Sub-Saharan Africa has been identified as one of the most vulnerable regions to climate change. The objective of this study was to explore knowledge and perspectives on climate change and health-related issues, with a particular focus on non-communicable diseases, in the informal settlement (urban slum) of Mukuru in Nairobi, Kenya. Three focus group discussions and five in-depth interviews were conducted with total of 28 participants representing local community leaders, health care workers, volunteers, policy makers and academia. Data were collected using semi-structured interview guides and analyzed using grounded theory. Seven main themes emerged: climate change related diseases, nutrition and access to clean water, environmental risk factors, urban planning and public infrastructure, economic risk factors, vulnerable groups, and adaptation strategies. All participants were conscious of a link between climate change and health. This is the first qualitative study on climate change and health in an informal settlement in Africa. The study provides important information on perceived health risks, risk factors and adaptation strategies related to climate change. This can inform policy making, urban planning and health care, and guide future research. One important strategy to adapt to climate change-associated health risks is to provide training of local communities, thus ensuring adaptation strategies and climate change advocacy. According to the United Nations (UN) Intergovernmental Panel on Climate Change (IPCC), climate change is one of the current biggest global challenges ,2. The UClimate change and many NCDs have the same root causes. The most obvious cause is air pollution, which causes an estimated 7 million deaths annually . ChanginSub-Saharan Africa has been identified as one of the most vulnerable regions to the impact of climate change. In addition, health systems in the region are insufficiently equipped to handle the increase in climate-related morbidity. The prevalence of NCDs is increasing rapidly in urban areas in East Africa. According to WHO, the Africa region will experience a 27% increase  in additional deaths due to NCDs during the next decade . This wiOne in which inhabitants suffer one or more of the following ‘household deprivations’: lack of access to improved water source, lack of access to improved sanitation facilities, lack of sufficient living area, lack of housing durability and lack of secure tenure” [Urban regulations developed outside the formal system recording land ownership, land tenure and a range of regulations relating to planning and land use, built structures and health and safety” [An estimated 1 billion people live in slum areas worldwide . Slum ho tenure” , “Urban  safety” . Poor ho safety” . Residen safety” ,14.In 2016, the Mukuru informal settlement  was estimated to have 301,683 inhabitants, living in 100,562 households . ConservEvidence on the knowledge, attitudes and practices regarding climate change adaptation and resilience is very limited. There is a scarcity of data regarding the perceived relationship between climate change and related NCDs in low- and middle-income countries (LMICs). In the future, both climate change hazards and NCDs will affect a growing number of residents in informal settlements with an increasing population density. Assessing and mapping knowledge, attitudes and practices regarding both direct and indirect effects of climate change related health threats is crucial to guide future interventions on climate change adaptation and resilience in high-density informal settlements such as Mukuru in East Africa and the world.The objective of this study was to explore the knowledge base on climate change related health risks and adaptation strategies among local formal and informal community leaders, health care workers and volunteers, and key informants working in academia and policy on climate change in Nairobi, Kenya.The study was conducted among 28 people working with climate change related health issues related to the Mukuru informal settlement in Nairobi, Kenya. Mukuru is one of the largest informal settlements and was selected as the study setting. Mukuru is one of the fastest growing informal settlements in East Africa, and is surrounded by major industrial complexes, which contribute to environmental health risks closely linked to climate change . In Mukuru, 92% of residents are renters/tenants and housing usually consists of 10 × 10 feet structures with walls and roof made of sheet metal, frequently with dirt floors . The pern = 6), Community Health Volunteers (CHVs) (n = 7) and local community leaders  (n = 10). The five purposively sampled informants for IDIs were recruited through their workplaces—African Population and Health Research Centre, Stockholm Environmental Institute Africa, Kenyatta University, and the Ministry of Health, Kenya. Participants were also sampled from among the NCD Alliance of Kenya (NCDAK) network. All participants were first contacted by email by the staff of NCDAK, a non-governmental, civil-society organization coordinating multi-stakeholder activities on NCDs.In total, 28 participants  took part in this study; three FGDs were conducted with 23 participants, in addition to five IDIs with key informants. Participants in FGDs were invited using convenience sampling from three purposively selected groups; Health Care Professionals (HCPs)  with the protocol number P906/2020.The data collection process respected local restrictions and regulations regarding COVID-19, e.g., by providing hand sanitizer and face masks, ensuring physical distance by limiting the number of people in a room, and observing curfews.The data analysis resulted in seven main themes: climate change related diseases, nutrition and access to clean water, environmental risk factors, urban planning and public infrastructure, economic factors, vulnerable groups, and adaptation strategies. The results are presented according to themes and sub-themes . A reprethe fact that you’re not able to anticipate, to plan, because it is not known what will happen tomorrow, that psychological stress also strains the body and I think it also has an effect” (IDI 3). Injuries and accidents related to both traffic and flooding were also highlighted as adverse effects related to climate change. Finally, infectious diseases were mentioned by the informants, such as waterborne diseases , malaria, respiratory tract infections (including tuberculosis), seasonal flu, and COVID-19- Climate change, “will cause people to get cholera. Especially when the floods come, our pipes, the water which comes from the tap, is connected with the sewer line” , and, “many people get malaria as a result of the water which has been stagnant due to flooding” .A wide variety of climate change related NCDs were mentioned in the eight interviews—hypertension, heart attack, lung disease, diabetes, cancer, kidney disease, heat stroke, ulcer, sunburn, and obesity. Mental stress related to climate change was mentioned in most interviews, “The issue of food security of course it’s also a problem because when we have harsh weather patterns, it also affects agricultural production, and you see, because in urban areas we don’t farm so they rely on food to be transported from other areas. Of course, the cost of that food will go up in the urban areas. It’s a challenge” (IDI 2). Moreover, malnutrition in relation to climate change was mentioned as a threat, “If there’s crop failure due to drought, it means people will not get food” (IDI 1). “There’s no food and you used to feed your children so well. They used to eat greens, protein, starch, things like that and now it is so hot. Everything is gone” . Poor quality of food and lack of access to good quality food was also mentioned as an important issue, “Now people are forced to use more chemicals in the food production chain” (IDI 5). The impacts of the available and affordable food on health were noted: “Actually, we see now the canned food, the processed food is more easily available than the natural food, so you get (…) more starchy foods, and which is not healthy so diabetes comes in” . Further, rising food prices was a major issue, “The prices of fish is really high. Fish from a fresh water lake has been a challenge” . Insecure water supplies are largely affected by extreme weather such as droughts or seasonal changes. This was reported to cause distress and disease in the informal settlement, “When there is lack of water and most of the taps are dry, these illegal water vendors come in with polluted water, dirty water” . “When drought occurs, when we have prolonged drought seasons, that affects our water resources that eventually now lead to water scarcity” (IDI 3).Food insecurity and rising food prices were mentioned as main challenges caused by climate change in all of the eight interviews , “There’s a lot of air pollution both indoor and outdoor” (IDI 5). “We are surrounded by a lot of industries, the way they dispose their waste changes the climate, and also the pollution, air pollution, within Mukuru” . “We have seen a high number in cases of NCDs. Also due to pollution of air around Mukuru, we’ve seen children developing asthma at a very young age and even adults are coming in with asthma because of air pollution caused by the factories and industries and all that” . Indoor air pollution was also regarded as an issue for NCDs in the informal settlements, “Indoor pollution is also a challenge. They either use charcoal or they use paraffin. (…) What they inhale, it’s also a challenge if you look at some of the respiratory illnesses” (IDI 2). Furthermore, many respondents mentioned contamination of food and water, “When I see those sukuma wiki  they look very clean, very nice, but you know they are already contaminated because the water they use is that sewerage (water)” , and “There are companies emitting mercury, lead, zinc and some other heavy metals which is a recipe for some dangerous diseases, dangerous NCDs like cancer and so on” . “The industries, they are urged to avoid flooding the rivers with bio-hazardous chemicals” (IDI 5). All respondent groups also brought up a lack of proper waste management as a pressing issue, “In Mukuru, we don’t have exactly a place to put our dirty waste. So, everybody will just throw their waste wherever they wish” .Air pollution was regarded as a major issue in the informal settlement across all interviews, “There is no proper arrangement of how those buildings are being constructed. Secondly, there is no right sewer lines. There are no right drains. There are no proper roads” . “One immediate thing when you look at our mobility patterns, when we move from point A to point B, of course, if it rains, it increases your travel time, so a distance where you could be taking 45 min (…), you find it is taking you 1.5 h or 2 h to reach your destination” (IDI 2). Public transportation costs were mentioned to triple during rainy seasons. Infrastructure and urban planning, in general, were additional main themes across the interviews, “The houses near the stream or next to water sources are not expensive, they are cheap” . “Earlier I never heard about landslides but now it is something that is happening now and then. People are being told: don’t live in this area because when it rains this area, it is sliding” . Migration and displacement of people due to climate