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Sexually Transmitted Diseases:
Article

Social Context of Sexual Relationships Among Rural African Americans

ADIMORA, ADAORA A. MD, MPH*†; SCHOENBACH, VICTOR J. PhD†; MARTINSON, FRANCIS E. A. MBChB, MPH, PhD*; DONALDSON, KATHRYN H. MPH*; FULLILOVE, ROBERT E. EdD‡ AND; ARAL, SEVGI O. PhD§

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From the Departments of *Medicine, School of Medicine, and †Epidemiology, School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; the ‡Community Research Group, Columbia University School of Public Health, New York, New York; and the §Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia

The authors thank Drs. Willard Cates, Jr., Paul Godley, Greg Samsa, and Gail Henderson for their review of the manuscript and insightful comments, First Research Company of Greensboro for their conduct of the focus groups, and the respondents for participating in this research.

Supported by National Institutes of Health grant no. 1R01 AI 39176–01 (to Dr. Adimora).

Reprint requests: Adaora A. Adimora, MD, MPH, Division of Infectious Diseases, 547 Burnett Womack, CB #703, UNC School of Medicine, Chapel Hill, NC 27599-7030.

Received for publication November 3, 1999,

revised May 31, 2000, and accepted June 12, 2000.

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Abstract

Background: Reasons for the strikingly increased rates of HIV and other sexually transmitted infections (STIs) among African Americans in the rural Southeastern United States remain unclear. Investigators have devoted little attention to the potential influence of the social and economic context on sexual behaviors.

Goal: To examine the potential influence of these contextual factors on behaviors that promote the transmission of STIs.

Study Design: Focus group interviews in which African Americans from rural North Carolina discussed life in their communities and contextual factors affecting sexual behavior.

Results: Respondents reported pervasive economic and racial oppression, lack of community recreation, boredom, and resultant substance abuse. Many perceived a shortage of black men because of their higher mortality and incarceration rates compared with whites, and believed this male shortage to be partly responsible for the concurrent sexual partnerships that they perceived as widespread among unmarried persons.

Conclusion: Contextual features including racism, discrimination, limited employment opportunity, and resultant economic and social inequity may promote sexual patterns that transmit STIs.

DESPITE RECENT DECLINES in sexually transmitted disease (STD) rates, African Americans remain disproportionately represented among reported cases of HIV and other STDs. The reasons for the strikingly increased rates of STDs in this population have not been fully defined. Many epidemiologic studies and interventions for HIV have focused on risk factors and behaviors of individuals, such as number of sexual partners, condom use, healthcare-seeking behaviors, and substance abuse. Although individual behaviors are undeniably important in the transmission and acquisition of STDs, including HIV, the paradigm of “biomedical individualism” that dominates the STD literature ignores the role of the social context in fostering the very risk factors that persons are instructed to avoid. 1 Moreover, the focus on personal behavior has done little either to help explain or to reduce the excess STD morbidity and mortality among African Americans, and the adequacy of the individualistic approach has recently been questioned. 2 Sexual behaviors occur within a context of demographic, social, economic, and other forces, yet investigators have devoted little attention to the potential influence of these forces.

For a study of behavioral and social risk factors for heterosexually transmitted infections among African Americans in 12 rural eastern North Carolina counties with high STD rates, we conducted a series of focus groups to determine the study population’s level of acceptance of our research protocols and their understanding of the study instrument’s language and questions. We also sought to improve our understanding of life in the communities under study and to explore the study population’s perceptions of societal forces on an individual’s sexual behavior. This report focuses on these findings.

