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.

INTRODUCTION

As drug-related epidemics extend from cities to rural areas, syringe service programs (SSPs) and other harm reduction programs have been slow to follow.¹ SSPs serve local communities by providing a range of preventative services, such as access to sterile injection equipment, infectious disease testing, and linkages to care for both substance use disorders and infectious diseases.² The limited availability of rural SSPs helps create and sustain rural/urban inequities in hepatitis C virus (HCV), overdoses, and other drug-related harms.^3,4 Kentucky, however, presents an interesting case where SSP coverage has rapidly expanded to rural counties due to the risk of the human immunodeficiency virus (HIV) outbreak in nearly half of Kentucky’s counties and as a response to Senate Bill 192.⁵ Senate Bill 192 allows for local health departments to give new needles to people who inject drugs (PWIDs) in exchange for their used needles with no criminal penalty for people who use drugs.⁵ As rural SSP expansion continues, it is vital to ensure that programs have a maximal impact to address urban/rural inequities in access to sterile syringes and other injection equipment, naloxone, behavioral education, and linkages to treatment.¹

Fidelity is defined as the extent to which an intervention is delivered as intended by program staff. Interventions have core components that must be delivered as intended and are essential to success.⁶ We identified 6 core components of SSPs (Table 1) by reviewing guidelines developed in previous research which include: (1) meeting participant needs for harm reduction supplies; (2) preventative health education and counseling for sexual, injection, and overdose risks; (3) coordination and cooperation between SSPs and local law enforcement; (4) provision, or coordination for the provision of other health and social services; (5) ensuring low threshold access to services; and (6) recognizing and promoting the recognition of PWID dignity.^2,7–12 These core components contribute to each SSP’s capacity to meet the needs of its clientele. This includes not only deliverables of the program, such as preventative health interventions (ie, provision of harm reduction supplies and HIV/HCV testing), but also supporting client initiation and continued attendance (ie, cooperation between SSP and law enforcement agencies, minimizing the effects of stigma, and protecting client anonymity). The success of programs has been attributed to the improved safety of program clients as a consequence of changes to the environmental setting due to program implementation.¹³ This safety includes not only the sterile injection equipment provided to mitigate drug-related harms but also preventing potential harms from street-level policing.¹³ Lack of fidelity to these 6 core components may limit the effectiveness of SSP services in reducing drug-related harms.^3,4,13–16

TABLE 1.

Deviations from the SSPcore components and related risk environment factors

Six SSP core components	Examples of deviations from the core component	Environmental factors (REM domains) as barriers for SSP fidelity
1) Meet participant needs for harm reduction supplies	Syringe exchange limits (caps and 1:1 exchange) Limited range of nonsyringe injection supplies Lack of naloxone provision	SSP policies set by Boards of Health and DHD (policy domain) triggered by stigma against PWID (social domain) and resource constraints (economic domain) Limited resources for service provision (health care intervention/criminal justice domain)
2) Preventative health education and counseling for sexual, injection, and overdose risks	Limited availability of education and counseling in some SSPs	Limited resources for service provision (economic and health care intervention/criminal justice domains)
3) Coordination and cooperation between SSP and local law enforcement	Harassment of SSP clients by individual police officers	Policing practices (health care intervention/criminal justice intervention domain) shaped by stigma against PWID (social domain)
4) Provide, or coordinate the provision of other health and social services	Unavailability of certain onsite services during SSP operations Criminal background checks by certain referral services Barriers to external services to which staff refer clients (eg, bed shortages, no county bus, and limited taxi/ride share availability)	Limited resources for service provision (economic and health care intervention/criminal justice domain) Stigma against PWID (social domain) Limited resources for service provision (economic and health care intervention/criminal justice domain) Underdeveloped public transportation (physical domain) Scattered and remote geography (physical domain)
5) Ensure low threshold access to services	Limited hours and days of operation in some SSPs	Limited resources for service provision (economic and health care/criminal justice intervention domain) Underdeveloped public transportation (physical domain) Scattered and remote geography (physical domain)
6) Recognizing and promoting the recognition of PWID dignity	None	Successful training and exposure to PWID promotes dignity among SSP staff (social and health care/criminal justice intervention domains)