change, e.g., losing their homes, was mentioned, “When there’s flooding, the people who live in that area are forced to vacate” . This was also stated to be a problem, e.g., for following up in immunization programs, “we can’t immunize (them), maybe they moved away to search for another place and they are not traceable” (IDI 5). Furthermore, it was stated that the local health services are not always climate change resilient, “we’ve had some of our facilities ruined because of the weather (…) because of either floodings…” (IDI 5). This further negatively impacts the ability to detect and treat NCDs, “there is no community structures, there’s no healthcare facilities, so you’re not able to catch these people early enough, so they’ll easily progress to get non-communicable diseases” (IDI 5). Poor housing and vulnerable placements of housing were a major concern for many informants, “They should build manholes for us, so that when the sewage burst it will flow into the manhole instead of into people’s houses” . “The flooding incidences, they really also affect our quality of life especially in these residences particularly the informal settlements because there’s no infrastructure, the storm water drains are not there, so eventually what we have is the waterborne diseases because they probably will have a mix-up of storm water into the drinking water and of course sanitation will also be affected because if you look at the type of facilities that they use, they are likely to be affected by that” (IDI 3).Lack of proper sewage and drainage systems in the informal settlement were highlighted, and the need to encourage authorities to ensure better sewage, was brought up, “The country is warming up because people are clearing vegetation and erecting high-rise buildings which tend to interfere with the ecosystem and the weather patterns keep on changing based on that” (IDI 1).Finally, deforestation as part of climate change related hazards, in addition to the need to replant trees, was mentioned on multiple occasions during the interviews, “Access to health services for those who fall sick, especially in the informal settlements due to climate change, is not something that they can easily get because some of them-if you look at their economic status-cannot afford the quality healthcare in high end institutions, health institutions, and if they access healthcare in the local, let’s say, county hospitals, most of the times they don’t have the capacity to handle such cases” (IDI 1). Lack of insurance against climate change hazards in Kenya and Mukuru was also mentioned.Generally, poverty related risk factors were mentioned in all interviews as a main factor for climate change related health hazards, “The vulnerable people, they don’t have anywhere to go so they don’t. (…) they can’t go anywhere because they don’t have any other place they can go to. They end up being homeless” . Children were stated as a vulnerable group in many interviews, “Especially the children are affected when the floods are all over our place. Because these kids don’t know if water whether it’s good or bad or whether it’s from the sewer line. They will just play with it and that’s where they get these diseases, the waterborne disease” . The elderly were also mentioned as another vulnerable group in the informal settlements, “The air is polluted, like maybe industries emitting the fumes, maybe garbage being burnt somewhere, you see, the old suffer a lot because their respiratory organs are a little bit weaker” . People living with NCDs (PLWNCD) were mentioned as vulnerable by several respondents, “Because they are suffering from a non-communicable disease (…) they are vulnerable and some of the impacts of climate change would actually be a risk to them” (IDI 4).Poverty in general makes many residents in informal settlements vulnerable when natural disasters occur, “Let’s transform our cities from highly motorable cities to walking cities. From a planning perspective, I see a core benefit with NCDs because this will provide room for exercise, room for clean air in areas where we have for recreation, and this will be good for our health” (IDI 4). Furthermore, reforestation and planting of trees and vegetation were brought up by many respondents.Respondents also offered insights into potential adaptation strategies. In terms of urban planning, it was suggested “Train us! I think we should be having more knowledge on how to help ourselves if the climate changes” . “By creating awareness, it’s going to change the attitudes and perceptions of the community on climate change and its impacts” (IDI 4). Regarding health and NCDs, it was mentioned, “Also, we’ll have more people getting non-communicable diseases because the opportunity for educating the public on how to prevent non-communicable diseases, which is done both at community and at healthcare settings, is not there” (IDI 5). In general, respondents agreed that, “The government really has to do a lot in terms of advocacy, in terms of educating the entire population” , and what is needed is to “coordinate efforts in the mechanism on climate change response, encourage greening and green product activities and green growth economy, encourage transition from policy to action” . According to many informants, the authorities must ensure climate change resilience and ensure, “government investment in climate change in the urban space” (IDI 3).In all eight interviews (FGDs and IDIs) it was stressed that educational measures must be taken to empower the residents in the informal settlements, and a willingness to learn and disseminate knowledge on climate change was emphasized, “There are major knowledge gaps on how to guide and develop interventions to improve climate change adaptation and resilience in relation to health at the local community level. A review of the literature from 2020 on health implications of climate change found just seven studies on climate change and health in LMICs ,22,23, wA knowledge, attitudes and practices (KAP) study in Guyana found that 36% of the 450 study participants experienced health hazards caused by climate change . A studyThe findings of this study are limited to a specified area, group and setting. The number of participants interviewed was limited, which may introduce underestimation biases. Furthermore, the purposive sampling strategy may have introduced selection bias, which could lead to overestimating climate change related health risks. Thus, the findings of this study may not be generalizable at national and international levels. Furthermore, this study focused specifically on non-communicable diseases. Although participants also reported on communicable diseases, the interviews and sampling of participants were focused on NCDs, limiting the scope of this study.The emerging themes of the IDIs and FGDs in this study were perceived disease risks related to climate change, climate change related risk factors for those diseases , vulnerable groups, and potential adaptation strategies. Access to affordable and healthy food, which is at risk due to changing weather and deforestation, was a prominent sub-theme. Pollution from industries, in particular air and water pollution, was another important perceived health risk. Many participants identified that unplanned urbanization with dense settlements close to rivers without sufficient sewage systems and lack of public infrastructure, in particular toilets and affordable health care, exacerbated climate change related health risks. Respondents identified the poorest, children, the elderly, and those with NCDs as most at risk of climate change related health effects.This study is the first to report on the experiences and perspectives of local health care workers and volunteers, informal and formal community leaders, and academia on climate change related health risks in an informal settlement in Africa. The seven main themes identified  may guide further research and climate change resilience interventions, and enable information and advocacy campaigns to be tailored to the local context. This qualitative evidence on climate change related health risks offers important understandings which may be useful for urban planners, academia, health care workers and policy makers locally and nationally, in addition to those in the East Africa region. Interestingly, community leaders and health care volunteers in this study demanded more training and education about climate change and environmental health to protect themselves and their communities. Further research, including mixed-method approaches, covering the general inhabitants of informal settlements in Nairobi, in addition to other countries and regions, is warranted.


Methamphetamine use and methamphetamine-involved deaths have increased dramatically since 2015, and opioid-related deaths now frequently involve methamphetamine. Nevada and New Mexico are states with elevated rates of opioid and methamphetamine use. In this paper, we report results from a qualitative analysis that examined patterns of methamphetamine and opioid co-use over participants' lifespan, factors that influence those patterns, and implications for health outcomes among users.Project AMPED was a multisite, mixed-methods study of methamphetamine use in Northern New Mexico and Northern Nevada. Between December 2019 and May 2020, qualitative interview participants were asked to describe their patterns of and reasons for co-administration of opioids and methamphetamine.n = 12), [2] using methamphetamine along with methadone (n = 4), [3] using prescription opioids and methamphetamine (n = 1), and [4] using only methamphetamine (n = 4). Among those who used methamphetamine and heroin simultaneously or sequentially, motivations drew from a desire to enhance the effect of one drug or another, to feel the “up and down” of the “perfect ratio” of a goofball, or to mitigate unwanted effects of one or the other. Among those who used methamphetamine and methadone, motivations focused on alleviating the sedative effects of methadone.We interviewed 21 people who reported using methamphetamine in the past 3 months. Four primary patterns of methamphetamine and opioid co-use were identified: [1] using both methamphetamine and heroin, either simultaneously or sequentially (To address the emergent trend of increasing methamphetamine-related deaths, researchers, health care professionals, and community health workers must acknowledge the decision-making processes behind co-use of opioids and methamphetamine, including the perceived benefits and harms of co-use. There is an urgent need to address underlying issues associated with drug use-related harms, and to design interventions and models of treatment that holistically address participants' concerns. On the heels of the 21st-century opioid overdose death crisis in the United States, a “fourth wave” of drug overdose deaths has emerged . Some auWhile recent surveillance data have focused national attention on the co-administration of opioids and methamphetamine, this phenomenon is not new. One of the most well-known patterns of co-administration, the simultaneous administration of heroin and methamphetamine in a single injection, colloquially referred to as a goofball, has been documented in numerous cities in the US and Mexico, principally in the West, since at least 2000 –9. More Another common pattern of combining opioids