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Methods

Setting

North Carolina is the 11th most populous state in the United States and the 28th largest in area. 3 Geographically, the state is divided into three main regions: the mountains in the west, the piedmont in the central portion, and the coastal plain in the east. The geology had a major role in shaping the history of the state, with plantation agriculture playing a dominant role in the flat sandy soil of the coastal plain. Because the eastern portion of the state is economically and culturally distinct from the rest of the state, it is frequently described as a region unto itself. 4 Approximately 2 million people (almost one third of the state’s population) reside in eastern North Carolina (ENC), which for purposes of this report will comprise the 41 counties bounded on the west, north, east, and south by Interstate 95, the Virginia border, the Atlantic Ocean, and the South Carolina border, respectively. Although ENC contains urban areas, the region remains predominantly rural, and almost 80% of its population resides in unincorporated areas or towns with fewer than 10,000 people. More than one third of the region’s population is nonwhite, and this nonwhite population is predominantly African American. Most minorities reside in ENC’s northern and southern areas, vestiges of the old cotton and tobacco belt economy. 4

Although ENC contains some pockets of wealth, poverty is a consistent theme in this region. According to the 1990 census, 14.1% of ENC families live in poverty, compared with 9.9% for the state as a whole. All but 3 of the region’s 41 counties had per-capita incomes below that of both the state and the United States as a whole, and 13.5% of the ENC population attained less than a ninth grade education, compared with 12.6% for the state.

This demography forms one part of the social context for the health problems and issues found in ENC. STD rates are substantially higher than the national rates, especially for African Americans, who as in the United States as a whole bear a disproportionate share of STD morbidity. For example, in 1995 ENC syphilis rates among whites were 6.9 (per 100,000 persons) compared with 36.6 among nonwhites. In 1995, the region reported crude gonorrhea rates of 563 per 100,000 persons compared with nonwhite rates of 1,496. 3 Rates for the entire US population that year were 149.5. The racial disparity in ENC’s AIDS rates is also striking, though the region’s rates are lower than the overall US rate. Among men, ENC’s reported AIDS rates among whites are 9.2 per 100,000 persons compared with 46.5 among blacks. Among females, white rates are 0.9 per 100,000 persons compared with 13.4 among blacks. 4

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Focus Groups

From August 1996 to October 1996, professional focus group leaders experienced in minority research organized and conducted 12 focus groups in five rural ENC counties for African Americans between the ages of 18 and 59 years. These noncontiguous counties, which are demographically similar to the study region and to ENC as a whole (e.g., in median income, racial composition), were chosen from the 12 counties planned for the larger case–control study to provide geographic representation of the study area. One focus group was conducted in each county for each gender and age group (age range, 18–24 years, 25–34 years, 35–59 years). Discussions were conducted in sites commonly frequented by participants, such as recreation centers, churches, community colleges, and meeting rooms of public housing during evenings and weekends to facilitate attendance of working (and nonworking) individuals. Several days before the discussions, professional focus group leaders worked with community liaisons to recruit participants in the appropriate age and gender categories through community organizations and churches. Participants received $25 and completed brief questionnaires concerning education, income, and demographic information.

Each moderator used a discussion guide to facilitate the interviews, which averaged 90 minutes. The guide included participants’ descriptions of their communities, personal goals and aspirations, perceptions of the church’s role in their communities, sources of recreation, and initiation and evolution of relationships between men and women. The moderator also asked respondents to evaluate selected questionnaire items concerning their language, interpretation, and the likelihood that their peers would respond truthfully. Men moderated interviews with male groups, and women facilitated those with women participants. All persons present during discussions were black. Two of the authors (AAA, FM) attended all but two of the sessions.

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Analysis

All discussions were tape recorded and transcribed. Transcripts, notes, and summaries of discussions were reviewed. Transcripts were read multiple times to identify major themes and patterns in the discussants’ examples and phrases. 5 Each group’s responses to each question were systematically summarized and analyzed. 6 Except where noted, there was striking unanimity of sentiment across groups concerning the concepts discussed later. Illustrative quotations are presented, each followed by a code that indicates the age group and gender of the discussants. We attempted to select quotations from both genders and all age groups. Quotations presented here were generally the most articulate statements that represented opinions endorsed by most or all members of the group in which they were expressed and that could be readily understood outside the context of the conversation.

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Results

A total of 93 residents participated in the 12 focus groups. Almost all participants had lived in the region for their entire lives. Forty-five percent of respondents reported an annual household income of less than half the state’s median ($37,586), 4 and 26% had not completed high school. Except where noted, responses were essentially unanimous concerning the topics outlined below and did not vary substantially by gender, age group, or county.

