Fraud Detection Protocol for Web-Based Research Among Men Who Have Sex With Men: Development and Descriptive Evaluation

Background: Internet is becoming an increasingly common tool for survey research, particularly among “hidden” or vulnerable populations, such as men who have sex with men (MSM). Web-based research has many advantages for participants and researchers, but fraud can present a significant threat to data integrity. Objective: The purpose of this analysis was to evaluate fraud detection strategies in a Web-based survey of young MSM and describe new protocols to improve fraud detection in Web-based survey research. Methods: This study involved a cross-sectional Web-based survey that examined individual- and network-level risk factors for HIV transmission and substance use among young MSM residing in 15 counties in Central Kentucky. Each survey entry, which was at least 50% complete, was evaluated by the study staff for fraud using an algorithm involving 8 criteria based on a combination of geolocation data, survey data, and personal information. Entries were classified as fraudulent, potentially fraudulent, or valid. Descriptive analyses were performed to describe each fraud detection criterion among entries. Results: Of the 414 survey entries, the final categorization resulted in 119 (28.7%) entries identified as fraud, 42 (10.1%) as potential fraud, and 253 (61.1%) as valid. Geolocation outside of the study area (164/414, 39.6%) was the most frequently violated criterion. However, 33.3% (82/246) of the entries that had ineligible geolocations belonged to participants who were in eligible locations (as verified by their request to mail payment to an address within the study area or participation at a local event). The second most frequently violated criterion was an invalid phone number (94/414, 22.7%), followed by mismatching names within an entry (43/414, 10.4%) and unusual email addresses (37/414, 8.9%). Less than 5% (18/414) of the entries had some combination of personal information items matching that of a previous entry. Conclusions: This study suggests that researchers conducting Web-based surveys of MSM should be vigilant about the potential for fraud. Researchers should have a fraud detection algorithm in place prior to data collection and should not rely on the Internet Protocol (IP) address or geolocation alone, but should rather use a combination of indicators

A Rural/Urban Comparison of Privacy and Confidentiality Concerns Associated with Providing Sensitive Location Information in Epidemiologic Research Involving Persons Who Use Drugs

Background—Analyses that link contextual factors with individual-level data can improve our understanding of the risk environment ; however, the accuracy of information provided by participants about locations where illegal/stigmatized behaviors occur may be influenced by privacy/confidentiality concerns that may vary by setting and/or data collection approach. Methods—We recruited thirty-five persons who use drugs from a rural Appalachian town and a Mid-Atlantic city to participate in in-depth interviews. Through thematic analyses, we identified and compared privacy/confidentiality concerns associated with two survey methods that (1) collect self-reported addresses/cross-streets and (2) use an interactive web-based map to find/confirm locations in rural and urban settings. Results—Concerns differed more by setting than between methods. For example, (1) rural participants valued interviewer rapport and protections provided by the Certificate of Confidentiality more; (2) locations considered to be sensitive differed in rural (i.e., others\u27 homes) and urban (i.e., where drugs were used) settings; and (3) urban participants were more likely to view providing cross-streets as an acceptable alternative to providing exact addresses for sensitive locations and to prefer the web-based map approach. Conclusion—Rural-urban differences in privacy/confidentiality concerns reflect contextual differences (i.e., where drugs are used/purchased, population density, and prior drug-related arrests). Strategies to alleviate concerns include: (1) obtain a Certificate of Confidentiality, (2) collect geographic data at the scale necessary for proposed analyses, and (3) permit participants to provide intersections/landmarks in close proximity to actual locations rather than exact addresses or to skip questions where providing an intersection/landmark would not obfuscate the actual address

Healthcare Contact and Treatment Uptake Following Hepatitis C Virus Screening and Counseling Among Rural Appalachian People Who Use Drugs

Background—Hepatitis C virus (HCV) remains a major contributor to morbidity and mortality worldwide. Since 2009, Kentucky has led the United States in cases of acute HCV, driven largely by injection drug use in rural areas. Improved treatment regimens hold promise of mitigating the impact and transmission of HCV, but numerous barriers obstruct people who inject drugs (PWID) from receiving care, particularly in medically underserved settings. Methods—503 rural people who use drugs were recruited using respondent-driven sampling and received HCV screening and post-test counseling. Presence of HCV antibodies was assessed using enzyme immunoassay of dried blood samples. Sociodemographic and behavioral data were collected using computer-based questionnaires. Predictors of contacting a healthcare provider for follow-up following HCV-positive serotest and counseling were determined using discrete-time survival analysis. Results—150 (59%) of 254 participants reported contacting a healthcare provider within 18 months of positive serotest and counseling; the highest probability occurred within six months of serotesting. 35 participants (14%) reported they were seeking treatment, and 21 (8%) reported receiving treatment. In multivariate time-dependent modeling, health insurance, internet access, prior substance use treatment, meeting DSM-IV criteria for generalized anxiety disorder, and recent marijuana use increased the odds of making contact for follow-up. Participants meeting criteria for major depressive disorder and reporting prior methadone use, whether legal or illegal, were less likely to contact a provider. Conclusion—While only 8% received treatment after HCV-positive screening, contacting a healthcare provider was frequent in this sample of rural PWID, suggesting that the major barriers to care are likely further downstream. These findings offer insight into the determinants of engaging the cascade of medical treatment for HCV and ultimately, treatment-as-prevention. Further study and increased resources to support integrated interventions with effectiveness in other settings are recommended to mitigate the impact of HCV in this resource-deprived setting

