Harm reduction via online platforms for people who use drugs in Russia: A qualitative analysis of web outreach work

Background Harm reduction services to people who use drugs (PWUD) in Russia are insufficient in terms of quantity, government endorsement, and accessibility. The situation has recently deteriorated even further because of social distancing measures of the COVID-19 pandemic. Recently several harm reduction organizations have started to provide some harm reduction services via online platforms by web outreach. However, little is known on how online outreach services are organized and implemented. Drawing on the example of St. Petersburg-based NGO “Humanitarian Action” we explored web outreach work in Telegram instant messenger. Methods 4 semi-structured interviews with the NGO staff and 301 cases of web outreach work with PWUD comprised the dataset. The process of web outreach, service provision to PWUD, and PWUD’s needs were thematically analyzed. Results Three stages of the process of web outreach work were determined: clients initiating communication, NGO workers addressing clients’ needs, and NGO workers receiving clients’ feedback. Communication proceeded either in group chat or in direct messages. Challenges in addressing clients’ needs happened when clients turned for help in nighttime, sent recorded voice messages, sent unclear messages, and/or were unwilling to transition to telephone communication. All web outreach workers reported receiving only positive feedback on their work. PWUD’s needs were categorized into two major themes, depending on whether they can be addressed fully or partially online. In cases of online only provision of services, web outreach workers helped PWUD treat minor injection drug use complications, obtain verified harm reduction information and receive general psychological support. In instances of partial online services provision, PWUD were assisted in getting treatment of severe injection drug use complications, overdoses, and in accessing offline medical, psychological, social, legal and harm reduction services. Conclusions Our research demonstrated that web outreach work is a convenient tool for delivering some harm reduction services to PWUD either partially or completely online and recruiting new clients (including hard-to-reach PWUD that avoid attending brick-and-mortar facilities). It indicates that harm reduction organizations should consider incorporating online harm reduction services into their activities. However, more research is needed to explore relative advantages and disadvantages of online harm reduction services delivery.


Introduction
People who use drugs (PWUD) are one of the most stigmatized and marginalized populations in Russia (1,2). People who inject drugs (PWID) are particularly vulnerable to HIV infection, HCV infection and fatal overdoses (OD) (3)(4)(5)(6)(7). Unfortunately, harm reduction programs that have been proven to be effective for combatting HIV, HCV and OD among PWID (8,9) are not o cially endorsed by the Russian government, their number is limited and access to them among PWID is low (10). Moreover, the number of needle and syringe exchange programs (NSPs) in Russia has been decreasing since 2010 (11), while opioid agonist therapy (OAT) remains illegal (10). In addition, harm reduction services were reported to be unattractive to young PWID in Russia (12).
Thus, additional ways of harm reduction services provision that would be more accessible for PWUD, and especially for hard-to-reach PWUD, such as young PWUD, are urgently needed in Russia. One such way is integrating harm reduction services into online platforms.
Darknet-based drug marketplaces are frequently used by PWUD. "Empire Market" (13), "Hydra" (in Russia) (14) and other darknet markets have operated as online platforms where users can anonymously purchase drugs as well as exchange information on the availability of particular drugs, experiences from using them, their effects and potential harms via integrated online forums (15)(16)(17).
Use of drug marketplaces and drug-related online forums to facilitate harm reduction has recently been gaining attention from researchers. A number of studies have shown that such online platforms could bring new opportunities to provision of harm reduction services (18)(19)(20). Social media platforms have also been reported as instruments that have the potential to bring greater access to harm reduction services among PWUD (21). Harm reduction interventions via online platforms are often referred to as 'web outreach', 'online outreach' or 'netreach' work (22,23).
Web outreach work implies that harm reduction workers contact PWUD through online platforms and provide them with harm reduction information and counselling upon individual requests of users or distribute harm reduction information publicly via online forums. Such work helps to encourage risk reduction behaviors among hard-to-reach populations of PWUD who do not attend brick-and-mortar harm reduction facilities (22,23). Moreover, while amidst the COVID-19 pandemic in-person harm reduction services experience di culties in their provision due to social distancing measures and shortages (24,25), web outreach helps the provision of harm reduction services to continue.
This research explores how web outreach work is organized and implemented by the oldest harm reduction NGO in Russia -"Humanitarian Action". The aims of the study are: (1) to describe the process of online harm reduction provision; (2) to identify needs expressed by PWUD in Russia in the process of online harm reduction services provision; (3) to identify services provided for PWUD by web outreach workers. To our knowledge, this is the rst study that explores web outreach work with regards to needs of PWUD and services provided to them.