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Employment and Economic Opportunities

Respondents unanimously agreed that their communities lack employment and economic opportunities. This theme, though unsolicited, recurred in group after group across all age ranges. According to the respondents, few jobs of any type are available in their local areas. Many residents are forced to travel substantial distances to work, but public transportation does not exist and persons often do not have access to cars. Available jobs are mainly in service occupations that pay poorly and offer little opportunity for advancement. A 35-year-old woman noted that,“Jobs are very limited and on a low pay scale. You know, you have to travel at least 20 minutes to get a decent job in this area.”

A 25-year-old woman commented, “Restaurants, farming, sewing, baby-sitting, those are the only jobs that are available around here.”

A 25-year-old male said, “I’d like to see a union here. Unfortunately, a lot of people living here in [this county] don’t know anything about a union. Basically, every job here is dead end with terrible pay.”

Opinion varied concerning the role of education in their difficulties finding work. Some respondents believed that most jobs necessitated a college education, and lack of education is a major hindrance in their employment search. Others, however, felt that racial discrimination is so overwhelming that no amount of education would afford a black person the opportunity for good employment. Some told of aggressive but unfruitful searches for employment. Others reported employment agencies’ tendency to refer blacks for factory work and steer them away from white collar jobs. “There are no real jobs here,” said an 18-year-old woman. “There’s no office jobs down here. Basically, the only thing you can get is factory jobs. There are no jobs for anybody coming right out of high school. Most of the jobs available are college jobs.”

A 25-year-old woman reported, “You can’t find good jobs here. You can have all the schooling in the world, but still, if you’re black you can’t get a good job.”

Another 25-year-old woman continued, “And, most of the temporary agencies from what I’ve seen, like to send the blacks to jobs in factories. Like that’s all they got or something.”

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Race Relations

Most people described race relations as poor. Although blacks and whites mingle to some extent at work and at school, their social worlds remain separate. Some respondents in one group reported an absence of hostile relations between blacks and whites, but even these comments were qualified by the implication that race relations were not bad because blacks and whites stayed apart. “Race relations aren’t that bad around here. Black folks and white folks stay to theyselves most of the time, so it’s okay,” said an 18-year-old woman.

Others confirmed the tendency of the races to remain separate. “There’s hardly any mingling of the races at all. Of course, you might see one or two couples together, usually somebody they know from school or work, but not much more than that,” commented an 18-year-old man.

Another 18-year-old man reported that, “If anything, we may have had some white friends in school. But you can just about count all the white people you know on one hand.”

Although participants described social segregation, this did not appear to particularly bother them. None described fear of racially motivated violence, and at least one participant noted the absence of this type of old-fashioned Jim Crow racism. Instead, their concerns focused on the pervasive institutional racism despite the picture of racial harmony they believed that some whites tried to portray. They described discrimination against blacks in hiring and job advancement and the inability to obtain mortgages. Participants also reported preferential opportunities for whites in hiring and education. “A lot of things are divided racially. Basically, you have a white side of town, and the black side of town doesn’t usually mix. Market Street basically divides the town. …It’s sort of covert. You don’t have white folks walking around in robes or anything, but in the schools and things you can see it,” said a 25-year-old woman.

Another 25-year-old woman commented, “But a lot of people ’round here won’t hire you because of race. If you’re white, you’ll get a job, but if you’re black, you won’t get the job. And, if you do get it, they’ve got to need you awfully bad, and then you won’t get more than minimum wage.”

A 35-year-old woman said that the situation was, “Very prejudiced in the area of jobs. Once you get the job it hinders you from going further.”

A 25-year-old woman commented, “I’ve been in the employment office here, and I was standing right up to the counter, and this white girl came in and the lady said, ‘I tried to call you at home to tell you about a job’ that wasn’t posted on the board, or it wasn’t in the computers. And, I’m saying, and the girl was giving the same qualifications that I know I had, and I said to myself, ‘Well nobody tried to call me at home.’ ”

Said a 25-year-old woman, “White people have a lot of privileges that black folks don’t. I would say it was greatly polarized. When I was going to school here in the high school, the type of classes you could get into, like the college prep courses, had a lot to do with what type of family you came from, your race, if you were in …I think it still goes on, in terms of how many black teachers they have, and where they even place the black teachers in the school.”