and methamphetamine is the use of methamphetamine while using methadone –15. GlobThe co-administration of methamphetamine and opioids, whether simultaneously or sequentially, can have important implications for the health and well-being of people who use drugs (PWUDs). This includes increased risk for overdose , 9, 11, Less is known about how methamphetamine and opioid co-administration has evolved in other areas, including more rural Western states. Nevada and New Mexico are two mostly rural Mountain West states with elevated rates of opioid-related overdose death and prevalent methamphetamine use . NortherData for the current study were collected as part of a larger sequential mixed-methods study . BetweenTrained qualitative interviewers used a loosely structured interview guide, which began with broad questions about the respondents' drug use, including reasons for using methamphetamine, current drug use patterns, and changes over time. Most relevant to the current analysis, we asked respondents to describe the context of their methamphetamine use, how their use began and how it has changed over time, how and when they use methamphetamine with or without other drugs, and what benefits and what drawbacks or negative experiences they are deriving from their methamphetamine use. Interviews were conducted in private or semi-private locations that were acceptable to the participants. Data were collected in English or Spanish, depending on participants' preferences. Written informed consent was obtained from all participants. A US$30 compensation was provided to all those who consented. All study activities were approved by the University of Nevada, Reno (UNR) Institutional Review Board (IRB). The University of New Mexico (UNM) IRB deferred oversight to the UNR IRB under a single IRB agreement.Interviews were digitally recorded and transcribed verbatim for analysis. After conducting a quality assurance review and redaction of the transcripts, data were analyzed using an inductive thematic approach. An MPH-level analyst reviewed all the transcripts and began by making a series of memos documenting the drug use history and patterns reported by each respondent, including types of drugs used and routes of administration. Those memos were discussed with a study PI, a Ph.D.-level mixed methods researcher with 20 years of qualitative research experience, and together they began identifying dominant patterns of opioid and methamphetamine co-administration, based on the type of drug, timing, and route of administration of each drug. We categorized participants into mutually-exclusive groups that were based on the participants' most common pattern of co-administration. This was determined in one of two ways: [1] The participants stated a distinct preference, or [2] They talked predominantly about one pattern of drug use. For the purpose of this analysis, we have excluded 4 individuals who only used methamphetamine and focused only on those who report co-use of opioids and methamphetamine. Then, the analyst developed a set of codes that identified the rationale for using that way and perceived benefits and harms associated with each drug and route of administration. These codes were then systematically applied to each transcript. After an initial round of coding, the coded transcripts were reviewed and discussed with the PI, and codes were further defined and refined, while memos were expanded to include a description of each pattern. Finally, the analyst and the study PI discussed the output from the coding and identified illustrative quotes. Quotes are provided using respondent ID, ethnicity, race, sex, age, and location of the interview.n = 11) and Northern New Mexico (n = 10). Respondents were 48% female and 40% Latinx. The median age was 35 years (IQR: 30–43). Just under half (48%) reported being homeless and 38% were employed full or part-time.We examined patterns of co-use of opioids and methamphetamine among a sample of 21 participants from Northern Nevada (n = 12); [2] methamphetamine and methadone (n = 4); [3] prescription opioids and methamphetamine (n = 1). However, it is important to note that most people had long-term histories of substance use and moved back and forth between different patterns of co-use within a given timeframe, so many people provided data about different patterns throughout their interviews. For example, Participant 4, a Hispanic/Latino Black/African American man in his 40's from New Mexico, began his drug use career snorting heroin. Subsequently, he switched to smoking heroin and began injecting methamphetamine, then switched to smoking methamphetamine. Now he is on methadone and smokes a “steady amount” of methamphetamine. Accounts of the transitions between patterns were particularly informative when identifying the motivations or rationales for preferring one pattern over another, which are discussed in the Materials and Methods section.Seventeen of the 21 respondents (81%) reported co-administration of opioids and methamphetamine . We categorized participants into three primary groups of methamphetamine and opioid co-use patterns and identified patterns within each group. The groups include using: [1] both methamphetamine and heroin, either simultaneously or sequentially  of our sample. Within that group, three sub-patterns were identified: simultaneous injection  or injection and smoking both drugs in quick succession, injecting heroin and smoking methamphetamine at separate times, and injection use of both drugs at separate times.People whose preference was using methamphetamine and heroin represented the majority . For example, Participant 3 described smoking methamphetamine as a “waste,” and explains why he prefers to inject methamphetamine separately:“I do heroin and then do the meth and for some reason, it makes the heroin last longer, so you don't have to you know, you know what I mean? I don't know how or what. But that's for me anyways. I'd rather inject it… because when you smoke it, you waste some.” –Participant 3, Hispanic/Latino Male, 30's, New Mexico.Participant 10 usually preferred goofballs, but sometimes injects heroin and methamphetamine separately, depending on his mood :I: Do you always mix them together or do you sometimes use [methamphetamine] separately?P: Sometimes, separate. Just depends on my mood.–Participant 10, Non-Hispanic, White Male, 30's, Nevada.Three participants described occasional methamphetamine use while taking methadone as part of an OUD treatment program. These respondents had engaged in several cycles of OUD treatment (including both methadone and buprenorphine) and periods of returning to heroin use. While they were on methadone treatment, their methamphetamine use increased compared to when they were using heroin:Now, it seems that I've been on the methadone, I smoke so much meth now – more than I ever have. I kind of think because the methadone gets you so tired, so down.” … “What's amazing, to be honest with you, after I went on that trip, now that I smoke [meth], it's a whole different thing. I don't get high like that no more. Now, I'm normal. It just wakes me up a little. That's it. I don't trip. Thank God.” –Participant 15, Hispanic/Latina Female, 40's, New Mexico. [emphasis added]“The “trip” that this participant refers to was an experience of injecting methamphetamine that led to undesirable hallucinations. After that experience, she switched to smoking methamphetamine, which for her does not result in the undesired psychiatric effects.Two respondents also described ongoing and occasional heroin use, in addition to their methadone and methamphetamine use. Participant 16, who is taking methadone as part of a treatment program but also continues to use heroin, methamphetamine, and cocaine, described the circumstances that lead her to choose one stimulant over another:“With the coke, I guess, the coke is like if I just wanted a real quick wake up, just to wake up real quick. Then the meth, if I have a few things I have to do for like the next few days, it'll keep me up for the next few days and keep me going. So [meth] kind of gives the energy too a little bit more than the coke.” –Participant 16, Hispanic/Latina, Black/African American Female, 20's, New Mexico.In one case, a respondent started her drug use with heroin and transitioned to buying prescription opioids on the street once she settled down and started a family with her husband. The switch to prescription opioids (in pill form) was precipitated by a desire to reduce the harms associated with heroin use. Subsequently, her husband introduced her to methamphetamine. They started by smoking methamphetamine but switched to injecting because it is easier to hide from other family members.We identified three primary groups of opioid and methamphetamine co-users. Within each group, sub-patterns were described based on timing and route of administration of the drugs. Several factors influenced how participants made decisions about their preferred route of administration  and sequence of co-administration, which we categorize into five themes: avoiding pain or discomfort, seeking pleasure, responding to social context, responding to drug availability, and achieving functional effects.Strategies to avoid pain or discomfort largely focused on the route and sequence of administration of opioids and methamphetamine, but also included using one drug or another to address specific pains or discomforts. For example, some people combined heroin and methamphetamine into a single goofball injection because they wanted to avoid the vein pain associated with multiple injections. For example, Participant 6 described a burning sensation associated with methamphetamine injection and a desire to “not poke twice”:And meth hurts. It burns bad. It burns. It hurts bad. My veins are just so raw because of constantly doing it [injections]. Mainly, I don't want to hit twice. I don't want to poke twice. They just hurt so bad already. I just want it [the heroin and meth] all at once.” –Participant 6, Non-Hispanic, White Female, 30's, Nevada. [emphasis added]“My veins are so sore because I do maybe 5, 10, 15 shots a day. That's the worst part about it. It's the effects on my veins and the bruising. I really use the same site like these over and over if I can, but that only lasts for maybe a day. Then they're off and so I have to go find new ones again. Then it hurts bad. Others who described vein pain and damage that they attributed to injecting methamphetamine switched to smoking methamphetamine to help avoid some of that pain. For example,I mean [meth] messes up your veins so bad. It's ridiculous how fast it messes your veins up. I just smoke it now. There's times where people offer me a shot. And if there's nothing else, I'll do it but I guess the chemicals or whatever that's in it. I mean it just – you go from having that vein there to not being able to hit it, it's just not having veins. And I always told myself I wouldn't be that person that was shooting up and taking hours and hours to hit but sometimes, I can't find a vein. And the methamphetamine messed up my veins a lot. Not that the heroin didn't either but it's just faster – the meth messes with me.” –Participant 5, Hispanic/Latina Female, 30's, New Mexico. [emphasis added]“Well, I shoot up heroin now and I used to shoot up meth until – smoking methamphetamine, and therefore preferred injecting it. For