Abbreviations: DHD, district health department; PWID, people who inject drugs; SSP, service program

We conceptualize barriers and facilitators to SSP fidelity using the risk environment model (REM), a framework that views individual-level drug-related risks as the function of environmental exposures and structures. REM conceptualizes the environment through 5 domains: the physical, social, economic, policy, and health care/criminal justice intervention environment.^17–20 Risk environments may differ in rural areas versus urban areas in ways that affect SSP fidelity. Two characteristics were considered in defining rural for the purpose of this paper: (1) rural-urban continuum code classification, and (2) county’s population residing in rural areas. Rural is defined as scoring a 7 or higher on the RUCC and having at least 2/3 of the population residing in a rural area as reported by the US Census Bureau.²¹ For example, limited public transportation availability in geographically remote rural areas, a feature of the physical environment, may restrict the accessibility of SSP services; and high drug-related stigma in small, tight-knit rural communities, a feature of the social environment, may increase PWID reluctance to enroll in local SSPs.^{14,15,22–25}

This analysis assesses the extent to which 5 of the 7 SSPs operating in the CARE2HOPE study in rural Central Appalachian Kentucky are faithful to the 6 core components of SSP fidelity. Two SSPs were not included in the analysis due to insufficient representative data. Kentucky is an outlier for SSP implementation in rural areas: it is a predominately rural state that responded to major HCV epidemics and overdoses by opening 62 SSPs between 2015 and the spring of 2021.²⁶ Local county health departments operate most SSPs. Per state law, SSPs’ implementation and practice guidelines depend upon approval by 3 local bodies: the Boards of Health, the fiscal court, and the city council.⁵ We explore SSP staff and clients’ perspectives about (1) the fidelity of recently opened SSPs operating in rural Kentucky counties, and (2) whether and how features of “rural risk environments” shape fidelity.

METHODS

This was a qualitative study of 7 SSPs in 7 counties located within 2 Central Appalachian health districts, conducted as a part of the Kentucky Communities and Researchers Engaging to Halt the Opioid Epidemic (CARE2HOPE) study. The area is hard-hit by the opioid epidemic: 54 of Kentucky’s 120 counties were highly vulnerable to a major HIV/HCV outbreak and the state’s age-adjusted overdose mortality rate is the seventh highest in the United States.^27,28

Sampling and recruitment

In-depth interviews were conducted among SSP staff (n = 16) and clients (n = 41) at 5 of the 7 SSPs operating in the CARE2HOPE study area at the time of data collection, due to insufficient data, representative of the 2 SSPs excluded. All were operated out of Kentucky health departments in rural counties. Rurality was determined based on ranking between 7 and 9 on USDA Rural-Urban Continuum Code (1––most urban, 9––most rural) and with population density ranging between 23 and 85 people per sq. mile.²¹ SSP hours of operation varied; some were open during most business hours 4 or 5 days a week, while others were open only a couple of hours 1 or 2 days a week. Census sampling was used for SSP staff, and invitations were extended to all SSP staff (n = 16) by phone or e-mail after referrals were provided by district directors. SSP staff provided signed consent for face-to-face interviews, and verbal consent for phone interviews. Most SSP staff interviews were conducted one-on-one; interviews at one SSP were conducted in a group because of scheduling challenges (N = 5 people).