A 35-year-old woman commented, “It’s a racially divided place. It’s economically poverty stricken. Some people have no self esteem. The city is divided between [County A] and [County B]. It’s the haves and the have nots. [County B] is the haves and [County A] is the have nots. You have the majority of your white homes in [County B].” “It’s hard to get a loan to get a house. Banks don’t just give black people loans. You got to know somebody. It’s very hard,” reported a 35-year-old woman. “Well, just like you say, people here keep you down and you just have to know somebody,” commented another 35-year-old woman. “I think the whites want to keep black people down,” said another.

A 25-year-old man reported, “You still have problems here between the black and the white community, even though they try to downplay it to make you think it’s really not like that. For instance, if a black person moves into a mainly white community, they’ll start moving out. But things are changing a little. You now have some of the younger white kids who come over to some of the parties in the black community.”

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Boredom and Lack of Recreational Outlets

Respondents of all ages universally reported a scarcity of recreational outlets and cultural activities. Participants agreed that this scarcity is a particularly acute problem for youth and young adults. Residents travel to the nearest large city (population, 46,305 persons) for recreation because local communities often lack facilities that residents would like to have, such as movie theaters, shopping malls, or “good” restaurants. Entertainment in many areas is limited to local sporting events, private parties and gatherings, and small nightclubs (“juke joints,” reportedly havens for illicit activities). Some respondents attributed STI risk-related phenomena, such as community substance abuse, to boredom and the absence of recreational outlets. “There are a lot of drug users and drunks down here. There’s nothing to do, so they drink every day. I see some of the guys I graduated with now, and from the time they get up in the morning until time to go to bed, that’s all they do. Drinking,” said an 18-year-old woman.

Another 18-year-old woman commented that, “[This county] is very boring. The community is very boring. There’s not much to do down here. I realize that most of the people, all they really do is sit around and smoke and drink, and play cards, all day, all weekend.”

Another reported, “The only thing people do for entertainment around here is ride around in cars in circles, and tend to other folks’ business. That’s all they enjoy doing around here.” “We go to Greenville and go shopping, ride around, or just hang out. They have better places to eat, and they stay open longer than they do around here,” said another.

Another 18-year-old woman continued, “I think there should be more programs for the children so they won’t be out in the streets all the time.” “There is not an abundance of cultural things to do, or places to go. You have to go far off to find something to do. When it comes to education and recreation, there’s not a lot to expose our youth to. We need more recreation for our youth,” said a 35-year-old woman. “We used to hang out at the skating rink, but that’s been changed because now they play mostly music geared toward the white crowd,” reported an 18-year-old man.

Another 18-year-old man commented, “Most people like sitting on the porch gossiping and watching cars go by. Some people just sit on the porch and get high.”

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Church

Respondents reported diverse feelings about the church and its role in the community. The church has historically played a central role in African American communities, and this continues to be true in many parts of ENC. According to respondents, the church provides its members with psychological support and helps them with their problems. “Church is a major outlet in [this county]. Coming to church keeps you busy and your mind occupied,” said a 35-year-old woman.

Another 35-year-old woman commented, “It helps to keep families together. This is a small community with no psychiatrist, so we depend on our churches, pastors, and brothers and sisters in the church for support. They provide counseling. You can pretty much get family problems solved.” “It’s a place of refuge. The church family comes together to solve community problems,” said another.

Moreover, the communities’ limited entertainment options have particularly highlighted the church’s importance as a source of recreation. “My church plays a great role for a lot for kids my age because there are things to do. They are active. You can say what you want to. You can be assertive, and say things to people and they won’t feel like you have an attitude. We have a lot of young kids. …We go places. We do things together. We sponsor talent shows and concerts and things like that …when you have problems, you know where you can go to get help,” reported an 18-year-old woman. “Basically, I attend church all the time. I try to keep myself busy. We do things together as young adults, like go on trips. Church helps to keep me together,” said an 18-year-old man. “I feel like [the church] can play a major role,” said another 18-year-old man. “They try to keep me on my toes and make sure I’m graduating this year. Plus, they try and make sure that I’m not getting in a lot of trouble.”