example, this person experienced unpleasant effects from smoking methamphetamine, which made her hesitant to try it again,Still, others described lung pain or potential for damage associated with “When I first took a hit of meth, they didn't tell me not to hold it in like you hold in crack. So when I blew it out, my head started pounding. My friend was like, “Oh yeah. By the way, don't hold it in. You'll crystallize your lungs.” I was like, “Well, thanks.” So I had a migraine for two days after that. I didn't like it. So it took me a long time to try it [methamphetamine] again.” –Participant 5, Hispanic/Latina Female, 30's, New Mexico.When she resumed methamphetamine use, she injected it to avoid the unpleasant effects of smoking that she experienced the first time.As described earlier by Participant 15, many people mentioned that they experience undesirable psychiatric symptoms from injecting methamphetamine. As a result, they switched to smoking methamphetamine to avoid the adverse effects but still receive the pleasurable effects . For example,It's much better – smoking it – for me.” –Participant 12, Non-Hispanic White Male, 50's, Nevada. [emphasis added]“I smoke it [meth]. I've only injected it a couple of times. It was too intense. When you inject it, it's more extreme. It hits you harder and it's more intense. Much faster and much harder. It hits you hard. Being almost erratic. It's just too much – breaking out in a cold sweat. Heroin-using respondents also described using methamphetamine to alleviate the pain and discomfort of opioid withdrawal:“If you're doing meth, you're sort of up and running around. If you get sick on heroin  and you do meth, you really don't feel sick on heroin anymore for quite a bit. So you can get a lot of shit done like walk around and do whatever you're going to do.” –Participant 11, Hispanic White Male, 30s, Nevada.A second theme concerned modifying the route or sequence of administration to enhance the pleasurable effects of one drug or the other. For those who prefer goofballs, the experience of injecting the drugs together was intensely pleasurable:“I was doing it with meth and heroin. It's like, I don't know, it's a disgusting sort of pleasure. I don't know but it's hard to describe. But yes, I mix the two. Once you get to the point where you're like, and especially since I struggled, the pullback and you see the blood go back in the barrel and you know you're in a vein and when you press down, you're going to get a rush, nothing in this world will ever compare to that.” –Participant 11, Hispanic White Male, 30's, Nevada.Participant 10, who also prefers goofballs, said:I: So, the stuff that you're getting right now, how does it make you feel? In your body, what does it feel?P: Oh, man. It's good. I do really large hits… But anyways, you fucking slamming here and then you flag it. The blood draws up back up in it. That's the fucking first time that I'm going to get fucking high as fuck. You feel it coming up your throat, you'll cough maybe, [inaudible] really good. It's fucking really good. It's really good. –Participant 10, Non-Hispanic, White Male, 30's, Nevada.Several people reported that injecting methamphetamine results in the most intense effects. Although some people considered that intensity to be unpleasant , others actively sought out the intense pleasure. For example,“It was bad, like, intense, like, knowing that that was what's supposed to happen. I would love to go back there but I was by myself in an apartment. I thought, “Oh, my god. I'm fucking going to die.” Yeah, it was really scary but knowing that that's what's supposed to happen. It's super, like, pleasure that you can never experience. I'm, like, coming to terms with the fact that there will never be a more purely pleasurable experience than that in my life. Orgasm, nothing, will ever compare to that. It's like a warmth and a sort of I don't know, weird headspace where sort of everything – it's strange to say. It's like your environment becomes erotic. Everything is sort of like a very – and later, I've realized, you actually like orgasm in your pants. You have a physical orgasm through injecting which... that sort of happened. I really put two and two together whereas now, I realize it's sort of like it's a sexual drug.” –Participant 11, Hispanic, White Male, 30's, Nevada.Some people found the effects of methamphetamine more pleasurable when they smoked it. Other people simply enjoyed the act of smoking and described smoking methamphetamine to satisfy the urge they have to smoke. For example,“Just smoking it [meth]. I was craving to smoke something, and cigarettes were – I was craving the smoke.” –Participant 2, Hispanic/Latina Black Female, 20's, New Mexico.Social context  was also influential in determining the route and timing of co-administration. Although most people reported a distinct preference when it came to their pattern of co-administration, some people were flexible and would accommodate the preferences of the people they were with, even if it wasn't their preferred method. This was especially evident when people described using drugs with a partner or significant other. As previously mentioned, Participant 17, who used prescription opioids and methamphetamine, was heavily influenced by her husband's preferred drug (methamphetamine) and route of administration (injection), but continued using prescription opioid pills to address underlying issues. She was concerned about hiding her methamphetamine use from family members, so it was easy for her to switch from smoking to injection use (which she believed was easier for her to hide), especially since her husband was there to show her how to inject.Participant 7, who earlier described the pleasure when a goofball achieves the “perfect ratio,” said he would rather do two separate injections of methamphetamine and heroin because, more often than not, that “perfect ratio” is not achieved and, as a result, one drug overpowers the other, rendering the injection “pointless” to him because he cannot feel the effects of the overpowered drug . When this happens, he finds himself spending more money on drugs or being miserable for the rest of the day if he is unable to afford more. Nevertheless, he uses goofballs with his girlfriend because that is her preferred method.Finally, in the exchange between Interviewer (I) and Participant (P) below, the participant describes how his decisions about how to use were influenced by other members of his drug-dealing network:I: Yeah. When you first used it, how did you use it? Did you smoke? Did you inject it?P: I smoked it and I inject it, snort it. I just went all the first time –I: Okay. Yeah. It's like all the different ones.P: – because I've been a part of the cartel for a while. I mean when they offer you something, you have to do it. It's not like, “Oh, I don't want it. No, thanks.”I: Yeah, just a little bit of like you've got to prove yourself.P: Yeah. It's like a disrespect. If you don't do it, they'll think you're a drug or you're a narc or you're something.–Participant 1, Hispanic Male, 40's, New Mexico.Another theme that influenced decisions about the route and timing of co-administration was drug or supply availability. Several respondents described specific preferences; however, they also described flexibility to adjust to changes in the availability and affordability of drugs and supplies . For those who preferred to use goofballs, they used them almost exclusively unless they could not afford it, leading to a hierarchy of drug use. This usually entailed using heroin first to avoid the negative effects associated with heroin withdrawal and then using methamphetamine once it became available. Participant 16 also described the declining quality of heroin, leading to a reduction in her use of that drug (while continuing to use methadone and methamphetamine). For those who preferred injection drug use, some reported resorting to smoking or snorting drugs if no  needles were available.P: I mean I just smoke [meth], shoot it, it depends… It depends, like, what I have. If I have the syringes.I: Yeah, okay. If you have syringes, if you have the equipment to inject it. Do you prefer one over the other? Smoking vs. injection?P: I [would] rather inject it.–Participant 3, Hispanic/Latino Male, 30's, New Mexico.Finally, there were some respondents who had familiarity with cocaine, but for whom methamphetamine appeared to be a newer stimulant. For those respondents, they described learning the differences between methamphetamine and cocaine and adjusting their use accordingly . Below, Participant 4 describes his first injection of methamphetamine, which he thought would be like cocaine but instead sent him into a “spiral”:it took me to a spiral. I had no idea what it would – I thought it would be used like a – I was told it was going to be the same thing as cocaine.” –Participant 4, Hispanic/Latino, Black/African American Male, 40's, New Mexico. [emphasis added]“Methamphetamine, my first time using it was shooting it up, and then This respondent subsequently started smoking methamphetamine, which gave a less intense high, and enjoyed using heroin to help him calm down from the methamphetamine.Finally, participants described using methamphetamine in conjunction with opioids to achieve functional effects. These included “relaxing” with methamphetamine, using methamphetamine to counter the sedation of heroin or methadone, and coping with trauma.Participant 4, whose primary pattern of co-use was smoking “a steady amount” of methamphetamine on top of his methadone, described the relaxing and calming effects he experiences from using heroin and methamphetamine. Importantly, he experienced undesired psychiatric effects from injecting the methamphetamine, and switched to smoking which gave him the desired effect:it does bring me into a calm mode. It gets me into a place of relaxation, not too deprived of energy, not too deprived of less energy.” –Participant 4, Hispanic/Latino, Black/African American Male, 40's, New Mexico. [emphasis added]“Now that I'm smoking [meth] with the bongs and the pipettes [rather than injecting it], I see myself – it does calm me down. It does allow me to – yes, Later, he went on to explain that the methamphetamine helps him stay busy, and he also uses heroin to relax and calm down from the busy-ness.Others described using methamphetamine to “wake up” or “get energy” when they feel overly-sedated from heroin or methadone. For example:I want to come up and I want to start cleaning, or I got to get energy to deal with stuff and I don't want to just be sleeping. I'll take a puff to wake up or to get going.” –Participant 15, Hispanic/Latina Female, 40's, New Mexico. [emphasis added]“I used to inject heroin. It's gotten cut down because of the methadone use.”... “I believe that I use meth with heroin sometimes. Like I said, I get a little bit lazy on the heroin or the methadone and then Similarly, Participant 9 took heroin to address underlying pain, and used methamphetamine to give her more energy. However, she doesn't use methamphetamine without using heroin:“I don't like to use meth without heroin. I don't know if it's because [it's] different nowadays. It is different, but I don't like the—it's like the heroin takes the edge off, because I like to be awake. I don't like to do a bunch of heroin. I don't like to be sleepy and stuff. I just like to—for one thing, I have pain but I don't have to do heroin. But I like doing the meth. It gives me energy”–Participant 9, Non-Hispanic White Female, 40s, NevadaParticipant 17, who started using methamphetamine when she switched from heroin to prescription pills, continued to use methamphetamine and occasional opioid pills because the methamphetamine helped her cope with long-term trauma, increased productivity and focus, and decreased tension with her partner.