SSP clients were recruited using 3 strategies of convenience sampling: (1) SSP staff informed their clients about the study during SSP visits, and interested clients contacted study staff to learn more; (2) research assistant members approached SSP clients at the SSP; and (3) participants from an ongoing CARE2HOPE study with PWID were invited to participate if they reported recently using an SSP and consented to be contacted about future research. Eligibility to participate required individuals to: (1) be 18 years of age or older; (2) report living in the county where a participating SSP was located for at least 6 months; (3) report receiving syringes at a participating SSP at least 3 times in the past 3 months; and (4) English-speaking.

We obtained verbal consent for face-to-face interviews with SSP clients and written consent from staff. Principal and coinvestigators on the grant conducted staff interviews, while research assistants conducted SSP client interviews. SSP staff and clients were compensated for their participation in 1.5-hour interviews. Staff received a $10 incentive for their participation. SSP clients received $20 for their participation.

Data collection

Semistructured interview guides for staff and participants covered the following: (1) SSP services; (2) features of the local risk environment; (3) the impact of poor fidelity on vulnerability to drug-related harms; and (4) perceptions of whether and how features of the local risk environment impede or supported program fidelity. Interviews were conducted between December 2018 and January 2020 (all SSPs had been operating for more than 1 year by the start of the interviews). Interviews were audio-recorded and transcribed verbatim.

Data analysis

We applied thematic analysis methods to analyze the resulting data SSP fidelity to the 6 core components after the interviews were deidentified. Two team members independently coded the interviews using NVivo 12.0 software and developed the initial codebook after coding the first 5 transcripts.²⁹ The coders compared the resulting coded transcripts for consistency. To further promote consistency in coding, every fourth transcript was double-coded. Two coders reconciled any discrepancies in coding through discussions, and if needed, a third coder served as a tiebreaker. Once the interviews were coded, 2 types of memos were developed: (1) memos mapping data on each SSP to 6 core components from staff and clients; and (2) memos comparing and contrasting SSP-specific findings from staff and clients for each core component across SSPs. Results from the memos were leveraged to conceptualize fidelity deviations and create the findings outlined below. REM was used as a theoretical framework to help connect these deviations as functions of environmental exposures and structures.

RESULTS

We present SSP staff members’ and clients’ perspectives on SSP fidelity in terms of 6 major themes that correspond to SSP core components. As described below and in Table 1, we found that SSPs (1) mostly meet clients’ needs for syringes and other supplies; (2) provide drug-related education; (3) protect their clients from police actions stemming from SSP participation; (4) provide or refer clients to a wide range of health and social services; (5) ensure low threshold access to SSP services; and (6) treat PWID with dignity and respect. The analysis also revealed some deviations from the core components, deviations that are products of features of REM’s physical, policy, social, economic, and health care intervention/criminal justice domains.

Particpant demographic information

Brief surveys were completed by 37 out of 41 SSP clients (4 clients did not complete the survey; Table 2). The subsample that responded to the survey included 17 women (45.9%) and 20 men (54.1%) with a mean age of 38 years. Almost all participants self-identified as non-Hispanic white, consistent with the local racial/ethnic composition. The most commonly used drugs were methamphetamines (67.6%), marijuana (51.3%), prescription opioids (40.5%), and prescription sedatives (40.5%). Methamphetamines were also the most commonly injected drug in the 3 months prior to the interview (64.9%), followed by prescription opioids (43.2%) and heroin (32.4%). On average, participants started visiting study SSPs more than a year before the interview time (mean = 13.2 months). According to the individual interview data, about half of our participants reported postponing their first visit to SSP for a month or longer after first hearing about the program, and several of them (7 out of 41) waited for 6 months or longer.

TABLE 2.

