Process of web outreach
Thematic analysis revealed that the process of the NGO’s web outreach includes three distinct stages: initiating communication, addressing the client’s needs, and receiving feedback from the client. Within each of the stages, several important issues came up, including PWUD’s behaviors, outreach workers’ actions, and challenges faced.
The first stage of web outreach is PWUD initiating communication with web outreach workers. Different scenarios for this stage were described by the informants, depending on how PWUD contacted the NGO in Telegram.
The most common scenario for a communication commencement is when PWUD send her request in the NGO’s Telegram chat. After the request is seen, a web outreach worker contacts the PWUD in the chat or sends a direct message to her. If the web outreach worker contacts the PWUD in the chat, both the request and the worker’s response are displayed to the other members of the chat. If the web outreach worker contacts the PWUD via direct message, only the request is displayed to the other chat members. In this case, the worker’s response is seen only by the worker and the PWUD who sent the request. Web outreach workers reported that they chose between the two options of contacting the PWUD depending on the request’s content. For cases where requests regarded common information, workers chose to reply in the chat as the information potentially could be of use to the other chat members. For cases where requests required a more personal and confidential approach, workers preferred to contact the PWUD directly.
Sometimes when a PWUD sends his request in the chat, other PWUD address his request and start communicating with one another. Under such circumstances, web outreach workers join and monitor the discussion to guarantee that the request of the PWUD was addressed properly. The deputy director of the NGO notes that such instances support the development of a safe space and a sense of community among members of the chat.
“[Communication between PWUD] is friendly and fun, but it is under my strict supervision. As a moderator, I supervise such discussions and whenever rudeness appears […] I intervene and explain that this is not a space for insulting each other […] we want this space to be of maximum safety for you [PWUD].” (Deputy director of the NGO)
Telegram messenger allows its users to anonymize themselves by not disclosing any personal information to other users.
“What Telegram is good for is that you can hide your phone number, use any made-up name or a nickname, and start messaging […] you won’t be identified. Then you can write there [in the NGO’s Telegram chat] anything you want […] and you will get a response.” (Deputy director of the NGO)
In addition, web outreach workers told us that sometimes they are contacted by PWUD in Telegram outside of the NGO’s chat, via direct messages. In such cases members of the chat cannot view requests of PWUD and responses of web outreach workers. One informant noticed that they were contacted more frequently in direct messages if they had been recently active in the Telegram chat and/or channel of the NGO.
“Sometimes questions [from PWUD] appear in response to newly published content by me [in Telegram channel and/or chat]. […] I noticed that the more often I respond [to PWUD’s messages in the chat], the more messages I get.” (Web outreach worker #3)
Another web outreach worker noted that some PWUD, who contacted her in direct messages but were not members of the NGO’s chat, got her contact information from the worker’s previous clients. Those clients seemed to advertise the worker’s services among their peers, thus increasing web outreach popularity among PWUD.
“They [PWUD] often message me saying, ‘my friend told me that […] you can give me some advice or teach me about something.’” (Web outreach worker #1)
The second stage of web outreach is the actual process of addressing clients’ needs by the NGO’s workers. Either the web outreach workers provide services to the clients themselves, or if they are unable to do it, they provide clients with contact information of other workers in the NGO, who are capable of assisting PWUD.
Telegram was described as a convenient “first step” of communication between a PWUD and a web outreach worker. These initial contacts via Telegram can open the door to harm reduction services being provided, both through further online consultations or referral to offline services.
“I find Telegram convenient, but it is just a start […] Comparing it to mobile units […] there is a door, which you enter […] then a window, where you get everything you need and get tested […] Telegram is the ‘door’, it is this first step […] It is what contact with a person starts from.” (Web outreach worker #2)
Several challenges related to the second stage of web outreach work were mentioned by informants, each of them related to specifics of the services online provision. One challenge is that PWUD send their requests to web outreach workers at nighttime when web outreach workers are unable to provide immediate help. In such cases, the clients are contacted in the morning and informed about time periods when workers are not able to respond to them promptly.