“I would say it [methamphetamine] helped me deal with my trauma, I guess. I mean it's very escaping. I'm not clouded by any trauma that I've had in the past.”—Participant 17, Hispanic/Latina Female, 30's, New Mexico.or methamphetamine , those who were dependent on heroin typically used heroin first, to ensure that they could avoid experiencing symptoms of heroin withdrawal.Finally, as described earlier, when participants had to make decisions about using heroin We interviewed 21 people who use methamphetamine about their patterns of opioid and methamphetamine use. Notably, the majority  engaged in some form of co-administration. While we were able to identify dominant patterns, most respondents had a long history of drug use and had transitioned through many different combinations of timing, drug type, and route of administration. Within each of their preferred patterns of drug use, respondents described sub-patterns that were influenced by a complex set of motivations and rationales that sought to enhance some experiences  and reduce or mitigate others .better than the effects of using methamphetamine with other opioids, such as heroin or opium. Our findings extend this knowledge by also describing drug-by-route interactions, such as attempting to avoid pain specifically associated with injecting or smoking methamphetamine to reduce undesirable effects and increase pleasurable ones.Our findings regarding the rationales underlying patterns of co-use are like those identified in other areas, including Melbourne, Victoria, Australia, and Oregon, USA. Palmer et al.  conducteThe social context of use is also an important determinant of both drug use patterns and related harms . For exad-methamphetamine salts without l-methamphetamine salts, which can be removed during some manufacturing processes . We also observed discussion of the changing  quality of drugs over time, and the influence of quality on consumption patterns. It may be that changes in methamphetamine composition could also underlie some of the experiences described in this study. Specifically, methamphetamine containing rocesses , has beerocesses , and morrocesses , some ofFinally, it is important to note the functional nature of the drug use patterns described by our respondents. Several studies have noted that function is a salient dimension of methamphetamine use, with people reporting increased ability to meet everyday tasks, better focus, and increased productivity  and to iand methadone. Concerningly, a recent study , it can elevate the risk for pathogen transmission if people do not have access to enough sterile injection supplies. While some respondents in our sample reported smoking (rather than injecting) when sterile supplies were unavailable, it is important to note that our respondents were recruited from communities with fairly robust syringe services programs. This may not be the case for communities throughout the Mountain West, and overall, the US has not yet achieved sufficient syringe supply to allow PWIDs to use a new, sterile syringe for each and every injection.Our findings suggest the potential importance of employing theoretical frameworks that can capture the functional (often ameliorative or protective) motivations for drug use, as well as associated risks and harms. The Trauma-Informed Theory of Individual Health Behavior (TTB) provides such a lens . InsteadOur results should be considered in light of the study's limitations. Qualitative methods are designed to elicit a diversity of narrative descriptions, rather than generalizable conclusions, and therefore the findings from this study may not be transferable to other regional, cultural, or social settings. Specifically, both New Mexico and Nevada have experienced a high prevalence of methamphetamine use for decades, which may suggest that co-use patterns in these states differ from the Eastern US and other regions where methamphetamine use is more novel. However, the similarity of our findings with other quantitative and qualitative studies suggests that our conclusions are robust to such variation. We arranged people into their respective groups based on either their stated preferences or their most predominantly discussed patterns of use. However, this does not encapsulate the whole picture because people engaged in several patterns of polysubstance use over time. Responses may be subject to social desirability bias, in which respondents alter their responses based on what they believe is acceptable to the interviewers. Interviewers for this study were trained to mitigate such bias, and were embedded within the harm reduction infrastructure in each community to enhance relationships and facilitate open and honest dialogue with respondents.We identified dominant patterns of opioid and methamphetamine co-use and described motivations that influenced the type of drugs used, timing, and route of administration. Findings suggest that respondents engaged in opioid and methamphetamine co-use to address a number of underlying issues and unmet needs, and their patterns of use changed in response to social conditions and drug availability. Patient-centered models of care and support should seek information from participants about their unique drug use patterns, including their motivations for use and the needs currently being met by their use, and interventions and programs should holistically address participants' concerns. Polydrug use, in particular, is understudied and the motivations for co-administration of methamphetamine and opioids needs further inquiry. One potential theory for the development of more patient-centered understandings of methamphetamine and opioid co-administration is the Trauma-Informed Theory of Individual Health Behavior (TTB) , which eBecause of the sensitive nature of the information contained in the transcripts  and potential for severe ethical, legal, and social consequences resulting from broken confidentiality, full transcripts will not be made publicly available. Redacted excerpts of the qualitative transcripts used in the current analysis will be made available to qualified researchers subject to review and approval by the appropriate Institutional Review Board(s). Requests can be made to the University of Nevada, Reno Research Integrity Office by calling +1-775-327-2368.The studies involving human participants were reviewed and approved by University of Nevada, Reno (UNR) Institutional Review Board (IRB). The patients/participants provided their written informed consent to participate in this study.We use the Contributor Roles Taxonomy (CRediT) refined by the Consortia Advancing Standards in Research Administration (CASRAI) for describing authorship contributions. BR and KDW: formal analysis. CM and KDW: writing—original draft. RH and KTW: project administration and investigation. KP and KDW: funding acquisition and supervision. RH, KTW, KP, and KDW: conceptualization and writing—review and editing. All authors contributed to the article and approved the submitted version.This research was provided by the Mountain West Clinical & Translational Research Infrastructure Network, in the form of a Multi-Site Pilot Project, through grant NIH/NIGMS U54GM104944; PI: Francisco Sy, MD, DrPH.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Although technologically well-developed and legal in many countries, it challenges and even contradicts the basic traditional concepts of family, motherhood, and gender roles. In the present study, we examined the types of stigma coping strategies surrogate mothers discussed in an online support group in post-Soviet Russia. (2) Method: We conducted a qualitative thematic analysis of 15,602 posts on a Russian-language online support group for surrogate mothers. (3) Findings: group members discussed four types of coping strategies: stigma internalization, stigma avoidance, group identification, and stigma challenging. Nevertheless, these strategies varied across the surrogate motherhood stages. Group members advised each other on specific strategies to use to cope with the state of discreditable (invisible) stigma , with different strategies for when the pregnancies became visible and they risked becoming discredited people. Furthermore, group members disclosed that they used these strategies even when they returned to their previous family and work routines. Theoretically, our findings challenge Goffman’s classic theoretical dichotomy and coping research concerning discreditable (invisible) and discredited (visible) stigma. (4) Conclusion: Our findings indicate that surrogate mothers anticipate experiencing stigma and therefore plan for it by discussing potential coping strategies in the online group. Moreover, any intervention designed to cater to the needs of surrogate mothers must, therefore, take into consideration the social needs of their entire family. The current information age offers various online channels for obtaining social support to individuals who are coping with stigma. Online support groups are formed or facilitated through digital platforms, which provide a sense of space, shared practice, shared resources and support, shared identities, and interpersonal relationships . Recent Drawing on stigma ,10,11,12The context of surrogate motherhood in Russia is unique in the sense that, unlike Western and Asian surrogate mothers (SMs), post-Soviet SMs construct surrogacy as a kind of paid work ,16. MoreIn this study we addressed the role of computer-mediated communication in coping with the stigma of surrogacy in Russia, thereby contributing to the study of stigma by applying extant offline stigma coping strategies to the online realm and by documenting the way SMs embrace or resist stigma through online communication. Unlike previous research that utilized surveys and interviews to examine stigma, in this study, we employed unobtrusive content analysis of messages posted on an online message board. The study also contributes to family, motherhood, and gender role literature by highlighting the ways in which local family norms influence the manifestation of different coping strategies in an online environment.distancing, describes how stigmatized individuals can cognitively separate themselves from others who are similarly placed, and this has been examined in stigma research [Generally, members of stigmatized groups have been depicted as passive victims of negative stereotypes, harmful attitudes, and discrimination. However, in the past two decades, stigma research has uncovered the distinct and varied ways that people cope with stigma ,12,20. Iresearch . HoweverStigma internalization, also referred to as self-stigma, is the process by which an external experience of stigmatization becomes part of one’s perception of self ,25,26. IFor example, a content analysis of Russian-speaking online support groups indicated that SMs are frequently told that they are bad mothers to their children and greedy for