Qualitative case study of needle exchange programs in the Central Appalachian region of the United States

Davis, Stephen M.; Davidov, Danielle M.; Kristjánsson, Álfgeir L.; Zullig, Keith J.; Baus, Adam; Fisher, Melanie

doi:10.1371/journal.pone.0205466

Cited by 23 publications

(31 citation statements)

References 38 publications

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“…This finding is also congruent with several other studies conducted in the following large, urban areas: Baltimore, MD [19, 41], Oakland, CA, Richmond, CA [16], Los Angeles, CA [14, 15], and San Francisco, CA [42], in the US and Moscow, Volgograd, and Barnaul in Russia [23]. To our knowledge, this work is the first to quantitatively assess this phenomenon in rural Appalachia and is congruent with a recent qualitative case study of rural Appalachian NEPs by Davis et al [43]. This case study observed a legal conundrum created by paraphernalia laws that manifested in PWID being cited for new needle possessions.…”

Section: Discussionsupporting

confidence: 77%

Barriers to using new needles encountered by rural Appalachian people who inject drugs: implications for needle exchange

et al. 2019

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Background: Using a new needle for every injection can reduce the spread of infectious disease among people who inject drugs (PWID). No previous study has examined new needle use barriers among PWIDs residing in the rural Appalachian part of the United States, an area currently in the midst of a heroin epidemic. Objective: Therefore, our primary aim was to explore self-reported barriers to using a new needle by PWID attending a needle exchange program (NEP). Methods: We conducted a cross-sectional survey of PWID attending two NEPs in rural West Virginia located in the heart of Central Appalachia. A convenience sample of PWID (n = 100) completed the Barriers to Using New Needles Questionnaire. Results: The median number of barriers reported was 5 (range 0-19). Fear of arrest by police (72% of PWID "agreed" or "strongly agreed") and difficulty with purchasing needles from a pharmacy (64% "agreed" or "strongly agreed") were the most frequently cited barriers. Conclusions/Importance: Congruent with previous findings from urban locations, in rural West Virginia, the ability of PWID to use a new needle obtained from a needle exchange for every injection may be compromised by fear of arrest. In addition, pharmacy sales of new needles to PWID may be blunted by an absence of explicit laws mandating nonprescription sales. Future studies should explore interventions that align the public health goals of NEPs with the occupational safety of law enforcement and health outreach goals of pharmacists.

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Section: Discussionsupporting

confidence: 77%

Barriers to using new needles encountered by rural Appalachian people who inject drugs: implications for needle exchange

et al. 2019

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“…For example, 19% of PWID surveyed in Appalachian Kentucky cited fear of stigma as a barrier to SSP enrollment [ 10 ]. The most prominent manifestation of anticipated stigma in our study was fear of police persecution, a theme recurring in other publications on rural Appalachia [ 20 , 55 ]. Enforcement of laws criminalizing possession of drugs and injecting equipment is a well-documented structural determinant of health.…”

Section: Discussionsupporting

confidence: 52%

Factors that influence enrollment in syringe services programs in rural areas: a qualitative study among program clients in Appalachian Kentucky