Demographic characteristics, drug use practices, and length of SSP participation (N = 37)

Characteristic	n (%)a
Age (mean, SD)	37.6 (8.9)
Gender
Men	17 (45.9)
Women	20 (54.1)
Race/ethnicity
White non-Hispanic	35 (94.6)
Other	1 (2.7)
Refused to answer	1 (2.7)
Commonly reported drugs used (past 3 months)
Methamphetamine	25 (67.6)
Marijuana	19(51.3)
Prescription opioid painkillers	15 (40.5)
Prescription sedatives	15 (40.5)
Heroin	12 (32.4)
Gabapentin	12 (32.4)
Suboxone	11 (29.7)
Fentanyl or carfentanyl	6(16.2)
Cocaine	5(13.5)
Commonly reported drugs injected (past 3 months)
Methamphetamine	24 (64.9)
Prescription opioid painkillers	16 (43.2)
Heroin	12 (32.4)
Suboxone	11 (29.7)
Fentanyl or similar	5(13.5)
Cocaine	3(8.1)
Number of months since first visit to the SSP (mean, SD)	13.2 (7.8)

^a% is calculated for participants who participated in the brief survey (n = 37).

Demographic data were not collected for SSP staff.

Meeting clients’ needs for harm reduction supplies

Syringe quantity

As reported by SSP staff and clients, SSPs largely met clients’ needs for sterile injecting equipment. However, limits on the amounts of sterile syringes SSP clients could receive came in 2 forms that were often combined: a cap on the number of syringes that could be distributed to a client during a visit and a 1–1 exchange policy.

Staff: “If you use three times a day, I’ll give you 30. That’ll do you like a 10-day supply. If you use more, you know, you don’t have enough to do until the next Monday, bring back what you have used [to exchange for sterile syringes].”

Client: “You bring in 20 used ones, they give you 20 new ones. It’s just a basic 20 for 20. You don’t get any more than that. You shouldn’t need any more than that.”

At the initial visit, all programs capped the number of new sterile syringes each client could receive at 20–40. At subsequent visits, SSPs in 1 district health department (DHD) also capped the number of new syringes issued to a client to 20–200 per visit, even if more syringes were returned. A feature of the local REM policy domain seemed to drive the cap: staff reported that caps were imposed by DHD to limit secondary exchange and motivate PWID to visit the programs and interact with SSP staff in person; in-person visits were encouraged to promote behavior change and access to additional services. This cap was also designed to prevent SSP clients from selling their syringes:

Staff: “Yesterday, I had a client bring in 600. His max was 900 that he’s brought in to me before. So, they’re dealers that come in from rural areas.”

The 1–1 exchange policy stipulated clients only receive as many syringes as they returned, after the first visit. The policy domain also drove this policy: SSP staff reported that their local Boards of Health imposed 1–1 exchange policy to ensure that the SSP did not increase the number of used syringes unsafely discarded in the community.

Some SSP staff expressed concerns that strict implementation of 1–1 exchange policy might limit clients’ access to sterile syringes. Some SSP staff also reported encouraging clients who had few syringes to exchange to retrieve used syringes from the streets and bring them for exchange:

Staff: “If I have someone that’s [lost syringes] once, then I will give them 10 [new syringes] and [...] I will give them a sharps container and tell them to go out, try to pick up some [used syringes]. [...] And so, they will go and pick those up and bring them back.”

Most SSP clients reported obtaining sufficient numbers of syringes from SSPs despite the caps and 1–1 policies. However, these policies created a burden for clients who needed larger quantities of syringes and had to return to the SSPs several times a week, a significant task for those who lived far from the SSP, lacked reliable transportation, or had work or family-care responsibilities:

Client: “I try to come every week but that’s just so hard for me to do. If I had it my way, I’d come every week.”

Type and quality of syringes

According to staff, the SSPs provided 2 types of needles (ie, 1/2 inch and 5/16 inch); 2 programs also offered syringes in 50- and 100-unit sizes. Logistical challenges sometimes limited the availability of different types of syringes and needles, as the staff needed to exhaust current stock before ordering new supplies:

Staff: “I do, well, I do the longs and short [needles]. [...] So I tell them, ‘Until I run out of stock, I can’t order anymore.’”

SSP clients, however, reported that the available syringe types and quality met their needs.

