With the increasing age of the global population, key components of healthy ageing including community, physical, and social participation continue to gain traction. However, management of the COVID-19 pandemic aimed to protect older adults and reduce the spread of the virus, this restricted community participation and reduced the opportunities for social interaction.This mixed methods study investigates community dwelling older adults’ community participation; physical activity and social interaction prior to, during, and following the COVID-19 lockdown in Adelaide, Australia. Twenty-six community dwelling older adults were monitored over three time-points between November 2018 and October 2020, with Global Positioning Systems, accelerometry and self-reported diaries. In addition, nineteen participants completed semi-structured interviews.(1) Reframing of meaning, (2) Redefining to maintain activities, (3) Revision of risk, (4) Reflection and renewal and (5) Future planning.Community participation varied across the three time points, with significant reduction in the number of trips taken out-of-home (p = 0.021), social interactions (p = 0.001) and sleep quality (p = 0.008) during restrictions. Five themes were identified to explain personal experiences of community participation during restrictions: During COVID-19 the physical and social activities of community dwelling older adults changed. Services that support older adults to adapt their activities   , considering their capacities and preferences, to facilitate community participation are required.The online version contains supplementary material available at 10.1186/s12889-023-15093-0. With the global ageing population, care for older people has become a focal point for governments, researchers and healthcare services . In 2019The management of the COVID-19 global pandemic and measures implemented to reduce the spread of the virus has restricted community participation for older adults . To prevA vast amount of research has been published detailing the impacts of COVID-19 worldwide. Following the declaration of a global pandemic by the World Health Organisation (WHO), physical activity (PA) including ‘any bodily movement produced by skeletal muscles that required energy expenditure’  and globTherefore, the aims of this mixed methods study were to:1) investigate community participation; PA and social interaction for a cohort of older adults living in the community, prior to, during, and post lockdown ,2) understand the facilitators and barriers to physical and social community participation during restrictions from participants’ perspective, and3) examine the associations between restrictions and health-related factors including quality of life, sleep quality, and loneliness.This study used a convergent mixed methods approach , quantitAustralia’s experience of the global COVID-19 pandemic, lockdowns, and social distancing restrictions varied from that of other countries, likewise the experience between states across Australia was not homogenous. To provide context, a timeline is provided in Fig. Participants were required to be aged 65 years or older, live-in metropolitan Adelaide, Australia, be able to walk independently with or without walking aids, speak and understand English and have sufficient cognition to understand study instructions. Individuals living in residential care facilities were excluded due to restrictions on community participation. Participants were recruited using flyers through local councils, community centres, organisations for older adults and via social media. Potential participants were invited to contact the Principal Investigator who screened potential eligibility over the phone. Cognitive capacity was assessed using the Standardised Mini Mental State Examination (SMMSE) prior to obtaining consent, with scores of 25 and over required to participate [The outcomes and related measures for this study have been previously published in detail elsewhere , howeverCommunity participation was measured using GPS (Qstarz BT1000XT) to calculate the number of trips away from home, type of location visited and the number of in- and out-of-home activities over three separate 7-day monitoring periods. The locations visited were identified and viewed on the street view of Google maps . The typTo provide context of community participation, self-reported participation diaries were completed by participants. These diaries reported the date, time, activity, duration, location, and social interactions that occurred outside of the home, as well as times of sleep and non-wear, an excerpt is provided in Appendix 1. This information was cross-checked against the quantitative data to identify activities and ensure accuracy of location where GPS data were missing.Physical activity was measured using wrist-worn GeneActiv triaxial accelerometers, . These devices have been deemed reliable and valid for classifying the intensity of PA in adults . Raw GenThe number of social interactions were self-reported in activity diaries by participants, allowing for the total number and location of interactions to be identified across the three monitoring periods.The Assessment of Quality of Life-8 Dimension scale (AQOL-8D)  was used‘can you describe ways you did things differently to keep active physically and socially during times of social distancing restrictions?’ A detailed interview guide can be found in Appendix 2.Participants were invited to take part in a semi-structured interview to provide their experiences of community participation prior to and during times of lockdown and social distancing. Interviews were carried out either in person  or over the phone. Questions included, The procedure, data processing and analysis have been previously published . These pTo be included in analysis, GPS data required a minimum of eight hours per day, complete for five of the seven days monitored, with accelerometer data required for at least eight hours of waking time for four days inclusive of one weekend day –34. IndiQualitative data were used to determine the validity of the quantitative results against lived experience . An inteInterviews were recorded and transcribed verbatim. Transcripts were imported into NVIVO 12 Pro for content analysis  which waAfter identifying themes from the interview data, a concurrent mixed methodology approach was used. Quantitative and qualitative data, including GPS locational data, minutes of physical activity, and self-reported activity diaries, were integrated to compare and combine the experiences of community participation for older adults. Aligned with Creswell (2018), mixed methods are useful where one data source could be insufficient to explore the complexity of a theme. An advantage of mixed methods is that the combination of methods can offset the inherent weaknesses of both quantitative and qualitative approaches, such as loss of GPS data and memory recall bias for subjective measures . This apA subsample of 27 participants from the original sample (n = 44) who completed the baseline study  participDuring the lockdown period participants took less trips out of home, compared with baseline, and the number of in-home activities increased Table .The most frequently visited locations at baseline were commercial (median (IQR)) 5.5 (3–8) followed by recreational 3 (2–7), residential 2 (0–3), local walk greenspace 2 (0–8), CBD 1 (0–3), with no visits to places of worship identified. During COVID-19 lockdown the most visited location type was commercial 6 (2–7), followed by local walk/greenspace 4 (1–10), residential 1 (0–3) with no visits to recreational, health, CBD, or places of worship identified. Post lockdown the most visited location was commercial 7 (3–10), followed by local walk greenspace 3 (0–6), recreational 3 (1–4), residential 1 (0–2) and health 1 (0–2) with no visits to CBD or places of worship detected. There was a significant difference in the number of trips taken out-of-home between monitoring periods (p = 0.012). Significant post-hoc pairwise calculations identified a reduction in the number of trips taken out-of-home from baseline to during lockdown (p = 0.021).Total minutes of MVPA reduced from baseline to lockdown for 73% (n = 19) participants, with a decrease in daily MVPA from post lockdown to lockdown for 54% of the participants (n = 14) as reported in Table Self-reported social interactions median (IQR) was 15.5 (8–20) at baseline, 9 (5–13) during lockdown and 11 (7–13) post lockdown. The locations of social interactions are provided in Table There was no significant difference in participant HRQOL across the three time-points Table . There w‘Reframing of meaning’, ‘Redefining to maintain activities’, ‘Revision of risk’, ‘Reflection and renewal’ and ‘Future planning’. The interaction between these themes, and the importance of reflection and renewal in the ongoing process of redefining community participation and future planning is illustrated in Fig. Qualitative data were collected until saturation was reached (n = 19), with five main themes emerging from the transcripts. These themes described participants’ perspectives of their community participation and identified differences in experiences between participants. The themes were ‘Reframing of meaning’ refers to changes in the meaning of activities, their setup, environment, and their importance in the lives of participants. Meanings of activities were framed in both positive and negative ways, with some acknowledging how different their social interactions were in the context of social distancing restrictions:I did see people, but it’s not the way I would normally socialise because there were no lunches with mates, and no work/volunteering-related stuff .Whilst others reported the activities they had been participating in prior to restrictions perhaps weren’t meaningful and fulfilling to them, restrictions provided the opportunity to complete other activities:I found the whole thing easy because I got jobs done… yeah, jobs that I had been waiting to do for so long, so I was grateful for the lockdown .‘good coffee’ whilst sitting down with a friend and having a chat. The process of getting a coffee became an organised, regimented activity, inclusive of incidental interactions with others, with one participant describing this made them feel special:Several participants reported that one of the hardest things was not being able to go out and get a So, every day, I would bop down and get a proper coffee, didn’t touch anything, paid in advance so that I got Rolls-Royce treatment because I was the one that had paid– they all knew my name and they made nice coffee for me, and that was a real motivator because I could say g’day to people on the way down .The importance of activities such as getting a coffee, acted as a motivator for individuals and made them realise, and appreciate the incidental social interactions they experienced when leaving the house.Following the easing of restrictions, some participants reframed the meaning of their activities in terms of what it was they liked about attending. For some, this highlighted that it was incidental chats in communal spaces that motivated them to attend:I really don’t like not being able to make a coffee – have a communal kitchen and do the communal things together. I realise that a large part of that activity was being communal, so we’d go into the kitchen and have a chat while waiting for the kettle to boil or the microwave, and they’re not allowed .The process of reframing made participants consider the value of their activities, change the way they participated and, in some cases, stop attending altogether.Redefining to maintain physical and social activity (detailed below) describes the conscious adaptations participants made to continue activities during lockdown when recreational facilities were closed. Redefining activities to ‘keep them’ was reported by 17 participants, and for some the ability to ‘redefine’ these activities was a coping mechanism closely related to feelings of control.With gyms closed and organised exercise classes cancelled some participants simply replaced their physical activities:Instead of going to work related things, I found myself going for more walks because I just needed to get out of the house .Many participants reported leaving the house with the intent to walk purely for exercise to replace previous commitments:I did go out walking, as the exercises classes I went to stopped, so I was walking about three times a week .