becoming surrogates . InternaThe strategy of stigma avoidance involves the active avoidance of interpersonal interaction, in anticipation of devaluation . The modSurrogate motherhood research has identified one way in which SMs conceal themselves. Saxena and colleagues  found thAt the opposite end of the spectrum of the previously mentioned stigma coping strategies are methods employed by those who oppose the widely accepted stereotypes concerning surrogate motherhood ,20. SurrTo reduce their stigma, stigmatized people are likely to search for others who share the same experience ,12,31. CResearchers carrying out interviews or surveys with SMs have shown that surrogacy develops in a disapproving environment and as a somehow morally reprehensible experience ,35 and tCommercial surrogacy in Russia is minimally regulated—no governmental guidance exists regarding the contents of a surrogacy contract. The two main arrangement options for clients who enter a commercial surrogacy agreement are either by employing a commercial surrogacy agency that undertakes the selection of suitable surrogacy workers and all necessary communication and steps with clinics and lawyers or by taking matters into their own hands and choosing a direct arrangement . UsuallyLocal regulations also impact the SMs’ family life. Surrogacy regulations in Russia require that SMs must have between one and three healthy children of their own . As suchTaking this local construction of surrogate motherhood stigma into account, it is essential to study how Russian SMs manage and neutralize the stigma associated with their “deviant” occupation ,42,43. RRecent research into stigma management among SMs from Russia highlights a different approach to surrogate motherhood. Weis’s ,38 interSocial networks of others in a similar situation can be formed or facilitated through online communities, which provide a sense of space, shared practice, shared resources and support, shared identities, and interpersonal relationships . In addiCollectively, previous research suggests that online support groups offer advantages over other forms of support as they enable one to remain anonymous and overcome logistical obstacles ,49,50. IFollowing research about SMs’ perceptions of their potentially stigmatized work, in this paper, we examined the coping strategies that SMs shared and discussed in online interactions on a Russian-language SM discussion board. As such, the current study illuminates the work of surrogacy, reveals the coping experience of SMs from Russia, and contributes to a growing body of literature on online support from other SMs.https://www.ostrov-kenguru.ru/board/ accessed on 19 November 2020). This subsection represents an online community for Russian SMs, who shared and discussed their experiences with their peers. The content of this discussion board is accessible without website membership and the website archived all its forums so that data were explicitly public.We conducted an inductive thematic analysis to investigate how Russian SMs manage stigma through online communities ,52. SpecDuring the data collection period (January–March 2018), the entire support group had over 8400 members, 55 sections (sub-support groups), 6099 topics, and more than 1.5 million posts. In 2021, the entire online support group was shut down. The authors tried to contact the support group administrators to find out the background behind this move, but no available contact information was left. Informal communication with members of a different online support group for intended mothers in Russia revealed that the group was initially set up by a fertility clinic and evolved into a place (as this study shows) where SMs could voice their experience and even complain about their treatment by the funding clinic. Eventually, the clinic took it down.Prior to data collection, we obtained institutional review board approval from the Ben-Gurion University of the Negev to conduct the study, which was exempt from further review as it relied on publicly accessible documents that do not require registration. Nonetheless, assuming that online support group members might perceive public digital spaces as private , and to To identify the themes emerging from the online discussion group, the second author (a native Russian speaker) first read all 213,505 posts from 278 discussion threads. Of these, 51 threads  included discussions about SM stigma, descriptions of stigma-handling experiences, and advice on how to manage SM stigma. All 51 threads were retrieved, converted to MS Word, and translated into English. Both authors then imported them into Atlas Ti  and read them in detail.stigma avoidance and group identification strategies: “Keep your mouth shut. Shut up and be quiet. Nobody, not at work, not relatives, not girlfriends. Especially girlfriends. If you need to speak out, come over and cry here”.Our next step was to observe which stigma coping strategies were discussed in the online support group. To do so, we identified and coded all mentions of stigma coping strategies by analyzing units—words, sentences, or paragraph-long statements—that provided context for the ideas within each post . Next, we narrowed down overlapping categories by discussing and comparing the 14 codes generated initially, agreeing on eight coding categories. Finally, we identified four main themes that embodied the way that support group participants discussed SM stigmas: stigma internalization, stigma avoidance, group identification, and stigma challenging. Once we identified these primary themes, we reread the posts, coded them, and placed them in a stigma coping strategy category. Out of the initial sample, 510 posts included expressions of stigma coping strategies. Within this group, 194 posts offered a combination of different stigma coping strategies. For example, we coded the following post as including both We employed three steps during the analysis to enhance the study’s credibility and trustworthiness ,56. FirsTo uncover how online support-group members shared their efforts to handle stigma, potential dimensions of managing stigma were defined as mentioned above. As in many other cases of stigmatized individuals ,22,24,59Stigma internalization, the process by which an external experience of stigmatization becomes part of one’s perception of oneself ,25, appe“It’s easy to understand your husband’s frustrations. It’s hard for a man to accept that his wife is not pregnant with his child. You should not push him. You need to understand your husband, find the right way to approach him. This situation is harder for him than for you. It is also difficult for men to come to terms with the idea that they cannot (in their view) adequately provide for their families. They also care about relatives’ opinions ... husbands of SMs are often treated like pimps. After all, they earn money using their wives! He fears the condemnation that he, a healthy man, allows his wife to do such a thing instead of just working harder!”Sofia was deeply concerned for her husband’s public and self-image due to her decision to become an SM. Her husband, guilty of nothing, was unfairly subjected to contempt. By becoming an SM, she was putting at risk her husband’s reputation, self-esteem, and social identity as a husband and a man.Online support group participants shared their practices of coping with the internalized stigma of the “bad wife.” Some wrote about their efforts, in contrast, to become the ideal wife. For example, Annette, whose husband consented to her participation in the surrogacy program, wrote about how she tried to compensate for and reward him for his moral and physical “suffering”:“My husband agreed on the condition that no one would know about the program. I put a lot of effort into making sure my participation in the program won’t hinder my husband. I cook his favorite dishes. I talk of how nice it’ll be to spend the money we get, try to support him somehow. I worry about my husband. We have not had normal intimacy for the last three months. I think this is very difficult for a man.”Annette was grateful to her husband for consenting to her participation in the program. She considered it his sacrifice. Knowing that his friends and acquaintances would condemn him, he nevertheless allowed her to participate. As a result, she felt the need to compensate him: to cook something special for him, to concern herself with his sexual needs, to encourage him to dream about their future wealth. Thus, while internalizing the stigma of a bad wife, surrogates seem to try to use a few different approaches to improve their situation. They try to compensate for their husbands’ discomfort by becoming super-wives in other aspects. These strategies may help SMs deal with the internalized stigma of being a “bad wife”.Believing that stigma was based on ignorance, some SMs shared stories in the online support group about their efforts to challenge stigma by educating (69 posts) or confronting the people in their environments (87 posts). Education was manifested in the form of explaining the mechanism and social value of surrogate motherhood. Publishing posts with information about surrogacy in other online support groups, under pseudonyms, appeared to be a safe platform for this education strategy. Angela said:“I recently tried to prove that being an SM is a noble cause at a mothers’ forum entitled: “Surrogate motherhood. Would you be able to?” I shared all the details, provided data, posted links to scientific articles. But it was me alone against hundreds. It was as if I could not be heard by them. Everyone responded by calling me a soulless prostitute, making money with my body, completely lacking any maternal instinct since I would sell my child for money. I argued and argued, and then I just got tired. It felt like I was trying to get water out of a stone. Everyone was stuck to their own opinions, and only a few supported me.”Angela used the online support group features in order to educate: that is, she had access to a virtual community of young mothers, the anonymity to speak warmly and openly, and the ability to post links to relevant online resources. However, as she described, the stigmatizers resisted the information she provided. Additionally, some SMs used education strategies with those in their immediate environments, such as relatives. For example, Anastasia said:“Why does the adult generation consider surrogate motherhood something terrible, scary, shameful???!!! At first, I thought it was because the majority simply did not understand how surrogacy works. People are very ignorant; they believe that a woman gives away her child or, even worse—she sells it. But it turned out that even if they are civilized people, and even if you describe to them the whole process, they still cannot accept it. Take, for example, my mom and dad. They are lovely people. But when I explained the process to them and said that I wanted to become an SM, I saw how my mother became nervous, and my father agreed to support me only on the condition that I would tell NOBODY about it. Even my brother! They still think that surrogate motherhood is terrible.”As seen from the quotation, providing information about surrogacy did not change Anastasia’s parents’ attitude toward surrogacy. They still considered surrogate motherhood a problematic occupation, one that should be hidden from everyone, even