et al. 2021

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Background Enrolling sufficient number of people who inject drugs (PWID) into syringe services programs (SSP) is important to curtail outbreaks of drug-related harms. Still, little is known about barriers and facilitators to SSP enrollment in rural areas with no history of such programs. This study’s purpose was to develop a grounded theory of the role of the risk environment and individual characteristics of PWID in shaping SSP enrollment in rural Kentucky. Methods We conducted one-on-one semi-structured interviews with 41 clients of 5 SSPs that were established in rural counties in Appalachian Kentucky in 2017–2018. Interviews covered PWID needs, the process of becoming aware of SSPs, and barriers and facilitators to SSP enrollment. Applying constructivist grounded theory methods and guided by the Intersectional Risk Environment Framework (IREF), we applied open, axial and selective coding to develop the grounded theory. Results Stigma, a feature of IREF’s meso-level social domain, is the main factor hampering SSP enrollment. PWID hesitated to visit SSPs because of internalized stigma and because of anticipated stigma from police, friends, family and healthcare providers. Fear of stigma was often mitigated or amplified by a constellation of meso-level environmental factors related to healthcare (e.g., SSPs) and social (PWID networks) domains and by PWID’s individual characteristics. SSPs mitigated stigma as a barrier to enrollment by providing low threshold services in a friendly atmosphere, and by offering their clients program IDs to protect them from paraphernalia charges. SSP clients spread positive information about the program within PWID networks and helped their hesitant peers to enroll by accompanying them to SSPs. Individual characteristics, including child custody, employment or high social status, made certain PWID more susceptible to drug-related stigma and hence more likely to delay SSP enrollment. Conclusions Features of the social and healthcare environments operating at the meso-level, as well as PWID’s individual characteristics, appear to enhance or mitigate the effect of stigma as a barrier to SSP enrollment. SSPs opening in locations with high stigma against PWID need to ensure low threshold and friendly services, protect their clients from police and mobilize PWID networks to promote enrollment.

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“…However, we believe this to be the first instance documenting first responder lack of knowledge of their own flagship programs. While county-wide programs like that offered in the county studied have been implemented before in other locations [22], those programs often only consist of needle exchange and typically are well-received and publicized. This underscores the need not just for inter-agency cooperation, but effective communication of new programs throughout the entirety of each agency as well.…”

Section: Discussionmentioning

confidence: 99%

Opioids, Needle Exchange, and Barriers to Care in the Rural Context: Interviews with Law Enforcement and Emergency Medical Personnel

Lawton

Leland²,

Leland³

2021

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Background The large increase in opioid use, subsequent addiction and related death has come to be known as a national epidemic in the United States, particularly affecting rural areas. The crisis has been met with an increase in attempts to address the large overdose rates. In many of these strategies, first responders such as police and emergency services personnel are placed on the front lines. The input and opinions of these individuals, and the communication with them from agency leadership during program implementation can dramatically affect the success of drug related policies. However, there is a paucity of research focused on the attitudes of primary responders, particularly in rural settings. This study conducts a geographically-focused investigation into the attitudes of rural EMS and law enforcement personnel in regards to opioid treatment in a location that was currently implementing a major substance use policy. Methods Qualitative semi-structured interviews were conducted with 24 members of law enforcement and 22 emergency medical providers within a single rural county in North Carolina. Interviews spanned three sections: demographics, barriers to opioid treatment and county-specific programs. Results The largest barriers to care cited were lack of local treatment resources, the stigma against drug use and a perception that people who use opioids did not want to change. A multi-agency approach to the crisis was supported by EMS personnel and law enforcement. However, first responders awareness of an active multiagency county-wide initiative was very limited. This was very surprising, as first responders were expected to implement the program, and this phenomena resulted in very low program efficacy to that point. This result underscored the importance of communication between and within agencies, particularly in environments that are resource-constrained. Conclusions This study is unique in comparing attitudes of rural EMS and law enforcement regarding substance use treatment. This paper provides insight into the viewpoints of rural first responders, with clear implications for rural drug policy. This paper further underscores opportunities for maximizing effective opioid policy in rural settings, particularly emphasizing clear communication between agencies.

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Qualitative case study of needle exchange programs in the Central Appalachian region of the United States

Cited by 23 publications

References 38 publications

Barriers to using new needles encountered by rural Appalachian people who inject drugs: implications for needle exchange

Barriers to using new needles encountered by rural Appalachian people who inject drugs: implications for needle exchange

Factors that influence enrollment in syringe services programs in rural areas: a qualitative study among program clients in Appalachian Kentucky

Opioids, Needle Exchange, and Barriers to Care in the Rural Context: Interviews with Law Enforcement and Emergency Medical Personnel

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