‘not the same,’  and that exercising alone was not as enjoyable as attending a group. Many participants looked to technology to redefine their PA, using the internet to find resources:Yet some identified that the intensity was Initially I was doing a lot of exercises from YouTube on the screen, as well as walking and that was great, so I got my steps and I got my exercise .In contrast there was a portion of the cohort who made no attempt to redefine PA in their routine during this time:I was very bad. I sat on my bum and didn’t do enough, but I’ve now got a large knee brace on my right knee because various things that were going wrong with me… I didn’t exercise enough, and I don’t like exercise, I exercise because I have to, not because I want to and I’m afraid I did less .Participants were aware of the importance of social interactions and were conscious to retain them. Social interaction was maintained by increasing the effort of reaching out to others, and often re-defined using technologies that allowed for virtual face-to-face interactions:Initially I made a point of ringing two or three people every day just so I could get some human interaction… I very quickly learned how to use Zoom and talk to my daughter online and do things with my grandchildren and that kind of thing .The inclusion of social media and technologies were enjoyable for some participants during this time:We were doing lots of Facetiming. And we were having the loveliest time. Especially doing those little icons where you could stick funny faces on and things. It was good because we sort of kept in touch .The environment and social activities were redefined regularly in the community:I would talk to the neighbours, and I started doing a lot of cooking and baking. The girl in that unit is still in the workforce, she was working from home. So, I’d make something and go around and give them all something. Then she’d make something. One day, she knocked at the door and she said, “Grab a cup of coffee and a chair. We’re going to sit out on the driveway.” So, the three of us did that, and that was nice .‘glass of wine together on the street in front of our houses’ . Despite the venues, length of time, and social activities changing over this period, social interactions were prioritised. Participants planned the modifications of their activities to maintain them whilst following social distancing guidelines. However, some participants also felt that restrictions were open to interpretation and activities could be maintained if appropriate social distancing was performed:Participants reported taking part in activities they wouldn’t have previously such as having a I missed being able to go to the coffee shop, and things like this, but we found ways around that a little bit. You know, picking up a coffee, and we went and sat up at the memorial park there apart from one another, and stuff like that. That was quite enjoyable, to do that. Before, it was like, take something with you, if we wanted to go and have a catch-up, I’d cut sandwiches and we’d take a couple of chairs and sit down along the beachfront. And I found that you’re a little bit up in the air to whether that was quite allowable, but I had police go past, and they’d just smile. But there was just two of us sitting there on a chair, good distance apart. .It was apparent that participants who didn’t redefine physical or social activities experienced social isolation and feelings of loneliness:I did feel isolation and lonely at times… I would wake up about 5:00 o’clock in the morning. And suddenly you think about everything that you shouldn’t be thinking about. And it always seemed to be magnified, because you think well, I don’t know who I can talk to. I can’t go out and have a cup of coffee with anyone. So, I did find that a bit – I mean I didn’t get the tearies. But I did find it was a negative. Yes, it was a negative. And then I found I couldn’t be bothered doing the things that I wanted to do .Participants described making a conscious effort to combine their physical and social activities to maintain them. These combined activities often occurred outside to follow social distancing guidelines and were enjoyed by participants:Thank goodness I have a couple of friends who like walking, so I walked a lot in company; so we were arm’s length apart, we can still talk, but we could go for long walks and just get out in the fresh air and I’d go on my own sometimes and I’d find other people – just seeing someone else out on the street doing what you’re doing and they’re waving and saying hello even if you don’t know them, made me feel better .‘Revision of risk’ describes the process of participants estimating the likelihood of contracting COVID-19 from the activities they attended and making decisions regarding future attendance. This theme raised concerns for the future, feelings of fear and uncertainty for many participants, with some fearful of returning to previous activities:I did eventually start going to the supermarket and the chemist. But I haven’t been to any other places. I haven’t been to a shopping centre yet. I hesitate a little to go where there are a lot of people .Others made the conscious decision not to attend over concerns that social distancing was too challenging, and the risk was too great:I go to one night of dancing less a week because of that- too many people there, and I think it’s hard to keep social distance with so many crowded in the room, even though they are allowed to have them, I think it’s too close. As well as being aware of others, a lot of people don’t want to start again. You know they’re old and are a bit frightened of getting into the crowd again .Participants who had chronic illnesses were particularly fearful of returning to their activities and frustrated at others who were healthy and did not understand the importance of following the rules. This was apparent in views around vaccinations:Gardening club has re-started, but I don’t go to it because… If there is someone in there who’s got an active COVID infection, and I get it then my chances of coming out of hospital alive are small…They just don’t get it. They don’t understand it because they are relatively healthy… there are some of us who can’t mix with people who don’t vaccinate .One participant self-identified as a social person and was aware of her need for community participation. On discussing the possibility of an extended lockdown she decided that she would take a risk:I just couldn’t do it. I would take the risk. I would rather take the risk of getting COVID than being that isolated. I could do it for two weeks, quarantine you do it for medical reasons, but to do it just in case? No, I would rather take the risk and let it get me rather than just be so lonely .Participants reported being fearful of contracting COVID-19 and surprised themselves in their reluctance to return to activities that they thought they would be desperate to get back to:The Prime Minister said we strongly suggest people over 70 or anyone who’s got a pre-existing medical condition should stay home. And I thought oh damn, that’s me. So, I rang my neighbourhood watch, my Meals on Wheels coordinator and said “I’m sorry. I have to stop”, and then I sat down and cried for half an hour. I didn’t go back for a while. Eventually, when Meals on Wheels said, “we’re happy to have people back”, I said “no, I think I’ll wait a little bit longer” .‘Reflection and renewal’ during the experience of lockdown and social distancing was described, with participants identifying activities they missed:I missed my recitals. I noticed it particularly last week because I went to the theatre for the first time in 6 months .‘I didn’t feel the obligation to go and interact with people. It was wonderful’ . This reflection for some allowed them to identify changes they would like to make into the future, ‘maybe I don’t want to do the pace that we did before’ .Others noted the things they enjoyed during social distancing, ‘I have signed up to complete 5 kilometres every day for 10 days’  and some made the effort to upskill their use of technology, ‘I’ve learned the - using remote sort of teleconferencing skills, that’s great’ .Many participants decided to take up new activities that they had always wanted to do On reflection, participants were able to identify positives that had come out of social distancing:I noticed everybody is cautious about hand sanitising and social distancing. So, I think that is a positive .For most participants, reflections turned into renewed appreciation for the activities they were able to return to:I felt deprived because of no symphony, no seniors club, no entertainment, no library because I love my volunteering and thank God I am back to that! .On reflection, several participants mentioned other people they were concerned for, including children’s education and those less healthy and more vulnerable than themselves:I’m quite concerned about some of the clients that I’ve been serving… So, I’ve met people, we would do a library delivery. They knew approximately what time we were coming, and we roll up about 11:30 and there are people still in pyjamas. No reason to get up and to get moving. It’s a bit sad isn’t it? So, I am concerned about some of the older folk who I work with that nobody is reaching to them in any way .What would you like to see in place to help you keep in touch with people and maintain your physical activity should we experience a second lockdown?’ Overall, participants found it difficult to articulate. Those who successfully redefined their activities during social distancing restrictions reported that they would do the same again:In response to the question relating to future planning, ‘We’re like this for the next 12 months, so I’ve adjusted to that, I’m quite happy to be doing things and being very careful, very, very careful .Others suggested that having means of connection with others was vital, and that technology addressed this need:Good technology, good internet, cheaper technology because I spent a lot of money upgrading technology .Reframing of meaning, Redefining to maintain activities, Revision of risk, Reflection and renewal and Future planning,’ highlighting the variation in experiences and importance of maintaining community participation.This mixed methods study investigated community participation in community dwelling older Australians before, during and after COVID-19 lockdowns. The recruited sample of participants were representative of Australian adults of similar age in health status, levels of obesity and HRQOL , 46. DurThis study found mixed results for how participants redefined their activities to maintain community participation during restrictions relating to COVID-19. The reduction in the number of trips out-of-home during lockdown was apparent in both quantitative and qualitative data. Conscious attempts to follow the rules were evident for older adults to protect themselves and others they deemed more vulnerable. The number of participants who didn’t leave the house for a whole day increased during lockdown, highlighting that the government’s recommendation to ‘stay home’ were followed. These findings reflect Finnish older adults who reduced the number of destinations they visited during times of social distancing .Commercial locations were visited most frequently across all three time points by older adults, as participants were dependent on these locations to obtain provisions. Likewise, individuals in France experienced consumer attachment, seeking commercial settings for familiarity, authenticity, and security . HoweverConnections to green space has previously been established as positive for the physical, social, and mental health of older adults . GloballA non-significant reduction in minutes of MVPA was found across the time points, which corresponds with 79% of the sample who were less physically active during lockdown. These individuals did not adapt their activities to maintain PA. However, 21% of the sample did adapt to maintain their PA, and on occasion increased it. The vast difference between participants is highlighted by the substantial variation of minutes of MVPA during restrictions, and contrasting personal experiences and approaches during this time, which may explain the insignificant overall results. The reduction of activity in this study is higher than Japanese older adults during COVID-19 restrictions where 47% reported reduced activity levels . This diOverall, HRQOL scores did not change significantly for this sample. Similar findings were reported with US older adults, however, increased feelings of anxiety and less satisfaction with participation were found . In thisSleep quality significantly reduced from baseline to lockdown. However, at baseline, numerous participants wore GeneActiv devices during extreme summer temperatures which could have affected these results. The increase in sleep quality between baseline and post lockdown may be due to ‘less worry’ as the situation improved. However, this was not evident in the qualitative data or in other research that found significant reduction in fatigue during times of lockdown .Loneliness levels did not change significantly, however, the sample were not classified as lonely at baseline and the de Jong Gierveld loneliness scale was likely not sensitive enough to detect changes. Despite the validity and reliability of the de Jong Gierveld loneliness scale, it has been acknowledged that the inclusion of positive or negative wording can change the response style , which iWhen analysing the results, there were two different approaches to social distancing restrictions. One group accepted that they could not participate in their usual activities and stayed home performing sedentary activities such as crafting and online gaming and the other group adapted their activities to retain them. Those who adapted generally reported more positive experiences and considered others worse off than themselves, which Verhage et al. (2021) suggested allowed older Dutch adults to maintain both self-esteem and self-confidence during COVID-19.During times of lockdown older adults relied on technology to maintain social connections . DespiteWhilst this study offers a detailed rich picture of community participation and the changes during and following COVID-19, there are limitations that should be acknowledged. The experiences reported mainly represent active older females who lived alone and therefore limits the generalisability of results. The strict lockdown restrictions were only enforced for five weeks in South Australia; therefore, the experiences would perhaps be different in other states where lockdowns were prolonged. Following participant drop out from the baseline sample and large SD of MVPA detected, this research is underpowered to find significant differences in the levels of physical activity for this population. In addition, the baseline levels of MVPA and sleep quality could have been affected by extreme temperatures during data collection meaning participants may have been more active if data collection were carried out over a cooler period . Despite these limitations this research reports a unique and important perspective of changes to community participation during a period of lockdown.This research suggests that individuals who adapted their community participation both physically and socially coped better during times of social isolation. It is therefore possible that supportive services aimed at assisting older adults to modify, reframe, and adapt their activities would be useful to reduce loneliness and social isolation. Further research with larger, more diverse samples is required to direct future intervention, as is deeper questioning to determine why older adults changed their behaviours during this time.This study suggests that during COVID-19 lockdown, the physical and social activities of community dwelling older adults changed. Older adults reduced their trips out of home yet maintained their trips to commercial locations. Some participants acted to redefine and reframe their activities to maintain them following the closure of recreational facilities, yet others accepted the loss of activities and reported feelings of loneliness and social isolation which they were unable to overcome. This study reports on a sample of older Australian adults who were not lonely at baseline, which raises concerns for those who were socially isolated and/or lonely prior to lockdown and social distancing restrictions. The effects of COVID-19 lockdowns and social distancing on older adults, in lesser health who were frail and vulnerable remains unknown. It is important to identify older adults at increased risk of social isolation. Further research is required to determine whether the experiences of more vulnerable older adults reflect those discussed in this study. The results of this study indicate opportunities to expand public health initiatives to promote healthy ageing in environments such as commercial establishments, where older people are commonly visiting. Furthermore, initiatives that assist older adults to reframe and redefine their activities to adapt to their capacities, to maintain participation and the subsequent health benefits, need to be considered. Fundamental is the codesign of these initiatives with older people to increase both the understanding of their expectations and behaviours to inform future policy, thereby maximising their health and wellbeing through participation.Below is the link to the electronic supplementary material.Supplementary Material 1Supplementary Material 2


Hypertrophic obstructive cardiomyopathy is a complex entity that often involves the mitral valve leading to eccentric mitral regurgitation. Utilizing multimodality imaging, assessing the severity of mitral regurgitation, and phenotyping the type of myocardial hypertrophy are achievable with certainty. We describe a case of a 42-year-old male who presented with palpitations and was ultimately diagnosed with hypertrophic obstructive cardiomyopathy with a mitral regurgitation. The torrential mitral regurgitation jet was so severe that it was “circumnavigating” the left atrium. In addition, we also draw historical parallelism with Magellan’s heroic “circumnavigation” of the globe as we celebrate 500 years of his journey. Furthermore, we also describe the multimodality assessment of hypertrophic obstructive cardiomyopathy utilizing transthoracic echocardiography and cardiac magnetic resonance imaging. We discuss the challenges in quantifying such severe mitral regurgitation with any individual imaging modality. Hypertrophic cardiomyopathy (HCM), previously thought to be a rare disease, is now estimated to have a prevalence of one in 200 to one in 500 . It is aA 42-year-old male presented with sudden onset dyspnea and palpitations. His heart rate was 160 beats per minute on his smart watch, which prompted him to seek immediate attention. He was found to be in atrial fibrillation with rapid ventricular response and endorsed profound dyspnea on minimal exertion over the previous six months. A TTE was obtained for further evaluation. Several important findings were noted, but chief among them was the presence of a markedly hyperdynamic left ventricle (LV) with apical and mid cavity obliteration with resultant bileaflet SAM. The result of this perturbed physiology generated severe torrential eccentric MR , angling medially and redirected toward the mitral valve, effectively “circumnavigating” the LA. However, “circumnavigation” is a unique term that has never before been utilized to describe MR. Indeed, “circumnavigation” had been heretofore universally used to solely to describe one penultimate observation: the Herculean effort of Ferdinand Magellan to circumnavigate the globe in 1522.History of “circumnavigation”Magellan, an adventurous Portuguese sailor who studied navigation and astronomy, having lost favor with the Portuguese king, King Manuel I, defected to Spain with hopes of completing that work which Christopher Columbus had failed to complete in 1492, namely, to find the Spice Islands. Though that was not his ultimate goal, he was convinced that by sailing west instead of going east as the Portuguese, by the Treaty of 1494, owned all lands to the east. Magellan, generations before his time, believed that he could map out a new route to Indonesia and India and, by finding the Spice Islands, claim certain fame and even fortune ,9. MagelHis colleagues endeavored to retreat from the Philippines, losing another ship and then finally another before they limped their way back to Spain but not before collecting samples of precious spices, discovering a new galaxy named the Magellanic Clouds in the Southern Hemisphere, and mapping a new route for European trade and the first to set the stage for a modern global economy. Limping into Spain with just 19 sailors and just one leaking dilapidated ship, Victoria, Magellan’s fledgling crew had achieved what Columbus could not ,9. The sThough, not as exciting as Magellan’s circumnavigation of the globe, torrential MR circumnavigating the left atrium epitomizes the term and is a worthy descriptor to depict unequivocal severity of MR. While “coanda effect” is sometimes used to describe this finding, the term fails to capture the enormity of such eccentric torrential MR depicted far more vividly with “circumnavigation.” Fitting in this description is the irony that Magellan circumnavigation occurred almost 500 years ago; we do not have to wait so long to invoke his namesake’s accomplishment to denote torrential MR.


