as they are reluctant to be seen participating in stigmatized research programs such as STI/HIV prevention programs. Yet, the current state of knowledge about the structural factors and contextual issues of this vulnerable group may not be developed to the point of informing effective structural-level STI/HIV prevention interventions. Formative studies are needed to identify the structural and socio-structural factors and contextual issues of Black males in relation to STI/HIV prevention. Additionally, formative research is needed in developing and testing instruments to measure the selected STI/HIV-related concepts for both genders. An intermediate step is to pilot test and refine the proposed model or models, followed by the final step of conducting a clinical trial of the intervention.


Several structural and socio-structural factors were identified by this select group of 26 women. These factors can inform effective structural-level STI/HIV interventions for southeastern, rural black women. Rural individuals tend to hold more firmly to traditional gender roles; therefore, structural and socio-structural factors are more likely to vary by gender. Finally, rural blacks may accept and participate more readily in structural-level STI/HIV prevention intervention than stigmatized individual-level intervention since they are not as likely to be singled out while participating in structural-level interventions. Thus, confidentiality is more likely to be maintained while the associated stigma diminishes.


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ACKNOWLEDGMENT: This research was funded by NIMH 5 P50-MH42459-15 and was administered by the University of California at San Francisco, School of Medicine, Center for AIDS Prevention Studies and the University of Central Florida.

Emma J. Brown, PhD, RN, Associate Professor, Chatlos Endowed Chair, Minority Health Care, School of Nursing, College of Health and Public Affairs, University of Central Florida, Orlando, Florida.

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