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.

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’s 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’s 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’s 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’s 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.

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Existing literature attests to water, sanitation, and hygiene (WASH) inequities among people experiencing homelessness (PEH) in the United States, but there is a dearth of research on such issues in rural areas. Homelessness is an emerging public health concern in rural areas where homelessness is on the rise, infectious disease outbreaks are becoming increasingly common, and PEH face unique WASH-related challenges compared to their urban counterparts. We conducted an exploratory study to understand the impacts of unmet WASH needs among rural PEH and their intersection with drug use through in-depth interviews (n = 10). Eligible participants were 18 years or older, lived in one of five Central Appalachian counties, and had experienced homelessness in the previous six months. Using thematic analysis, we identified factors that inhibit WASH access, and adverse health and well-being outcomes that result from unmet WASH needs. We also explore how WASH experiences compare among rural PEH who self-reported drug use to those who did not. Our findings revealed that factors at multiple levels inhibited WASH access, including stigma and place-based characteristics, which contributed to the adverse physical, mental, and emotional health of PEH. Comparisons between PEH who used drugs to those that did not revealed the intricate relationship between WASH, homelessness, and substance use in communities impacted by the opioid epidemic. Expanded WASH facilities that are safe and available with no prerequisites can address inadequate access among rural PEH and collaboration with harm reduction services may be advantageous to reach those who inject drugs.

Objectives Rural communities in the United States are increasingly becoming epicenters of substance use and related harms. However, best practices for recruiting rural people who use drugs (PWUD) for epidemiologic research are unknown, because such strategies were developed in cities. This study explores the feasibility of web- and community-based strategies to recruit rural, young adult PWUD into epidemiologic research. Materials and Methods We recruited PWUD from rural Kentucky to participate in a web-based survey about opioid use using web-based peer referral and community-based strategies, including cookouts, flyers, street outreach, and invitations to PWUD enrolled in a concurrent substance use study. Staff members labeled recruitment materials with unique codes to enable tracking. We assessed eligibility and fraud through online eligibility screening and a fraud detection algorithm, respectively. Eligibility criteria included being aged 18-35, recently using opioids to get high, and residing in the study area. Results Recruitment yielded 410 complete screening entries, of which 234 were eligible and 151 provided complete, nonfraudulent surveys (ie, surveys that passed a fraud-detection algorithm designed to identify duplicate, nonlocal, and/or bot-generated entries). Cookouts and subsequent web-based peer referrals accounted for the highest proportion of screening entries (37.1%, n = 152), but only 29.6% (n = 45) of entries from cookouts and subsequent web-based peer referrals resulted in eligible, nonfraudulent surveys. Recruitment and subsequent web-based peer referral from the concurrent study yielded the second most screening entries (27.8%, n = 114), 77.2% (n = 88) of which resulted in valid surveys. Other recruitment strategies combined to yield 35.1% (n = 144) of screening entries and 11.9% (n = 18) of valid surveys. Conclusions Web-based methods need to be complemented by context-tailored, street-outreach activities to recruit rural PWUD.