Although the church has maintained its role as a focal point in the lives of older persons and some youth, many respondents indicated estrangement of young adults, particularly males. “If you go in the average church here, you won’t see many people our age there,” said a 25-year-old man.

A 35-year-old woman commented, “The men aren’t in the church. It’s mostly women in church.” “Since I’ve got grown I don’t go to church at all,” said an 18-year-old man. “I know I should but I don’t.” “Church used to be important before I reached my teenage years. But now I’ve stopped going and started getting into the streets more,” said another 18-year-old man.

An 18-year-old woman reported, “It’s mostly female, and older people that go to church around here. Some females about our age go to church, but most of them don’t.” “I don’t feel like church plays a major role in the lives of people our age,” said an 18-year-old man. “They’re more focused on the younger kids than they are on people like us.”

Despite the estrangement of some persons from the church, many believe that church remains a potential political force in the community, as has been the case in the past. Nevertheless, they described lack of unity in the institution and waning of its influence in the community and as a political force. “Church plays a big role but not as big as it should. We have too many different black churches. All of them are teaching something different. If we got together like the white churches did, we could probably do something,” said a 25-year-old man. “The churches here got so many cliques in them. They talk a good game, but they aren’t willing to come together to make it happen,” said another 25-year-old man. “It plays a big role and not so big a role, if you know what I mean,” a 35-year-old man commented. “The church is the one thing that helps bring the community together. Still, it doesn’t play the role it should play, especially politically.” “It plays a primary role. In order to change the system, church is going to have to be used to educate the people. It’s the strongest institution in the community, especially for blacks,” said another 35-year-old man.

Another 35-year-old man commented, “Without the church the community is nothing.”

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Relationships Between Men and Women

Respondents perceived a dramatic disparity in the ratio of available African American men to women because of attrition of men from death, drug addiction, or incarceration. One group of woman 25 to 39 years believed that women, particularly those who are poor or uneducated, feel dependent on men. Comments of both men and women suggest that the relative scarcity of black men and the extremely adverse socioeconomic plight of black women (and men) profoundly influence partner selection, women’s sexual availability, and both genders’ participation in sexual risk behaviors. “There’s so many black men in prison, strung out on drugs, or dead, that if a decent black lady finds a decent black man, she’s not going to spend a whole lot of time trying to hold him off. She’s gon’ do whatever it takes to get him,” said a 25-year-old man.

A 25-year-old woman commented, “If you can afford to do it, you might find a good man if you go up to Fort Bragg, but other than that, it’s just a sad, sad situation. We’re just far enough away from everything. To get to the next semiurban city where you go to get everything, if you don’t have a car, and you ain’t got a good husband, or you don’t have a job, or a good education, you’ve got to depend on somebody to get you there. For young black women, it’s not a good position to be in [this county], without a good education or a good job.” “The choices in men are very limited around here. I guess the women put up with the men they have because there aren’t that many,” said a 35-year-old woman.

Another 35-year-old woman reported, “It’s not that many good men worth anything in this area. It’s very rare you find a good one.” “The ratio of women to men is very high,” said another 35-year-old woman.

When asked whether women date men from the same county or those who reside outside, a 35-year-old woman commented, “They date whoever they can find from wherever they can find them. Black women in particular have a very hard time. That’s why you have to watch your husband. Many young girls prefer married men.” “When you go out you have to bring your husband with you because women will date wherever they find them [men]. That’s why you have to watch your husband,” said another 35-year-old woman.

Another 35-year-old woman continued,“These women in [this city] are so bold. Especially at work, single women will try to get your husband.”

An 18-year-old woman said, “he treats her wrong and she just deals with it, so, I guess that’s what she want, ’cause she been with him for a long time.”

An 18-year-old man reported, “Some people I know have side relationships just for monetary value.” “Here’s the situation with my friend,” a 25-year-old man commented. “As soon as he, you know, as soon as they get somebody, then another female want to come up. And he’s the type of guy, he don’t want to turn that down, ’cause you know, that’s the type of attitude he got. You know, it’s gonna be another notch on his belt.”