family. Thus, the strategy of educating those in the SMs’ environment directly or via online support groups appeared to fail. The people in their environment resisted awareness; providing information about surrogacy did not overcome the stigma.Some participants perceived their husbands as fragile: seeing them as being hurt as a result of their own (the SMs’) decision to become surrogates. They, therefore, considered it their duty to defend their husbands and confront the stigma on their own. Anna shared her opinion:“I don’t give a damn about peoples’ attitudes, but my husband does care deeply. He worries, so I support him. If anyone says anything, I’ll react so badly that they’ll think twice about saying anything to us again. What’s important is that my husband and I both know that we earned that money and that another couple can have their little miracle, and these parents are happy. Soon the talk will dry up. Let them eat their poison.”Anna perceived herself and her husband as partners, standing shoulder to shoulder to fight against the stigmatizing society. They perceived surrogate motherhood as a rewarding experience: an honest occupation that helped childless couples, and they would defend their honor.Many members of the online support group wrote about how “dodging the stigma” worked for them. In their online communications, group members recommended to one another actively avoiding interpersonal interactions that were likely to make them feel devalued. Group members divulged that they withdrew from offline interactions with prejudiced people or people who inquired about their reproductive statuses. This strategy manifested in three ways: (1) secrecy—concealing labeling information and keeping one’s reproductive status a secret; (2) withdrawing from social interactions and familiar environments; (3) covering and passing—deflecting attention from the stigmatized attribute and using tactics such as joking and attributing symptoms to some other condition. The SMs moved between these three strategies according to how visible their pregnancies were.When there was still little physical evidence of their pregnancies , a very widely employed strategy used by the SMs was controlling the stigmatizing information. They handled risks by dividing the world into two: a large group to whom they disclosed nothing, and a small group to whom they disclosed everything, and upon whose help they then relied. This division was challenging, as it was essential to find a balance between dodging stigmatizing social interactions and finding support. Sadly, this avoidance did indeed hinder receiving support from others. The SMs viewed self-disclosure as risky, potentially leading to rejection and banishment; therefore, secrecy was highly recommended, as Alice shared:“It is better not to tell anyone. Neither friends nor relatives. You never know who in your surroundings is ignorant. Also, you will never know what people are actually thinking in their minds. They can say one thing but think in a completely different way (that often happens). They will kind of support you in words, but then it will come back to haunt you. Therefore, don’t try to explain anything, or prove anything—and tell no one! The risks are too high. I have no one. NO ONE knows that I am an SM.”Alice had doubts about her relatives and friends and saw the disclosure of her surrogate motherhood status as a social threat. She was convinced that social sanctions would follow self-disclosure, even if she did not know exactly who would apply such sanctions. Moreover, she did not believe in the sincerity of people’s support. In her view, information about participation in the program would permanently weaken her position among friends and relatives.Like Alice, many SMs did not even tell their parents, as Polina shared: “I believe that the fewer people know, the better. Explanations might not help. Therefore, I didn’t disclose it to my parents: I don’t want to take a risk and put my relationship with them to the test.” Polina admitted that even if she tried to educate her parents about surrogacy, they would not accept her choice to become an SM. She did not want to risk and disclose her occupation and consequently give up on receiving support. Polina’s fear, it should be said, was not without cause. For example, other online support group members shared that family members often denied them support after disclosing their SM status. For instance, Lenna wrote how her mother refused to host her during her pregnancy:“I wanted my mom to know. I thought that I could stay with her during the late stages of my pregnancy and that she would help me a little with my son. I had no plan to hide from people because I’ve done nothing wrong. But my mother lives in a small town and she cares too much about people’s opinions. She says that they will remember this for the next 100 years. First, she seemed to support me, but then she said, ’Do not come to us when your belly is visible.’”Lenna described her mother’s fear of the SM stigma spilling over onto the entire family. Her mother, fearing this stigma, refused to support her daughter once the pregnancy could be seen. Other SMs also needed to keep their occupation a secret for the sake of their loved ones, as Lolia noted:“I don’t give a damn about the opinions of others. I would carry this pregnancy out in the open. But the children. I’m afraid for my children. They will be humiliated later, and I cannot harm them. And my husband, I feel sorry for him too. They’ll perceive him as guilty for allowing it. I agree that the fewer people know, the better.”As disclosing their surrogacy even to their own parents was risky, and the chances of getting support were low, many SMs did not see the point in doing so. In addition, some SMs did not tell their relatives about their participation in the program, in order to spare them the stigma, as Daria divulged: “I decided not even to tell my mother. She does not need even more anxiety.” Thus, the SMs decided to narrow the circle of “sympathetic others” as much as possible, thereby reducing their social network and their chances of receiving much-needed support.In addition to secrecy, avoiding stigmatizing social interactions seemed an ideal option to many SMs. When their bellies were small, at the beginning of their pregnancies, this strategy did not require much effort. They stayed at home, and avoided going to public places or receiving guests, as Karin wrote:“Well, you can stay at home for six months, not meet with anyone, not walk anywhere, and you can also live without theaters and shops. You can breathe the air late in the evening when it is dark and there are no people out on the street.”Withdrawing from social interactions also meant hiding the pregnancy when visiting public places, such as the hospital, according to Karin:“It is possible to hide it very well. In the winter I put on an extra-large coat and a massive scarf on top. If I went somewhere, I held a coat in my hands or some kind of bag. I also tried to stay out of view. For example, my husband drove up to the hospital entry gate and left quickly.”However, withdrawing from stigmatizing interactions required more effort during the period when their pregnancies became visible. The online support group members shared stories about moving to other cities during this period, as Lola described:“You don’t even worry about what people will say. People do not need to say anything. You go on a “business trip,” and you come back with money, and that’s it. Unfortunately, it is necessary to leave your children and husband for a long time. And then you have to search for work again.”Or as Polina wrote:“In the first program, my husband and I told our families and our children that we would be working in Italy for three months—the last trimester. We called them from ‘Italy’, and brought them ‘Italian’ gifts.”As the quotes above suggest, the stigma coping strategy of avoiding social interactions had many limitations and disadvantages. It demanded finding a place to hide, from mid-pregnancy onward. It also required a long separation from the family, eventually also from the SM’s children. Moreover, this option did not allow SMs to continue to work in their regular jobs. Thus, avoiding the surrogacy stigma required a temporary interruption of social life and prevented the fulfillment of the women’s roles of wife, mother, and working woman.Most online support group participants preferred to hide the fact of their participation in the SM program. However, those who could not leave their family or work had to make up stories to explain their bodies’ changes as the pregnancies progressed. To cope with the anticipated social judgment, the SMs shared three types of “cover stories” that helped them deflect the SM stigma. The first was pretending that they had gained weight. The second cover-up was pretending that they had been pregnant but lost the baby. The third strategy was to tell others that they were SMs but were doing so for a relative and not being paid for it. In the first two cover stories, the SM stigma was replaced by another stigma—being fat or losing the pregnancy. These two attributes were socially more acceptable. For example, Ksenia camouflaged her growing belly and explained her physical changes as weight gain:“I was sometimes asked, ‘What’s up??? Are you waiting for the fourth one??!’ I always answered with a sarcastic tone—“Aha!!!—FIFTH!!!!”  Well, then I added with a sigh: “I need to eat less...”Presenting herself as a weak-willed person, unable to resist overeating, seemed more acceptable to Ksenia than being an SM.Making up a story about losing a baby was another possible strategy for SMs who could not hide their pregnancies. The online support group members advised one another on how to “playact”. First, one needed to express joy about the “future addition to the family” and discuss how the older children and the husband were waiting eagerly for the arrival of the baby. Then, after fulfilling their legal obligation and handing the child over to the biological parents, they suggested returning to work with a purposefully “sad face,” according to Annette:“I was a surrogate twice while still holding down a job. I was entitled to maternity leave after each pregnancy but after giving birth to the surrogate baby, I went back to work. I informed management that the reason I was back at work was due to the loss of my child. I made a sad face and said that this topic was taboo for my family. I also told my acquaintances, ‘I don’t want to discuss it’... People usually do not ask further direct questions, and indirect questions might not be answered.”Or, as Milana suggested:“I learned not to talk much with strangers—again, not to attract attention—and if necessary, to tell lies. In my son’s kindergarten, they still communicate with me with a mournful half-whisper. The best strategy is to tell them: ‘Don’t want to talk about it, and don’t ask my son anything about it.’”Hinting about the loss of the child discouraged information requests from those in the SMs’ social environments. For those who worked as SMs more than once, covering the stigma of being an SM by replacing it with the stigma of being a woman who miscarried was a successful strategy. Nevertheless, these performances were not easy for all SMs. For some, the need to lie and upset people made them feel uncomfortable. For example, Olga shared: “My