“We all need some time for ourselves. Any web outreach worker, including me, is sleeping at 4 AM. What you do is just explain [that you were unavailable] and, of course, provide services according to the request.” (Web outreach worker #3)
Another challenge arises when clients record voice messages instead of sending text messages. In such instances web outreach workers may not have an opportunity to listen to PWUD’s voice messages promptly, thus the provided services are unlikely to be as immediate as the clients expect. Web outreach workers described that under such circumstances they asked clients if they could send a text message instead. Depending on their reply, counselling was offered after their text message was received or when the worker had an opportunity to listen to the voice message.
“If I get a voice message, I message the client, asking if it’s possible for them to send me a text message instead. If not, they have to wait. When I exit the subway, I’ll listen to it. Or I am working with other clients currently, and when I’m done with them, I’ll listen to it.” (Web outreach worker #3)
Another challenge was when web outreach workers were unable to understand the content of the clients’ messages. Such occurrences happened when clients did not formulate their requests clearly. In these cases, the workers either tried to clarify the request by asking additional questions or suggested discussing the request by phone. Web outreach workers noted that some clients trusted them enough to discuss their requests on the phone, while other clients refused to continue their communication with a phone call and agreed to only text-form communication, as giving their phone number would compromise their anonymity. One informant reported that some clients stopped messaging her completely after a phone call was proposed:
“[After I suggest calling the PWUD] some of them send me their phone number or they ask me to send mine. Some of them exit the chat, and don’t reply there anymore.” (Web outreach worker #3)
Phone calls were mentioned by several web outreach workers as the next step in communication between them and some of their clients. Depending on the requests of PWUD, phone calls were favored as a continuation of communication by workers because in such instances they were able to gain a better understanding of their clients’ emotions and, consequently, provide their services more effectively.
“Sometimes it is hard because you want real-life communication to understand what a person feels [...] When you talk to them in person, you see their reactions, it’s easier to monitor some moments […] [for example,] whether they are ready to open up […] In Telegram, I don’t see the person and it’s hard for me to do my job to the fullest extent if a person doesn’t call me.” (Web outreach worker #2)
The third stage of web outreach is receiving client’s feedback on provided services. Web outreach workers described this stage as being crucial to their work, as it helps them to verify whether the services that they provided were of use for their clients and whether the clients knew whom to contact if they required help in the future. One worker narrated that it was very important for her to end communication with clients by leaving her contact information:
“This is my ‘message’: I always leave my phone number no matter what the request was, so that, just in case, they will know that they can call me.” (Web outreach worker #2)
All web outreach workers reported receiving only positive feedback on their work.
Needs and services
In this section of the paper we explore the first two stages of the process of web outreach work in terms of needs of PWUD and services provided to them. We identified two major themes in regard to whether the needs can fully be met or that the needs can only partially be met via online platforms. We distinguished several sub-themes in each theme based on common requests of PWUD and matched the sub-themes with services provided by web outreach workers.
Theme 1. Needs for online only harm reduction services
The first major theme is composed of needs for harm reduction services, which can be provided to PWUD entirely online. The following sub-themes were included in this theme: minor injection drug use complications; information regarding harm reduction, HIV and HCV; information regarding at-home detoxification; information regarding the COVID-19 pandemic; general psychological support.
The most common sub-theme was treatment of minor injection complications. Injection complications were defined as “minor” if their treatment did not require the offline assistance of a doctor. Such complications included collapsed veins, blown veins, venous ulcers, varicose veins and rashes. PWID described their injection complications in text and/or by sending a photo of their injury. PWID who requested help in such instances were offered advice from web outreach workers on how PWID could treat and prevent their injuries. Medical professionals verified the advice before web outreach workers sent it to clients. In cases where web outreach workers felt that more skilled assistance was needed, they provided PWID with contact information of doctors who work at the NGO. The doctors would then could provide medical advice via Telegram.
