Drug-related community issues and the required interventions in open drug scenes in Tehran, Iran: a qualitative study protocol.

BACKGROUND AND OBJECTIVES: Many low-income and middle-income countries experience problems with open drug scenes and drug-related community issues (DRCIs). These experiences occur in settings with varying levels of health and law enforcement initiatives, and accordingly a range of approaches are implemented to curb the problem. Most of the published literature stems from Western and high-income societies. With this concern, the present study aims to describe a planned project to explore DRCIs in the open drug scenes of Tehran, including its typology, and predisposing and reinforcing factors. In addition, the study attempts to investigate the perceptions with respect to the required interventions and barriers to their accessibility.
METHODS: To this end, the current study focuses on the Farahzad drug scene due to its structure and the difficult access to the scene by harm reduction providers. Data collection techniques encompass field observation, indepth interview and focus group discussion. Further, semistructured interviews are conducted with people who use drugs and other key informants who are engaged at this drug scene, including business, community, voluntary and statutory stakeholders, for an average of 90 min (average of 45 min for each part of the study). Furthermore, as a complementary method, field observation is performed regarding the themes of DRCIs at this scene. Then, focus group discussions are held to further describe the themes of DRCIs as well as to explore the required interventions, for an average of 90 min. Finally, the results are evaluated using qualitative content analysis. ETHICS AND DISSEMINATION: Ethical approval for the study was obtained from the Ethics Committee of Iran University of Medical Sciences, Iran. Additionally, participants are to provide written informed consent. The findings of the study are expected to play a role in promoting the current intervention. © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Our study is one of the few studies in low-income and middle-income countries in general, and the first one in Iran in particular.

In the field observation method, a wide range of drug-related community issues can be observed without perception bias.

The study will be conducted in one region only (ie, Farahzad drug scene); therefore, the results may not be generalised to other open drug scenes.

In addition, using a camera in the field as a complementary method is impossible due to the structure of the Farahzad drug scene.

Interviews with some members of the Farahzad drug scene, such as drug dealers, are difficult or impossible owing to its complex situation.

Background

The drug market is considered a new research area,1 and various explanatory causal models such as pharmacological, economic, systematic, sociological and common-cause types are available to understand this phenomenon.2 In a common-cause model, no direct relationship is observed between the drug market and its community issues, while it is related to factors including socioeconomic deprivation such as inequality, neighbourhood disadvantage, unemployment and low educational attainment. Despite the existing models, there is a need for an appropriate theoretical model that can demonstrate the dynamic relationship between the people who use drugs (PWUDs), the environment, market operation, and interventions such as law enforcement, treatment and harm reduction.2 The open drug scene is considered one of the drug market settings, along with small meeting points and hot zones.3 The typology of the open drug scenes can be conceptualised based on three dimensions, namely visibility, size and site.4 Based on dimensions, three types of open drug scenes exist, namely concentrated, disperse and hidden drug scenes.4 In many countries, the citizens living around the above-mentioned situations, as well as health and law enforcement professionals, have challenges with drug-related community issues (DRCIs).5 DRCIs refer to all drug-related behaviours, activities and conditions (eg, the disruption of public order, crime, insecurity and adverse economic consequence) that individuals or a community perceives undesirable, unpleasant, annoying, threatening or harmful.3 6

There are a variety of open drug scenes in Iran, and these include Farahzad, which is one of the open drug scenes in Tehran. According to the study by Maarefvand et al 7, Farahzad, among other drug scenes, has some unique features in terms of its site, size and structure. For instance, it is located in a valley in the north of Tehran, naturally enclosed by trees and mountains. In addition, this scene has the hierarchy and discipline of smugglers, drug sellers, watching guards (who are recruited by smugglers to monitor and provide security for drug dealing), as well as both women and men who use drugs and their children. In terms of size, a considerable resident and non-resident people use and/or deal drugs. Thus, the features of the Farahzad drug scene impede providing any harm reduction services for PWUDs.7 8

According to previous research, open drug scenes and DRCIs are addressed using different ways in various settings in different countries.9 In several countries such as Ireland, Luxembourg, the Netherlands, Belgium and the UK, the policing of community issues is integrated into the national drug policy as a key objective.10 These countries have specific legislation focusing on drug-specific community issues, for example, the Anti-Social Behaviour Act in the UK.3 Furthermore, the policies of different countries such as Iran, Hungary, the Czech Republic, France, Germany, Greece, Italy and Slovenia focus on public order, security and safety as general legislation to address public issues.3 11 For example, balancing between law enforcement and harm reduction measures is regarded as one of the most important community issues in some countries3; thus, there are also laws such as regulating dealing, transportation, possession, use of drugs and the like (eg, in Norway) with regard to combating drug-related public issues.10

