Discreet but accessible: a qualitative study with people who use drugs and service staff about the optimal design of a harm reduction vending machine in rural Kentucky

Background: Rural Appalachia has been significantly affected by drug-related harms (Hepatitis C, HIV, overdose deaths) over the past two decades, but harm reduction responses still lag behind other regions. Harm reduction vending machines (HRVMs) are an effective intervention for preventing overdose and the spread of infection, though they are newer to the US and have rarely scaled out to rural areas. Here, we report on guidance from people who use drugs (PWUD) and health department staff on how to adapt HRVMs to suit local needs in rural Appalachian Kentucky. Methods: Focus groups were conducted with local health department and syringe service program (SSP) staff, PWUD who use the SSP, and PWUD who do not use the SSP. The interview guide covered key HRVM features including identification for access, contents, location, and appearance. Focus groups were recorded and transcribed, and data thematically analyzed. Results: The results yielded 3 major themes: participants sought an HRVM that was discreet and nonjudgmental, accessible and equitable, and holistic. These themes informed their decisions when ranking features of the machine’s location, content, appearance, etc. Focus groups favored discreet machines that were out of plain sight; placing the machine somewhere walkable to ensure it is accessible; and including items that address needs beyond harm reduction to give participants more holistic help. Conclusions: HRVM scale out in this rural area should be guided by discreet and non-judgmental approaches that create an accessible and equitable machine that responds holistically to community needs. Future efforts to scale out HRVMs into rural areas could use this guidance as a starting point for exploring local priorities, to help ensure successful implementation in under-served rural areas.