Young African American Perceptions of Substance Use in Rural Eastern Arkansas Communities

Abstract

This study examined barriers to substance abuse treatment through focus group interviews of African American youth in three rural, eastern Arkansas counties of the Mississippi Delta region. Adolescents with a current or prior history of substance use, non-substance using adolescents acquainted with other substance users, and young adults who initiated substance use during adolescence were included (N=41). Grand tour and subsequent probe questions elicited multiple themes regarding rural adolescent substance use, treatment decisions, and preferences. Adolescents’ perceptions of substance use indicate that treatment and/or prevention programs will need to address multiple dimensions, ranging from individual to community-wide factors.

Substance use by adolescents is associated with increased health risks, including injuries or death, whether due to accidents, suicides, or homicide; early pregnancy-related complications; or unprotected sex, potentially resulting in sexually-transmitted diseases (Clark, Belgrave, & Nasim, 2008; Dunn et al., 2008). Adolescents who use substances are also more likely to experience unemployment and its related poverty cost, engage in criminal behaviors at the risk of incarceration, and demonstrate academic problems (Chilenski & Greenberg, 2009; Doherty, Green, Reisinger, & Ensminger, 2007; Henry, 2010; Kogan, Luo, Brody, & Murry, 2005; Lopez, Katsulis, & Robillard, 2009). In essence, use of substances poses a risk to developmental milestones in the life of adolescents (Botvin, Malgady, Griffin, Scheier, & Epstein, 1993; 1998; Brody, Kogan, Chen, & McBride Murry, 2008), which may be more severe among African American rural youth.

Despite the growing problem and the negative social outcomes, there has been little written about African American adolescent’s substance use in rural communities and their perceptions of available treatment options. A number of researchers have reported that the rates of adolescent and adult rural substance use are similar to or higher than rates in urban areas (Brody, Kogan, Chen, & McBride Murry, 2008; Botvin, Malgady, Griffin, Scheier, & Epstein, 1998; Cronk & Sarvela, 1997; Dawkins, 1996). Of particular concern in rural areas is the increasing prevalence of substance use among African American youth (National Center on Addiction and Substance Use, 2000). However, the reported findings are mixed. In a study of past 30 days use of cocaine and amphetamine, Allen and Page (1994) found that African Americans in rural Mississippi were not significantly different in drug use than Caucasians. However, Kogan and his colleagues (2005) found that use of marijuana, cocaine, inhalants, methamphetamine, and alcohol were higher in African American males living in rural communities compared to African American males in urban and suburban communities. Similar results were found for African American females with the exception of marijuana (Staton-Tindall, Oser, Duvall, Havens, Webster, Leukefeld, & Booth, 2008).

Using a phenomenological approach (Creswell, 2007; Miles & Huberman, 1994), this study explores in detail rural African American youth’s perception of substance abuse treatment in three rural, eastern Arkansas counties of the Mississippi Delta region of the United States. By interviewing adolescents directly, we sought to understand the factors that hinder treatment seeking, entry or engagement. Our approach was phenomenological in that we attempted to capture our participants’ personal experiences with substance use and substance use treatment. The process allows the researcher the opportunity to understand the problem of substance abuse from the perspective of the participant (Rubin & Babbie, 2010).

Method

Participants

During 2008 and 2009 five focus groups were held in two eastern Arkansas counties of the United States. Participants were recruited from St. Francis, Lee and Phillips Counties in the Arkansas Mississippi Delta. Participants of this current study represent a subsample of adolescents in two larger projects including young adults and adolescents. Of the five groups, two consisted of young adults (18–21 years old) who were enrolled in a larger project of adult rural substance abuse and reported they had started using alcohol and marijuana before the age of 15. During involvement in this current study, the participants were between the ages of 22 and 26. None of these had received treatment services. Two additional focus groups included adolescents who were recruited because they had enrolled in but not completed a substance abuse treatment program in their community. The fifth group consisted of adolescents who reported they did not use substances but were aware of peers and/or adolescent family members who did. Participants in that group were recruited from a local youth advisory board group affiliated with an adolescent substance abuse treatment program. Participants in each of the latter three groups were between 13 and 19 years of age.