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Concurrent Sexual Partnerships

The community’s perception of gender imbalances may also influence sexual behaviors of both men and women and the types of male sexual behavior that women believe they must tolerate. According to respondents, sexual relationships within the context of marriage are usually monogamous, but among unmarried couples concurrent sexual partnerships (partnerships that overlap in time) are common. There were mixed opinions concerning how widespread this pattern is among women, but many agreed that it is common among men. “Most [unmarried] couples aren’t going to be true to each other. They’re just in it for the moment. If the opportunity to be with someone else presents itself, nine times out of ten it’s going to happen,” said a 25-year-old man. “If they aren’t planning on getting married, they’re probably going to have relationships on the side,” reported a 35-year-old man.

Another 35-year-old man said, “I think they’re going to have side relationships because not everyone’s looking to get married. That determines whether they’re going to be faithful.”

An 18-year-old woman commented, “Both [men and women] generally have somebody on the side.”

But a 25-year-old woman said, “I think it’s more common for guys to be involved with more than one woman at the time.” “I say it’s quite common for people to be involved in relationships with more than one person at a time,” said a 25-year-old woman. “And it’s not just on the men’s part, it’s on the women’s part as well. I mean women are becoming more liberated. Waiting to Exhale let a new breed of women out.” “There are a lot of people who have relationships with more than one person at the time. A lot of them end up pregnant, too,” commented an 18-year-old woman. “Basically, most people have someone on the side,” said an 18-year-old man. “That way, in case one messes up, you have somebody to fall back on. It’s what you call having a side shot.”

Another 18-year-old man reported, “The way it is now you can’t really trust anyone, because everybody is trying to mess with everybody else. So when you’re with a girl you don’t really trust her to be faithful.” “Some people have side relationships for monetary reasons,” commented another 18-year-old man. “The person they love may be broke, so they get someone else on the side to cover the costs. That’s the way a lot of people play the game.”

Said another 18-year-old man, “I think it’s getting better, but most people are still stroking someone on the side.”

A 25-year-old man commented, “I’ve got a friend that as soon as he gets somebody, another girl comes along and starts trying to talk to him. He’s not the kind of guy that’s going to turn anything down. So he ends up messing with both of them.”

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Discussion

Our focus group respondents perceive widespread economic oppression and racial discrimination that hinders their education, employment, job advancement, and other aspects of their lives. All groups reported scarcity of recreational outlets, and boredom was reported to be a particularly acute problem among youth. Several respondents expressed concern that the lack of recreation increases the likelihood of substance abuse in the community. Respondents reported that concurrent sexual partnerships are widespread among unmarried persons. Many perceived a shortage of black men because of their higher risk of death or imprisonment, and believed that this male shortage was partly responsible for the practice of concurrent sexual partnerships.

Because our respondents were a modest number of self-selected volunteers rather than a large, randomly-selected sample, our findings are not statistically generalizable. Self-selection of the participants may have resulted in a sample that is not representative of the target population. In addition, the quotation style of data reporting may facilitate the yield of stereotypic conclusions from individual statements. Nevertheless, participants reasonably reflected the young and middle-aged adult African American population of ENC regarding sex, age, education, income, and geography. The study’s use of focus groups is a strength; we, like others, found that the groups helped subjects feel more comfortable and allowed them to share personal experiences more readily than they might have in one-on-one interviews. 7

Participants were not directly asked about their perceptions of the influence of their social context on STI risk, but a number of them expressed belief in the association between sexual risk behaviors and various aspects of the community’s social environment. For example, participants commented on the links between absence of recreation, resultant boredom, and substance abuse; extremely adverse socioeconomic situations experienced by women and dependence of women on men; and low sex ratio and its effects on partner selection and sexual availability of women.