Another common sub-theme was requesting harm reduction, HIV and HCV-related information. Nearly a sixth of requests made by PWUD concerned general information about harm reduction services provided at the NGO’s mobile units and the schedule of the mobile units. PWUD, who were taking antiretroviral therapy (ART) or wished to start ART, also requested information on the relevant schedule of the AIDS Center where ART is provided. A few clients requested information on transmission routes of HIV and HCV infections. The clients were provided with verified information on the topics, as well as with the contact information of other NGO workers, whom they could connect with should they have more specific questions.
A less common, yet still important, sub-theme was requesting information about at-home detoxification: only five clients conveyed interest in it. Web outreach workers articulated to such clients the potential risks of at-home detox, provided them with general information about medically assisted detox and shared contact information of workers, whom the clients could message regarding such issues.
Since April 2020, a number of COVID-19 information-related needs emerged. Several clients requested information on how they could enroll in a detoxification center and/or a rehabilitation program under the conditions of the pandemic. As in the previous cases, web outreach workers provided their clients with relevant and verified information in accordance with their requests.
A final sub-theme was that PWUD requested general psychological support via the Telegram IM. PWUD contacted web outreach workers to receive general psychological support concerning a number of personal issues. Common examples of PWUD’s requests included having difficulties in combatting drug addiction; expressing anxiety about repercussions of quarantine measures taken during the COVID-19 pandemic (e.g., shortages of medications); experiencing difficulties in coping with a partner’s death; and feeling anxiety about being infected with HCV. As the clients did not request help from a certified psychologist, web outreach workers provided them with advice based on their personal experience and contact information of the NGO staff whom they could message if they required additional help.
Theme 2. Needs for online and offline harm reduction services
The second major theme is comprised of harm reduction services, which cannot be provided to PWUD fully online, as some of their aspects require PWUD’s offline presence. This theme is represented with the following sub-themes of needs: getting medical, psychological, social and legal services; severe injection drug use complications; getting harm reduction services; and drug overdoses.
The most common sub-theme was getting medical, psychological, social and legal services. In nearly a third of cases in the dataset, PWUD requested help from the NGO in getting the following offline services: personal assistance in getting ART at the AIDS center, delivery of ART to PWUD’s homes, personal assistance in being hospitalized at clinics for detoxification and rehabilitation, receiving counselling from a certified psychologist, obtaining identity documents, and obtaining disability status. In such cases, web outreach workers matched PWUD with other NGO staff, who specialize in working with these specific requests. PWUD were invited to the NGO mobile unit where outreach workers initiated face-to-face communication, the PWUD’s needs were thus met offline.
Injection drug use complications in this theme were categorized as “severe” because their treatment required offline visits to a doctor. Such complications included severe cases of blown veins and venous ulcers, as well as edemas and skin abscesses. In such instances web outreach workers referred PWID to doctors at the NGO as the workers themselves were not qualified enough to provide necessary help to their clients. The doctors contacted the clients online and after consulting them invited the PWID to the NGO mobile unit to receive treatment offline or encouraged them to go to a clinic to get necessary treatment.
Another major sub-theme was PWUDs requesting help in getting specific harm reduction services: HIV testing, HCV testing, harm reduction motivational packages, and PrEP medication. Web outreach workers could not address such needs via online platforms, thus they provided PWUD with instructions regarding how they could obtain such services offline at the NGO or affiliated clinics (in the cases of PrEP medication).
Overdoses (OD) was the least common sub-theme; only four cases of OD were mentioned in the work reports. In each case, the PWUD asked for help in treating an OD. Web outreach workers provided PWUD with a link to the NGO’s “Overdose bot” in Telegram. This bot, a built-in Telegram application created by the NGO, serves as an automated service, which provides Telegram users with information on symptoms of OD, cardiopulmonary resuscitation (CPR) techniques, and medications to treat an OD. It also provides them with contact information of a doctor, whom the PWUD can contact in order to get help online. Therefore, instead of web outreach workers manually searching and sending information to PWUD, they share a link with the PWUD, who then find the necessary information themselves using the bot. In each instance web outreach workers provided their clients with a link to the bot. In two out of the four cases, PWUD had to call an ambulance for OD treatment. Thus, in addition to sending the link to the bot, the web outreach workers continued their communication with the clients until an ambulance arrived.