Nonsyringe injection equipment

All SSPs provided tourniquets, alcohol pads, cotton pads, Band-Aids, and sharp containers (biohazard containers or sports drink bottles); 2 programs also provided sterile cookers. Again, a feature of the local REM policy domain limited the range of supplies some SSPs could offer: staff in 2 SSPs reported budgetary constraints and Boards of Health members’ comfort with the practice of distributing cookers determined cookers availability:

Staff: “It is depending on where you get your funding and what [the Board is] comfortable with. ...It just depends on what they’re comfortable with.”

SSP clients described the quality of nonsyringe injection equipment as adequate, though in 2 SSPs, cotton pad density led clients to use multiple pads or to use cigarette filters instead.

Client: The cottons they give you, you can’t hardly pull nothing up through. They’re not very good. I actually use cigarette filters. [...] That way you don’t pull a piece of the cotton and stuff.

Naloxone distribution

None of the SSPs provided naloxone regularly, but some counties hosted trainings occasionally or have allowed outside organizations to host trainings at the Health Department. According to staff, limited resources of small rural counties prevented SSPs from providing naloxone, despite the unmet needs of SSP participants.

Staff: [Our] county is very small, doesn’t even have a red light, so resources are limited. ...what we do is, we give them the little flier and say, you can go up here and get [naloxone] anytime.

SSP participants expressed a need for naloxone distribution at the SSPs. This need reflects participants’ experiences with overdose in these communities, as participants described the prevalence and dangers of fentanyl for PWID. One participant described the provision of naloxone as an opportunity for education and training in overdose response SSP attendants:

Participant: He just got in a place where he couldn’t get the help that he needed and it happens, unfortunately. They’ve got Narcan, and that would probably be a good thing to get started around here is a Narcan program, to educate some of these people on the use of and how to administer it. Because it happens every day, death does, because of an overdose. And it can be - it may not happen.

Preventative health education

According to SSP staff, all SSPs offered safer injection and safer sex education. Some programs provided oral sessions provided primarily during a client’s initial visit and written pamphlets, which were always available to clients. Other SSPs provided one or the other. Here, the local health care intervention/criminal justice domain affected the provision of education services: as explained by an SSP staff, lack of trained staff members and SSP clients asking for additional information were the reasons for not offering safer injection education sessions.

Staff: “I really haven’t [provided safer injection education] because I really haven’t had any training on it, so I don’t know. We don’t really have anybody [SSP clients] ask.”

Clients in all 5 SSPs mentioned not receiving safer injection education through the SSPs, but several explained that they lacked interest or time during an SSP visit. Still, many clients expressed interest in being educated on risks specific to their communities, such as the expanded education on overdoses, HCV outcomes, and safer injection education.

Client: “How easy it is to get Hep C, or any of the hepatitis’s, or even any liver—because I know how much people relate hepatitis C to needle use, and it is a prominent way. But, there are more ways.”

Coordination and cooperation between SSP and local law enforcement

SSP staff in each county tried to protect clients from police harassment and drug paraphernalia charges, a persistent feature of the local REM health care/criminal justice intervention domain. The staff mentioned negotiating client protection with local police prior to opening SSPs. This included meetings with law enforcement to explain the SSP’s purpose, operations, and participant rights. SSP staff also educated police officers on needlestick injuries and provided them with syringe disposal containers.

Staff: “We give them sharp containers for their vehicles and stuff. They really haven’t said nothing negative about it. Because we provide them clean sharps containers too.”

As a result, staff noted that several police chiefs became more supportive of SSPs over time as the impact of the SSP was noticed within the community, and most police officers developed tolerant attitudes toward SSP clients.

Staff: “We had trouble with the old sheriff. You know, it took us two years to get the program here because there was conflict there [with police]. You know what I’m saying? Not everybody [was supportive of SSP]. So now [the new sheriff], he’s all for [SSP].”