Route of administration for illicit prescription opioids: a comparison of rural and urban drug users

<p>Abstract</p> <p>Background</p> <p>Nonmedical prescription opioid use has emerged as a major public health concern in recent years, particularly in rural Appalachia. Little is known about the routes of administration (ROA) involved in nonmedical prescription opioid use among rural and urban drug users. The purpose of this study was to describe rural-urban differences in ROA for nonmedical prescription opioid use.</p> <p>Methods</p> <p>A purposive sample of 212 prescription drug users was recruited from a rural Appalachian county (n = 101) and a major metropolitan area (n = 111) in Kentucky. Consenting participants were given an interviewer-administered questionnaire examining sociodemographics, psychiatric disorders, and self-reported nonmedical use and ROA (swallowing, snorting, injecting) for the following prescription drugs: buprenorphine, fentanyl, hydrocodone, hydromorphone, methadone, morphine, OxyContin^®and other oxycodone.</p> <p>Results</p> <p>Among urban participants, swallowing was the most common ROA, contrasting sharply with substance-specific variation in ROA among rural participants. Among rural participants, snorting was the most frequent ROA for hydrocodone, methadone, OxyContin^®, and oxycodone, while injection was most common for hydromorphone and morphine. In age-, gender-, and race-adjusted analyses, rural participants had significantly higher odds of snorting hydrocodone, OxyContin^®, and oxycodone than urban participants. Urban participants had significantly higher odds of swallowing hydrocodone and oxycodone than did rural participants. Notably, among rural participants, 67% of hydromorphone users and 63% of morphine users had injected the drugs.</p> <p>Conclusions</p> <p>Alternative ROA are common among rural drug users. This finding has implications for rural substance abuse treatment and harm reduction, in which interventions should incorporate methods to prevent and reduce route-specific health complications of drug use.</p

COVID-19 and Opioid Use in Appalachian Kentucky: Challenges and Silver Linings

Appalachian Kentucky is currently fighting two public health emergencies – COVID-19 and the opioid epidemic – leaving the area strapped for resources to care for these ongoing crises. During this time, people who use opioids (PWUO) have increased vulnerability to fatal overdoses and drug-related harms (e.g., HIV). Disruption of already limited services posed by COVID-19 could have an especially detrimental impact on the health of PWUO. Though the COVID-19 pandemic is jeopardizing hard-won progress in fighting the opioid epidemic, innovations in state policy and service delivery brought about by the pandemic may improve the health of PWUO long-term if they are retained

A Qualitative Study on Pharmacy Policies toward Over-the-Counter Syringe Sales in a Rural Epicenter of US Drug-Related Epidemics

BACKGROUND: Expanding access to sterile syringes in rural areas is vital, as injection-related epidemics expand beyond metropolitan areas globally. While pharmacies have potential to be an easily accessible source of sterile syringes, research in cities has identified moral, legal and ethical barriers that preclude over-the-counter (OTC) sales to people who inject drugs (PWID). The current study builds on prior urban-based research by elucidating (1) pharmacy OTC policies and (2) pharmacists\u27 rationale for, and barriers and facilitators to, OTC syringe sales in a US rural area hard hit by drug-related epidemics. METHODS: We conducted 14 semi-structured interviews with pharmacists recruited from two Eastern Kentucky health districts. Interview domains included experiences with, and attitudes toward, selling OTC syringes to PWID. Constructivist grounded theory methods were used to analyze verbatim transcripts. RESULTS: Most pharmacists operated restrictive OTC pharmacies (n = 8), where patients were required to have a prescription or proof of medical need to purchase a syringe. The remainder (n = 6) operated open OTC pharmacies, which allowed OTC syringe sales to most patients. Both groups believed their pharmacy policies protected their community and pharmacy from further drug-related harm, but diverging policies emerged because of stigma toward PWID, perceptions of Kentucky law, and belief OTC syringe sales were harmful rather than protective to the community. CONCLUSION: Our results suggest that restrictive OTC pharmacy policies are rooted in stigmatizing views of PWID. Anti-stigma education about substance use disorder (SUD), human immunodeficiency virus (HIV), and Hepatitis C (HCV) is likely needed to truly shift restrictive pharmacy policy

Factors that Influence Enrollment in Syringe Services Programs in Rural Areas: A Qualitative Study among Program Clients in Appalachian Kentucky