Some European cities including Amsterdam, Frankfurt, Vienna, Zurich and Lisbon successfully developed a combination of harm reduction services and law enforcement.9 However, other countries such as the Islamic Republic of Iran,7 Canada,12 Ireland,10 Norway13 and Brazil5 14 are still facing open drug scenes and related community issues despite providing many treatments, harm reduction and rehabilitation services. Recently, authorities have implemented a wide variety of programmes to provide treatment and harm reduction, along with managing the community issues related to the open drug scenes in Iran. For example, they have performed actions such as drop-in centres (DICs), mobile van, outreach services, shelter, as well as urban regeneration and restriction measures such as the retention of PWUDs and dealers by the police and compulsory treatment.8

Such programmes are running in some countries such as the USA and in Canada as well. Some measures of these countries include the so-called specific restriction rules of ‘red zones’ or ‘stay out of drug area’ as barriers for PWUDs for tackling disorderly behaviours in public spaces such as panhandling and vagrancy, along with preventing the entry of PWUDs into drug scenes.15 Moreover, harm reduction programmes, such as medically supervised safer injecting facility, are simultaneously conducted to relieve the burden on the community, especially public drug use.16

The authorities are now at loss to respond to DRCIs. The lack of knowledge on the characteristics and dynamics of DRCIs is considered one main problem in this respect.17 Although similar studies are conducted in other countries using a specific method, to the best of our knowledge, the only study on open drug scenes of Tehran is about typology.7 Additionally, the State Welfare Organization of Iran is running a project entitled ‘ Rapid Assessment and Response to Highrisk Behaviors among People Who Use Drugs and Sex Workers’ in open drug scenes.18 Therefore, to manage the problems related to open drug scenes, a study will be conducted to describe the situation and the required interventions on DRCIs (which refer to a recently implemented programme described briefly before) in the open drug scene in Farahzad, Tehran, Iran. The study seeks to describe the themes of DRCIs, along with predisposing and reinforcing factors. Finally, the study attempts to explore the required interventions and the barriers to their accessibility that the key stakeholders experience in/around the open drug scene.

Methods

Study design and setting

Design

This is a qualitative study using semistructured interviews, focus group discussions and field observation methods. Data will be analysed by means of conventional content analysis.19 Similarly, an interpretivist paradigm is considered in this study20 because, according to previous research,3 the level of tolerance and perception towards PWUDs and drug-related activities in a community is a key element in understanding DRCIs. In this paradigm, the researchers assume multiple subjective realities instead of a single reality (positivist or postpositivist) and thus will design a study to describe these multiple realities.17

Setting

The study will investigate the Farahzad drug scene due to its situation which includes a high number of hangouts, its structure and the difficulties experienced by harm reduction providers.

Sample size

The number of interviews continues until data saturation occurs and the interviews no longer reveal new properties based on the comparative method of data analysis.21 22 The researchers expect to reach saturation by around 15 participants per group (ie, PWUDs and other key informants) according to the principle of theoretical saturation.23 24 In other words, an 80:20 male to female ratio is ideally taken into account in the open drug scene because it is found that 20% of the participants in the open drug scene are women.25

PWUDs include men or women over the age of 18 who meet at the Farahzad drug scene and spend their time at the scene using or dealing soft or hard drugs publicly.

Individuals who have some experiences about DRCIs or are somehow involved in the phenomenon. These key informants are local informants such as business people, police officers and residents/neighbours, as well as general informants such as experts, healthcare/harm reduction providers and authorities.

Participants are required to speak in Persian.

PWUDs and other key informants with no involvement in DRCIs.

PWUDs encompassing intoxicated individuals who prevent the interviews.

Some members of the Farahzad drug scene such as drug dealers who cannot be interviewed since it is difficult or even impossible due to the complex situation.

Characteristics of the participants

The participants (ie, PWUDs and other key informants) are selected using different sampling strategies.

PWUD samples.

Service providers in the DIC close to Farahzad are asked to provide PWUDs with a business card and set up an interview (purposeful sampling).

Outreach workers at the drug scene will distribute the same cards to PWUDs in this area (purposeful sampling).

Snowball technique is used to assure PWUDs not in contact with DIC and outreach workers are included as well. In addition, participants of the study are encouraged to identify other PWUDs at this drug scene and give them the intended business card.