Some SSPs established formal memoranda of understanding with local law enforcement. Additionally, SSPs issued participant cards to the clients to protect them from paraphernalia charges while carrying injection equipment to and from the SSP. However, staff acknowledged that some police officers still targeted clients and confiscated their syringes, despite formal program protections. In several cases, SSP staff had charges against their clients dropped after the program advocated for them.

Many clients described significant police interference with their engagement in the SSPs. They described being stopped by or harassed by police near the SSPs and being questioned, searched, and arrested. SSP clients reported that officers confiscated their syringes during stops, though in some cases, SSP participant cards prevented the confiscation. Police harassment may be a barrier to SSP attendance, as explained by a client whose friend stopped attending the program:

Client: “Oh, yeah. What’s the point? Because they’re going to stop me on the way home and get me with another [charge]. After three I’m jail bound.”

Provide, or coordinate the provision of, other health and social services

Access to testing services

Staff reported that all SSP programs provided onsite HIV testing, and all but 1 county reported onsite HCV testing, due to limited resources to acquire testing supplies. SSP staff proactively advertised other services available to the clients at the health department:

Staff: “We let them know that we do free hep C testing and that we can do the hep A shots, that we have HIV testing. [...] [I]f they want to do any other kind of services while they’re in here, we can go ahead and get that done that day.”

However, as explained by a client, these tests may be offered outside of SSP hours, requiring an additional appointment at the health department and a barrier to accessing them.

Client: “Hep C or HIV and all the above, like tell me if I want to get [...] tested for Hep C or anything, I just show up Wednesday morning [for the testing] rather than be here Wednesday evening [for the syringes].”

Referrals to external services

SSP staff described establishing extensive referral networks linking clients to a range of health and social services, including drug and HIV treatment, housing, and employment. SSP staff observed that utilization of referrals by SSP clients was suboptimal, despite the availability of referrals to external services. Staff attributed this suboptimal uptake to features of REM’s physical, economic, and health care/criminal justice intervention domains: transportation barriers, cost, and criminal background checks.

Staff: “So, I tell [HIV service provider]”, “What am I supposed to do because people can’t [access the service]? They can’t take off a full day of work, especially if they don’t work somewhere like the state and have vacation days or sick days, so what are they supposed to do?” Staff: “Yeah, if you have a felony you cannot get, like, in the low-income apartments and that’s a real problem.”

SSP staff also cited clients’ fear of mistreatment by health care workers as a barrier, a feature of REM’s social domain:

Staff: “If it’s a problem that might be associated with injecting drugs, they’re concerned that they won’t get the [health] care that they need or that they will have to go through shame and embarrassment for getting the care that they need.”

Clients mentioned drug treatment resources, such as rehabilitation programs, clinics, and detox programs, as popular referral options. However, they agreed with SSP staff that transportation and cost impeded service utilization:

Client: “But rehab is just so expensive, I mean unless they are like free ones and then they got a waitlist. [...] I haven’t got a vehicle, so I got to find a ride, and you got to go every week.”

Ensuring low threshold access to services

Several features of the SSPs enhanced access by lowering thresholds, including but not limited to their location within the health departments and their hours.

SSP location

According to SSP clients, the program location at local health departments was convenient for individuals living nearby. However, those living outside of the central city/town faced barriers in REM’s physical domain. Public transportation was unavailable in many areas, and clients faced multiple barriers to driving to SSPs, including vehicle access or having their driving licenses suspended. While friends and neighbors may give a ride to the SSP, this option was not always reliable.

Client: “Right now I’m currently staying with my cousin, and they can’t really bring me in... as I need to, so I don’t know, I might skip a week or something like that, which is kind of rough [...].”

Hours of operation

Most SSPs were open 4–5 days a week during health department hours, while 2 SSPs operated 2–3 hours per week. Again, features of REM’s health care/criminal justice intervention environment affected service provision: a staff member referred to budget constraints as the reason for limited hours of operation:

Staff: “We didn’t have the staff to work evening hours. [...] We only had a few hours to offer, because all of the other programs that we have are going to limit what we can do.”