Patterns of movement, heterogeneity of context, and individual space-time patterns affect health, and individuals’ movement throughout the landscape is shaped by addiction, meeting basic needs, and maintaining relationships. Place and social context enable or constrain behavior and individuals use social networks and daily routines to accomplish individual goals and access resources.This article explores drug use as part of daily routines and daily paths among people who inject drugs in Dnipro City, Ukraine. Between March and August 2018, we interviewed 30 people who inject drugs living in Dnipro City, Ukraine. Study participants completed a single interview that lasted between 1 and 2 hours. During the interview, participants described their daily routine and daily path using a printed map of Dnipro as a prompt. Participants were asked to draw important sites; give time estimates of arrival and departure; and annotate on the map the points, paths, and areas most prominent or important to them. Participants also described to what extent their daily routines were planned or spontaneous, how much their daily path varied over time, and how drug use shaped their daily routine.We identified 3 major types of daily routine: unpredictable, predictable, and somewhat predictable. Participants with unpredictable daily routines had unreliable sources of income, inconsistent drug suppliers and drug use site, and dynamic groups of people with whom they socialized and used drugs. Participants with predictable daily routines had reliable sources of income, a regular drug dealer or stash source, and a stable group of friends or acquaintances with whom they bought and/or used drugs. Participants with somewhat predictable daily routines had some stable aspects of their daily lives, such as a steady source of income or a small group of friends with whom they used drugs, but also experienced circumstances that undermined their ability to have a routinized daily life, such as changing drug use sites or inconsistent income sources.Greater attention needs to be paid to the daily routines of people who use drugs to develop and tailor interventions that address the place-based and social contexts that contribute to drug-use related risks. Ukraine continues to have one of the highest HIV infection rates in Europe, with most HIV infections among people who inject drugs (PWID) and their sex partners –4. RatesAn activity space approach, which explores the local areas in which individuals habitually move during the course of daily activities, posits that understanding where PWID sleep, work, relax, socialize and use drugs can deepen our understanding of where risky behaviors such as syringe sharing are more likely to occur and where to locate to harm reduction services such as syringe exchange programs . StudiesPrevious studies on the relationship between place, social networks, and drug use have focused on quantitative dimensions of place, such as the correlation between measures of activity space distance and risk behaviors such as syringe sharing , 32, 33 Between March and August 2018, we interviewed 30 PWID living in Dnipro City, Ukraine. Dnipro, with a population of about 1 million people, is Ukraine’s fourth largest city and a large industrial center in the southeastern region. Dnipro is the main commercial and industrial center of eastern Ukraine and serves as a strategic junction between Ukraine, Russia, and other European countries. Between 11,000 and 30,000 PWID live in Dnipro, with an estimated HIV and HCV prevalence among PWID being 39.7 and 63.8% respectively , and it’ll be my treat.I met [my friend] by accident. Well, he was going for stuff Similarly, Oleg, 42 years old, was unemployed and made money “in any possible way,” including stealing and reselling goods and or injecting other people (in exchange for drugs or money). He spent most of his time “on the street” and “on the move.” He explained how these chance encounters related to drug purchase and use:Unpredictable daily routines often fostered larger networks of people with whom to potentially buy and use drugs, a greater number of places to buy and use drugs, and many places—both public and private—to inject. In these situations, PWID potentially interacted with a variety of individuals throughout the day. Engagement in the informal economy often meant that who showed up to a job site could change and they became acquainted through their shared goal of obtaining drugs. They often injected with whomever was “around” in a drug purchase or use site out of convenience, even if they preferred to use alone or privately at home. The unpredictable daily routines could also relate to periods of intense drug use and staving off withdrawal that demanded greater income generation than some wage work would afford.R: Everything comes down to money … We will help each other, so to speak … All the time lately. Because, you understand, even 100 hryvnias a day for a person who doesn’t work … I can give [the drugs] to that person, and then I’ll use it on my own, and he’ll use it on his own. Well, it depends. There are people who I will definitely not bring home. But if it is an old friend, I can bring him home or sit there for half an hour and talk about something, drink tea...(drugs) outside your home?I: Does it happen that you use R: No, it’s difficult now … To inject in bruises - it’s difficult. It’s cold now, veins hide … I don’t inject in the thick veins, which you can quickly inject in … Sometimes you can mess around for an hour …. It’s stressful, of course.Daily routines characterized as predictable included participants who often had reliable sources of income, a regular drug dealer or stash source, and a stable group of friends or acquaintances with whom they bought and/or used drugs. They often had highly circumscribed daily paths and did the same activities with the same people daily. One such participant was Tetiana, a 42-year-old woman who lived in a one-bedroom apartment with her boyfriend, who knew about her drug use. Tetiana did not work because her criminal record prevented her from being hired. Instead, she got money from her boyfriend and government child subsidies for her 14-year-old daughter who lived nearby with a relative. She had a network of people she knew with whom she pooled resources to purchase drugs and bought her drugs from a dealer that she went to school with. Sometimes she would inject with the people she bought drugs with, but her health condition often made it difficult to use drugs around other people:She characterized her life as a “drab existence.” After her morning injection, she spent the day cleaning the house and looking at things on the internet and social media.malyas [a concentrated drug precursor] and myself go to my place. That’s a person I trust. I know that he won’t bring the police to my place the next day. I’ve known him a long time, we are acquaintances. That is not the first time, nor a second time, nor the last time, hopefully … Let’s put it that way, I have three or four people who can be at my side at such time. If a dude approaches me in the street tomorrow saying, “Hey, let’s go buy some drugs,” that will absolutely never happen. I won’t get in a car with some Joe Schmoe and go buy drugs.The owner of that Other participants who were not formally employed developed similar strategies to secure some sort of steady income and small group of drug use partners that contributed to stability and predictable daily routines. Viktor lived in an apartment with his mother and characterized his own daily routine as something that “absolutely doesn’t differ.” He did not work and had no personal income . Instead, he facilitated drug purchases for other people, who then paid him in drugs or cash. He bought and injected drugs with the same group of friends each day, rotating whose responsibility it was to procure the drugs, and typically bought from the same dealer.Participants with predictable routines had steady sources of income, such as through pensions or partners, and bought their drugs from the same known source each day. In addition, participants with predictable routines often  tried to use drugs at home and limit their interactions with other people, including other PWID.Daily routines characterized as somewhat predictable had participants with some stable aspects of their daily lives, such as a steady source of income or a small group of friends with whom they always used drugs, but also experienced circumstances that undermined their ability to have a routinized daily life, such as ever-changing drug use sites or inconsistent income sources. Sergiy, for example, was 36 years old and worked full-time in a plastics manufacturing company. He used drugs 3–4 times per day, including at home, at work, and in public places. His job created relative stability in Sergiy’s daily life and drug use. Three of Sergiy’s coworkers also used drugs, and they pitched in money to buy stashes together, either before work or during lunch breaks. They would also use drugs together in the locker room at work. While his job and coworkers brough stability to his life in terms of an income source and some steady drug use partners, Sergiy also had elements of instability and unpredictability in his daily routine, particularly around where he used drugs and who might be present when he injected. Sergiy explained that if he was experiencing withdrawal, he would use drugs in the apartment of a friend who lived near where he bought drugs, or in the restroom of a fast-food restaurant or other publicly accessible restroom on his way home if he “wants to inject very badly.” When he was in these situations, fears about getting “caught” by his supervisors, mother (with whom he lived), police, or other people hanging around caused Sergiy to inject quickly.Sergiy’s job brought some predictability to his drug use, particularly because he had a steady source of income and some regular people with whom he injected. Other people with somewhat predictable daily routines experienced work-related instability, such as seasonality, but had other aspects of their daily routine, including drug use, that were more consistent. For example, Petro worked as a parking attendant but the actual day-to-day work could be highly unpredictable and unstable. As an unsanctioned activity, the specific lots where he parked cars changed every day. While Petro preferred to work in the parking lot of the city’s largest bazaar, he would work anywhere in the city if necessary. This unpredictability countered his highly predictable and stable drug use patterns: he mostly used drugs by himself, typically at home, but would occasionally use drugs in the entrance halls of apartment buildings, abandoned buildings, construction sites, or the riverfront.Say that we’ve successfully stolen money before that … and during these thefts, we have some amount of drugs on us. We find a place where this can be used so that people wouldn’t see, we shoot up and continue stealing … [It can be in] some wooded area, an abandoned building, something like that … We come in, it’s quick, just 2 minutes, shoot up and leave.Ivan’s daily routine similarly combined elements of stability and unpredictability. He generated income through stealing and pickpocketing  with a friend that he had known since high school and who also used drugs. Ivan characterized their relationship as “close” as they “trust each other.” Ivan served as the “accomplice” and looked out for passersby and cops. Ivan had decided that his drug use was incompatible with legal, fulltime employment because no job he would be able to find as a person who uses drugs would pay him enough to support his drug addiction. Pickpocketing provided Ivan with stability in that he spent most of his days with the same person. However, they traveled all over the city to different second-hand shops, clothing stores, and markets to both steal and sell the stolen items. Because they moved constantly through the day, their drug purchase and use sites changed constantly:Ivan and his friend bought drugs at different locations scattered across the city, but the small circle of people who he used