Original Article

Affilia: Journal of Women and Social

Work

Gender, Race, Class, and Health: 2017, Vol. 32(4) 531-542

ª The Author(s) 2017
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DOI: 10.1177/0886109917713975
of Substance Abuse and HIV journals.sagepub.com/home/aff

Through a Cultural Lens

Yarneccia Danielle Dyson1, Sarita Kaya Davis2,

Margaret Counts-Spriggs3 and Neena Smith-Bankhead4

Abstract
This study explores the intersection of race, class, and gender on substance abuse treatment and
human immunodeficiency virus risk among 12 incarcerated black women by integrating the Health
Belief Model with Black Feminist Theory. The findings suggest that the culture and context of substance
abuse not only influenced the women’s perception of susceptibility of risk and severity of risk but,
perhaps more importantly, the perceived benefit of the intervention on their life circumstances. These
findings have implications for the conceptualization, implementation, and evaluation of substance abuse
treatment, HIV prevention education, and prison reentry programs targeting Black women.

Keywords
Black Feminist Theory/Womanism, Health Belief Model, HIV, Intersectionality, micro, research
categories, social work history, social work practice, social work/social welfare history and
philosophy, substance abuse

The combination of drug-related crimes and prostitution arrests is increasing among Black low-
income women (Swavola, Riley, & Subramanian, 2016). The intersection of drug use and prostitu-
tion places this population at increased risk for contracting human immunodeficiency virus (HIV).
While some correctional facilities offer substance abuse and HIV prevention education to inmates,
the theoretical underpinnings of such interventions are typically rooted in public health models and
lack cultural sensitivity with regard to the impact of gender, race, class, and health on inmates.

1
The University of North Carolina at Greensboro, Greensboro, NC, USA
2
Georgia State University, Atlanta, GA, USA
3
Clark Atlanta University, Atlanta, GA, USA
4
Emory University, Atlanta, GA, USA

Corresponding Author:
Yarneccia Danielle Dyson, The University of North Carolina at Greensboro, PO Box 26170, Stone Building 257, Greensboro,
NC 27402-6170, USA.
Email: yddyson@uncg.edu
532 Affilia: Journal of Women and Social Work 32(4)

The purpose of this study was to investigate the utility of integrating a traditional public health
model with a nontraditional cultural framework. Thus, this research sought to infuse Black Feminist
Theory (BFT) with the Health Belief Model (HBM) to better understand cultural issues that can
affect HIV risk among incarcerated substance abusing Black women.

Background
In 2014, Blacks accounted for 44% of estimated new HIV diagnoses in the United States (Centers for
Disease Control and Prevention [CDC], 2016). Regarding women, incidence rates reveal that there
were 1,350 Hispanic/Latino women and 1,483 White women diagnosed with HIV in comparison to
5,128 Black women in this time period (CDC, 2016). Further, there are several factors that contrib-
ute to the increase of HIV susceptibility in Black women when compared to other races/ethnicities.
Specifically, personal characteristics such as childhood sexual abuse, post-traumatic stress disorder
(PTSD), and substance abuse, in addition to relationship dynamics and intimate partner violence,
contribute to greater susceptibility of HIV among Black women (El-Bassel, Caldeira, Ruglass, &
Gilbert, 2009). Other factors and root causes that increase HIV susceptibility among Black women
include structural barriers such as poverty and access to HIV preventive services as well as cultural
values and belief systems that relate to gender roles and social norms regarding safe sex practices
(El-Bassel et al., 2009).

Women and Substance Abuse Treatment

Many researchers agree that women are less likely than men to seek out treatment for substance
abuse (Schober & Annis, 1996; Walitzer & Connors, 1997). Research shows that women who do
enter treatment are less likely to be married (Wechsberg, Craddock, & Hubbard, 1998) and more
likely to report experiencing other abuses (Pettinati, Rukstalis, Luck, Volpicelli, & O’Brien, 2000),
use alcohol and/or cocaine (Pettinatti et al., 2000), and have more family responsibilities (i.e., child
and parent–related issues). Black women were least likely to complete substance abuse treatment,
especially if they were in semiskilled positions such as housekeeping/cleaning or restaurant services
such as a waitstaff (Mertens & Weisner, 2000).

