In rural communities, distance prevents many people from accessing harm reduction services. Mobile syringe service programs (SSP) offer a solution, bringing sterile supplies, linkage to treatment and other important services directly to people who might otherwise be excluded.
Mobile services are particularly important in Appalachia, where overdose rates remain far higher than the national average and structural disadvantage amplifies barriers to care.
A new study in Harm Reduction Journal surveyed over 250 people living in rural Kentucky counties who inject drugs, asking about their preferences for service delivery.
“Given the geographic barriers and transportation barriers in rural Appalachia, we wanted to look at the willingness among rural Appalachian people who use drugs to engage with mobile syringe service programs,” lead author Dr. Alexander Elswick, of the University of Kentucky, told Filter.
Nearly 60 percent were willing to use a mobile SSP, with interest concentrated among the most disadvantaged populations. Participants preferred clinical, discreet vehicles with evening hours of operation.
The survey is part of the Kentucky Communities and Researchers Engaging to Halt the Opioid Epidemic project (CARE2HOPE), founded in 2019 by Elswick’s colleague Dr. April Young. The research team recruited 259 adults across five counties who had used opioids or injected drugs to get high in the previous 30 days.
All participants completed a baseline survey that assessed their willingness to use a mobile SSP, and 135 returned six months later for a follow-up survey which gathered their feedback on how best to design mobile programs.
Overall, 59.9 percent of participants said they would be likely to use an SSP “that operated out of a mobile van that made visits throughout the community.” Importantly, mobile SSP were especially popular among many of the people they are designed to reach.
“It’s the more vulnerable population—those who experienced geographic and transportation barriers—who would be more likely to use the SSP,” Elswick said.
“Everybody knows everybody, and anonymity is so much more of a concern.”
People unable to access transportation were significantly more willing to use a mobile SSP, as were people earning less than $500 per month. Acceptance was also higher among people who tended to reuse their own syringes or share with others.
While a 60 percent acceptance rate might seem low, Elswick found these results encouraging.
“I took it generally as a positive,” he said. “Particularly in communities where there’s so much stigma … even moderate willingness is probably a good thing.”
However, one subset of participants was unenthusiastic about mobile services: people who reported feeling shame about their substance use. Elswick suspects that the tight-knit nature of some rural communities, which makes privacy difficult, might exacerbate fear of receiving services.
“There’s something unique about some of these rural Appalachian communities that are very small,” he said. “Everybody knows everybody, and anonymity is so much more of a concern.”
A desire for anonymity seems to have influenced participants’ stated preferences for mobile SSP deployment and design. Most participants endorsed parking mobile units at hospitals or clinics, but more general public locations—like large retail parking lots, gas stations and churches—were substantially less popular.
Participants also preferred vehicles to be smaller, and with more discreet markings—such as a research study logo, rather than health department branding.
“Appalachia has experienced a disproportionate burden … yet it’s underrepresented in research.”
“Another thing that surprised me was that there was low desire to engage with a peer who uses drugs,” Elswick said. “What participants preferred in terms of setting and provider were both more clinical in nature.”
That preference differs from those expressed by service users in other places—which underscores the importance of designing harm reduction services in conversation with their intended users, to reflect specific local circumstances and needs.
Syringe service programs have been legal in Kentucky since 2015, and their coverage has dramatically increased in recent years. But they’re only effective if people feel comfortable using them.
“Acceptability of the services really matters,” Elswick emphasized. “Design preferences have to be taken into consideration in order to increase engagement.”
While their findings suggest that rural Kentuckians prefer discreet, clinical mobile outreach services, the researchers are cautious about extrapolating these conclusions to other rural communities. Instead, they hope to shed light on Appalachians’ unique harm reduction needs and desires.
“Appalachia has experienced a disproportionate burden and consequences from the opioid epidemic and drug-related harms in general,” Elswick said. “Yet it’s underrepresented in research.”
Elswick’s stake in the work is not only academic. He is a Kentuckian in recovery himself, and a co-founder of Voices of Hope, which operates its own mobile outreach program. His research has left him feeling cautiously optimistic about the future of harm reduction efforts in his home state.
“This is a positive sign, but there’s still the need to reduce stigma and shame so that more people can get on board,” he concluded.
Image via County of Los Angeles Public Health