As shown in Table 1 a total of 41 participants (16 young adults and 25 adolescents) participated in the focus group interviews. The participants in both groups were primarily male, had less than a high school education, had a household yearly income of $20,000 or less, and were never married (see Table 1). The mean age for the young adult group was 24.3 years versus 16.3 years for the adolescent group. The adolescent group identified themselves primarily as students (80%), while the young adult group identified themselves primarily as unemployed (50%). All participants identified themselves as African American with an exception of one adolescent who self-identified as African American/Native American. Three (19%) of the young adults and one (4%) of the adolescents also identified themselves as Latino.

Table 1.

Demographic Information for Young Adults and Adolescents (N=41)

		Young Adults (N=16)	Adolescents (N=25)
Gender	Male	10 (63%)	17 (68%)
	Female	6 (38%)	8 (32%)
Employment a	Employed (Full or Part-time)	6 (38%)	3 (12%)
	Laid Off	1 (6%)	--
	Unemployed	8 (50%)	1 (4%)
	Student	1 (6%)	20 (80%)
Mean Age		24.31	16.26
Education a	Less than High School	11 (69%)	18 (72%)
	High School Diploma	5 (31%)	5 (18%)
Ethnicity	Latino	3 (19%)	1 (4%)
Race	African American	16 (100%)	24 (96%)
	African American/Native American	--	1 (4%)
Annual Family Income	$20,000 or less	12 (75%)	6 (24%)
	Over $20,000 < $30,000	2 (13%)	3 (12%)
	$30,000 < $50,000	--	4 (16%)
	$50,000 < $75,000	--	2 (8%)
	$75,000 < $100,000	---	1 (4%)
	$100,000 >	2 (13%)	2 (8%)
Marital Status b	Married	3 (19%)	--
	Widowed	1 (6%)	--
	Never Married	11 (69%)	24 (96%)

^aAdolescent participants’ information missing

^bAdolescent and young adult participants’ information missing

Procedures

Participants were recruited by a research assistant familiar with this region of the Delta, who had also worked on similar research projects targeting adolescent/early adult substance use. Focus groups occurred in a rented office space in Marianna, Arkansas, a small town located in Lee County; at a local church in Helena/West Helena, Arkansas, located in Phillips County; or in a rented space in Forest City, Arkansas, located in St. Francis County. Each focus group session lasted approximately one and a half hours. The research assistant in the area gained consent and assent for all of the participants who expressed interest in participating in this study prior to the assigned group discussion date with the exception of eight adolescents whose consents and/or assents were completed the day of the focus group. Participants under 18 years of age were assented and parental consent was provided. Participants over the age of 18 years of age completed the consent process. Institutional Review Board (IRB) approval was granted prior to the start of the project (IRB approval # 107721). In addition to participating in the focus groups, participants completed a one-page demographic form. Participants were provided with $20 for time and travel costs.

Data Analysis

All focus group discussions were digitally recorded, transcribed and entered into Ethnograph Software Version 5 for data management. Once transcripts were reviewed for accuracy of content and all identifying information deleted, the recordings were erased. A phenomenological approach was used during the focus group interviewing process to capture the experience of participants with substance use. The researchers sought to allow dominant themes to emerge from the data analysis process (Miles & Huberman, 1994).

The same grand tour question was asked of every group. Based on responses, subsequent probe or follow-up questions were asked to capture the information concerning the adolescents’ perceptions of substance use and treatment. The grand tour question for each of the focus groups was, “What are the most important barriers for adolescents and their families to receive care for substance use in this community?”