Substance Abuse Treatment Disparities

In addition, in an article by Le Cook and Alegria, the authors conducted a meta-analytic review of
various studies examining the disparities that exist within substance abuse treatment. The reported
reasons were the relationships between race–ethnicity and substance abuse treatment by income,
previous involvement with criminal justice system, access and eligibility to treatment services, and
the severity of the disorder. The authors concluded that future studies must address the intersection
of race–ethnicity, socioeconomic status, and criminal history when understanding the disparities that
exist within substance abuse treatment.
The literature suggests there are many gender differences in the substance abuse treatment
experiences of men and women. Additionally, women who receive substance abuse treatment while
incarcerated are more likely to have more severe abuse issues and experience greater barriers upon
release (Opsal & Foley, 2013). However, the extant literature is virtually silent on the substance
abuse experiences of incarcerated Black women. Gilfus (2002) reported that incarcerated Black
women are often exposed to structural affects such as poverty, racism, and violence as a result of
childhood abuse and victimization. Consequently, factors such as the onset of substance abuse, self-
harm, depression, suicidal ideation, relationship disturbances, and running away from home and
entry into prostitution were found as frequent negative consequences the abuse. Further, Olphen,
Dyson et al. 533

Eliason, Freudenberg, and Barnes (2009) also found that the substance abuse experiences of Black
women who have been incarcerated are tied to structural affects such as histories of abuse, low
education, and poverty. As a result, this population also faces stigma upon release and experiences
challenges reintegrating to their communities. There is a gap in the literature regarding the inter-
rogation of substance abuse treatment and HIV prevention for incarcerated substance using Black
women from a cultural lens. While this population stands to benefit greatly from HIV prevention
programs during incarceration, very little is known about their experiences and how best to meet
their unique needs in a culturally relevant manner.

Theoretical Frameworks
The Health Belief Model
The Health Belief Model is a cognitive learning theory that focuses on health-related perspectives and
motivations and utilizes a cost–benefit perspective in explaining preventive health behaviors (Mantell,
DiVittis, & Auerbach, 1997). The original model is rooted in psychology and was developed by
Rosenstock (1974) for the purposes of promoting the work of social psychologists. This model was
based on four constructs designed to predict the social response to a behaviorally based treatment or
intervention. These four constructs include perceived susceptibility, perceived severity, perceived
barriers, and perceived benefits (Janz & Becker, 1984; Rosenstock, 1974). In essence, the HBM
assumes that individuals will make a change in negative health behaviors, such as substance abuse
and risky sexual encounters, if they believe this practice will decrease their chances of acquiring HIV.
There have been revisions made to the HBM that included the addition of two constructs, cues to
action and self-efficacy. For the purposes of this study, the author used the original model of the
theory which focused on the four constructs that specifically addressed susceptibility of risk, sever-
ity, barriers, and the benefits of changing behaviors in regard to health for the target population of
incarcerated substance using Black women who were at risk for HIV.

Black Feminist Theory

Black Feminist Theory explores how race, class, and gender intersect to produce an incorporated
examination of power and oppression (Burnham, 2001; Crenshaw, 1989). A distinguishing charac-
teristic of BFT is its insistence that both the changed perception of individuals and the social
transformation of political and economic institutions constitute true essential components for social
change. According to Collins (1991), Black feminism endorses four basic principles:

1. Racism, sexism, and classism are interlocking systems of oppression.

2. We must maintain a humanist vision that will not accept any amount of human oppression.
3. We must define ourselves and give voice to the everyday Black woman and everyday
experiences.
4. We must operate from the standpoint that Black women are unique and our experiences are
unique.

Collins posits that offering subordinate groups new, rediscovered, knowledge about their own
experiences can be empowering. In sum, revealing new ways of knowing allows these oppressed
groups the opportunity to redefine their own reality which has larger implications.
Few (2007) provides the notion that when conducting research that will sufficiently focus on the
lived experiences of Black women in the United States, social scientists must first examine and
understand how Black women view themselves in the context of their relational and familial
relationships as well as carefully consider how research methodologies, data interpretation, and
534 Affilia: Journal of Women and Social Work 32(4)

