Syringe exchange programs (SEPs)—programs providing unused needles to intravenous drug users (IDUs)—have been crucial in reducing the global spread of bloodborne diseases. In addition to allowing individuals to exchange used syringes for unused ones, these programs have been a safe space for IDUs to receive necessary services, obtain social support, and decrease perceived stigma. However, the use and implementation of SEPs remains controversial some 30 years after their initial inception in the US, despite support from the public health and medical professions. While this can be viewed as resulting from the stigma surrounding drug use, the spread of SEPs to rural areas has resulted in conflict between public health experts and harm reduction advocates who found themselves in contention with policy makers and community members who decry needle exchanges as a negative aspect of their communities. With this context undergirding the study, the author examines barriers and facilitators to the creation and implementation of SEPs in rural and conservative communities.
The author conducted 26 semi-structured qualitative interviews with employees at 22 syringe exchange programs in the US state of Michigan from May-December of 2020. Michigan was chosen for the rapid increase of SEPs in the state: while there were four SEPs in 2016, this number increased to 27 by the end of 2020, with most new SEPs located in rural and politically conservative parts of the state. Qualitative interview questions focused on how and why the syringe exchange was started, perceptions of the syringe exchange by the community and policy makers, and how the organization obtained community and legislative support. Data was professionally transcribed and analyzed using NVIVO qualitative software. Constructed grounded theory was used as the primary analytical framework in data analysis.
Findings show that locating SEPs in health departments often tempered initial community antagonism, especially in rural communities where the need for SEPs trumps disapproval of community residents. In order to preempt the “Not In My Backyard” (NIMBY) phenomenon, SEP employees engaged in certain actions to introduce the community to the SEP: knocking on residents’ doors to introduce the SEP, attending city council meetings to explain the purpose of the new organization, and locating the SEP within the health department, alongside other common (and less controversial) services. However, SEP employees noted that gaining support from the community came at a cost in terms of program utilization. As respondents worked to increase community support for the SEP, the SEP neglected gaining the support and interest of potential clients. Thus, there was programmatic failure in reaching the local IDU population, resulting in lower than expected SEP utilization in communities with high levels of drug use.
Findings reveal the importance of service providers being attuned to community residents, and informing community residents on the possibility of controversial service provision in their neighborhood. However, service providers must strike a balance between gaining support from the community, and supporting the needs of their marginalized clients. As such, programs may fail to meet the immediate needs of their target population.