Methods
Setting "Humanitarian Action" (henceforth, the NGO) is a non-governmental charitable organization based in St. Petersburg,Russia (26) that was established in 1997 and has been providing low-threshold harm reduction services for PWUD in Russia for over 25 years. Their services include exchange and disposal of used needles and syringes; provision of a motivational package containing sterile syringes, alcohol wipes, water for injections, ointments, bandages for PWUD; express testing for HIV, HCV, HBV, syphilis; support and referral of clients to the AIDS center for HIV diagnosis con rmation and start of antiretroviral therapy (ART); naloxone provision for opioid drugs overdose treatment; case management of PWUD in accessing social, medical and legal services (27). Services are provided at no cost to PWUD, who come to the NGO's mobile units -two buses that circulate in St. Petersburg and follow schedules available on the NGO's website (28).
"Humanitarian Action" added web outreach work to its activities in an effort to increase the program's accessibility and extend its reach to hard-to-reach PWUD, who do not attend mobile units. The NGO uses two online platforms for provision of harm reduction services: darknet forum in "Hydra" (the largest drug cryptomarket in Russia) and Telegram instant messenger (IM) that is popular in Russia. "Hydra" was established in 2015 and was reported to have a rapidly growing user base of over 2.5 million people in 2019 (14). Telegram had over 400 million monthly active users worldwide (30 million in Russia) as of June 2020; it is widely considered to be one of the most secure messengers for its end-to-end encryption method of communication, which facilitates greater anonymity of its users (29,30). As both platforms are commonly used means of communication among PWUD in Russia, it is reasonable to assume that provision of online harm reduction services with the use of these platforms will be convenient for them.
In January 2019, "Humanitarian Action" started its online program on the drug forum on "Hydra." The organization's own research of the forum's content showed that it lacked information on HIV and HCV, and services provided by harm reduction organizations in Russia. The NGO's deputy director was interviewed about the organization's harm reduction services; the interview was published on Telegram channel of "Hydra." (In addition to the IM chat function, Telegram offers the opportunity to setup a "channel" -a newsfeed, to which people can subscribe). The interview gathered around 100,000 views and became a part of web outreach work that increased the number of visits to the NGO's o ine harm reduction services. After the interview publication, the NGO launched three threads on the "Hydra" forum dedicated to HIV, HCV and harm reduction services available in St. Petersburg. In addition to providing detailed information on the three topics, these threads serve as darknet-based platforms where users can interact with the NGO's staff. Although these threads did not become popular among the forum's users (more time and human resources are likely needed to increase their popularity among PWUD) they served as additional recruitment venues for services provided via Telegram IM.
In March 2019, the NGO started its web outreach work in Telegram IM. Humanitarian Action outreach workers have their own channel as a way to communicate to its subscribers and provide general information to PWUD. Two venues in Telegram were launched: an open-access channel and a restrictedaccess chat. The open-access channel is a newsfeed available to anyone interested in what the NGO does -its participants can nd drug-related news, the NGO's announcements and general harm reduction services information there. Participants can only read the NGO's posts there; they cannot leave their messages in the channel. The restricted-access chat was aimed to be more interactive and tailored to the PWUD's needs. At the initial stage of the chat's launch, access to it was distributed among PWUD when they attended the NGO's mobile units and through drug sellers in Telegram (the NGO asked sellers to promote the NGO's services among their customers). Currently, access to the chat is granted to PWUD when they attend the mobile units, but in addition to that, PWUD themselves are able to provide access to the chat to their peers thereby increasing its popularity among PWUD. As of 19 August 2020, the chat had 1125 members. The chat functions as an online platform for PWUD where they can request various services from the NGO's web outreach workers.
After the NGO started their online harm reduction services, they experienced an 89% increase in the number of requests for services in comparison with the time when only o ine harm reduction services were provided (31).

Data collection and research design
Data collection included 4 semi-structured interviews and 8 work reports of web outreach workers. The interviews were conducted in June 2020: 1 with the NGO's deputy director and 3 with web outreach workers. The interview guide for the deputy director included topics related to the establishment and development of web outreach work, the current state of web outreach in the organization, and the organization's plans for the future of web outreach. The interview guide for web outreach workers included experience in their web outreach work, ways of contacting clients, di culties in communicating with clients, clients' feedback on provided services, and perceived differences between online and o ine harm reduction provision. Interviews were conducted in Russian and online via Zoom or Telegram. They were recorded and lasted around 30 minutes each. All participants provided written informed consent.