An SSP staff member from a health department that was open 2 hours a week exclusively for SSP clients explained that these SSP-only hours were set because of available staff resources.

According to clients, limited hours made SSP visits difficult for clients working full-time.

Client: “I mean [some of us are] working at that time, and not every addict, you know, is a bum...Some of us do, you know, have lives.”

Confidentiality and anonymity

SSP staff took several steps to enhance client confidentiality. SSP visits were anonymous, and staff collected only nonidentifying sociodemographic and health-related information (eg, drug use history and employment). SSP staff organized clients’ flow to minimize their exposure to and interaction with other visitors of local health departments. This also helped protect confidentiality. In 1 SSP, clients waited in the common area with non-SSP patients, allowing them to blend in with other visitors. In some SSPs, staff reported prioritizing SSP clients by calling them back to the office immediately when they arrived rather than having them wait with non-SSP patients. However, some staff noted the unintended consequences of possibly identifying SSP clients, despite not using client names.

Staff: “Obviously, they’ll be sitting there waiting for their appointment, and they’ll see us taking something, and they’ll be thinking, ‘Why are they taking them back?’”

All SSPs served their clients in a private SSP area, reducing their chances of encountering non-SSP staff or visitors who might recognize them.

Overall, almost all SSP clients were satisfied with SSP confidentiality. However, some SSP staff and clients reported that some PWID remained reluctant to visit the program for confidentiality reasons:

Client: “...I got a few friends that won’t come because they got little kids and they have to bring their kids up here [...] and they’re afraid a doctor will see them, and they won’t come.”

Recognizing and promoting PWID dignity

All SSPs provided services in a nonjudgmental and friendly manner to maintain client dignity. According to staff, antistigma trainings helped them improve their attitudes toward PWID. Staff observed that treating SSP clients with respect and dignity was very important to attract them to services. SSP staff also promoted their clients’ dignity through conversations with other community members, including law enforcement and the general public. These conversations often framed injection drug use as a health problem, compared to the general public’s perception of it as a social problem.

Staff: “If anyone brings it up to us, we try to approach them with the disease aspect of it, with how we’re preventing, you know.”

All interviewed clients mentioned friendly treatment by staff, and many noted it as a key factor for their continuous SSP attendance.

Client: “[SSP staff] are super nice and super sweet. There is always a smile on their face. I mean I wouldn’t come back if they were hateful or anything, probably wouldn’t be welcome back because I don’t respond well to that. [...] They want you to be safe.”

DISCUSSION

This qualitative study of SSPs operating for over 1 year in rural Central Appalachian Kentucky found relatively high program fidelity to 6 core components: (1) meeting participant needs for harm reduction supplies; (2) preventative health education and counseling for sexual, injection, and overdose risks; (3) coordination and cooperation between SSPs and local law enforcement; (4) provision, or coordination for the provision of other health and social services; (5) ensuring low threshold access to services; and (6) recognizing and promoting the recognition of PWID dignity. This fidelity to the core components indicates the successful implementation of harm reduction services in this rural setting. We also, however, learned that certain features of the risk environment in these rural areas, including stigma against PWID, limited health care resources, and geographic remoteness, may affect SSP fidelity.

Our findings suggest that stigma against PWID was a key barrier toward fidelity to the core components. Stigma, a known barrier to program access for urban PWID, has been identified as a prominent barrier for PWID in rural Kentucky.^22,30 Emerging literature on rural risk environments shows that stigma may manifest at the intersection of social and policy domains by influencing policies governing SSPs and other evidence-based harm reduction services.^14,15 Accordingly, we found that Boards of Health established syringe exchange caps and 1:1 exchange policies to assuage concerns that the programs would increase the volume of discarded syringes in the communities. Similarly, Boards of Health reluctance to approve the distribution of cookers and some other injection equipment might also reflect community stigma against PWID and public views that the SSP may enable injection drug use. We note below, however, that limited funding has also played role in restricting SSP supplies.