utility may impact how the information is translated. She further wrote that the essence of Black
feminism provides a safe space where Black women can “legitimately” stand in two or more
realities—the perceptions of being “Black” and a “woman” at the same time (Martin, 1993).
Bell-Scott (1995) highlighted the notion that Black feminism acknowledges the shared struggles
of oppression faced by Black women and men that result from racism, classism, and in some forms,
sexism. From a methodological perspective, Black feminists and Womanists use a variety of tradi-
tional research methods such as interviews, surveys, and so on, as well as nontraditional tools such as
music, art, and spoken word in examining the lives of Black women and their families. This provides
a sense of empowerment for Black women to articulate and share their lived experiences in any
creative manner they select when engaging in research studies.
Black Feminist Theory has been applied in HIV prevention research targeting low-income Black
women. Gentry, Elifson, and Sterk (2005) used BFT to interpret how 45 low-income Black women
in Atlanta, GA, negotiate their social conditions and interpret their high- and low-risk behavior in
regard to contracting HIV. The study identified five themes unique to Black women struggling with
substance abuse and HIV risk: (1) Self-definition and self-evaluation are critical to understanding
risk perception and motivation of behavior; (2) an interconnectedness between race, class, and
gender; (3) Black women have unique experiences in America; (4) controlling social images dis-
tracts poor Black women; and (5) agency can play an important role is social change. Ultimately, the
study results challenge the traditional practice of using behavioral theories as a singular framework
by which human behavior is interpreted.

The Use of BFT and HBM as a Treatment Model

In using BFT, the focus is simultaneously placed on the individual, in this case, the incarcerated
substance abusing Black woman, as well as on the community in which she lives and the structures,
institutions, and policies which dictate her trajectory (Constantine, Gainor, Ahluwalia, & Berkel,
2003). The individual versus communal perspective is a critical point of divergence between
behavior-focused public health theories and cultural theories. While the HBM focuses only on the
individual as the source of the problem/issue and the site of agency, BFT acknowledges the inter-
dependence of the Black woman, community, and history. The lens of BFT and the HBM allows us
to see how Black female stereotypes emerge to codify into law the inhumane treatment of already
victimized Black women. Consequently, the integration of the HBM with BFT broadens the research
question to capture contextual issues that inform perception of risk and benefit of action.

Method
Sample
Institutional Review Board (IRB) approval for this study was obtained from the Office of Sponsored
Research. The researchers employed a mixed methods phenomenological research design. Women
were eligible to participate in the study if they were 18 years of age, identified as Black, had been
arrested for a drug offense or reported having drug problems at the time of their arrest, had engaged in
sexual intercourse (vaginal, oral, or anal) with a man at least once in life, and had a negative HIV
serostatus at the time of the study. Moreover, a number of women had participated in the Women for
Women (W4W) Program (a group-level program/intervention) at least 2 times and for some, failure to
complete the mandated program resulted in a prison sentence for their offense(s). The benefits of this
program included sobriety, the termination of pending penal cases, and newfound, lifelong supportive
relationships (D. Rasouliyan, personal communication, February 2009). To ensure anonymity, study
participants selected pseudonyms; their government names/identities were not provided.
Dyson et al. 535

The W4W Program

The W4W Program is an in-custody addiction treatment program for women in a small-sized
medium security detention center in an urban city. This program does not operate from a specific
therapeutic model. The curriculum consisted of alcohol and drug education, group therapy and
community meetings, career and vocational training, parenting skills education, domestic violence
education, self-esteem education, individual therapy/case management, and transition to aftercare
services. Participants engaged in this program for a minimum of 9 months and were automatically
transferred to an aftercare program at a local substance abuse treatment center.

Data Collection
In addressing this topic, there were three data collection approaches that were utilized in answering
the research questions. These included the use of a survey, individual interviews, and two focus
groups. The following are the research questions that guided this study:

Research Question 1: What are the inequities that exist in substance abuse treatment, whereby
the oppressive issues such as race, class, and gender are barriers to substance abuse treat-
ment for Black women that should be addressed?
Research Question 2: How does forced recovery (incarceration) influence a women’s percep-
tion of their substance abuse?
Research Question 3: What is the perceived susceptibility of risk for HIV among Black
women in recovery?
Research Question 4: Are women who do not successfully complete substance abuse treat-
ment at greater risk for HIV infection?

