Typology of Street Substance Users' Communities in Tehran, Iran.

BACKGROUND: There are different street substance users' communities (SSUCs). Typology of SSUCs in Tehran, Iran was approached in this qualitative study.
METHODS: Using content analysis and saturation principles, 22 street-outreach workers were recruited and interviewed. Data were analyzed using open, axial, and selective coding.
FINDINGS: Three types of SSUCs were identified. SSUCs were different in geographic location, the community hierarchy, roles of residents and its function during a 24-hour period. Type 1: surrounded naturally by trees, mountains etc. or located in places like canals that make them not simply reachable, a nonresident smuggler (or a small group of smugglers) has the most power in its hierarchy, works 24 hours with at least two shifts, structured with special roles (nonresident smuggler, the Balancer, sex-worker, seller, armed guard, resident substance users and nonresident costumers). Type 2: mostly located in the city gardens, several nonresident smugglers with limited power, works 16 hours or less in a day, semi-structured with roles of nonresident drug dealer, sex-worker, resident substance users and nonresident costumers. Type 3: houses that their landlords are the resident drug dealers and let the costumers to use drug in the house. The substance users have to leave the house after using drug. The house is open less than 24 hours a day.
CONCLUSION: Strategies for delivering harm reduction services in different types of SSUCs should be modified according to characteristics of these communities.

Introduction

Street substance users (SSUs) are drug users who either have no place to sleep, or sleep in public or private shelters. There is no estimation of the number of SSUs in Tehran, Iran. Studies support the idea that injection drug use is contributing to the increased spread of human immunodeficiency virus (HIV) and viral hepatitis B and C among Iranian homeless.1-3 Therefore, harm reduction programs should be expanded, particularly among homeless injection drug users.2 Iran is one of the pioneering countries in harm reduction in Middle East and North Africa (MENA) region4 and has a unique model for treatment and harm reduction program.5

Although it is argued that the use of harm reduction may be affected by the characteristics of injected drug users (e.g., living partners and geographical location),6 and the culture and community of this group of people plays an important role in how the outreach workers deliver harm reduction services, the communities of SSUs have not been investigated in Iran. Homeless people who have high risk behaviors (e.g. vulnerable women and/or intravenous drug users) are considered as important bridging population for driving HIV epidemics,6,7 therefore, it is necessary to increase their access to harm reduction services.8

As a client-oriented and community-based harm reduction method, outreach allows health and social services to be delivered to communities and clients in their own settings without the need for them to enter static services.9,10 Outreach program is a key component of harm reduction programs and ensures interventions reach all who need them. The World Health Organization (WHO), Joint United Nations Program on HIV and AIDS (UNAIDS) and United Nations Office on Drugs and Crime (UNODC) have highly recommended outreach programs as an effective intervention for HIV prevention.8

Street Substance User Community (SSUC) is a group of SSUs that join together to use drugs in a special place. SSUs may stay in these places for a long time. Community involvement is necessary to deliver harm reduction services and identify SSUCs structure and it is essential to involve the community and design successful harm reduction programs. In a comprehensive review of literature, we did not find studies that have been conducted to explore the typology of SSUCs. Therefore, the aim of this study was to describe the typology of SSUCs.

Methods

To answer the research questions, we used an inductive approach to qualitative content analysis.11

This study was conducted from March to August 2016 among front-line harm reduction staff, supervisors, and administrators in Tehran. Harm reduction organizations provide services to SSUs through outreach programs. Some of the staffs in these organizations are ex-addicts. The number of participants was determined based on saturation principles (n = 22). Data was collected through Focus Group Discussions (FGDs). Each FGD incorporated several key questions or open-ended statements beginning with general questions, gradually progressing to more specific ones. Probing was performed according to the reflections of group members, concerning their knowledge and experiences of providing services in SSUCs. FGDs ranged in length from approximately 90 to 120 min.

All FGDs were recorded, transcribed verbatim, and analyzed based on a content analysis approach.11 Data analysis took place simultaneously in order to identify ideas, which then guided the next FGD. An initial analysis of each FGD was conducted before the next FGD and if important issues emerged, these were then brought up in the next FGD. The research team carefully read the texts to obtain an overall understanding of the full text. Then the interview transcriptions were compared with the recorded digital files for accuracy. During the open coding phase, all the FGDs were read several times, and keywords or phrases and facts in the text were noted. Data collection process was continued until saturation of each concept was reached and further data collection failed to contribute new information. During the FGDs, any identified concepts were discussed until saturation.12-14 The authors started open coding by reading each transcript. After completion of the open coding, the preliminary codes were determined that emerged from the text and then the remaining transcripts were coded with the established preliminary codes. When the authors encountered data that did not fit an existing code, new codes were added. In the next steps, similar codes were grouped and placed into categories.