Interview data obtained at each focus group session was transcribed by project personnel, using standard identifiers (R=Respondent; F=Facilitator) to protect the confidentiality of all responses. Accuracy of transcriptions was verified by a research assistant. Personal identifiers were removed from all interview tapes. Transcriptions were entered into Ethnograph and verified by comparing the audiotape to the text. Simultaneously, research codes were generated and entered as appropriate to index segments of text that referred to specific themes. The research team individually reviewed the same focus group transcript to identify key themes for first-level coding. After this review, the group met to discuss these themes and identify commonalities that would serve as primary codes for further data analysis. Based on this discussion, the fourth author proposed a set of primary themes, distributed these to the team for feedback, and refined the themes and their definitions accordingly. Using this document as a guide, all four team members individually coded all utterances of the initial focus group, reviewed and compared the coding of these utterances, discussed discrepancies until consensus was reached, and revised the coding scheme. Notes from discussions were documented to create an audit trail for the purposes of validation of the coding process. Once consensus was attained on the primary codes, team members independently coded a second focus group transcript. All coding was subsequently reviewed, disagreements resolved through consensus, and the coding definitions revised again. The research team was subsequently divided into two pairs to code the other three focus group transcripts. The pairs worked independently and met to discuss their coding. Questions between members of the pairs were resolved through discussion or consultation with members of the other pair. Based on definitions of the primary codes and a thorough review of all transcripts, sub-themes (or secondary codes) were developed and reviewed by the research team for accuracy and thoroughness. The first author subsequently coded all utterances within each primary code using the secondary codes. Coding for each utterance was reviewed and approved by the second author in consultation with the third and fourth authors. In the case of disagreements, the results were discussed until consensus was reached.

Results

Four primary themes relating to substance abuse treatment for youth were identified from participant responses: Identification of the Problem, Decision to Seek Services, Support Selection and Community Influences. Identification of the Problem was conceptualized as the identification or labeling of a concern, state of difficulty or unresolved situation as it relates to the topic of substance use. This theme primarily focused on the perceived factors contributing to adolescent substance use and included individual, peer as well as generational influences. Decision to Seek Services was defined as the factors participants considered to be influential in seeking help for problems related to substance use. These could include the acceptability, affordability and accessibility of services; efficacy and satisfaction of services; perceived barriers to services; or the motivation or lack thereof to seek services. Support Selection was defined as the tangible or intangible resources identified, selected and/or used by the individual that had the highest probability of success or effectiveness or that best fit the desired goals, desires, lifestyle or values of the community or individual. This could include service goals; service supports, including job placements or spirituality; reference to specific interventions; informal supports such as friends or families; and prevention practices in schools, social programs or religious organizations. Community Influences were defined as factors that adolescents perceived influence substance use and/or substance use distribution that arise out of interactions between the adolescent and his/her larger environment. This could include lack of opportunities in the community; violence, crime or economic loss in the community; transfusion of new substances in the community; and the lack of social capital in the community. Table 2 contains the primary themes, sub-themes, definitions, and examples.

Table 2.