Our results suggest that contextual factors may substantially influence behaviors that contribute to the epidemics of sexually transmitted infections (STIs) among African Americans in the rural southeastern United States. Sociologic and public health literature extensively document the links among poverty, low socioeconomic status, and substance use, and the additional association between substance use and sexually transmitted infections. Both alcohol and illicit drug use are associated with an increased risk of acquiring HIV infection and other STDs. 8 Substance use decreases the likelihood of implementing safer sex measures, and illicit drugs (most notably crack cocaine) are strongly associated with high-risk sexual behaviors, such as trading sex for drugs. 9 Crack cocaine has helped to fuel the epidemics of syphilis and HIV in US inner-cities and in some parts of the rural southeastern United States. 10

Less well explored, however, is the relationship between substance use, boredom, poverty, and HIV–STD transmission behaviors. Our respondents perceived a high prevalence of substance use in their communities, and many attributed this to the profound boredom of their surroundings. Despite the frequency of boredom in society and its potential influence on behavior, this phenomenon has received little attention from public health and social science researchers. Orcutt 11 used the term existential boredom to describe frequent boredom with a lack of purpose in life, and found that younger and lower-income respondents were more likely to experience this type of boredom than those who were older and wealthier. His survey of college students also identified an association between boredom and frequency of alcohol use among males. The implications of these findings for our study population are substantial, given the profound and pervasive boredom described by the respondents. Moreover, once the prevalence of alcohol use becomes high, the risk of alcohol use among persons in the community appears to further increase, because the association with others who drink alcohol is a predictor of alcohol use. 12,13 Few data are available concerning associations between boredom and use of illicit drugs, but it seems likely that introduction of crack cocaine to a community with limited recreational, educational, employment, and economic options is likely to result in widespread drug use. Boredom may also push young people toward sex, that being one of the few recreational pastimes that is available and inexpensive.

Social science data suggest that the social and economic environment can influence sexual partnership patterns and a person’s likelihood of maintaining long-term monogamous relationships, which in turn directly influence the the population dynamics of sexually transmitted infections. Compared with sequential monogamy, concurrent relationships (sexual partnerships that overlap in time) may permit a more rapid spread of an STI through “a connected population.”14 Our respondents described (and regional census data verify) poverty and poor employment opportunities, conditions that social scientists have associated with marital instability. 15,16 Sociologists have argued that among blacks, increasing male unemployment has contributed to the rising proportions of female-headed households. 17 Another social factor that threatens long-term monogamy is the low sex ratio (i.e., proportion of men to women) among African Americans. 18,19 A critical finding of our focus groups was the observation that persons perceive this low sex ratio, and their comments suggest that this perception alters relationships between men and women and may promote concurrent partnerships and other behaviors that maximize a person’s chances of attracting, securing, and maintaining a sexual partner.

Historically, the church has played an important role in the lives of African Americans, and has functioned not only through its spiritual and political leadership but also by providing social, psychological, and economic support. 20 W. E. B. Du Bois found that historically, the church has served as “a real conserver of morals, a strengthener of family life, and the final authority on what is Good and Right.”21

Many of our respondents noted the church’s positive role in the health of the community, citing its psychological support for members and role in problem solving. Because of the extremely limited entertainment options in many areas, the church’s role in recreation is extremely important for all age groups, and is especially critical for youth. However, a substantial number of respondents reported estrangement from the church. Some, though acknowledging the institution’s potential political importance, decried what they perceived as its current lack of political power. As previously observed by Eng and Hatch, 20 virtually all participants agreed that few young men regularly attend church services.

In recent decades, epidemiologists have turned to a “biomedical individualism approach” in which the individual’s risk factors and lifestyle are the predominant focus of study and intervention. 1 HIV-prevention efforts, for example, have largely focused attention on personal risk behaviors, educating people about transmission, and encouraging persons to adopt safer-sex behaviors. These interventions have been successful for some segments of the population, but success in other parts of the population has been limited. Our focus group participants appeared to have a relatively high level of knowledge about HIV transmission and prevention, though we did not specifically evaluate this issue. They also regarded HIV and other sexually transmitted infections as important issues for themselves and their communities. Their discussions revealed contextual features such as racism, discrimination, and resultant economic and social inequity, which promote sexual patterns that, in turn, promote sexually transmitted infections (e.g., concurrent partnerships).

To be effective in changing individual behaviors in safer directions, HIV-prevention efforts must address these contextual factors simultaneously with individual interventions. Advances in AIDS prevention among subpopulations, such as the rural African Americans described in this report, may require a paradigm shift toward interventions addressing broader social issues that influence sexual behavior.

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