BACKGROUND: Enrolling sufficient number of people who inject drugs (PWID) into syringe services programs (SSP) is important to curtail outbreaks of drug-related harms. Still, little is known about barriers and facilitators to SSP enrollment in rural areas with no history of such programs. This study\u27s purpose was to develop a grounded theory of the role of the risk environment and individual characteristics of PWID in shaping SSP enrollment in rural Kentucky. METHODS: We conducted one-on-one semi-structured interviews with 41 clients of 5 SSPs that were established in rural counties in Appalachian Kentucky in 2017-2018. Interviews covered PWID needs, the process of becoming aware of SSPs, and barriers and facilitators to SSP enrollment. Applying constructivist grounded theory methods and guided by the Intersectional Risk Environment Framework (IREF), we applied open, axial and selective coding to develop the grounded theory. RESULTS: Stigma, a feature of IREF\u27s meso-level social domain, is the main factor hampering SSP enrollment. PWID hesitated to visit SSPs because of internalized stigma and because of anticipated stigma from police, friends, family and healthcare providers. Fear of stigma was often mitigated or amplified by a constellation of meso-level environmental factors related to healthcare (e.g., SSPs) and social (PWID networks) domains and by PWID\u27s individual characteristics. SSPs mitigated stigma as a barrier to enrollment by providing low threshold services in a friendly atmosphere, and by offering their clients program IDs to protect them from paraphernalia charges. SSP clients spread positive information about the program within PWID networks and helped their hesitant peers to enroll by accompanying them to SSPs. Individual characteristics, including child custody, employment or high social status, made certain PWID more susceptible to drug-related stigma and hence more likely to delay SSP enrollment. CONCLUSIONS: Features of the social and healthcare environments operating at the meso-level, as well as PWID\u27s individual characteristics, appear to enhance or mitigate the effect of stigma as a barrier to SSP enrollment. SSPs opening in locations with high stigma against PWID need to ensure low threshold and friendly services, protect their clients from police and mobilize PWID networks to promote enrollment

Will HIV Vaccination Reshape HIV Risk Behavior Networks? A Social Network Analysis of Drug Users\u27 Anticipated Risk Compensation

Background An HIV vaccine could substantially impact the epidemic. However, risk compensation (RC), or post-vaccination increase in risk behavior, could present a major challenge. The methodology used in previous studies of risk compensation has been almost exclusively individual-level in focus, and has not explored how increased risk behavior could affect the connectivity of risk networks. This study examined the impact of anticipated HIV vaccine-related RC on the structure of high-risk drug users\u27 sexual and injection risk network. Methods A sample of 433 rural drug users in the US provided data on their risk relationships (i.e., those involving recent unprotected sex and/or injection equipment sharing). Dyad-specific data were collected on likelihood of increasing/initiating risk behavior if they, their partner, or they and their partner received an HIV vaccine. Using these data and social network analysis, a post-vaccination network was constructed and compared to the current network on measures relevant to HIV transmission, including network size, cohesiveness (e.g., diameter, component structure, density), and centrality. Results Participants reported 488 risk relationships. Few reported an intention to decrease condom use or increase equipment sharing (4% and 1%, respectively). RC intent was reported in 30 existing risk relationships and vaccination was anticipated to elicit the formation of five new relationships. RC resulted in a 5% increase in risk network size (n = 142 to n = 149) and a significant increase in network density. The initiation of risk relationships resulted in the connection of otherwise disconnected network components, with the largest doubling in size from five to ten. Conclusions This study demonstrates a new methodological approach to studying RC and reveals that behavior change following HIV vaccination could potentially impact risk network connectivity. These data will be valuable in parameterizing future network models that can determine if network-level change precipitated by RC would appreciably impact the vaccine\u27s population-level effectiveness

Enhancing Timeliness of Drug Overdose Mortality Surveillance: A Machine Learning Approach

BACKGROUND: Timely data is key to effective public health responses to epidemics. Drug overdose deaths are identified in surveillance systems through ICD-10 codes present on death certificates. ICD-10 coding takes time, but free-text information is available on death certificates prior to ICD-10 coding. The objective of this study was to develop a machine learning method to classify free-text death certificates as drug overdoses to provide faster drug overdose mortality surveillance. METHODS: Using 2017–2018 Kentucky death certificate data, free-text fields were tokenized and features were created from these tokens using natural language processing (NLP). Word, bigram, and trigram features were created as well as features indicating the part-of-speech of each word. These features were then used to train machine learning classifiers on 2017 data. The resulting models were tested on 2018 Kentucky data and compared to a simple rule-based classification approach. Documented code for this method is available for reuse and extensions: https://github.com/pjward5656/dcnlp. RESULTS: The top scoring machine learning model achieved 0.96 positive predictive value (PPV) and 0.98 sensitivity for an F-score of 0.97 in identification of fatal drug overdoses on test data. This machine learning model achieved significantly higher performance for sensitivity (p \u3c 0.001) than the rule-based approach. Additional feature engineering may improve the model’s prediction. This model can be deployed on death certificates as soon as the free-text is available, eliminating the time needed to code the death certificates. CONCLUSION: Machine learning using natural language processing is a relatively new approach in the context of surveillance of health conditions. This method presents an accessible application of machine learning that improves the timeliness of drug overdose mortality surveillance. As such, it can be employed to inform public health responses to the drug overdose epidemic in near-real time as opposed to several weeks following events