A semistructured interview guide was designed by the first author to obtain information regarding
the constructs of the original HBM (Research Question 4) and the perception of risk for HIV and
influence of substance abusing behaviors. The following are a sample of questions that were
included in the semistructured interviews and focus group in order to draw comparisons among the
two methodologies: Do you consider yourself at risk for HIV? Why do you think Black women are at
risk for HIV? Tell me about ways you earn money and how does your use of drugs impact your ways
to earn money? Do you consider your arrests for prostitution severe to your health? What are some
factors that cause you to have sex for money? Interview items were developed based on the con-
structs of the HBM and BFT. The author utilized the same open-ended research questions for both
interviews and focus groups.
Based on eligibility criteria, individual interviews were conducted with 12 women who reported
being HIV negative at the time of the interview. Voluntary HIV testing was done on sight at the jail.
As the study focused on perceived risk for disease acquisition, there were two members who were
excluded from the study as they reported being “HIV positive” and “having AIDS.” Based upon
preliminary qualitative data analysis, the findings revealed certain results according to age (older
participants vs. younger participants). Subsequently, further focus groups were stratified according
to age for the purposes of deeper analysis. Stratified sampling was used to select participants from
each age cohort to yield a total of four for each group. When using this method of sampling, the
population is divided into groups called strata. This technique is most useful when stratifying
variables are simple to work with and closely relate to the research topic (Kalsbeek, 2008).
Regarding perceived susceptibility of HIV, the study participants were asked, “Why do you think
Black women are at risk for HIV.” Interestingly, the older participants in the study (ages 35–
54 years) identified that Black women were collectively at risk for HIV infection but did not identify
536 Affilia: Journal of Women and Social Work 32(4)

their own individual risk. On the contrary, younger participants (ages 19–34 years) acknowledged
their own individual risk for infection as well as the collective risk among Black women.
Prior to the administration of any data collection tools (survey, interview, and focus group), the
researcher read the informed consent aloud to each participant, insured they understood their voli-
tion for participation, and obtained their signatures on each of the informed consent forms (survey
and interview informed consent were combined and the focus group informed consent). Each
individual interview was conducted in a small cell in the jail. Two chairs were placed in the cell
and a pod officer, an employee of the jail who provides supervision and monitoring over the inmates,
instructed the researcher to sit nearest to the door for safety precautions. The focus groups were
conducted in the larger group meeting room with a pod officer present.
The interview and focus group guides were semistructured with a prepared list of topics and
questions related to perception of their substance abuse history, perception of HIV risk, perception of
susceptibility to HIV due to substance abuse, barriers to HIV risk and substance abuse efficacy, and
perceived benefits of intervention. Prior to each interview, the study participants completed a brief
12-item survey that focused on their demographic characteristics (i.e., age, ethnicity, arrest record,
drug history, and substance abuse treatment history).

Data Analysis
We utilized the constant comparative method developed by Glaser and Strauss (1967) in analyzing
the data in this study. This method of analysis, simply put, involves the researcher “constantly
comparing” the data as they are collected. The use of this method provided an opportunity to
organize the data analysis process in order to increase the traceability and substantiation of the
analyses (Boeiji, 2002). Further, reflexivity was used to ensure reliability in this study. The lead
author developed a statement detailing her personal biases and also conducted member check-in and
interrater reliability with other members of the research team (Johnson, 1997; Stenbacka, 2001). In
addition, another researcher listened to each audio recording, read each transcript, and coded each
set of interviews. This also assisted in addressing any bias that existed by the lead author and
satisfied interrater reliability for this study. The lead author and researcher then compared their
data coding to observe similarities and differences.

Results
Characteristics of Participants
The sample included Black women, averaging 35 years of age, ranging between 19 and 53. For the
purposes of anonymity, study participants selected pseudonyms which were used for the duration
of the study. Most of the women possessed a ninth grade level education, were heterosexual (57%),
and preferred crack as their drug of choice (57%). Only eight participants had previously
attempted substance abuse treatment prior to the study; however, all had relapsed. The length
of addiction ranged from 3 to 40 years, with the substance abuse beginning in adolescence and
typically as the result of a trauma (i.e., death of a parent, sexual abuse, or violent assault). A
majority of the women were unskilled with only one possessing a professional cosmetology
license. Over half (57%) of the women had never worked and engaged in prostitution or theft
as their primary source of income. Those who had worked previously held jobs as janitors, land-
scapers, and grocery store clerks. While 6 of the 12 women reported having children, only 2
women primarily raised their children. The children of the remaining women were raised either in
the foster care system or by relatives.
Dyson et al. 537

Further, there was a clear intersection between race, class, and gender in the sample, as it pertains
to their perception of HIV risk. Perceptions of HIV risk based on substance abuse are discussed
below.