Stigma, manifesting through police threats and actions against SSP clients, was a major barrier to utilizing SSP services in US cities and rural areas.^30,31 Relationship building with law enforcement was a core component of SSP fidelity, and officer noncompliance with SSP policies may cause participants to distrust the program.⁶ We found that by engaging local police early and communicating the significance of the program to officers, SSP staff either ensured officer acceptance of the SSP (as evidenced, eg, by police honoring SSP clients’ IDs) or at least neutrality toward it. By providing needlestick safety training and syringe disposal containers, SSP staff provided further support to local law enforcement and an additional opportunity for injection drug use education. Establishing formal memoranda between law enforcement agencies and SSPs may also provide additional protections for SSP clients, as some staff reported their experiences in contesting charges against SSP clients for transporting injection drug paraphernalia. These findings add to the literature on the effective engagement of police officers, which has previously largely been limited to cities.^31–33

SSPs also minimized the adverse impacts of stigma by lowering thresholds to services, through anonymous service provision, arranging patient flow and service areas to minimize disclosure of clients’ drug use status, locating SSPs in local health departments, and promoting clients’ dignity. Still, stigma remains a major challenge for SSP implementation, as shown by clients’ accounts of harassment by police and fear of community stigma. Literature on the rural risk environment acknowledges stigma as a major barrier to accessing evidence-based services and calls for comprehensive policy reforms and community interventions to address it.^{16,30,34–36}

Limited resources within REM’s economic and health care/criminal justice intervention domains negatively influenced fidelity to SSP core components. Resource constraints prevented SSPs from distributing naloxone for the reversal of an opioid overdose, a key intervention in rural areas experiencing high opioid overdose rates. Lack of resources also restricted some SSPs from offering comprehensive safer injection education, a range of injection supplies, and operating hours. Rural areas, in particular rural Appalachia, often suffer from scarcity of health care resources, a problem exacerbated by dwindling local economies and lower revenue to invest in health care.³⁶ Deviations from SSP core components in resource-constrained rural areas may be particularly painful: our findings indicate that limited SSP hours were a major hurdle for SSP access in remote counties lacking public transportation, a feature of REM’s physical domain. Previous literature finds that mobile SSPs may help programs reach hard-to-reach and high-risk groups by acting as a bridge between potential clients and a fixed-site location by providing similar services and improving access and confidentiality.^37,38 Harm reduction kiosks, or dispensing machines, may also help to address the barriers of stigma, remoteness, and issues with limited hours of operation.³⁹

Findings should be understood considering study limitations. We did not interview PWID who did not attend the SSPs or those who attended an SSP less than 3 times in the prior 3 months. Hence, perspectives of PWID who potentially experienced the greatest barriers may not have been captured because they would be unable to attend the SSP to be recruited for participation in this study. Multiple steps to enhance validity were taken. Additionally, demographic data were not collected for SSP staff. We accounted for perspectives of SSP staff and clients; multiple coders analyzed verbatim transcripts, and we systematically developed themes through comprehensive memos and meetings among coders in lieu of calculating intercoder reliability statistically.^40–42 Results were presented to SSP staff, but the ability to present findings to clients as well would have further strengthened the findings.^43,44

CONCLUSIONS

As drug-related epidemics continue to expand outside cities, scaling up SSPs to serve rural PWID is essential. In this study, SSP programs operated with high fidelity. Deviations from core components (syringe dispensing limits, limited hours, etc.) were largely produced by features of the risk environment (eg, police interference, stigma, resource constraints, health care service barriers, etc.). Future research should explore whether the risk environment features identified here also influence SSP fidelity in other rural areas and develop and test strategies to strengthen core components in these vulnerable areas.