Exploring the Impacts of Rurality on Service Access and Harm Among Image and Performance Enhancing Drug (IPED) Users in a Remote English Region

Image and performance enhancing drugs (IPEDs) have been highlighted in recent years as posing a potential risk to public health, with much research dedicated to exploring the use of these drugs and associated harms. While recent work has considered harm reduction for IPED users, the geographic and cultural impacts of rurality on IPED use and harms, particularly in relation to harm reduction service access, remains comparatively under-explored. Features of rurality relating to levels of economic distress, the inheritance and decline of manual labor, and rural conceptions of masculinity are important in shaping drug harms. Consequently, the “rural risk environment” for IPED users is in need of exploration. This research examines the experiences of IPED users in a remote two-county region of rural England, drawn from a multi-year ethnography and 18 qualitative interviews with IPED users, to explore the impacts of rurality and the “rural risk environment” on service access and harm (reduction) within this population. Findings highlight a number of ways in which rurality impacted on IPED users’ access to harm reduction services such as needle and syringe programs (NSP), as well as engagement with healthcare practitioners (HCP). Issues included the distances required to access services and lack of public transport between towns; the impacts of stigma in a small town context where there is little anonymity; Distrust of HCP relating to cultural mindsets and regionally derived fears regarding impacts on employment prospects, particularly military; and the impacts of rural masculinities and perceptions of the self-sufficient “real man” on help-seeking when experiencing harm. The research highlights the need to incorporate cultural geographic understandings into harm reduction policy for IPED users, and the significance of rurality on experiences of harm.