drugs with remained consistent: in addition to using throughout the day with his accomplice, in the evenings, Ivan typically went home and used drugs with his girlfriend and sometimes the same friend with whom he pickpocketed during the day.Analysis of participants’ daily paths and daily routines revealed three primary patterns—unpredictable, predictable, and somewhat predictable—and how these different levels of predictability shaped drug use practices. These daily paths and daily routines were shaped by income-generating strategies; the drug market and drug availability; and relationships with dealers, other PWID, and family. Income generation strategies were among the primary determinants of whether participants experienced predictable or unpredictable daily routines. Participants who had no steady income source, whether full-time employment, a pension, a partner’s income, or financial support from family members, entered the informal economy to generate cash for both buying drugs and daily living expenses. Some participants who earned income in the informal economy moved throughout the city daily and encountered large numbers of different people each day. Happenstance regarding where scrap could be collected and sold, where drug stashes were picked up, and who was at a job site on a given day shaped who people bought and used drugs with. In contrast, other participants encountered few—if any—new people throughout their day, had a relatively steady source of drugs, and often used drugs alone or with the same small group of people.are able to obtain work, employment may be in low-paid, unstable industries that may not pay enough to cover the costs of continued drug use. Interventions that address employment and economic opportunities to reduce poverty and increase socioeconomic stability among PWID could have potential health benefits, including HIV risk reduction [Previous research has documented that unemployment among PWID is common and that without access to formal employment, PWID engage in informal or illegal income generation activities such as recycling, theft, and sex work , 38. Reseduction .Our analysis of PWID daily routines indicates that Dnipro lacked a specific “drug scene,” or specific geographical inner-city areas characterized by high concentrations of drug users . While sThis study has several limitations. First, the Ukrainian drug use context is somewhat unique. The drug market has thus far been largely unaffected by the introduction of fentanyl and other synthetic opioids that has penetrated the US and other drug markets , 51. TheThe framework of daily path and daily routine as applied to drug use practices indicates that not all PWID face the same vulnerabilities and that these different potential harms are shaped by economic, place-based, and social factors. This study indicates that greater attention needs to be paid to the daily routines and lived experiences of PWID to develop and tailor interventions that address the place-based and social contexts that contribute to drug use-related risks. The link between income generating strategies, daily path, and drug use suggests that PWID in Ukraine are a “structurally vulnerable population:” they occupy a marginal social position within the labor market, shaped by discrimination and stereotypes about PWID and policies that exclude them from the labor market, that in turn shape opportunities and produce disparities in health and social outcomes over time . Underst


Temporal contrasts in speech are perceived relative to the speech rate of the surrounding context. That is, following a fast context sentence, listeners interpret a given target sound as longer than following a slow context, and vice versa. This rate effect, often referred to as “rate-dependent speech perception,” has been suggested to be the result of a robust, low-level perceptual process, typically examined in quiet laboratory settings. However, speech perception often occurs in more challenging listening conditions. Therefore, we asked whether rate-dependent perception would be  compromised by signal degradation relative to a clear listening condition. Specifically, we tested effects of white noise and reverberation, with the latter specifically distorting temporal information. We hypothesized that signal degradation would reduce the precision of encoding the speech rate in the context and thereby reduce the rate effect relative to a clear context. This prediction was borne out for both types of degradation in Experiment  Speech is a highly variable acoustic signal that listeners have to map onto their language system  in order to understand what is being said. Moreover, the listening environment is hardly ever quiet, but rather the to-be-decoded speech signal may be heard in background noise or distorted by room acoustics. Nevertheless, intuitively, speech perception does not seem like a major challenge to most listeners. This is because the human brain has a number of processes at its disposal that help listeners deal with the variability in the signal. The present study focuses on one of these processes— namely, rate-dependent speech perception—whereby listeners use earlier temporal information—that is, speech rate—in a preceding context sentence to recognize upcoming words. Specifically, we test how robustly the temporal information in a preceding context sentence is encoded in challenging listening conditions, such as background noise and reverberation.bannen, “to banish,” contain a short /a/, and words like bahnen, “to channel,” contain a long /a:/  listening environment, to serve as a starting point to understand the workings of a given perceptual process. Still, an increasing body of literature is concerned with the need to understand speech perception in everyday communication involving possible listening adversities  to the amplitude envelope of speech . We predicted that a fast context sentence should increase the probability of participants reporting bahnen with long /a:/, while the same target word should be more likely to be perceived as bannen with short /a/ if embedded in a slow speech rate . Critically, we applied two types of non-linguistic signal degradation: white noise mixed with the speech signal at 0 SNR and reverberation simulating a “big room” (see Methods for details). Note that we used relatively “moderate” degrees of signal degradation, challenging listening while maintaining intelligibility, as corroborated by ceiling performance on a separate intelligibility test (for details see the documents on OSF [https://osf.io/4fgkz/]). Consequently, we could in principle predict that the rate effect will not be affected by our two types of “moderate” signal degradation. This prediction would be supported by earlier claims that rate-dependent perception “is driven by a timing mechanism that requires hearing input as intelligible speech” , the speeding up of the perceived tempo would presumably apply to both contexts and targets, removing the perceptual tempo difference between context and target.Alternatively, the signal degradations could have similar effects on rate-dependent perception as increased cognitive load. According to the “shrinkage of time” account, the same speech is perceived as faster under high versus low cognitive load, which may apply likewise to forms of Finally, the signal degradation could also induce “noisy,” less precise temporal encoding of the speech rate, triggering a reduction of the rate effect in degraded speech versus quiet. Note that the two types of signal degradation—noise and reverberation—were chosen to compare their specific characteristics with regard to the way they distort the signal. White noise with its uniform spectrum and a lack of amplitude modulation was taken as a baseline for overall energetic masking of the signal. Since humans do not perceive all frequencies equally, white noise applies masking of all frequencies while not interfering with these natural perceptual nonlinearities. Its masking of the spectral information should reduce the overall clarity of the speech signal. Poorer access to spectral information might consequently disrupt the encoding of temporal information needed to calculate speech rate and in this way lead to reduced rate effects on the categorization of a target word. Reverberation, in contrast, involves reflections of sound from the room’s walls and surfaces that mix with the direct sound source, specifically inducing changes in the signal’s temporal envelope . He showed that adding reverberation to the target word continuum shifts the categorization boundary towards more sir responses. This suggests that listeners perceptually incorporate the reverberation with the sound such that the added “tail” from reverberation is fused with the actual sound obscuring the (closure of) /t/. Critically, this effect was reduced if the target word was embedded in a reverberant sentence context suggesting that information from the context could be used to compensate for the masking effect on the target. This compensation for context even held across “changes in room”  [in February 2021] and were paid for their participation. In order to be eligible for the study, they were required to be a native speaker of German living in Germany, be between 18 and 50 years of age, use a desktop computer rather than their cellphone or a tablet, and wear headphones. Based on the number of participants in comparable previous studies . They all confirmed to meet the criteria of being native speakers of German, and to have no history of hearing impairment or dyslexia. Nineteen reported to use over-ear headphones, nine on-ear, and 22 in-ear headphones. All participants gave informed consent to participate. The study was carried out in accordance with the research guidelines of the funding organization (German Research Council) and the requirements for good practice of the online platform (www.prolific.co) that was used for recruitment.Participants were recruited via the web-platformbannen–bahnen, “banish”–“to channel”; rammen–Rahmen, “drive by impact”–“frame”; Ratte–Rate, “rat”– “installment”). Each target pair had been recorded in a different carrier sentence that did not contain any tokens of the two critical vowels. Those unique context-target pairings were kept for the present experiments. However, targets and sentences were manipulated separately before being spliced back together. In addition to using three context-target pairings, materials from two speakers were used. Both speakers were young female adults and native speakers of Standard German. Both voices had already been used in the previous study  and how natural a given manipulation sounded. These values were identical for the two speakers. The pretests also determined that the rate manipulation of the context sentences was sufficiently strong to shift the perception of the vowel duration depending on the context rate. For the minimal word pairs and continuum steps selected for the present study, the difference in “long vowel” responses following the fast versus slow contexts was 15%.In short, the /a/–/a:/ vowel duration continua were created by starting with the two speakers’ average duration of the long vowel for each word pair and subsequently creating 16 shorter continuum steps by using the duration tier in PRAAT . Note that the levels of noise and reverberation were chosen specifically to challenge listening while maintaining intelligibility. A separate intelligibility test with new German-speaking participants confirmed ceiling performance with these signal distortions . Thus, the present study serves as a starting point for exploring potential effects of signal degradation on rate-dependent perception.For the noise manipulation, an existing PRAAT scriptwww.gorilla.sc), an online platform supporting web experiments.Stimuli were presented blocked by context condition with order of blocks roughly counterbalanced across participants. In the end, 7-9 participants completed each of the six possible orders. The slight imbalance was caused by the automatic assignment of block orders that did not account for participants who did not complete the experiment and were