Several techniques were also employed in order to establish trustworthiness of the data collection and analysis, including constant comparison, member checks, and peer debriefing. The authors returned to the data several times during the analysis to verify and develop categories (constant comparison). A summary of the primary results was discussed with some of the participants to check whether the results were in accordance with their experiences (member check) and the emergent codes and categories were discussed continuously between the lead author and the co-authors (peer-debriefing).12-14

The study was approved by the Ethics Committee of Iranian Scientific Association of Social Work (case number: 95/A/534). Participation in the research was confidential, anonymous, and voluntary. All participants were informed about the research project by an oral presentation. The research team confirmed that participants understood their rights by a member check.

Results

The demographic and background characteristics of the 22 outreach workers are described in table 1. Majority of the participants were men (72.8%), worked in shelters (81.9%), had 1-3 years of experience in harm reduction (45.0%) and reported 12 years of successful education (50.0%). Data analysis revealed three main SSUC types which were named as prototypes in this research: Farahzad, Shush and Kholazir types of SSUCs.

Table 1

Demographic profile of the study participants

Variables		n (%)
Gender	Women	6 (27.2)
	Men	16 (72.8)
Education (year)	< 12	4 (18.1)
	12	11 (50.0)
	> 12	7 (31.9)
Workplace	DIC	4 (18.1)
	Shelter	18 (81.9)
Experience in harm reduction (year)	1-3	10 (45.0)
	4-6	8 (36.9)
	7-12	4 (18.1)

DIC: Drop in center

Type 1. Farahzad type of SSUC: Farahzad type of SSUCs are surrounded naturally by trees, mountains, etc., or located in places like highways or canals that make them not simply reachable. It is too difficult and sometimes dangerous for nonresidents to go to these SSUCs. Most of these SSUCs have an armed guard that has been employed by the SSUC owner(s) and monitors all of the community events and threats. The armed guard provides the security of drug dealing process in Farahzad type of SSUC. The especial locations of such SSUCs let the armed guards to inform drug sellers to escape from the police.

Outreach worker, 35-year old woman, 6 years of harm reduction experience:

"The owners of a Patoq (SSUC) do not come and stay there. The Balancer is a person who is drug user and is employed by the owner of the Patoq and has the highest level of power after the owner… He decides how to deal with substance users. For instance, he could decide about discounts or bartering drugs for stolen goods, etc."

Outreach worker, 53-year old man, 12 years of harm reduction experience:

"… There are some Patoqs which are impassable. For example, the most organized Patoq was named Ali-Baba in Niyayesh [highway] before Yadegar-e-Emam, in the right side there is a Patoq which has an impassable way… They can inform that the police are near to the Patoq at least 15 minutes before the police pass the way… They can run away or stash everything…"

SSUC owner is a smuggler (or are a small group of smugglers) who is not resident of the SSUC but manage it by employing the drug sellers (who is the internal manager of SSUC) and armed guard. Most of Farahzad type of SSUCs' names refer to their owner. Farahzad type is the most organized SSUC and there is a special hierarchy in this type of SSUC (Figure 1).

Figure 1

Level of power in Farahzad type of street substance users' communities (SSUCs)

The owner of SSUC has the most power in its hierarchy and children and women substance users and sex workers have the lowest power. The owner rents the SSUC to drug sellers. SSUC works 24 hours with at least two shifts which each shift is managed by a drug seller.

Although there are some resident substance users in Farahzad type of SSUCs, nonresident costumers come to SSUC to buy and use drugs. A resident substance user may not leave the SSUC for months because everything he/she needs for drug use is ready in SSUC. Some peddler substance users sell all things necessary for drug use (e.g. pipe, foil, and lighter).

Director of harm reduction center, 38-year old man, 11 years of harm reduction experience:

"We go to Farahzad valley Patoqs at nights … there is a Patoq that its name is Changiz … someone sells foil, someone sells lighter, someone sells pipe … he yells Pipe … Pipe!"

There are some women substance users in Farahzad type of SSUCs. Mostly they are supported by a man who is their partner and responsible for providing their drug and protect them from physical and sexual abuse. Women substance users may trade sex for drugs. There are also children in Farahzad type of SSUCs who use drugs and may be abused and exploited by adult substance users in or out of the SSUC.

Providing harm reduction service in Farahzad type of SSUCs is too difficult. Outreach workers should build trust before going to SSUC and assure the drug seller and armed guard that will not threat them. Outreach workers who are ex-addicts are more successful to connect to such SSUCs and provide harm reduction services.

Outreach worker, 53-year old man, 12 years of harm reduction experience:

"Going to such Patoqs are so dangerous. Once we went to a Patoq that they did not allow us to enter. They searched our pockets and backpacks to be sure that we were not police! If the armed guard feels threatened, may attack everyone including the outreach workers…"

Type 2. Shush type of SSUC: Shush type of SSUCs are mostly located in the city gardens with a flexible system which could be expanded in a large area. Several nonresident smugglers with limited power sell drugs to resident and nonresident substance users. Shush type of SSUCs are easily accessible by substance users, outreach workers and police. There is no guard in this type of SSUC and compared to Farahzad type of SSUC, it is less organized. Although Shush type of SSUCs have resident substance users, drug dealers work 16 hours or less in a day. Because a Shush type of SSUC is not secure enough, drug dealers mostly come to SSUC by motorcycles and stop there just for limited time and leave there soon.