The researchers received copies of the work reports of web outreach workers from Humanitarian Action's deputy director. The reports included detailed information on 301 cases of web outreach work, including date of contact (from November 2019 to June 2020), description of PWUD's requests, and description of services provided to the PWUD. The NGO provided only anonymized reports with respect to identities of PWUD and web outreach workers: no personal information of either was given to researchers.
Interviews were transcribed verbatim for data analysis. Thematic analysis (32) of interviews and work reports were conducted. The data were read by two researchers (AD and PM), and coded and organized into initial themes by one researcher (AD). Further discussion of these initial themes by the two researchers led to clari cation and elaboration of these themes on consensus basis. Thematic analysis of interviews helped researchers to explore how web outreach processes are implemented in the NGO. Thematic analysis of work reports assisted in identifying the needs of PWUD and understanding the extent to which and how these needs were addressed by web outreach workers. The study was approved by the Ethical Committee of the St. Petersburg Association of Sociologists.

Process of web outreach
Thematic analysis revealed that the process of the NGO's web outreach includes three distinct stages: initiating communication, addressing the client's needs, and receiving feedback from the client. Within each of the stages, several important issues came up, including PWUD's behaviors, outreach workers' actions, and challenges faced.
The rst stage of web outreach is PWUD initiating communication with web outreach workers. Different scenarios for this stage were described by the informants, depending on how PWUD contacted the NGO in Telegram.
The most common scenario for a communication commencement is when PWUD send her request in the NGO's Telegram chat. After the request is seen, a web outreach worker contacts the PWUD in the chat or sends a direct message to her. If the web outreach worker contacts the PWUD in the chat, both the request and the worker's response are displayed to the other members of the chat. If the web outreach worker contacts the PWUD via direct message, only the request is displayed to the other chat members. In this case, the worker's response is seen only by the worker and the PWUD who sent the request. Web outreach workers reported that they chose between the two options of contacting the PWUD depending on the request's content. For cases where requests regarded common information, workers chose to reply in the chat as the information potentially could be of use to the other chat members. For cases where requests required a more personal and con dential approach, workers preferred to contact the PWUD directly.
Sometimes when a PWUD sends his request in the chat, other PWUD address his request and start communicating with one another. Under such circumstances, web outreach workers join and monitor the discussion to guarantee that the request of the PWUD was addressed properly. The deputy director of the NGO notes that such instances support the development of a safe space and a sense of community among members of the chat.
"[Communication between PWUD] is friendly and fun, but it is under my strict supervision. As a moderator, I supervise such discussions and whenever rudeness appears […] I intervene and explain that this is not a space for insulting each other […] we want this space to be of maximum safety for you [PWUD]." (Deputy director of the NGO) Telegram messenger allows its users to anonymize themselves by not disclosing any personal information to other users.
"What Telegram is good for is that you can hide your phone number, use any made-up name or a nickname, and start messaging […] you won't be identi ed. Then you can write there [in the NGO's Telegram chat] anything you want […] and you will get a response." (Deputy director of the NGO) In addition, web outreach workers told us that sometimes they are contacted by PWUD in Telegram outside of the NGO's chat, via direct messages. In such cases members of the chat cannot view requests of PWUD and responses of web outreach workers. One informant noticed that they were contacted more frequently in direct messages if they had been recently active in the Telegram chat and/or channel of the NGO. Another web outreach worker noted that some PWUD, who contacted her in direct messages but were not members of the NGO's chat, got her contact information from the worker's previous clients. Those clients seemed to advertise the worker's services among their peers, thus increasing web outreach popularity among PWUD. The second stage of web outreach is the actual process of addressing clients' needs by the NGO's workers. Either the web outreach workers provide services to the clients themselves, or if they are unable to do it, they provide clients with contact information of other workers in the NGO, who are capable of assisting PWUD.
