Expanding access to harm reduction in rural communities through community-informed public health vending machines

The opioid epidemic continues to disproportionately impact rural communities across the United States, where structural barriers, including geographic isolation, limited public health infrastructure, and heightened stigma, restrict access to harm reduction services. Public Health Vending Machines (PHVMs) that distribute naloxone and other wellness supplies (e.g., hygiene, wound care, socks, glasses) offer a promising, low-barrier, anonymous method for increasing access to life-saving interventions. However, the implementation of PHVMs in rural areas remains limited, and few studies have examined how these tools can be effectively and sustainably integrated into such contexts.

We employed a community-based participatory research (CBPR) approach, guided by the structural indicators of community-based participatory action research (SI-CBPAR). A qualitative needs assessment was conducted in six rural counties in North Carolina. Individuals with lived experience of substance use were trained as interviewers to recruit and conduct semi-structured interviews with peers. A total of 60 interviews were completed between June and December 2024. Participants discussed access to naloxone, stigma, preferred PHVM locations and distribution models, and desired harm reduction and wellness supplies. Transcripts were coded using a priori codes, with coding validation through inter-rater reliability and team-based consensus.

Participants described a range of community-level challenges and assets related to naloxone accessibility, leading to the first overall theme, current community context of naloxone accessibility, with subthemes highlighting the sources of naloxone, its perceived importance, and structural and social barriers to access. Participants also provided input on the implementation of PHVMs (the second theme), expressing preferences for 24/7 access, private locations to reduce stigma, and expanded content to include additional harm-reduction supplies. These findings underscore the need for community-informed strategies to improve equitable access to naloxone and related services.

This study demonstrates that PHVMs are viewed by community members as an acceptable and community-supported strategy for expanding access to harm reduction in rural areas. The findings provided critical insight into the social and contextual factors that shape community readiness for PHVM implementation. The CBPR approach ensured the relevance and cultural alignment of the findings, reinforcing the importance of engaging individuals with lived experience as partners in implementation science. Sustainable deployment of PHVMs in rural communities requires tailored strategies that address local stigma, logistical barriers, and community needs. The results support the development of rural-specific PHVM implementation toolkits to reduce overdose deaths and promote health equity.