Perceived Susceptibility
Perceived susceptibility refers to how a person assesses their risk for acquiring a disease, and the
majority of the women in the sample agreed that Black women as a whole were more susceptible to
contracting HIV due to their substance abuse. Perceptions of susceptibility were attributed to four
primary factors: (1) more money for engaging in unprotected vaginal and oral sex, (2) an innate
belief about the promiscuity of Black women, (3) Black men who have sex with men and women,
and (4) age.
In addition, several women noted an increasing number of Black women and young girls who
were engaging in prostitution and substance abuse in their communities. One participant who
strongly attributed increased HIV to ethnicity said, “A lot of Black women play around in the
street.” This was her rationale and why she believed Black women were more promiscuous than
any other race. Another participant admitted that a desire for more money and feeling lonely were
her triggers for engaging in unprotected sex. She shared, “I got a real bad sex drive . . . I mean . . . I
want it when I want it,” and chuckled as she made this statement. Further, this statement is related to
both men and women, as she disclosed being “bisexual.” Money was considered a trigger, as she
stated the following, “I could git whatever I want once I got it . . . so if I got money, I can git
drugs . . . if I git drugs I can git sex . . . ,” relating the triggers together. In addition, regarding Black
men who had sex with men and women, a participant stated, “most Black men like to have sex ‘raw’
or without a condom . . . they are the same nasty motherfuckers who have sex with other boys.”
Interestingly, the perception of risk differed by age, with older women in the sample seeing
themselves less at risk for contracting HIV. Most of the older women in the sample felt less at risk of
HIV transmission because they tended to have the same sexual partners for years, always used
condoms, and didn’t become sexually active with men who were infected. One older participant
stated, “I don’t feel my substance abuse increases my risk because I don’t bother with anyone that
got HIV . . . I try to stay away from those people.” Even when she admitted to not using condoms
during a period of heavy drug use several years ago, she still didn’t think she was at risk because she
never had anal sex. Specifically, she stated, “oh hell naw, you aint finna do dat, I ain’t havin’
that . . . I don’t do back doors . . . in yo’ asshole . . . anal sex . . . I can’t do dat one.”

Perceived Severity
The constructs of class and gender intersect uniquely to inform how incarcerated substance abusing
Black women view the “severity” of their abuse and by default their risk of contracting HIV.
Perceived severity refers the assessment of consequences as a result of engaging in risky behaviors.
According to eligibility self-reports, the sample of 12 women totaled 105 arrests with an average
number of 40 arrests for substance abuse and 65 arrests for prostitution. In individual interviews,
however, the women did not interpret their arrest record as an indicator of the severity of their
substance abuse but rather a reality of their lack of job skills. The participants indicated that their
lack of job skills translated to the use of sex as a means of income and served as a motivation for the
risk behavior. One participant who completed the seventh grade and worked as a landscaper reported
that she “never had a job.” She shared, “it’s easier for me to sell pussy . . . plus, I can always count on
someone taking care of me.” Another participant reported that she “turned tricks” for US$60–US$70
and as her drug habit got worse, she had engaged in risky sexual behaviors for as little as US$3 as her
focus was on acquiring more crack. As such, perceived severity of risk for HIV was nonexistent
538 Affilia: Journal of Women and Social Work 32(4)

because the participants justified their behaviors of having risky sex for money due to their lack of
job skills. Other ways in which the women obtained money included cleaning homes, shoplifting,
selling drugs, and setting up drug deals for the police. One respondent said it best by saying, “You
gotta suck and fuck for money” and “freakin’ in the streets gets my children fed and bills paid.”
Consequently, it is impossible to view perceived severity and perceived barrier as separate
entities in the context of BFT. Many of the women in the sample spoke to the need to have a
“hustle” to make money to live and care for their children. They understood the severity of their
actions yet confounded the barriers as a result of meeting their needs.
The lens of BFT allows us to see that in the context of substance abuse and HIV risk, perceived
severity to contracting HIV and barriers are enmeshed and measured against the importance of other
realities in the lives of these Black women.

Perceived Barriers
Issues related to employment status, children, partners, and community ties presented a unique
mixture of supports and barriers for the study participants. Perceived barriers in the context of the
HBM refer to how one assesses the drivers that promote/discourage engaging in risky behaviors. The
average education level of sample was ninth grade with little to no vocational skill training and
prostitution the primary trade of the sample. Consequently, breaking the cycle of addiction for this
sample is intimately interwoven with their ability to earn a livable wage upon release from jail.
Another barrier for the women was the perception that substance abuse treatment was an unten-
able option as evidenced by the fact that a majority (57%) of the women in the sample never sought
treatment for their addition for myriad reasons, including access to resources, lack of family support,
fear of losing children to foster care, and simply not wanting to leave their communities. Over-
whelmingly, the women who had children agreed that their children were a source of inspiration for
their recovery. However, many women were single parents with multiple children and no family or
father who could maintain custody during their absence.

