A qualitative analysis of rural syringe service program fidelity in Appalachian Kentucky: Staff and participant perspectives

Abstract

Purpose: As drug-related epidemics have expanded from cities to rural areas, syringe service programs (SSPs) and other harm reduction programs have been slow to follow. The recent implementation of SSPs in rural areas demands attention to program fidelity based on core components of SSP success.Methods: Semistructured interviews conducted with clients and staff at 5 SSPs in 5 counties within 2 Central Appalachian health districts. Interviews covered fidelity of SSP implementation to 6 core components: (1) meet needs for harm reduction supplies;(2) education and counseling for sexual, injection, and overdose risks; (3) cooperation between SSPs and local law enforcement; (4) provide other health and social services;(5) ensure low threshold access to services; and (6) promote dignity, the impact of poor fidelity on vulnerability to drug-related harms, and the risk environment's influence on program fidelity. We applied thematic methods to analyze the data.Findings: Rural SSPs were mostly faithful to the 6 core components. Deviations from core components can be attributed to certain characteristics of the local rural risk environment outlined in the risk environment model, including geographic remoteness, lack of resources and underdeveloped infrastructure, and stigma against people who inject drugs (PWID) Conclusions: As drug-related epidemics continue to expand outside cities, scaling up SSPs to serve rural PWID is essential. Future research should explore whether the risk environment features identified also influence SSP fidelity in other rural areas and develop and test strategies to strengthen core components in these vulnerable areas.

Barriers to utilizing substance use disorder treatment and harm reduction services in Appalachia.

“…Fear of legal consequences was a frequently mentioned barrier to obtaining substance use treatment among the included studies. PWUD repeatedly expressed fears about receiving criminal charges or being arrested for participating in harm reduction services (Batty et al, 2023; Davis et al, 2018; Ibragimov et al, 2021). For example, carrying syringes and other safe injection supplies is considered paraphernalia possession and punishable as a misdemeanor offense in many states, leading some PWID to avoid utilizing SSPs, especially when they are located near law enforcement (Cloud et al, 2019).…”

Houselessness and syringe service program utilization among people who inject drugs in eight rural areas across the USA: a cross-sectional analysis

“…In our rural sample, PWID who lived within walking distance of an SSP were more likely to use its’ services, indicating that proximity to services will be critical to improve utilization. While SSPs have rapidly expanded to rural US areas in the last decade, our findings highlight the implications of unique challenges that the rural context presents to SSP utilization, including fewer SSPs [ 11 , 15 ], limited SSP hours of operations and resources [ 11 , 13 , 96 ], geographic dispersion of resources and people [ 11 , 91 , 92 , 95 – 97 ], and lack of public, affordable transportation [ 11 , 13 , 91 , 92 , 95 ]. Continued improvement of SSP access and utilization for rural PWID who are and are not unstably housed will be essential to mitigate drug-related epidemics.…”