Director of harm reduction center, 45-year old man, 12 years of harm reduction experience:

"Darvazeh-Ghar is completely different… I remember that once while we were there, someone came with a motorcycle and during a very short time distributed drugs and collected money and left there…"

Sometimes substance users are organized for a short-time in small colonies. These colonies could be collapsed when the members have no drug to use or during a police attack.

In Shush type of SSUCs, there are also women substance users and children. Sometimes homeless women substance users join to colonies and are supported by men substance users. Most of them are sex workers who exchange sex for drugs. Although street children are not residents of Shush type of SSUCs, some of them are its nonresident's costumers and sometimes they are exploited for drug dealing.

Director of harm reduction center, 63-year old woman, 12 years of harm reduction experience:

"Children under age of 12 are present there [Darvazeh-Ghar]. They are with their mom or dad…"

Most of drop in centers (DICs) and shelters have been located around Shush type of SSUCs. The outreach workers could access to the target group easily and provide harm reduction services in most of SSUCs of this type.

Type 3. Kholazir type of SSUCs: Kholazir type of SSUCs are communities which include houses in a community that their landlords are the resident drug dealers and let the costumers to use drug in their houses. The SSUs have to leave the house after using drug. The house is open less than 24 hours a day. Closed-circuit televisions (CCTV) is used to increase the security of these houses.

Providing harm reduction services in Kholazir type of SSUCs is not so easy. Most of landlords do not let the outreach workers enter their houses and SSUs leave the community soon after using drugs. A small number of harm reduction centers are located in these communities. Therefore, the costumers of Kholazir type of SSUCs have less access to harm reduction services.

Three types of SSUCs are compared in table 2.

Table 2

Comparison of three types of street substance users' communities (SSUCs) in Tehran

SSUC types	Sample	Ecological characters	Working hours	Hierarchy	Security	Roles	Harm reduction services
Farahzad	Farahzad valley (including Changiz, Mamad Deraz, etc.), Yadegar-e-Emam highway	Surrounded naturally by trees, mountains etc. or located in places like canals that make them not simply reachable	24 hours with at least two shifts	A nonresident smuggler (or a small group of smugglers) has the most power in its hierarchy	Armed guard	Resident smuggler, sex-worker, seller, armed guard, resident substance users and nonresident costumers	Hard to reach and so dangerous for providing harm reduction services
Shush	Darvazeh-Ghar, Harandi city garden	Mostly located in the city gardens	16 hours or less in a day	Several nonresident smugglers with limited power	-	Nonresident drug dealer, sex-worker, resident substance users and nonresident costumers	Accessible for outreach workers Most of harm reduction centers are located around these type of SSUCs
Kholazir	Brick kiln, behind the Garage alley	Houses that their landlords are the resident drug dealers and let the costumers to use drug in the house	Less than 24 hours a day	The resident landlords who are smugglers/drug dealers have the highest power	CCTVs	Resident smuggler/drug dealer, sex-worker, and nonresident costumers	Hard to reach for providing harm reduction services

SSUC: Street substance users' community; CCTVs: Closed-circuit televisions

Discussion

Research validates the notion that outreach programs are essential for HIV prevention among substance users.8,9 Outreach program is a community based (CB) intervention and conducting situation analysis and risk assessment are two essential activities of CB interventions. Outreach workers need to know the profile of SSUCs and be prepared for probable risks. The outreach workers also need to be trained for dealing with violence, harms and dangers they face in SSUCs and prevent and reduce the risk of injury. Outreach workers should have access to appropriate safety equipment (for example alarm devices).

Without involving influential and key persons, delivering harm reduction services in Farahzad type of SSUC will be impossible and probably dangerous. It seems that before conducting harm reduction services in this type of SSUC, it is essential to increase the influential and key persons' trust on outreach team. Outreach workers could provide harm reduction services in Shush type of SSUC for individuals or small groups of substance users without involving influential and key persons. Landlords' permission for delivering harm reduction services is needed in Kholazir type of SSUC.

Although this study has a number of limitations, we believe these results are reasonably robust, transferable and relevant for consideration in harm reduction policy development. This study focused on experiences of front-line harm reduction staff, supervisors, and administrators in Tehran and does not reflect the views of other outreach workers in other cities. Also, our study was qualitative and may suffer from all traditional limitations of such studies. Future studies can focus on recruiting a wider variety of outreach workers in other cities.

Conclusion

In conclusion, our study reveals experiences of outreach workers in SSUCs in Tehran and the study participants introduced three types for SSUCs and explained characteristics of each type. It seems community involvement and harm reduction guideline for each SSUC need to be tailored according to their characteristics. Different level of risks in SSUCs should be considered in outreach workers' training and self-care guidelines. Each identified SSUCs had a special hierarchy, security and network model which affects the methods of outreach workers' trust-making activities. The accessibility of substance users is affected by location of SSUCs. Outreach workers could easily access members of Shush type of SSUC, but accessing members of two other SSUCs could be difficult and sometimes dangerous.

Due to varieties of SSUCs, harm reduction delivering services’ strategies should be modified according to the characteristics of each community.