hence not included in the present dataset. Within each block, all stimuli were presented in fully random order  twice with the restriction that all stimuli had to be presented once before being repeated. The experiment was implemented in the Gorilla Experiment Builder  were presented visually on the screen with the letters “f” and “j” written underneath the words. These were the buttons that participants were asked to press on their computer keyboard to indicate their choice. They should press “f” if they thought they heard the word on the left, and “j” if they thought they heard the word on the right. The word with the long vowel was always presented on the right, so any potential bias was the same across conditions and experiments. On each trial, the text appeared at the same time as the audio started playing and stayed on the screen until the response was logged by button press. The next trial started automatically after 1,000 ms.Participants were informed up front that some of the stimuli might sound “noisy” but they should ignore this noise. They received three practice trials, randomly sampled from the main experiment but identical for all participants, one in each condition, in the order clear context, noise, reverberation. After these practice trials, participants were asked to adjust the sound level of their computer to a comfortable level such that they won’t need to change it anymore during the experiment. After another three (randomly selected) practice trials, they were informed that now they were not supposed to change the volume anymore for the rest of the experiment. The experiment started by pressing space bar. Between blocks as well as once within each block, participants were allowed to take a self-paced break. The experiment consisted of a total of 360 trials and took approximately 30 minutes to complete.Statistical analyses were conducted using linear mixed-effects models as implemented in the lme4 package , Speech Rate was contrast coded to fast rate coded as 0.5, and slow rate coded as −0.5. Condition was factor coded with the level clear context mapped onto the intercept (as it serves as a baseline), and contrasts being reported for clear versus noise, and clear versus reverberation.The random-effects structure included a random intercept for participants. Random slopes were then added one at a time and kept in the model if they significantly improved the model fit as determined by model comparisons using log-likelihood ratio tests. We report the best fitting model that converged and did not give us a singularity error. Unless noted otherwise, random slopes for Continuum Step, Speaker, Condition, and Speech Rate were included. Note that a random intercept over items was not included, since any single factor contributing to variability in items had too few levels as to be meaningful as a random factor.The results of the final model are listed in Table b(Rate) = 0.70, SE = 0.09, z = 8.17, p < .001; reference is reverberation: b(Rate) = 0.57, SE = 0.08, z = 6.80, p < .001. Furthermore, even though we did not set out to match and compare the two degraded context conditions directly, the additional models suggest that the magnitude of the decrease in the effect of rate did not differ between the noise and reverberation condition relative to the clear condition—reference is noise: b(Rate:conditionReverb) = −0.13, SE = 0.10, z = −1.40, p = 0.162. This opens the issue for future studies to address in more detail how rate-dependent perception changes not only in different types but under different degrees of signal degradation. The dataset, code, and results for all models can be found on OSF (https://osf.io/4fgkz/).Additional analyses using statistically equivalent models with the factor Condition coded such that the levels noise and reverberation were mapped onto the intercept showed that despite the reduction of the rate effect relative to the clear condition found in the main model, effects of rate were found for each of these conditions—reference is noise: to the context sentences only; the target words were always presented without degradation  [in February 2021] according to the same criteria as those for Experiment www.prolific.co) that was used to recruit participants. Forty-eight participants  took part, roughly matching the overall sample size of Experiment SD = 6.9). In a post-experiment questionnaire, they all confirmed to be native speakers of German, and to have no history of hearing impairment or dyslexia. Twenty-one reported to use over-ear headphones, 10 on-ear, and 17 in-ear headphones.Participants were recruited via the web-platform Prolific . The covariates trial number within each block and block order also did not improve the model fit for Experiment Data were analyzed using the same generalized-linear mixed-effects model as described Experiment Experiment However, two differences are worthwhile mentioning here. Firstly, we found a main effect of ConditionNoise, with more long vowel responses in the noise than clear condition. While this is in line with the hypothesis that suboptimal listening conditions “make speech sound fast”  of a context to interpret duration cues for spoken-word recognition Bosker, . HoweverDifferent possible accounts of rate-dependent perception under signal degradation, specifically in white noise and reverberation, were proposed. Firstly, if the effect of signal degradation was similar to the effect of taxing cognitive resources through a secondary task  then the degraded signals could have led to the impression of the stimuli being overall faster. This would predict more long-vowel responses in the degraded conditions than in the clear. Such a finding has previously been interpreted as supporting a “shrinkage of time” account where reduced cognitive resources lead listeners to miss speech samples in the calculation of rate  degradation between two conditions is hard to quantify. That is, in each condition, the signal is degraded in qualitatively distinct manners and—with ceiling intelligibility performance—it cannot be claimed that the two conditions equally affect perceptual processing. This is why we refrain from interpreting a direct comparison between these two context conditions, albeit, if one insists on such a comparison, the magnitude of reduction of the effect of rate appeared not to differ between the noise and reverberation context relative to the clear context in Experiment Experiment unattended talker in multitalker listening conditions has been found to influence the perception of targets produced by an attended talker (Bosker et al., Note that the reduced rate effects in Experiment In addition to the observed rate effect under different conditions of signal degradation in both experiments, two additional findings warrant mentioning with regard to previous studies on rate-dependent perception and phonetic categorization more generally. Firstly, despite the fact that under signal degradation processing resources are likely taxed, the present results differ from previous studies testing rate-dependent perception in a foreign language or a dual task situation. For instance, Bosker et al.  showed tSecondly, in addition to differences between context conditions in the magnitude of the rate effect (i.e., in Experiment The rate-dependent perception effect tested in the present study is an example of an acoustic context effect. It has also been referred to as “temporal contrast effect” (Bosker et al., The present outcomes also speak to the mechanisms of acoustic context perception proposed in Bosker et al. . They puThe present experiments present a first step towards exploring the consequences of different types of listening environments on the functioning of low-level perceptual processes that listeners use during speech perception. Different results in the two experiments reveal the value of experimental control, while also advocating the use of more naturalistic auditory environments. That is, while Experiment


Drug overdose mortality continues to increase, now driven by fentanyl. Prevention tools such as naloxone and medications to treat opioid use disorder are not sufficient to control overdose rates; additional strategies are urgently needed.We sought to adapt a behavioral intervention to prevent opioid overdose  that had been successfully piloted in San Francisco, California, United States, to the setting of Boston, Massachusetts, United States, and the era of fentanyl for a full efficacy trial.We used the assessment, decision, adaptation, production, topical experts, integration, training, and testing (ADAPT-ITT) framework for intervention adaptation. We first identified opioid overdose survivors who were actively using opioids as the population of interest and REBOOT as the intervention to be adapted. We then performed theater testing and elicited feedback with 2 focus groups (n=10) in Boston in 2018. All participants had used opioids that were not prescribed to them in the past year and experienced an opioid overdose during their lifetime. We incorporated focus group findings into our initial draft of the adapted REBOOT intervention. The adapted intervention was reviewed by 3 topical experts, and their feedback was integrated into a subsequent draft. We trained study staff on the intervention and made final refinements based on internal piloting. This paper describes the overall ADAPT-ITT process for intervention adaptation, as well as a qualitative analysis of the focus groups. Working independently, 2 authors (VMM and JA) reviewed the focus group transcripts and coded them for salient and common themes using the constant comparison method, meeting to discuss any discrepancies until consensus was reached. Codes and themes were then mapped onto the REBOOT counseling steps.Focus group findings contributed to substantial changes in the counseling intervention to better address fentanyl overdose risk. Participants described the widespread prevalence of fentanyl and said that, although they tried to avoid it, avoidance was becoming impossible. Using alone and lower opioid tolerance were identified as contributors to overdose risk. Slow shots or tester shots were acceptable and considered effective to reduce risk. Naloxone was considered an effective reversal strategy. Although calling emergency services was not ruled out, participants described techniques to prevent the arrival of police on the scene. Expert review and internal piloting improved the intervention manual through increased participant centeredness, clarity, and usability.We successfully completed the ADAPT-ITT approach for an overdose prevention intervention, using theater testing with people who use opioids to incorporate the perspectives of people who use drugs into a substance use intervention. In the current crisis, overdose prevention strategies must be adapted to the context of fentanyl, and innovative strategies must be deployed, including behavioral interventions.ClinicalTrials.gov NCT03838510; https://clinicaltrials.gov/ct2/show/NCT03838510 Since 1999, drug overdose deaths have risen 4-fold in the United States, with the majority of overdose deaths related to opioids ,3. From Providing naloxone to laypeople who may witness an opioid overdose is highly effective at preventing overdose mortality -10; howeTo address the emergence of fentanyl in eastern US states between the pilot and REBOOT 2.0, as well as to ensure that the intervention was appropriate for a broader geographic region, we sought to adapt the REBOOT counseling intervention using the assessment, decision, adaptation, production, topical experts, integration, training, and testing (ADAPT-ITT) model . We descADAPT-ITT is an effective framework for adapting HIV-prevention evidence-based interventions to new populations and settings, which includes 8 sequential phases to iteratively elicit feedback from the population of interest and key stakeholders . This isThe aim of phase 1 of the ADAPT-ITT model is to identify the population at risk, and the aim of phase 2 is to identify the appropriate intervention to adapt. We identified people with overdose history as the population at risk, considering their elevated