Perceived Benefits
Perceived benefits refer to how a person conceptualizes the positive results of avoiding risky
behaviors. Many women struggled to articulate the value of substance treatment and HIV prevention
education for themselves. There seemed to be a greater sense of fatalism about their inability to
transcend substance abuse and HIV risk. One participant who had relapsed 15 times attributed her
lack of success to being scared of success. She said she was “afraid of the unknown” and felt
“unworthy” because she had done things in her life that caused her shame and regret. Another
participant shared the following,

I have sold pussy for crack and fucked without rubbers for money . . . and the truth is, I may be clean
when I leave here but I’ll probably go back to my lifestyle because I will still be broke.

Moreover, an older participant felt the experience was very beneficial saying,

By bein’ in here I don’t think I have any chance of getting it (HIV) and when I get outta here I’m through
with this . . . I’m not goin’ to jail . . . this is it for me . . . I’m goin’ home.

In most cases, the women felt HIV and substance abuse prevention should be focused on young
Black girls because of the risky behavior they observed on the streets. One participant said,
Dyson et al. 539

Classes on protectin’ yo’ self from AIDS needs to be in drug treatment and young Black girls need to
know what to do to protect themselves, especially with Black men ‘cause they have a lot of risky
sex . . . they fast!

Discussion
A central revelation in the women’s narratives about perceived susceptibility revolved around the
intersectionality of Black femaleness regardless of age. Younger Black women felt at increased risk
because they believed that Black women were innately more promiscuous. Older women, and some
younger women, contended that they were less at risk because White prostitutes were perceived to
be more sexually adventurous (i.e., engaging in anal and group sex) and thus more likely to be
exposed to HIV. Being Black and female was simultaneously a protective and risk factor. Their
notions of Black femaleness appear to have roots in mainstream media stereotypes about Black
women.
Moreover, a perceived barrier that the participants shared was the enforced philosophy of sub-
stance abuse treatment wherein intimate relationships are prohibited. Several of the women in the
sample expressed how supportive and instrumental their partners were in their seeking treatment. In
some cases, expressing that their partners disdain of their addiction being the impetus of their
decision to enter treatment. Women with children explained their children influenced their decision
to not seek treatment, stay in treatment, or end treatment. This information calls into question the
common wisdom of substance abuse treatment programs that typically have hard-and-fast policies
against participants being involved in intimate relationships during recovery. Cultural theorists
support the notion that Black people live in a duality where identity always supersedes position,
gender, and role (Akbar, 1984; Jarama, Belgrave, Bradford, Young, & Honnold, 2007; Nobles,
1978, 1985). The fact that Black women in this sample often found solace, motivation, and encour-
agement in their relationships with family and community give further support to greater cultural
grounding in substance abuse treatment to improve the treatment outcomes of Black women.
Most disturbing perhaps is the perceived benefits of substance abuse treatment and HIV educa-
tion among the sample. There was overwhelming sense of being unworthy of recovery and restora-
tion. These feelings were not necessarily expressed in the context of substance abuse and ethnicity.
One respondent shared the following reflection, “I’ve done some fucked up things in my life . . . it’s
like . . . sometimes, I feel like I don’t deserve a clean start.” When probed about the feelings of
unworthiness as it related to success and recovery, another participant shared the following,

I’ve had 14 relationships in my 33 years of living . . . none of them worked and all failed relationships
because the men just left . . . used me up and left . . . .so at times I don’t think this (recovery) will work.