Telegram was described as a convenient " rst step" of communication between a PWUD and a web outreach worker. These initial contacts via Telegram can open the door to harm reduction services being provided, both through further online consultations or referral to o ine services. Several challenges related to the second stage of web outreach work were mentioned by informants, each of them related to speci cs of the services online provision. One challenge is that PWUD send their requests to web outreach workers at nighttime when web outreach workers are unable to provide immediate help. In such cases, the clients are contacted in the morning and informed about time periods when workers are not able to respond to them promptly. "We all need some time for ourselves. Any web outreach worker, including me, is sleeping at 4 AM. What you do is just explain [that you were unavailable] and, of course, provide services according to the request." (Web outreach worker #3) Another challenge arises when clients record voice messages instead of sending text messages. In such instances web outreach workers may not have an opportunity to listen to PWUD's voice messages promptly, thus the provided services are unlikely to be as immediate as the clients expect. Web outreach workers described that under such circumstances they asked clients if they could send a text message instead. Depending on their reply, counselling was offered after their text message was received or when the worker had an opportunity to listen to the voice message.
"If I get a voice message, I message the client, asking if it's possible for them to send me a text message instead. If not, they have to wait. When I exit the subway, I'll listen to it. Or I am working with other clients currently, and when I'm done with them, I'll listen to it." (Web outreach worker #3) Another challenge was when web outreach workers were unable to understand the content of the clients' messages. Such occurrences happened when clients did not formulate their requests clearly. In these cases, the workers either tried to clarify the request by asking additional questions or suggested discussing the request by phone. Web outreach workers noted that some clients trusted them enough to discuss their requests on the phone, while other clients refused to continue their communication with a phone call and agreed to only text-form communication, as giving their phone number would compromise their anonymity. One informant reported that some clients stopped messaging her completely after a phone call was proposed: "[After I suggest calling the PWUD] some of them send me their phone number or they ask me to send mine. Some of them exit the chat, and don't reply there anymore." (Web outreach worker #3) Phone calls were mentioned by several web outreach workers as the next step in communication between them and some of their clients. Depending on the requests of PWUD, phone calls were favored as a continuation of communication by workers because in such instances they were able to gain a better understanding of their clients' emotions and, consequently, provide their services more effectively. The third stage of web outreach is receiving client's feedback on provided services. Web outreach workers described this stage as being crucial to their work, as it helps them to verify whether the services that they provided were of use for their clients and whether the clients knew whom to contact if they required help in the future. One worker narrated that it was very important for her to end communication with clients by leaving her contact information: "This is my 'message': I always leave my phone number no matter what the request was, so that, just in case, they will know that they can call me." (Web outreach worker #2) All web outreach workers reported receiving only positive feedback on their work.

Needs and services
In this section of the paper we explore the rst two stages of the process of web outreach work in terms of needs of PWUD and services provided to them. We identi ed two major themes in regard to whether the needs can fully be met or that the needs can only partially be met via online platforms. We distinguished several sub-themes in each theme based on common requests of PWUD and matched the sub-themes with services provided by web outreach workers.

Theme 1. Needs for online only harm reduction services
The rst major theme is composed of needs for harm reduction services, which can be provided to PWUD entirely online. The following sub-themes were included in this theme: minor injection drug use complications; information regarding harm reduction, HIV and HCV; information regarding at-home detoxi cation; information regarding the COVID-19 pandemic; general psychological support.
The most common sub-theme was treatment of minor injection complications. Injection complications were de ned as "minor" if their treatment did not require the o ine assistance of a doctor. Such complications included collapsed veins, blown veins, venous ulcers, varicose veins and rashes. PWID described their injection complications in text and/or by sending a photo of their injury. PWID who requested help in such instances were offered advice from web outreach workers on how PWID could treat and prevent their injuries. Medical professionals veri ed the advice before web outreach workers sent it to clients. In cases where web outreach workers felt that more skilled assistance was needed, they provided PWID with contact information of doctors who work at the NGO. The doctors would then could provide medical advice via Telegram.
Another common sub-theme was requesting harm reduction, HIV and HCV-related information. Nearly a sixth of requests made by PWUD concerned general information about harm reduction services provided at the NGO's mobile units and the schedule of the mobile units. PWUD, who were taking antiretroviral therapy (ART) or wished to start ART, also requested information on the relevant schedule of the AIDS Center where ART is provided. A few clients requested information on transmission routes of HIV and HCV infections. The clients were provided with veri ed information on the topics, as well as with the contact information of other NGO workers, whom they could connect with should they have more speci c questions.
A less common, yet still important, sub-theme was requesting information about at-home detoxi cation: only ve clients conveyed interest in it. Web outreach workers articulated to such clients the potential risks of at-home detox, provided them with general information about medically assisted detox and shared contact information of workers, whom the clients could message regarding such issues.
