Research Context
There has been an increase in methamphetamine use across North America, including Canada (12,13). Methamphetamine is one of the primary drugs identified among those who died from an illicit drug overdose in BC from 2019-2021 (14). A recent study conducted among people who use harm reduction services in BC found a 12% increase in reported methamphetamine use from 2018 to 2019 (15). Prior research has shown that many people who use methamphetamine use other substances such as opioids (12,16,17). Therefore, in 2020, the harm reduction services of the BC Centre for Disease Control (BCCDC) initiated a study to explore reasons for concurrent use through in-depth qualitative interviews with people who used methamphetamine concurrently with other substances in the past month. The study's ethics approval was obtained from the Office of Behavioural Research Ethics at the University of British Columbia (#H20-01475).
The research team included academic researchers and peer research assistants (PRA). PRA and academic researchers conducted in-depth qualitative interviews using a semi-structured interview guide. The PRAs were enrolled from peer-led organizations and peer advisory groups across the province, including Professionals for Ethical Engagement of Peers (PEEP) (18). This established peer consultation team at BCCDC with representatives from across the province meets regularly and enabled ongoing input regarding study methods, interview guide, and identifying potential interviewees. PRA training and data collection for this study were conducted from August 2020 to May 2021. Table 1 summarizes the differences in research methods adapted while conducting peer-led research during the COVID-19 compared to the peer-led studies conducted before the onset of the pandemic.
REFLECTIONS ON ENGAGING WITH PEER RESEARCH ASSISTANTS
Initially, eight PRAs from the five geographic health regions across BC were involved. However, due to the challenges induced by the COVID-19 public health guidelines and other competing priorities, some PRAs were unable to complete the training or perform interviews and withdrew from PRA roles but continued to provide input or feedback via study team meetings.
The PRAs were prepared on the research ethics, methodology of conducting semi-structured interviews, and safe research protocols to implement while doing interviews in-person during the pandemic. The research ethics training comprised of supporting the PRAs to complete the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (TCPS 2: CORE) course on research ethics. The PRAs received the electronic recorders and a manual describing the steps to follow while interviewing by mail. The manual included details on participant recruitment, obtaining consent, operating the electronic recorders and steps to follow after conducting the interviews. Additional training was provided on using the electronic recorders to record interviews, transferring interview recordings on a safe server, and subsequently deleting them from the recorder, enabling the PRAs to develop new skills. Previously, practicing and observing practice interviews (i.e., fishbowl style) in person and receiving feedback was fun and a skill-developing and relationship-building activity for PRAs. Also, efficient use of time as PRAs learned together while supporting each other. However, because of the COVID-19 public health restrictions, the PRAs were unable to travel to a central location to receive in-person group training from academic researchers. Also, because of the PRA's initial lack of experience with using video conferencing software such as Zoom, most trainings were conducted by teleconferencing; this included registration and completion of the TCPS 2: CORE tutorial and obtaining certification. PRAs worked together and supported each other virtually while learning new techniques; these collaborations may have helped mitigate the stress and anxiety resulting from exposure to new knowledge and developing new skills.
An adapted 'fishbowl' learning style was implemented to prepare the PRAs to conduct semi-structured interviews virtually, where a PRA was mock interviewed by an academic researcher. At the same time, other PRAs paid attention and contributed by discussing questions and potential situations that may arise while doing the interviews. This team activity aided PRAs in gaining confidence as they practiced conducting interviews with academic researchers and discussed the interviewing techniques or tips with the team. Employing experiential workers in group settings helps allay the power differential and promote social safety due to the support experiential workers provide each other (3,5). The academic researchers also offered one-to-one training sessions when the PRAs were unable to attend group training sessions.
REFLECTIONS ON PARTICIPANT RECRUITMENT AND CONDUCTING INTERVIEWS
In general, projects led by the BCCDC have worked closely with harm reduction service providers and drug user advocacy networks. In-person participant recruitment has often been a preferred method of gaining interest from those accessing these services. However, the pandemic made participant recruitment more difficult. The PRAs faced challenges in scheduling interviews with participants who did not have phones and were in remote locations. Public health measures to avoid COVID-19 transmission prevented the PRAs from visiting rural or remote areas to recruit and interview participants. Before the onset of COVID, interviews were often conducted in an in-person focus group setting with the provision of snacks. During COVID, interviews conducted by phone quickly became an alternative whenever it was possible to do so. Yet, as many participants did not have access to a computer or a telephone that they could use for the purpose of the interview, the study team had to be creative to find ways for these individuals to participate. Strategies included collaborating with a harm reduction service in the communities that individuals resided in who would be able to provide them with access to a phone and a private and quiet space for the interview to take place. Moreover, as word spread about the study, those who had participated would assist individuals who also wanted to participate by sharing their phones with them for the duration of the interview. Evidently, a strong sense of community emerged among participants that helped with participant recruitment through word of mouth and assisted with the interview process.