risk for opioid overdose , and choThe REBOOT counseling intervention aimed to engage participants in a discussion of their opioid overdose history, both witnessed and experienced; discuss overdose risk behaviors; and identify feasible risk reduction strategies that the participant would be interested in using. Specifically, the 6 counseling steps are as follows: (1) explore participants’ experiences witnessing an overdose and contributing factors, (2) discuss participants’ own most recent overdose and contributing factors, (3) review overdose risk behaviors, (4) review ways to reduce overdose risk, (5) discuss participants’ current and additional planned strategies to reduce overdose risk and provide them with a wallet card listing risk-reduction strategies, and (6) review 3 steps in the Skills and Knowledge on Overdose Prevention (SKOOP) Project overdose recognition and reversal curriculum  . In addiIn phase 3 of ADAPT-ITT, the intervention is theater tested, and feedback from the audience is elicited. Theater testing involves inviting individuals of the population at risk to watch a demonstration of the intervention and then answer questions about their opinions of the intervention. On September 26, 2018, we conducted theater testing with 2 focus groups in Boston, Massachusetts, United States. REBOOT had been piloted in San Francisco, and at that time there was very little fentanyl being used in that city; thus, the adaptation effort was focused on Boston, where fentanyl was the dominant opioid .We contacted individuals who had reported opioid use while participating in previous studies at the Boston Medical Center and provided consent for future contact for research. Eligibility criteria for the focus groups included age 18 to 65 years, living in the Boston metropolitan area, using an opioid in the past year that was not prescribed, lifetime history of overdose, and comfort participating in the focus group in English. Participants who were screened for eligibility reported their demographic characteristics , overdose history, lifetime naloxone use, and past-year opioid use. Participants reviewed an information sheet with study staff and provided verbal consent for participation.In each focus group, participants were shown the same video of a counseling session with a participant from San Francisco. The counseling session lasted 39 minutes and was conducted by a trained clinical psychologist with expertise in motivational interviewing following the REBOOT counseling steps. The handouts provided to the participant at the counseling session were also provided to focus group participants for review. A video recording of the session was used, rather than a live demonstration, because of the short-acting nature of fentanyl and the risk that focus group participants would develop opioid withdrawal symptoms if there were delays in the procedures.During the viewing of the video and afterward, participants were asked questions following a semistructured interview guide about their opinions and perspectives regarding the counseling session . At the Working independently, 2 authors (VMM and JA) reviewed the focus group transcripts and coded them for salient and common themes using the constant comparison method . A list This study was approved by the University of California San Francisco Institutional Review Board (17-24203).Focus group findings were used to produce a draft of the adapted counseling intervention (phase 4), which was reviewed by 3 topical experts (phase 5). The experts were overdose education and prevention professionals from the Boston Public Health Commission, Harm Reduction Coalition, and the Education Development Center. The expert feedback was integrated into the subsequent draft of the counseling intervention (phase 6).We then trained our counseling staff (phase 7) and tested the adapted intervention (phase 8) to make final refinements. We modified phase 8 of ADAPT-ITT by conducting internal monitoring with the study team and not a pilot with the population of interest. The final adapted counseling intervention is being evaluated in the ongoing REBOOT clinical trial.In total, 21 individuals were eligible and invited to participate in the focus groups. Of these 21 individuals, only 10 (48%) attended the focus groups, with 6 (60%) in one focus group and 4 (40%) in the other. The mean age of participants was 44.1 (SD 13.8) years, and the majority were men . Half  of the sample was Hispanic/Latinx; in terms of race, 20% (2/10) were Black or African American, 30% (3/10) were White or Caucasian, and 50% (5/10) reported another race. All participants had experienced an overdose involving fentanyl, and 90% (9/10) had used fentanyl in the past year .All participants reported that they had witnessed an opioid overdose. Participants described various strategies to respond to a witnessed overdose, including using naloxone, calling 911, and other strategies stemming from their lived experience.All participants had previously received take-home naloxone and were generally knowledgeable about how to use naloxone. In total, 80% (8/10) of the participants reported administering naloxone to someone who was overdosing:Narcan [a brand name for naloxone]...I have that in my house for my son. I have a ring and it shows you what to do...Focus group 1, attendee 2Participants thought that calling 911 had inherent risks, including arrest and loss of housing. Strategies to mitigate these risks included relying on the Good Samaritan law, although there was discussion regarding how it only protected the individual calling 911 from arrest, and not others present at the scene of an overdose. Participants also recommended not telling a dispatcher that the person had overdosed, but instead saying that they were “not breathing” or “unresponsive” so that medical services would arrive without the police:A lot of people are afraid to call the cops [for an overdose] because they think they’re going to get locked up. I’ve seen people like, “Leave him, leave him. Let’s go.”Focus group 1, attendee 5I’m not trying to be a jerk, but you pull [the person who overdosed] out in the hallway and [tell 911], “Listen. I came outside, and there’s somebody unconscious on my ground. Is it drug-related? I don’t know. Here’s the address.” And hang up quick so they can make it there quick.  see how it made me feel. If it made me feel alright, I would just save the other shot, because, at the end of the day, you can only just do more. I looked at my girlfriend, I’m like “Fuck that I’m going to do the whole 30.” I did it and I felt the heat from my toes up I was like “Damn that shit was strong.” Next thing I remember, I’m holding onto a fence, I’m like “What the hell?” I'm looking around, she’s crying. I’m like “What the hell happened?” She’s like you’ve been dead for like seven minutes. I’m like “Oh my god.” She had just woke me up. They Narcan-ed me like three times, sternum rubbed me and when they threw water on me, I guess that’s when I responded.Focus group 1, attendee 6In step 3 of the counseling session, the counselor provided a handout to the participant listing several behaviors that increase the risk for an overdose . The couParticipants across both focus groups described fentanyl as prevalent and a major contributor to opioid overdose:They [are] even putting [fentanyl] on the weed. On the cocaine...Focus group 1, attendee 4There’s no heroin around anymore. It’s all fentanyl.Focus group 2, attendee 4Participants also described how fentanyl was being mixed with other drugs unbeknownst to those using those drugs:They’re putting [fentanyl] in the coke now, the cocaine. My friend [who] only does coke...when he stopped doing coke, he was like dope sick. He don’t do dope or nothing and had all the symptoms of dope sickness and then—it’s a couple—when she did her test at the methadone clinic, she was coming up for fentanyl and she was only doing coke.Focus group 1, attendee 2Lower opioid tolerance after not using opioids for a period of time, in particular after being in jail or substance use disorder treatment, was identified as a risk factor for overdose:Every time someone just get[s] out [of jail or treatment] they think they can do the same thing as when they went in...[but] they’ll automatically OD.Focus group 2, attendee 1Focus group participants described overdose risk as higher among people who had recently begun using opioids. Participants frequently described themselves as people who had used opioids for a long period of time and therefore were at less risk of overdose. The median length of time since first using opioids that were not prescribed was 26.5 (IQR 17-35) years. A participant described the utility of counseling among those starting to use opioids:I think [overdose counseling] would be helpful for kids who are just starting using, who aren’t like smart into the lifestyle and know the game...who are more reckless than a lot of us who have been using for years.Focus group 2, attendee 4Although participants described their duration of opioid use as lowering their overdose risk during the focus groups, on the screening questionnaire, of the 10 participants, 7 (70%) said that they felt their risk of overdose was high, 2 (20%) said that it was moderate, and 1 (10%) reported low risk. The participant who reported low overdose risk had used opioids for the shortest period of time (5 years). Thus, although participants who had used opioids longer thought that their overdose risk was lower than people starting to use opioids, they still reported a moderate to high risk for overdose.In step 4 of the counseling session, the counselor provided another handout to the participant that listed several strategies that could be used to reduce one’s risk of opioid overdose . After wThere was consensus that not using alone was an effective way to lower the risk of opioid overdose, and most participants reported that they usually use with others, and when they use alone, they may call someone, use in a bathroom in a monitored environment , or make sure a friend can access them:I try to hang out with friends, I don’t use by myself now. It’s like you kind of do it in a group, you know? So, each know each other’s tolerances.Focus group 1, attendee 3When I do [opioids] by myself in my house, I leave the doors unlocked, you know? I got a good friend of mine that has a copy of a key. That’s the only thing that I do [for overdose prevention].Focus group 2, attendee 5Across both focus groups, participants discussed how they aimed to avoid fentanyl because of its prevalence and potency; however, they considered avoiding fentanyl increasingly difficult because of the rapidly rising prevalence of fentanyl. Ways to identify fentanyl included its gray color; sweet taste; and smell, which is different from that of heroin. Using fentanyl test strips, as suggested in the counseling video, were discussed but were not considered accessible to focus group participants in Boston at the time:[I do] a whole lot [differently because of fentanyl in the drug supply], make sure you don’t get that bullshit. Go to somebody you know that’s got real dope.Focus group 2, attendee 3Yeah, a lot of them [lie and] say “No, it’s straight dope, it’s straight dope. There’s no fentanyl.” That's why a lot of people they’re doing pills. They rather be doing pills than do the dope.Focus group 1, attendee 6Participants also described a paradox, whereby although they typically tried to avoid fentanyl, if they learned of strong opioids, they wanted to use them—they sought them out:Some people would see somebody overdose and be like, yo, who did he buy that from?...Because if it puts you out then it means it’s some good shit.So other people be like, yo, where do you buy that from? I want some of that shit. If over there in the corner, somebody comes and tells me...”that shit over there is killing motherfuckers,” I’m going to go over there, excuse my language, because there’s some good dope over there. We never learn. You understand? I’ll ask who’s got the good stuff, “that one’s killing people be careful” and I’ll go over there. One way that participants rationalized this paradox was that they thought that