Since April 2020, a number of COVID-19 information-related needs emerged. Several clients requested information on how they could enroll in a detoxi cation center and/or a rehabilitation program under the conditions of the pandemic. As in the previous cases, web outreach workers provided their clients with relevant and veri ed information in accordance with their requests.
A nal sub-theme was that PWUD requested general psychological support via the Telegram IM. PWUD contacted web outreach workers to receive general psychological support concerning a number of personal issues. Common examples of PWUD's requests included having di culties in combatting drug addiction; expressing anxiety about repercussions of quarantine measures taken during the COVID-19 pandemic (e.g., shortages of medications); experiencing di culties in coping with a partner's death; and feeling anxiety about being infected with HCV. As the clients did not request help from a certi ed psychologist, web outreach workers provided them with advice based on their personal experience and contact information of the NGO staff whom they could message if they required additional help.

Theme 2. Needs for online and o ine harm reduction services
The second major theme is comprised of harm reduction services, which cannot be provided to PWUD fully online, as some of their aspects require PWUD's o ine presence. This theme is represented with the following sub-themes of needs: getting medical, psychological, social and legal services; severe injection drug use complications; getting harm reduction services; and drug overdoses.
The most common sub-theme was getting medical, psychological, social and legal services. In nearly a third of cases in the dataset, PWUD requested help from the NGO in getting the following o ine services: personal assistance in getting ART at the AIDS center, delivery of ART to PWUD's homes, personal assistance in being hospitalized at clinics for detoxi cation and rehabilitation, receiving counselling from a certi ed psychologist, obtaining identity documents, and obtaining disability status. In such cases, web outreach workers matched PWUD with other NGO staff, who specialize in working with these speci c requests. PWUD were invited to the NGO mobile unit where outreach workers initiated face-to-face communication, the PWUD's needs were thus met o ine.
Injection drug use complications in this theme were categorized as "severe" because their treatment required o ine visits to a doctor. Such complications included severe cases of blown veins and venous ulcers, as well as edemas and skin abscesses. In such instances web outreach workers referred PWID to doctors at the NGO as the workers themselves were not quali ed enough to provide necessary help to their clients. The doctors contacted the clients online and after consulting them invited the PWID to the NGO mobile unit to receive treatment o ine or encouraged them to go to a clinic to get necessary treatment.
Another major sub-theme was PWUDs requesting help in getting speci c harm reduction services: HIV testing, HCV testing, harm reduction motivational packages, and PrEP medication. Web outreach workers could not address such needs via online platforms, thus they provided PWUD with instructions regarding how they could obtain such services o ine at the NGO or a liated clinics (in the cases of PrEP medication).
Overdoses (OD) was the least common sub-theme; only four cases of OD were mentioned in the work reports. In each case, the PWUD asked for help in treating an OD. Web outreach workers provided PWUD with a link to the NGO's "Overdose bot" in Telegram. This bot, a built-in Telegram application created by the NGO, serves as an automated service, which provides Telegram users with information on symptoms of OD, cardiopulmonary resuscitation (CPR) techniques, and medications to treat an OD. It also provides them with contact information of a doctor, whom the PWUD can contact in order to get help online. Therefore, instead of web outreach workers manually searching and sending information to PWUD, they share a link with the PWUD, who then nd the necessary information themselves using the bot. In each instance web outreach workers provided their clients with a link to the bot. In two out of the four cases, PWUD had to call an ambulance for OD treatment. Thus, in addition to sending the link to the bot, the web outreach workers continued their communication with the clients until an ambulance arrived.

Discussion
Our ndings describe the process of web outreach work implemented by the NGO "Humanitarian Action", a low-threshold harm reduction organization in Russia. Web outreach work to PWUD has only recently been implemented in Russia, a place that continues to struggle with reaching PWUD's need for harm reduction services. We described the stages of the web outreach process, needs of PWUD, who request help via online platforms, and services that are provided to them by web outreach workers. Our research demonstrates that a number of PWUD's harm reduction-related needs can be met entirely through web outreach work, while some can only be partially met online. These ndings are in line with the existing literature on online platforms bringing new opportunities to harm reduction services provision (18)(19)(20). They also contribute to the growing amount of literature regarding the processes of web outreach work (22,23) and bring new evidence on how various needs of PWUD are addressed by web outreach services.