The interviewed PWUDs will receive an honoraria of $15 (1 500 000 rial) to compensate for their time.26

Other key informants.

They are chosen using purposive sampling. In other words, they include a wide range of individuals and groups who have first-hand information about DRCIs by having direct experiences or providing services and implementing interventions at the Farahzad drug scene, including business, community, voluntary and statutory stakeholders.

Data collection methods

As mentioned earlier, interviews, field observation and focus groups are applied to study DRCIs. First, semistructured, face-to-face interviews (provided by the second author) are conducted with participants involved in DRCIs with five general questions (table 1). Then, open-ended questions are progressively revised following each interview based on the findings of the previous interview. The follow-up questions are reviewed and revised by an expert panel. Next, the researcher along with six to eight participants in each homogeneous group are engaged in focus group discussions.23 In a focus group discussion, group dynamics can encourage individuals to describe their views in ways that are less likely to happen in an individual interview. This results in obtaining information through interaction between participants and participants’ common understanding of the subject. Therefore, the dynamics of the group adds to the quantity and quality of information. Accordingly, group discussion is more than a series of individual interviews and thus can facilitate the expression of information concerning sensitive subjects due to common experiences.25 The researcher will take notes during the interviews and will also tape-record the interviews. Interviews are conducted by the researcher applying one of the following methods:

Table 1

Interview guide

Topic	Main question	Probe
Introduction	–
Warm-up questions(demographic characteristics and substance use)	Number of participants. Age. Gender. Marital status. Income source. Residence. History of substance use. History of treatment. History of imprisonment. Number of times using drugs at the Farahzad drug scene. History of the Farahzad drug scene emergence. Reason for choosing the Farahzad drug scene.
Main question	What are the effects of the Farahzad drug scene (in which people use and deal drugs) on your neighbourhood? What factors predispose and reinforce these effects? What types of interventions are needed to reduce these effects on this scene? What barriers do you observe regarding having access to required interventions? What barriers do you find concerning implementing the required interventions?	Personal experience, other experiences of PWUDs.
Ending	Is there anything you want to add? That’s the end of the interview. Thank you very much for your time. As I need to be sure that I appropriately got your message and to share the findings of the interview with you, when can we interview again?

PWUDs, people who use drugs.

The semistructured, face-to-face interview is conducted with PWUDs and other key informants. The interview is recorded using note-taking and audio-recording techniques.

General informants such as experts and authorities complete the interview questions.

Further, field observation is performed as a supplementary method to describe patterns at the scene. For this purpose, an observational protocol23 is developed to record information during the observation (table 2). The researcher accompanies the trained outreach workers (such as a peer group) to observe DRCIs at the Farahzad drug scene, and the peak hours of this scene are determined during the indepth interviews. The observations are undertaken at different time points of the peak hours by random start hour. Furthermore, general questions are asked to allow the participants to freely provide their perspectives on the situations, behaviours and activities during field observation, and the data are recorded by taking notes.

Table 2

Observational protocol

1. Demographic characteristics:
Date:
Time:
Geographical place:
The observation setting:
Duration of observation:
2. Information about the subject:
Descriptive notes	Reflective notes
Portraits of the participants, a reconstruction of dialogue, a description of the physical setting, and accounts of particular events or activities.	The researcher’s thoughts such as speculation, feelings, problems, ideas, hunches, impressions and prejudices.

In the current study, the observer is referred to as a ‘complete observer’. The researchers observe without participating in the study due to the conditions of the scenes (high stigma and its criminal nature) and only take notes without tape-recording in the field due to the structure of the Farahzad drug scene and the presence of the watching guard. In addition, this study uses overt observations owing to the nature of the study setting and its fewer ethical dilemmas.23

Likewise, indepth interviews and focus group discussions are conducted with participants involved in DRCIs, including PWUDs and other key informants, in order to evaluate the barriers encountered with regard to accessibility and implementation of the required interventions. The first enrolment took place on 23 August 2018, and data collection is terminated on 30 October 2019.

Data analysis

The transcriptions obtained from interviews, focus groups and observations are analysed using content analysis in order to classify a large amount of text into some categories that represent similar meaning.18 Additionally, qualitative content analysis is inductively employed due to rare previous studies on DRCIs.

The data analysis starts after the first interview and the audio-recorded interviews are transcribed verbatim. The transcripts are then reviewed by the interviewer for accuracy and coded by the research team using a consensus approach.