COMPENSATING PRAs AND STUDY PARTICIPANTS
In accordance with BCCDC paying peers' best practice, peers should be provided with a cash honorarium in appreciation for their time and expertise immediately after completing the training or participating in interviews (19). However, because the training sessions with the PRAs and interviews with the study participants from across the province were often conducted over the phone or by Zoom, providing cash on completion of training sessions or interviews was sometimes not possible. To compensate the PRAs after training sessions, the academic research team transferred the funds electronically to most PRAs. The PRAs were also sent the honorariums to be provided to the study participants via e-transfer or Canada Post money order. The study team understood that while transferring funds electronically could be effective at times, many study participants did not have a personal banking account or email address where the honorariums could be sent. When necessary and permitted by the public health guidelines, the interviewer would travel to an agreed location to provide the participant with cash. In many ways, the problem-solving efforts between the study team and participants demonstrated a solution-focused approach and a high level of mutual respect for one another.
FUTURE DIRECTIONS
From our experience in conducting research with PWUD at BCCDC, we would like to suggest potential ways forward to enhance engagement with the PWUD in a research setting during adverse circumstances. In the future, when public health or other crises unfold (e.g., floods, wildfires), researchers will need to continually evaluate their research processes while being prepared to integrate changes and peer perspectives as necessary.
A high level of flexibility in research processes, specifically qualitative methods, allowed for greater spontaneity and creativity while presenting a myriad of learning opportunities and reflection. The COVID-19 restrictions have disrupted the access to support services that PWUD often depend on. These interviews may have been one of the few means of interaction that participants were able to have with the PRAs or their other peers. When possible, interviewers checked in with participants after interviews to determine whether participants were knowledgeable of the supports and resources currently available in the region that participants resided within. Interviewers also offered to connect participants to these if needed. Overall, these interviews were viewed as being important opportunities for participants to engage in, necessitating increased attentiveness and compassion among interviewers. The interviewers adapted active listening in which thoughtful communication were conscious of tone while avoiding language perceived as stigmatizing. It was often helpful to explain the 'why' behind the study's approaches to offer participants a sense of control and ease uncomfortable feelings and thoughts.
A high level of flexibility in research processes, specifically qualitative methods, allowed for greater spontaneity and creativity while presenting a myriad of learning opportunities and reflection. Altogether, in working closely with PWLLE, the importance of remaining open to new ideas and making changes to the overall study design cannot be understated. During the study team meetings, the interviewers discussed the challenges they faced while conducting semi-structured interviews or recruiting study participants midst of the pandemic. Changes to the study design and interview guide were incorporated to reduce the barriers peers faced while conducting these interviews. Further, identifying community-based organizations that provide harm reduction services was pivotal in our work during the COVID-19 pandemic, particularly in helping to garner attention to our study through word-of-mouth. Moreover, employing technology offered a pathway to training PRAs via teleconference, and one-to-one interviews were facilitated over the phone. This allowed us to gain verbal consent over the phone rather than through a signed consent form, and participants were able to confirm the receipt of their honorarium. Most participants were also sent the study information via email or text message for review.
Conducting over-the-phone interviews compared to in-person interviews enabled the interviewers to conduct interviews at times convenient to the participants (including late evenings and weekends). The interviewers did not have to depend on the opening hours of the local community sites to schedule an in-person interview with the participants. Moreover, interviewers located in one region of the province were able to interview participants from other geographical regions across the province. For interviews conducted in-person, mutually agreeing to meet at a public place such as a park or local coffee shop was helpful. The in-person interviews were conducted while considering the public health measures, i.e., both the interviewer and participants wore masks and maintained physical distancing. Before doing in-person interviews, the interviewers would sanitize the hard surfaces such as furniture at community sites or coffee shops. Also, to avoid sharing documents, even during the in-person interviews, the participants were asked to provide informed verbal consent regarding their participation in the study and verbal confirmation of their receipt of honorarium.
In seeking to ensure that participants received their honorariums quickly, electronic transfer payments were invaluable. Yet, there were also challenges associated with this in that many participants did not have banking access. Also, amidst the pandemic, the interviewers located in one region of the province would not be able to travel to provide cash honorariums to the participants located in other regions. In these circumstances, using the email address of a friend or harm reduction worker to transfer electronic funds was helpful. In general, interviewers exhibited tremendous flexibility in accommodating interviews and providing participant honorariums, noting that we identified developing strong collaborations with community-based harm reduction service agencies as an essential step in facilitating participant recruitment and interviews. This particular engagement strategy will likely aid future research projects in delivering honorariums to the study participants.
Over the course of our study, many PRAs, as a part of the PEEP advisory group, upgraded their technological skill and learned to use Zoom with support from staff at BCCDC. Initiating peer-led support services to enhance the capacity of the community to use video conferencing applications such as Zoom could further help in facilitating the engagement of the PWUD in research studies (20). Also, training PRAs to develop skills to conduct qualitative interviews in the context of this research project may perpetuate empowerment and increase their employability in other research projects as researchers (3,5).