We identi ed a three-stage process of web outreach work. The process illustrates the bene ts that PWUD gain from online harm reduction services provision without face-to-face contact with web outreach workers. An absence of requirement for physical presence of PWUD at a harm reduction organization facilitates greater level of anonymity in comparison with o ine harm reduction services provision. In addition, the use of text messages brings greater convenience to PWUD, who do not feel comfortable with discussing drug use-related issues in person. These factors indicate that web outreach work helps to encourage harm reduction behaviors among PWUD who, otherwise, might not seek or have access to brick-and-mortar harm reduction services.
Our analysis of the needs of PWUD and services provided to them demonstrates two major functions performed by web outreach workers: 1. They can provide certain services completely online, and 2. They navigate clients within the organization in order to match the needs of the PWUD with a person who can address them. Our research on web outreach work indicates an increasing level of e ciency that comes from online provision of harm reduction services. Instead of travelling to a harm reduction facility, PWUD can contact the organization via an online platform. Furthermore, harm reduction services provided entirely online gain particular relevance amidst the COVID-19 pandemic when o ine harm reduction organizations experienced new challenges to providing in-person outreach services.
Our ndings suggest that online harm reduction services provision can be improved in terms of accessibility and e ciency. A challenge for web outreach work, as described by informants, was the inability of workers to communicate with PWUD at night. One possible solution is to automatize some processes with Telegram bots, as it was done with the cases of OD. Currently, web outreach workers manually send information to PWUD. If automatized, then PWUD themselves could use a bot to get necessary information at any time of the day. However, not all services can be automatized with a bot; therefore, it may be necessary to employ some workers, who could reply to PWUD's requests at night. This is especially important in emergency situations, such as OD. Another way to develop provision of online harm reduction services is to increase their presence on Darknet forums. Greater presence could potentially make online services accessible to more groups of PWUD, who request urgent help at nighttime and/or who do not use Telegram. Another obstacle in increasing accessibility of online harm reduction services was that some clients refused to continue communication with web outreach workers via the phone. More research is needed to explore the needs that PWUD have in such cases, identify the reasons why certain PWUD refuse to communicate via the phone, and explore how web outreach work can be provided in such instances.
Our research has several limitations worth noting. First, as anonymity of their clients is a priority for the NGO, all communications in direct messages are terminated a short time after work with them is completed. In some instances, workers lled their work reports after direct messages were terminated, which meant that they had to ll the reports based on memory. This implies a potential recall problem in descriptions of needs and services. Second, as in interviews informants were asked to review their months-long work experience, another recall problem arises as a limitation of the study. Third, web outreach work of the NGO in darknet forums was not included in the research due to its limited volume at the time of the study. Nonetheless, our ndings provide rich descriptions of the novel web outreach work being done in Russia today. Our timely and descriptive ndings can serve as the foundation and a reference point for further research into online harm reduction services as well as provide important information for existing organizations that seek to expand their harm reduction services to meet the needs of PWUD who may best be reached via online platforms.

Conclusions
The ndings from our research suggest that web outreach work is an instrument that should be considered by harm reduction organizations to potentially increase e ciency of the provision of their services and their access to hard-to-reach populations of PWUD. However, web outreach work requires further research in order to explore its bene ts for PWUD and harm reduction organizations. It is vital to examine which harm reduction services can be delivered entirely online rather than o ine by estimating the net bene t for PWUD and harm reduction organizations: such aspects as total anonymity and convenience of online platforms as well as potential loss in quality of services provision caused by online platforms should be considered. The positive net bene t would indicate that harm reduction organizations are to incorporate online harm reduction services provision into their activities or increase them. The web outreach work may be an important approach to help address challenges in reaching the younger generations of PWUD and also to ensure continuity of services during the COVID-19 pandemic and social distancing measures in place. The data used and/or analyzed during the current study is available from the corresponding author on reasonable request. Quality of Life) and by the New York State International Training and Research Program grant D43-TW000233, from the National Institutes of Health/Fogarty International Center and the National Institute on Drug Abuse.
Authors' contributions AD, PM, AL participated in the development of the study's research design. AD and PM developed the interview guides. AL provided contact information of informants and work reports. AD collected the interviews, aggregated the work reports and coded the data. AD and PM discussed the study results and determined the study's major ndings. AD wrote the preliminary draft. PM, AL and EK gave substantive comments on the draft and AD, PM and EK prepared the nal manuscript. All authors have read and approved the nal manuscript.