The first codes are extracted from the interview guide. After each interview, the research team revises the coding framework, as well as the interview questions based on new data that reflected DRCIs and the required interventions (figure 1). Then, the research team categorises these codes in a subcategorisation, generic and main categorisation, and revises them to include the emerging codes.27 Finally, the team will consider the stigma on the Farahzad drug scene to interpret the findings due to its impact on participants’ negotiation with regard to DRCIs.

Figure 1

Schematic plan of the current study.

Accordingly, the descriptive form of the field observation data on DRCIs is coded to support and depict participants’ verbal experiences with respect to this phenomenon. Therefore, DRCIs are defined by participant accounts.

Similarly, the complementary views about extracted categorisations are taken into account using the complementary views of another person about the study (peer debriefing).

The MAXQDA 12 software is used to manage the data.

Techniques for enhancing the trustworthiness

The trustworthiness of the findings in qualitative research is evaluated using four major criteria, namely credibility, dependability, transferability and conformability.28

Credibility or validity is enhanced by the following strategies:

Using different data sources of information, such as observation and interview (triangulation).

Asking the participants to confirm the accuracy of their experiences by reviewing the findings through the final report or specific categorisation (member checking).

Using peer debriefing.23

As regards dependability or reliability, the data are checked by the accurate recording of the steps and the availability of data.29 In this study, reliability is ensured by comparing the results with the other colleagues, which is referred to as cross-check codes.30

Transferability or generalisability is investigated through a rich, thick description of the participants, time in addition to data collection setting and sampling method.23

Finally, the research process (ie, tape-recorded, notes, memos and themes) is carefully documented so that the others can review it (conformability or objectivity).29

Patient and public involvement

In this research, participants who use drugs as well as outreach workers such as peer groups are involved in the recruitment by distributing business cards that include a phone number and an invitation to call for setting up an interview with other PWUDs at this drug scene. Further, based on the obtained data concerning PWUDs’ views at the Farahzad drug scene, as well as those of community, voluntary and statutory stockholders, participants are requested to confirm the accuracy of their experiences by reviewing the findings on the final report or specific categorisation in order to increase the trustworthiness of the findings.

Likewise, the researcher, together with the trained outreach workers such as a peer group, observes DRCIs at the Farahzad drug scene. Thoughts and preferences on the required interventions are requested as well. Ultimately, the participants receive the summaries of the published findings throughout the study period.

Possible results of the study

The qualitative content analysis is used to analyse the interviews and the following questions are addressed in this respect:

What types of DRCIs are there at the Farahzad drug scene?

What factors predispose and reinforce DRCIs at this scene?

What types of interventions are needed to reduce DRCIs at this scene?

What barriers do key actors at the scene see in regard to access of required interventions?

What barriers do they observe to compromise the implementation of the required interventions?

Based on these findings, an empirical typification of DRCIs is developed as it is presented at the scene.

Discussion

The findings of the present study are expected to provide new insights and information on DRCIs and required interventions in open drug scenes, especially at the Farahzad drug scene. The obtained information is also useful for law enforcement and healthcare authorities, as well as community service providers who deal with the scenes.

In addition, the findings clarify the barriers that might hinder the needed interventions, and provide the chance to elucidate the gap between needs and interventions.

Similarly, the planned description of the situation is hoped to result in improved knowledge as a prerequisite to the development of appropriate interventions on DRCIs at this open drug scene, ultimately improving the quality and accessibility of services and thus the quality of the life of PWUDs, as well as the business and residents of the Farahzad drug scene.

Ethics and dissemination

Following research ethics board approval, the key informants are required to sign the written consent form which describes the purpose and procedures of the study, along with the risks and benefits of participation. Furthermore, the researchers set up an interview in a formal and private place whenever they receive a telephone call from PWUDs. To protect the privacy of the participants, each of them is given a code number to keep their identity anonymous. The participants can as well discontinue the study at any point. Before the interview, verbally informed consent is obtained and the interviews are tape-recorded with the participant’s approval. The generated and/or analysed data sets during the current study are not publicly available because the individual’s privacy could be compromised, but it is available from the corresponding author on a reasonable request. In the observational part of the study, the purposes of the research study are explained to the observers in the fieldwork in order to build trust and better relationship with such people. Moreover, the field notes are written in English instead of in native language so that no one can read and know about the key informants and their circumstances if they find a copy of the field notes.31 Although the problem of confidentiality remains in the group discussion, participants are only called by their names, and the members are informed that the confidentiality of information is the duty of all the members of the group.28