Adolescent Reponse with Major Themes, Defintions and Examples

Theme	Definition	Sub-themes	Examples
Identification of the Problem	The identification or labeling of a concern, state of difficulty or unresolved situation associated with or contributing to adolescent substance use.
		Pleasurable Aspects of Using	“Maybe they’re enjoying what they were doing.” “See right now, weed and alcohol or whatever it is, that’s the excitement we get around here right now. That’s the excitement we get.” “You’re having too much fun. “I’m not going to stop smoking. I want to smoke weed.”
		Minimization of Substance Use and Consequences	“If that man chooses to do drugs, that’s him; I’m sure all of us feel like that. If that man chooses to do drugs, that’s him.” “I manage my habit.” “Who says you can’t be successful on drugs, though?”
		Coping Mechanism	“Once you do it, I mean, I had friends, whenever they were stressed, they had to pick up a cigarette. They’d be like, ‘Man, I don’t know what to do about this.’ Their hand would reach into their pocket you know, trying to light one up. I mean, when they don’t have one, they don’t know what to do. They don’t have any other way to cope with what they’re coping with. They smoke and drink.” “Also a reason to use drugs…if you call it an excuse …the emotional stuff… pregnancy, sexual abuse, things like that…for women, it’s emotional. It’s an emotional thing.” “Some people use drugs and they get smart.”
		Economic Benefits	“Hey, if I can’t help the young man…somebody’s going to sell it to him, it would be better if I sell it to him. I’d rather get to him and sell him a bag of smokes.” “As the money gets high, he gets high.” 13 year old on crack…12 year old on heroin…they getting’ rich off them, taking allowance off them.”
		Peer Sanction	“You hang around your friends and you don’t want to leave…and that’s when the peer pressure starts.” “And then some people who aren’t their friends, they give into peer pressure.” “I mean, they have influences, their peers influence them. I mean, it’s a lot of things that could stop them from wanting help.”
		Generational Transmission	“But all these other kids, from like 15 and up… more than likely, they’ve got somebody in their family that do it, and that’s the influence, and I mean, their mama is either on it or their daddy is on it.” “If I can’t help her (my sister), I’ll sell it to her.” “At least if you’re goin’ to do it, don’t do it around your kids.”
Decision to Seek Services	Factors influencing support selection that were considered or would be considered in seeking help for addiction and substance use problems.
		Internal Motivation to Change	“Yeah, if you want a good job, they’re going to be doing test, so you’re going to know you’re going to have to stop.” “If they can’t ever find it in their heart to come in on their own, it just ain’t going to help.” “You know, like say for instance, you come close to death and live, you know, then at the time you know you get to thinking about your life then.”
		Family Considerations	“Like if you’re lost, your parents tell you there’s different ways of coping.” “I know this might sound crazy on my behalf, but I have a lot of friends, and I have an eight month old son, and if I really, really, really needed help, I wouldn’t go. I love my baby just that much. I would not go. I would just, I would try my best to quit at home, because I wouldn’t, I would not leave my baby with no stranger for nothing…” “[If] parents know their child is substance abusing, [they think], ‘Oh, we’re not good parents,’ so they wouldn’t say too much about it, because they’re feeling bad about themselves.”
		Stigma/Shame/Fear	“A lot of people don’t like to admit they need help and if they do, don’t want to admit they’re crazy or needy and what wants to fee like that?” “What if other people find out?” “Being a teen, you feel like you have your own problems. You don’t want to go to anybody. You get an attitude; you don’t want to go to no one.” “If one of us goes [to treatment], we’re the joke.”
		Lack of Service Accessibility/Availability	“If we were into hard drugs, it ain’t nowhere to go to get help” “I mean, we don’t have nothing in [town]. It’s small. We don’t have that down here.” “[Name of a treatment facility], and they’ll guide her to another place, but the other place ain’t going to be here. She’s going to be out of town somewhere.” “It costs an arm and a leg, and I ain’t got it.”