they personally would not overdose from drugs that others had overdosed from because they had a higher tolerance:We don’t think we’re going to OD off of it. We think like, “Oh, my habit’s worse than your habit...” I have a 500-dollar-a-day habit.Focus group 2, attendee 4slow shot) or doing a tester shot. Participants stressed that using less was especially important when fentanyl might be present:Participants discussed strategies to reduce the amount of drugs used or sample drugs before using them, through either partially depressing the plunger before injecting all of the solution :When I’m getting [high], I’m getting [high]. Forget about that partial test.Focus group 1, attendee 4I’ve learned that every time I get out of jail I just do less, like a tester shot now. My boyfriend would always say to me, you can always do more, but you can’t take one back. So, stop being a glutton, it’s right here...It stuck in my head like he’s got a point. You can do another one, but you can’t take one back.Focus group 2, attendee 2The participant in the counseling video used the same dealer to avoid getting fentanyl. Across both focus groups, participants did not think that using the same dealer was an effective way to avoid fentanyl because of the uncertainty in the drug supply:[The lady in the video] gets it from the same guy all the time...That don’t mean nothing. The guy doesn’t know what chemicals the drug got. He could say, “It’s good don’t worry about it,” and when she gets home [she overdoses]. You never know what could happen.Focus group 1, attendee 4Well, because he could be the same drug dealer, but he might have gotten a different batch. They don’t always get the same thing. There are different grades of fentanyl. There are stronger grades that have legs, there are shit grades that you really get pissed about...Focus group 2, attendee 2Although, in line with the participant-centered harm reduction counseling approach, MOUD was included on the handout of possible strategies to reduce the risk of opioid use disorder, it would only be discussed with the participant if they demonstrated interest in MOUD. A few  of the focus group participants said that they thought this was not sufficient and that the counseling intervention would be more effective if MOUD was emphasized more:I think it was helpful to encourage [the participant in the video to stay] clean, but [the counselor in the video] didn’t offer any places like we should try, like methadone maintenance, if you haven’t been able to maintain completely off anything, or Suboxone or halfway house.Focus group 2, attendee 2Toward the end of the counseling session, the counselor created a wallet card for the participant based on the overdose prevention strategies that the participant described as part of their current practice or additional strategies of interest to them. Focus group participants thought that providing a wallet card to participants to remind them of what was discussed in the counseling session was helpful. Using other forms of technology to remind participants of the discussed strategies was also suggested:Maybe even, nowadays with technology, it could even be on an iPad...Or text messages, or another app that you can check on.Focus group 1, attendee 2Although participants thought that the wallet card was useful, participants recommended providing more handouts, naloxone, and fentanyl test strips, as well as providing training for rescue breathing and naloxone administration:If you’re actively using, [a brochure about resources is] just a piece of paper, it’s nothing, you know what I mean? But if you’re trying to change your life and get help then like it can be extremely helpful. But it all depends on where you are.Focus group 2, attendee 4The last step was to review a handout that described the 3 steps in management of a witnessed overdose from the SKOOP Curriculum : recogniWhen [the counselor in the video] had it in black and white right in front of her and she was reading and she’s like, “Oh I didn’t know about the recovery position,” so she was very perceptive to it, you know what I mean?...rather than just talking about things, like when it’s in black and white, right in front of you. Like for me, I tend to pick things up by reading them...’cause I’ll forget what you’re telling me...if it’s right in front of me, it’s hard to ignore.Focus group 2, attendee 4Focus group participants reported that they already knew a lot of the information that was shared in the counseling session, and they thought that the best audience would be younger people who have not used opioids for very long:[The counseling session] might be helpful for the people just getting into this game, but I’ve been in this game since ’69, so it might be helpful to the newcomers.Focus group 2, attendee 1Some  of the participants recommended including a conversation about the root causes of people’s substance use and expanding the intervention to include a broader counseling intervention:I’ve heard [the content of the counseling session] multiple times. I think I agree with the whole overdose prevention and training in Narcan, reiterating it and whatnot. But I think they could’ve focused on a little bit more of core issues of why people use and why do they continue to go back. Because [the woman in the video] had six months clean in jail. You know what I mean? Like she didn’t have to go back and get high. Like granted nine out of 10 of us are going to. You know what I mean? But like at that point you’re already over the physical part of it. So, like start dealing with your mental side and like those cravings...I think they could like integrate that into a lot of the conversations.Focus group 2, attendee 4We incorporated the focus group findings to adapt the REBOOT counseling intervention to better address fentanyl overdose risk. Specifically, we highlighted avoidance of fentanyl and using tester shots and de-emphasized using the same dealer. We added the recommendation to test drugs for fentanyl and identified locations to refer participants to obtain fentanyl test strips. Counseling staff were alerted that even among those who are aware of fentanyl’s overdose risk there may be a desire to use fentanyl; they were directed to explore this paradox with individuals who use opioids during counseling and tailor overdose prevention strategies as appropriate. Staff were also trained to understand that participants may underestimate their overdose risk, and they were provided guidance on how to help participants develop a realistic personal overdose risk assessment. We also added tips when calling 911 to mitigate the chances of police arriving at the overdose scene.We shared a draft of the counseling manual describing the adapted REBOOT intervention informed by the focus groups with 3 overdose prevention and education experts for their review and feedback. All 3 experts sent suggestions for the draft intervention, which were incorporated into the next iteration of the counseling approach.Recommendations included adding less risky routes of administration as a way to reduce overdose risk  and asking participants to “walk through” a typical day to visualize how overdose prevention strategies could realistically be implemented in their life, as well as asking participants what they want to “change” about their substance use, not whether they want to “reduce” or “stop” their substance use.In response to participant and expert feedback, we developed an assessment of the level of interest in substance use treatment and any plans or needs to access substance use treatment, which is conducted in at least one of the 4 REBOOT counseling sessions. Similar to the overdose counseling approach, the substance use treatment counseling component aims to be participant-centered and begins by exploring participants’ previous substance use treatment experience before assessing interest.After incorporating the expert feedback into the counseling intervention, we trained study site staff by reviewing the manual and handouts, and team members conducted role plays with a trained clinical psychologist. Study staff provided further minor modifications to the approach to best operationalize it. Recommendations included improving readability , including the expected duration of the counseling session at the beginning, and using a more open-ended question when assessing the participants’ personal overdose history .We adapted an opioid overdose prevention intervention to the era of fentanyl and a broader geographic region through the ADAPT-ITT process. As expected, the prevalence of fentanyl in Boston was the dominant issue for overdose prevention, and the process resulted in multiple adaptations to the final intervention. Focus group participants who used opioids emphasized the importance of fentanyl avoidance , as well as the growing impossibility of avoiding fentanyl. The predominant role of fentanyl in increasing overdose risk has also been reported in other studies among people who use opioids -27.Although participants described the importance and difficulty of avoiding fentanyl, they also described the desire to use drugs that were involved in an overdose because of that indicated potency. This mix of fentanyl avoidance and seeking was also seen in a qualitative study in Pennsylvania, United States, among persons with recent opioid misuse or heroin use . ParticiThe predominant role of fentanyl in opioid overdose affected participants’ perceptions of traditional overdose prevention strategies. Using the same dealer was not considered an effective strategy to reduce overdose risk because of the uncertainty in the drug supply at every level, which has been reported in another study among people who have survived opioid overdose . Tester In addition to opioid overdose prevention strategies, we discussed effective overdose response. Participants had experience responding to overdose, including using naloxone, which was considered an effective and acceptable response strategy. Participants also described witnessing overdose reversals when stimulation was used . Study participants considered these alternative response strategies as effective, which has been reported in another study among people who use opioids . For nalThere was a common fear of arrest or other negative consequences related to calling 911 in the event of an overdose, a common finding from prior research ,34-41 thThe subsequent phases of the ADAPT-ITT process, including expert review and testing, further helped to refine the intervention. These later modifications were typically minor, including additional detail to improve clarity and changing the manual’s formatting to increase usability. After internal testing at the study sites, we finalized the REBOOT 2.0 counseling manual and are currently evaluating the efficacy of the intervention in our ongoing clinical trial.This study includes limitations. The focus groups were small, which can limit the generalizability of findings; however, considering the narrow and clear scope of the research , active participation of the attendees, and repeat themes that arose during conversation, we believe that the number of attendees (n=10) was sufficient for the aims of this study . Our finOf the 10 participants, 3 (30%) were women, and additional research may be needed to further explore potential gender-specific intervention adaptations ,45. We rWe successfully used the ADAPT-ITT approach to modify an opioid overdose prevention intervention, ensuring its applicability in a new geographic area and in the setting of a more potent street opioid. We conducted theater testing with people who use opioids, a challenge given the short-acting nature of fentanyl. Important adaptations resulted from this stage of the process, which led to a more appropriate intervention for people who use fentanyl. Incorporating input and lessons learned from people who use substances was key to optimizing our counseling intervention and messaging. Additional improvements were made through expert review and internal piloting. As fentanyl became the dominant street opioid in San Francisco during the full REBOOT trial, these adaptations proved essential.