People's beliefs and practices impact health care service delivery in a variety of ways. In rural areas, for example, residents may not seek out health care services in relation to substance abuse and infectious disease for many reasons, including:

• Silence - HIV, STDs, and substance abuse may be perceived as issues that occur only in urban areas, thus creating a sense of invulnerability. Lack of awareness due to limited discussion of such issues in schools, community-based activities, and the media also can feed into silence on the part of the individual and the community.
  
  
• Exclusion - Stigma surrounding infectious disease and substance abuse, particularly in smaller and close-knit communities, can mean that rural residents are unwilling to disclose their conditions for fear of being targeted and excluded.
  
  
• Isolation - Rural residents may not feel comfortable discussing concerns related to infectious disease and substance abuse with their regular physician, or may not have access to health care providers that are equipped to provide the required prevention, treatment, and/or care services.

Silence, exclusion, and isolation are very real barriers faced by rural residents in relation to HIV. The National Rural Health Association summarized a number of studies looking at HIV/AIDS in rural areas, and found that rural residents:

• May be more likely to travel to urban areas for HIV testing due to confidentiality concerns.
  
  
• Are less likely to seek HIV testing than urban residents.
  
  
• Tend to be diagnosed in the later stages of AIDS because their physicians don't consider them to be at risk for HIV infection.
  
  
• Often travel great distances to receive HIV/AIDS treatment and care services because they lack confidence in their local physicians, are unable to find physicians who will treat them, and have confidentiality concerns.
  
  
• When HIV+, often lack access to mental health and substance abuse counseling services, do not have formal or informal support systems, and face discriminatory attitudes (National Rural Health Association, 1997).