		Informal Supports	“…not enough encouragement from people around you or people trying to help you.” “We ain’t got no sponsors out there in the streets or in the schools or anywhere.” “Like, for instance, if the role model is doing substance abuse and they get treatment, then they [the substance abuser] may want to get help too.” “Somebody’s got a friend somewhere. I mean, even if your friend has kids…somebody’s got to help me, because I’ve got to get help, and I don’t want my kids to be in foster care, or you know, split out everywhere.”
Service Selection	The tangible or intangible resources or services identified, selected and/or used by the individual that had the highest probability of success or effectiveness or that best fits the desired goals, desires, lifestyle or values of the community or individual.
		Treatment Components	“I’d have it [treatment program] open from the time school is out until about 9:30–10:00 pm.” “If this program tells their parents they’re smoking, nobody will go in the group. If family members were in there, they wouldn’t open up.” “I’d have some like, you know, some people don’t actually know, I’d have a picture up there of a guy fighting inside his body…I’d have a diagram of the body, showing the inside, showing what drugs will do to you. That would scare some people. They’ll actually wake up and realize…” “Where would we put it? You see all these big fields out here? I’d take some of these folks’ fields.” “I mean, they go swimming every day, they will when it gets warm. Swimming, they have activities, volleyball, softball, they got a basketball court. When you feel like you’ve got a urge, go play basketball, tennis.” “And for the outpatient’s that’s going in and out, they have to take a drug test. When they come back in, they have to have a test, I’d say every 3–4 weeks.” “…I’d make it an incentive thing, to where if you move from one level to the next level, then you get such and such. Then move on up, you get such and such more, then something like that. Something that’ll make them want to change.” “I would have stuff about God, and ‘Look the opposite way,’ and other stuff like that; little slogans that you see on key chains and stuff. “They could have drug classes…alcohol classes…all different kinds of things.” “Some people have never finished school. They could probably have a class where they could get their GED.”
		Desired Treatment Relationship	“I need that trust thing; if I talk to you, I just wanted to trust you. You’re here for me, not just for your pay.” “If I really need some help, I would have a place here in town. It would have the nicest greeting. I would have somebody out there with the nicest greeting. When they pull up, they would want to come in there. [They would want to come in] because of the greeting.” “If they stayed in the program long enough and I know they’re …that they’ve done changed over…you could get it on a gift card. Don’t give them no money, because…give them gift cards.” Everybody’s accepted, because if I wanted to get help, I’d want to be accepted.”
Community Influences	Drug use and/or distribution that arises through the relationships and interactions among the adolescent and his/her environment.
		Pervasiveness of Substances	“…and then they know it’s out on the street. They’re in [town], or they know it’s on the street, so they’re going to get out and go get it if they want it.” “Anybody, a 10 year old, can go buy some drugs if he got his money or she got her money right.” “Yeah, and if they got the party they want, and they got their money, them people out there actually don’t care about themselves or the next person; so they will give it to them.”
		Lack of Human and Social Capital	“People that’s got good jobs don’t smoke or drink. But people that ain’t got no job, smoking and drinking.” “See now, it ain’t no activities. That’s why, that’s why 90% of [town] is on drugs, because you know, it ain’t nothing, it ain’t no type of excitement.” “[There] are more negative things to do than positive things. Negative things seem to be taking over…”
		Drug-Related Violence	“Everybody down there, everybody’s got pistols too, just like yesterday it was fixing to be a shootout like the wild, wild west. Last week they had a wild, wild west shooting.” “I’m talking about they’re going to hide in your bushes, or they’re going to wait, they’re going to be right outside your window, knocking on your window with a pistol.”
		Community Response	“They’ll tell you, ‘You ain’t going to make nothing out of your life.’” “ Old people, like the parents, aren’t encouraging them to do things, aren’t supporting them.” “If you’re out here doing drugs, it ain’t nobody around here [who will] just come and pull you off the street, like, ‘Hey man, you need to stop doing this.’ You know, it ain’t none of that…They just let you do this until you just die out.”

