Capacity for sustainment of recently established syringe service programs in Appalachian Kentucky: The central role of staff champions

Hannah L.F. Cooper, Skylar Gross, Emma Klein, Monica Fadanelli, April Ballard, Scott Lockard, Evan Batty, April Young, Umed Ibragimov

Research output: Contribution to journalArticlepeer-review


Introduction: Ensuring adequate harm reduction infrastructure in rural areas is imperative, as drug-related epidemics expand into them. Here, we explore the capacity for sustainment of syringe service programs (SSP) in Appalachian Kentucky. Methods: We interviewed all staff (n = 16) of all SSPs (n = 7) in two Kentucky health districts in 2018–2019 using semi-structured one-on-one qualitative interviews; local departments of health (DOH) operated the SSPs. Interview domains encompassed: (i) SSP establishment; (ii) day-to-day operations, participation and health impacts; (iii) perceived prospects for sustainment; and (iv) perceived influences on #i–#iii. We analysed verbatim transcripts using thematic analytic methods; Schell's ‘capacity for sustainment’ constructs were treated as sensitising concepts during the analysis. Results: Most community members, law enforcement and DOH staff opposed SSPs before they opened, because of stigma and concerns about enabling and needlestick injuries; DOH staff also opposed SSPs because they believed they lacked the capacity to operate them. Training, technical assistance, visible evidence of the programs' public health impact and contact with SSP participants transformed DOH staff into program champions. As champions, SSP staff developed programs that had strong capacity for sustainment, as defined by Schell (e.g. visible public health impact, stable funding, political support). Staff reported that the SSPs had high prospects for sustainment. Discussion and Conclusion: As in SSPs that opened in cities decades ago, staff in emerging SSPs in these rural areas appear to have become crucial champions for these controversial programs, and may serve as vital resources for expanding harm reduction programming more broadly in these underserved areas.

Original languageEnglish
Pages (from-to)863-872
Number of pages10
JournalDrug and Alcohol Review
Issue number4
StatePublished - May 2022

Bibliographical note

Funding Information:
The article was supported by NIH grant UH3DA044798, Young/Cooper PIs. Authors have no connection with the tobacco, alcohol, cannabis, pharmaceutical, gaming or gambling industries, other like industries, organisations funded by these industries or other commercial interests. Aligned with appreciative evaluation methods, members of the syringe service program leadership teams were affiliated with the study. Grant funding supported their effort on the project, and one of the district health department directors, AL, served as a co‐author on the manuscript. DHDs helped create the interview guide and informed staff that they were aware of the project before we launched recruitment; as a co‐author, AL reviewed manuscript drafts. DHDs were not informed which SSP staff participated, nor were they permitted to review transcripts or take part in interviews or member checks. SSP staff were informed of these protections during the consent process, and were also told that their participation was voluntary; had no bearing on their jobs; and that neither individual information on participation nor identifiable data would be shared with directors.

Funding Information:
In several counties, SSP staff helped DHDs develop strategies to finance the programs. While staff salaries were funded through tax dollars that flowed to the health department, SSP staff and leadership were wary of using local tax dollars to fund the purchase of controversial harm reduction supplies (e.g. syringes, cookers). Identifying alternative stable sources of funds proved challenging and delayed some SSPs' opening. At last, staff at one SSP secured alternative funding from a local substance use coalition that received annual funds from Kentucky's tobacco settlement. Once funds were secured, the program opened. Other SSPs used a similar funding structure. To further bolster their ability to secure controversial harm reduction supplies, staff at several SSPs also persuaded local physicians to donate syringes to the SSP.

Funding Information:
We are grateful to the SSP staff, to the Gateway Health District Director and to our funders (UH3DA044798, Young/Cooper).

Publisher Copyright:
© 2022 Australasian Professional Society on Alcohol and other Drugs.


  • harm reduction
  • rural areas
  • sustainment
  • syringe service programs

ASJC Scopus subject areas

  • Medicine (miscellaneous)
  • Health(social science)


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