Other respondents commented about the innate promiscuity of Black women, which suggests
internalized racism. Further, this sense of fatalism and unworthiness existed among the majority of
the study participants. The hope of substance abuse treatment is that one can separate themselves
from addiction and learn to value their inherent worth. However, if some Black women see them-
selves as inherently unworthy because of their ethnicity where can restoration be found?
The implications of these findings for social work practice and substance abuse treatment are
critical in that the individual—as the source and site of problem and recovery—is antithetical and
possibly detrimental to substance-abusing Black women. Historical antecedents and contemporary
educational, economic, and penal structural barriers that have defined and continue to shape the
trajectory of Black women must become an integral part of substance abuse treatment and HIV
prevention education. Success in treating substance abuse and educating women on HIV prevention
540 Affilia: Journal of Women and Social Work 32(4)

is tied to notions of worth and value. It is less relevant to begin the conversation at the juncture of
self-esteem, gender, and ethnicity for white women; however, for Black women who often times
internalize societal notions that defeminize and dehumanize them, it is requisite. Notions of worth
are not tied so much to their substance abuse, but rather their ethnicity, and ethnicity is unchanging.
Based upon the study populations’ long history of substance abuse, poor recovery history, and
perhaps most importantly, the absence of cultural relevance in the substance abuse intervention,
we hold out little hope for overwhelming success for this group. Based upon the study findings, we
conclude it to be true for this sample that continued substance abuse treatment that fails to consider
the individual and collective historical antecedents that have systematically contributed to their
economic marginalization, social victimization, and patriarchal oppression, offer little hope of
sustained recovery.
This study has several limitations. This was a convenience sample of women, who may differ
from the general population of substance abusing incarcerated Black women in another metropolitan
area. In addition, the small sample size did not allow comparisons in perspectives on substance abuse
patterns and HIV risk by sexual orientation or other personal characteristics. Furthermore, both
individual interviews and focus groups were conducted in the presence of a pod officer. This is a
limitation because it challenges participants’ ability to feel safe in sharing their lived experiences.
Finally, alcohol usage among this population is unknown and this presents a limitation in fully
understanding the extent of participant substance abuse.
In conclusion, the purpose of this study was to explore the integration of a traditional public
health model and nontraditional cultural framework in addressing HIV prevention and incarcerated
substance abusing Black women. The intersection of race, class, gender, and health in the context of
substance abuse and HIV risk represents a very different cultural experience for White and Black
women. Until culture and context become a central component in substance abuse and HIV treat-
ment, design, implementation, and evaluation, Black women will continue to be marginalized and
enslaved by oppressive racist stereotypes from without and within.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or
publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

References
Akbar, N. (1984). Africentric social science for human liberation. Journal of Black Studies, 14, 395–414.
Bell-Scott, P. (1995). Life notes: Personal writings by contemporary Black women. New York, NY: Norton.
Boeije, H. (2002). A purposeful approach to the constant comparative method in the analysis of qualitative
interviews. Quality and Quantity, 36, 391–409.
Burnham, L. (2001). The wellspring of Black feminist theory. Southern University Law Review, 28, 265–270.
Centers for Disease Control and Prevention. (2016). HIV among African Americans. Retrieved August 16,
2016, from http://www.cdc.gov/hiv/group/racialethnic/africanamericans/
Collins, P. (1991). Black feminist thought: Knowledge, consciousness, and the politics of empowerment.
New York, NY: Routledge.
Constantine, M. G., Gainor, K. A., Ahluwalia, M. K., & Berkel, L. A. (2003). Independent and interdependent
self-construals, individualism, collectivism, and harmony control in African Americans. Journal of Black
Psychology, 29, 87–101.
Crenshaw, K. (1989). Demarginalizing the intersection of race and sex: A black feminist critique of antidis-
crimination doctrine, feminist theory and antiracist politics. University of Chicago Legal Forum, 1989, 8.
Dyson et al. 541

