Using health belief model constructs to understand the role of perceived disease threat and resilience in responding to COVID-19 among people who use drugs: a cluster analysis.

Introduction: The Health Belief Model (HBM) has been successfully applied to understanding adherence to COVID-19 prevention practices. It has not, however, been used to understand behavior in people who use drugs (PWUD). The aim of this study was to use the HBM to better understand COVID-19 perceptions among PWUD and understand how resiliency affects those perceptions. Materials and methods: A cross-sectional survey was completed from September to December 2021 with PWUD (n = 75) who utilize services at a large harm reduction organization in Philadelphia. Segmentation analysis was done using a k-means clustering approach. Two clusters emerged based on perceived COVID-19 personal impact and resiliency (Less COVID impact/High resilience (NoCOV/HR) and High COVID impact/Low resilience (COV/LR). Differences in responses by cluster to perceptions of COVID-19 and individual pandemic response grouped by HBM constructs were assessed using Student's t-test and chi squares. Results: Significant differences in HBM constructs were seen between clusters. Those in the COV/LR cluster were more likely to think they were susceptible to getting COVID-19 and less likely to believe they knew how to protect themselves. The NoCOV/HR cluster believed they were able to protect themselves from COVID-19 and that they were able to easily understand messages about protecting themselves. Conclusion: Understanding how PWUD conceptualize disease threat and using HBM can better inform interventions to improve future pandemic response. Findings suggest that resilience is key to protecting PWUD from future infectious disease outbreaks. Interventions aimed at increasing resiliency among PWUD may improve preventative behavior and decrease disease burden in this vulnerable population.

"It's my frenemy": A qualitative exploration of knowledge and perceptions of fentanyl use during the COVID-19 pandemic in people who use drugs at a syringe services program in Philadelphia, PA.

Background: Exacerbated by the COVID-19 pandemic and the proliferation of fentanyl and fentanyl analogs, overdose deaths have surged in the United States, making it important to understand how individuals who use drugs experience and perceive the risks of fentanyl use and how it has changed during the COVID-19 pandemic. Methods: Twenty clients from a Philadelphia syringe services program completed a questionnaire and in-depth interview about their fentanyl experiences from January to March 2021. These interviews were transcribed and analyzed using thematic analysis methods. Results: Sixty percent of participants were female and racial/ethnic minority. Participants indicated they believed fentanyl use accounted for most Philadelphia opioid-related overdoses and understood that fentanyl was different from other opioids. Fentanyl use was characterized as "all-consuming" by taking over lives and inescapable. While most perceived their risk of fentanyl overdose as high, there was low interest in and reported use of harm reduction strategies such as fentanyl test strips. The COVID-19 pandemic was noted to have negative effects on fentanyl availability, use and overdose risk, as well as mental health effects that increase drug use. Conclusions: The divide between perceived risk and uptake of protective strategies could be driven by diminished self-efficacy as it relates to acting on and engaging with resources available at the syringe services program and represents a potential intervention target for harm reduction intervention uptake. But the COVID-19 pandemic has exacerbated risks due to fentanyl use, making an effective, accessible, and well-timed intervention important to address the disconnect between perceived overdose risk and use of preventive behaviors.

"We figured it out as we went along": Staff perspectives of COVID-19 response efforts at a large North American syringe services programme.

Syringe services programmes face operational challenges to provide life-sustaining services to people who use substances and those who have substance use disorders. COVID-19 has disrupted operations at these programmes and is a threat to people with substance use disorder because of severe poverty, de-prioritisation of COVID-19 safety and high prevalence of comorbidities. This phenomenological qualitative study describes 16 in-depth interviews with staff of one of the largest syringe services programme in North America-Prevention Point Philadelphia, located in the Kensington neighbourhood of Philadelphia, Pennsylvania. Interviews were conducted from December 2020 to February 2021, audio-recorded, transcribed and coded to develop a thematic framework. Participants were mostly white (71.4%) and female (68.8%) with a median age of 31.5. Three main and four sub-themes related to the impact of COVID-19 on the syringe services programme were identified: (1) COVID-19 altered services provision (sub-theme: select service changes should be retained); (2) unclear or absent COVID-19 response guidance which compromised mitigation (sub-themes: COVID-19 messaging was difficult to translate to practice, learn-as-we-go); and (3) staff and clients experienced elevated mental anguish during the pandemic (sub-theme: already limited resources were further strained). COVID-19 presented complex challenges to an organisation normally strained in pre-pandemic times. A staff culture of resourcefulness and resiliency aided the syringe services programme to balance client needs and staff safety. However, staff experienced a serious psychological impact, largely attributable to being unable to find reprieve from the stressors of COVID-19 and the difficulties associated with navigating and acting-on contradictory public health messaging. Staff also shared a belief that the relaxing of some pre-pandemic barriers allowed staff to link clients more readily with services. Syringe services programmes should embrace the potential for lasting changes to health services delivery brought about by wide-scale changes in service provisions because of COVID-19.