Discussion

The initial aim of this study was to understand adolescents’ perceptions of treatment for substance use in rural areas of the Arkansas Mississippi Delta region. Although participants in each of the groups addressed factors which may facilitate or hinder initiation of care, they were also likely to discuss how the problem of substance use evolves and is sustained by a myriad of community, family and individual factors. In other words, adolescents wanted to talk about the substances they and others use, their reasons for maintaining substance use, and the problems they encounter in seeking services. In addition, multigenerational and community influences appear to be particularly important for these rural adolescents, highlighting a cultural interconnectedness that should be considered as we view the problem of substance use within the individual and strategize about successful solutions (Laszloffy, 2009).

As shown in the results sections, adolescents held several beliefs about substances that legitimized their use, and they frequently identified these benefits while overlooking costs or risks. First, they believed that substances enhanced their functioning, helped them cope, provided entertainment, and offered economic security. These beliefs did not vary across groups with the exception of the group of self-identified non-users, who attributed these thoughts to other adolescents but not themselves. Secondly, peers and family members played a significant role in the adolescents’ initiation and maintenance of substance use. Specifically, adolescents conceptualized substance use as an inter-generational phenomenon in which use and sales of substances are transferred either indirectly or directly from parent or other familial adult to child. Parents who attempted to gain control of the problem and who seemed intent on preventing their children from using drugs were seen by these participants as ineffectual or powerless against the devastating influence of this problem. In essence, the availability of “involved-supportive parenting” (Brody, et al., 2009, p. 8) appears to be lacking in these counties from the perspective of the youth participants. Adolescents also described the pressure they feel from peers to use and the fear they face should they decide to quit. Participants therefore expressed emotions of fear or embarrassment if they were found by peers to be attempting to terminate drug usage. They explained that because they lived in rural areas, everyone knew each other. Peers, consequently, would be aware of changes in behavior, given the fact that they would be likely to also use drugs. Passetti, Godley & White (2008) found somewhat similar results in their qualitative study of adolescents who entered drug treatment programs. Although half of the participants reported that they received positive or non-negative comments from peers who knew they were involved with drug treatment, the other half of the participants received significant and intense amounts of negative feedback from peers.

As shown in Table 2, adolescents also discussed multiple factors influencing their decision to seek treatment. However, their responses sometimes differed by focus group. For example, young female adults focused on concerns about childcare – given that they were more likely to have children – and consequences of substance use if they were employed. By comparison, adolescent discussions centered more on the stigma of seeking help and low internal motivation to change. Self-reported non-users were less likely to mention decisions about entering substance use treatment, presumably because this would not be a primary issue for them. The adolescents also discussed aspects of informal and formal support that would be most acceptable to them. Participants in all groups emphasized the relational aspects of recovery, including role models who have been successful in discontinuing substance use; supportive adults, including ministers and teachers, who will “reach out” or mentor youth; and counselors in treatment programs who have the capacity to emotionally connect with them. Participants also addressed the most desirable components of a treatment program, which would require a multi-disciplinary approach ranging from psycho-education to recreation to vocational development in residential and community settings.

The most unexpected comments from adolescents reflected the despair and hopelessness they experience about substance use as well as unavailable resources that they perceived would promote behavior change. The dominant thought voiced by all groups was that the communities in which they lived contributed to the problem of substance use, because of the pervasiveness of drugs as well as resident’s proclivity to ignore what was happening. As one participant described, “They just let you do this [use drugs] until you just die out.” A majority of participants verbalized a desire to be helped by the community on multiple levels from developing a substance abuse treatment program for teens to creating more jobs, recreational outlets and vocational training. These comments highlight the need for a multi-dimensional, multi-level approach to substance use remediation in rural communities.

There are several methodological weaknesses in this study which may limit the extent to which findings can be generalized to other rural communities. While the voices and opinions of the participants of these youth were adequately captured within focus groups, it is not possible to verify whether their perceptions are based on actual facts. A second limitation to this study is the small area that was studied. The three counties were all located in the eastern part of the state. Different findings may be gathered from other rural counties in Arkansas as well as other states. Furthermore, because of the small number of individuals included in the focus groups, the results may be biased and not generalizable to a larger population of adolescents in this area.

Despite these weaknesses, the study explores the problem of substance use in the words of rural African American adolescents and young adults (who were adolescent at the time of substance initiation). Multiple types of prevention and treatment options are explored at multiple levels. However, what is particularly clear is that the community itself needs to be a part of developing an effective drug program that represents the needs of the individual as well as families and the larger culture. Further studies need to explore the cooperative role of recreational centers, schools, churches, and other informal institutions in rural settings to effectively address the problem of substance use in rural areas.