El-Bassel, N., Caldeira, N. A., Ruglass, L. M., & Gilbert, L. (2009). Addressing the unique needs of African
American women in HIV prevention. American Journal of Public Health, 99, 996–1001. doi:10.2105/
AJPH.2008.140541
Few, A. (2007). Integrating Black consciousness and critical race feminism into family studies research.
Journal of Family Issues, 28, 452–473.
Gentry, Q., Elifson, K., & Sterk, C. (2005). Aiming for more relevant HIV risk reduction: A black feminist
perspective for enhancing HIV intervention for low income African American women. AIDS: Education
and Prevention, 17, 238–252.
Gilfus, M. (2002). Women’s experiences of abuse as a risk factor for incarceration. Harrisburg, PA: VAWnet, a
project of the National Resource Center on Domestic Violence/Pennsylvania Coalition Against Domestic
Violence. Retrieved September 6, 2016, from http://www.vawnet.org
Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded theory. Chicago, IL: Aldine Press.
Janz, N. K., & Becker, M. H. (1984). The health belief model: A decade later. Health Education & Behavior,
11, 1–47.
Jarama, S. L., Belgrave, F. Z., Bradford, J., Young, M., & Honnold, J. A. (2007). Family, cultural and gender
role aspects in the context of HIV risk among African American women of unidentified HIV status: An
exploratory qualitative study. AIDS Care, 19, 307–317.
Johnson, B. R. (1997). Examining the validity structure of qualitative research. Education, 118, 282–292.
Kalsbeek, W. D. (2008). Stratified sampling. In P. J. Lavrakas (Ed.), Encyclopedia of survey research methods
(pp. 849–851). Thousand Oaks, CA: Sage.
Mantell, J. E., DiVittis, A. T., & Auerbach, M. I. (1997). Evaluating HIV prevention interventions. New York,
NY: Plenum.
Martin, J. M. (1993). The notion of difference for emerging womanist ethics: The writings of Audre Lourde and
bell hooks. Journal of Feminist Studies in Religion, 9, 39–51.
Mertens, J. R., & Weisner, C. M. (2000). Predictors of substance abuse treatment retention among women and
men in an HMO. Alcoholism, Clinical, and Experimental Research, 24, 1525–1533.
Nobles, W. (1978). Toward an empirical and theoretical framework for defining Black families. Journal of
Marriage and the Family, 40, 679–688.
Nobles, W. (1985). Africanity and the Black family. Oakland, CA: A Black Family Institute.
Olphen, J., Eliason, M., Freudenberg, N., & Barnes, M. (2009). No where to go: How stigma limits the options
of female drug users after release from jail. Substance Abuse Treatment and Policy, 4, 1–10.
Opsal, T., & Foley, A. (2013). Making it on the outside: Understanding barriers to women’s post-incarceration
reintegration. Sociology Compass, 7, 265–277.
Pettinati, H. M., Rukstalis, M. R., Luck, G. J., Volpicelli, J. R., & O’Brien, C. P. (2000). Gender and psychiatric
comorbidity: Impact on clinical presentation of alcohol dependence. American Journal on Addictions, 9,
242–252.
Rosenstock, I. (1974). Historical origins of the health belief model. Health Education Monographs, 2, 328–335.
Schober, R., & Annis, H. M. (1996), Barriers to help-seeking for change in drinking: A gender focused review
of the literature. Addictive Behaviors, 21, 81–92.
Stenbacka, C. (2001). Qualitative research requires quality concepts of its own. Management Decision, 39,
551–555.
Swavola, E., Riley, K., & Subramanian, R. (2016). Overlooked: Women and jails in an era of reform.
New York, NY: Vera Institute of Justice.
Walitzer, K. S., & Connors, G. J. (1997). Gender and treatment of alcohol problems. In R. W. Wilsnack & S. C.
Wilsnack (Eds.), Gender and alcohol: Individual and social perspectives (pp. 445–461). New Brunswick,
NJ: Rutgers Center of Alcohol Studies.
Wechsberg, W. M., Craddock, G. G., & Hubbard, R. L. (1998). How are women who enter substance abuse
treatment different than men? A gender comparison from the Drug Abuse Treatment Outcome Study
(DATOS). Drugs & Society, 13, 97–115.
542 Affilia: Journal of Women and Social Work 32(4)

Author Biographies
Yarneccia Danielle Dyson, PhD, MSW, currently serves as an assistant professor in the Department of Social
Work at The University of North Carolina at Greensboro. Her research interests include Sexually Transmitted
Infections (STI) and HIV prevention, women’s studies, and community engagement. She also has interests in
higher education administration and transformational leadership as a framework for organizational
management.

Sarita Kaya Davis, PhD, MSW, currently serves as an associate professor and the graduate program director in
the Department of African American Studies and an affiliate faculty in the School of Public Health at Georgia
State University. Her research is primarily in HIV prevention education and culturally relevant research and
evaluation assessment.
Margaret Counts-Spriggs, PhD, MSW, a 28-year Clark Atlanta University faculty member, is an associate
professor in the Whitney M. Young Jr. School of Social Work. She has served as an administrator in higher
education for the past 10 years; and over the past 5 years, her research focus has slightly shifted to address
students in higher education. She recently received a 3-year grant award addressing suicide prevention among
African American College students.
Neena Smith-Bankhead, MS, currently serves as an assistant director of programs in the Rollins School of
Public Health at Emory University. Most of her research is in the area of HIV prevention and care, and she also
provides prevention training to providers working in highly impacted communities.