neighbor was sincerely happy about our addition for the new year. When she recently called, I didn’t have the guts to lie and tell her I’d lost it.”Several participants decided not to hide the fact that theirs were surrogate pregnancies. Instead, to avoid stigma, they preferred to keep silent about the commercial nature of the surrogacy. This covering-up strategy also seemed to be successful. Marta wrote:“If anyone expresses interest in my pregnancy, I tell them right away, “My sister is infertile, and I’m helping her.” In the fertility clinic that hired me, I said that I was carrying for my sister. The attitude toward me was very kind. In the maternity hospital, too. Everyone thought I was having a baby for my sister .”Marta chose to present her participation in the program as an altruistic act, as a sacrifice for the greater good of the family. This strategy allowed her to reveal her pregnancy; the people in her environment approved of surrogate motherhood as long as it was done altruistically and free of charge.To reduce stigma and avoid discriminatory behavior, users of the online community identified more closely with surrogate mothers than with other mothers and approached the group for online support. Under these conditions, the community for many of its participants was a safe haven, as Faina admitted:“My mother does not know, and neither do any of my relatives. So, I quenched my thirst for communication during both programs here. On the “Island,” you can rest your soul. You read familiar topics and stories and feel better because you do not feel weird or like a “special case.” It was only on the forum that I realized that we, the SMs, were actually doing a good thing, supporting a good cause!”The role of the online support group in supporting the group identity strategy was vital, as the SMs felt they were understood by women who confronted the same challenges, as Galina wrote:“In the first program, I didn’t know about the Island. This was a sad and lonely period. I was ashamed of being unmarried and pregnant. I thought I was the only single mother who was doing surrogacy. Now, after reading the posts I don’t feel like the ‘black sheep.’ No one can understand SMs like other SMs. Thanks for the support, my beloved Island.”In some cases, identifying with group members took place even before joining a surrogacy program. Some members were women who were still considering becoming SMs. At first, they were only observers of the online group interaction , as Nadia wrote:“I have been reading the forum for a long time, and it’s so lovely to see how much kindness there is here. I decided to join you earlier to at least get a little support. Thank God there is a forum where you can get helpful information or vent your soul. In the real world, there is almost no one to talk to about such topics. So, add me to your ranks, please.”Forming a group identity through the online support group was such an essential source of support for the members that some even felt it should be recommended as a source of support by the fertility clinics who hire them. Alice wrote:“Every week there are more and more of us. It is a pity the clinics do not direct people to the online support group. So many girls go through the program alone. And here, they can always find advice and calm down.”As the quotes from Nadia and Galina show, even passive participation, such as being an observer of the online support group, was helpful enough. The online community provided communication with people going through similar experiences and served as a digital haven. This community seemed to function as a place where SMs felt closer to the other anonymous participants than to their own relatives. They shared familiar topics and stories and created an online realm where being an SM was acknowledged as challenging but acceptable.In this study, we investigated the stigma coping strategies that SMs discussed in an online support group for surrogacy in post-Soviet Russia. In line with the stigma coping strategies literature ,22,24,59The communication among the SMs studied here reveals the efforts expended by the SMs in protecting what they perceive as a businesslike exchange. Although, in the post-Soviet context, SMs, professionals, and intended parents frame surrogacy work simply as a job , their iThis study has several implications. Our findings expose an interesting dynamic around the use of stigma coping strategies throughout the pre- and post-natal stages. During the first few months of their pregnancies, when there were few physical signs of pregnancy, the online support group members shared and recommended coping with the discreditable/hidden stigma via a stigma avoidance strategy in the form of secrecy. However, when the pregnancy became physically visible, and the risk of becoming a discredited person appeared, the SMs recommended other strategies, such as withdrawing or covering and passing. Unlike people with, for instance, mental illness or epilepsy, who must consistently cope with stigmatizing attributes that are generally not visible, SMs must shift between strategies (as their stigmatizing attribute shifts from invisible to visible). Moreover, these coping strategies must change once again after the baby is handed over to the biological parents, and the SMs must return to their previous work and family routines. In this postnatal phase, the stigma coping strategy that they used was covering, making up stories of the loss of a child. As such, theoretically, this finding challenges Goffman’s  classic Empirically, our study highlights an interesting finding concerning surrogate motherhood stigma not only in post-Soviet Russia but also globally: it is a stigma that the SMs anticipate and can therefore plan for, by discussing potential coping strategies in the online group. In some cases, online coping with stigma is even practiced by women who are still only considering becoming SMs. These expectations lead to the use of the group as a springboard to discuss and prepare for the social ramifications that they fear. This process of preparing for an experience of stigma by engaging in an online group discussion may result from the social construction of surrogate motherhood as “dirty work” in post-Soviet Russia. Dirty work is viewed as a deviant occupation, as opposed to more legitimate or noble occupations and professions ,61. Our Practically, our finding regarding the SMs’ fear that the stigma will spill over to other family members emphasizes the need to provide SMs with a context of support and care that includes their entire family. Surrogacy regulations in Russia require that SMs must have between one and three healthy children of their own . As suchAlthough quantifying the use of online stigma coping strategies was not the goal of our study, it is nevertheless impossible to ignore the finding that most of the SM posts regarding coping strategies were devoted to stigma avoidance strategies. Specifically, the vast majority of the posts involved avoidance strategies (453), compared to 156 posts about challenging, 63 about identification, and 32 about internalization. Avoidance strategies were the most discussed topic and the most recommended of the strategies in the online community. Avoidance strategies were manifested in the ways that the community members taught each other how to conceal their pregnancies. Although our study method does not allow us to evaluate whether this strategy was indeed successful, our finding follows that of Lamba and colleagues , who comIt is important to stress that stigma researchers  have fouFollowing Link and colleagues’  advice, Practically, our study indicates that any international or global regulation of surrogacy needs to take the local moral frameworks towards surrogacy into account ,65. ThusThe current study had a few limitations. First, it analyzed SMs’ discussion of stigma coping strategies under pseudonyms in a discussion board for SMs. This anonymity restricted us from examining the expression of stigma coping strategies per user as we had no information about users’ identities. In addition, this anonymity limited identifying how many distinct users used the online discussion board. Second, some posts included more than one single coping strategy, but we approached each strategy separately. Hence, the results do not indicate the richness of each message in terms of stigma coping strategies. Third, our study focused on the manifest content in the online posts, as with any type of content analysis. Therefore, we cannot indicate the users’ motivations or the “hidden meaning” underlying the posting and discussion of stigma coping strategies in the online support group. Lastly, we analyzed messages posted to a single online support group for SMs. The extent to which the observed pattern of stigma coping strategies is generalizable to other online groups has yet to be tested. Future research should seek to explore the categories of stigma coping strategies expressed, provided across multiple SM online support groups.


Postdigital theory assumes that the digital is no longer new, and disruption now mundane. It gets us beyond binaries such as online/offline, virtual/real, old/new media, digital/analogue, technical/natural, biological/informational Cramer .1 RatherAt the same time, the postdigital condition is one of ‘imperial and industrial ruin’  seems exciting, flagging a ‘with’ rather than the ‘self’ of autopoiesis. The friction of tyres on roads or the noisy hum of daily life could be good to think with.From the broad array, I shall try out three concepts in a little more detail to think about the postdigital: postdigital assemblages, postdigital practices and postdigital noise. These can be seen as alternatives or as complementary concepts. Although they overlap a good deal, each opens up slightly different priorities. The conclusion reflects on some implications for educational research.agencement for her notion of assemblage, adding ‘polyphonic’ to emphasise that the kind of assemblage she finds helpful is about knots, not networks, about human and nonhuman ‘ways of being’ as ‘emergent effects of encounters’, rather than community influence. Polyphonic assemblages are inspired by music such as the madrigal or fugue; when we listen, we can ‘pick out separate, simultaneous melodies’ and ‘the moments of harmony and dissonance they created together’  schooling through these practices.Noise is different from contradiction, misunderstanding and misrecognition. I draw here on the notion of noise in data science. In this context, noise refers to corrupt, incorrect or meaningless data. Noisy data are strange, they don’t fit expectations. Data scientists acknowledge that most complex data sets include noise. Noise is not a glitch; it is a constant feature of real-life data sets. We hear noise when we notice that data are ‘broken’  for minerals, to build machines in (loud) workshops . I would trace how the people working with the material infrastructures engage with these universal rhetorics, how they deal with the practical dilemmas they face, which workarounds they find for when the noise becomes palpable and things don’t work smoothly  policy  expansion and standardisation of data infrastructures and policies. Instead, they alert us to what is going on in the mycelia, the mud or the lines of flight; they help us notice the multiple, layered, intra-woven rhythms of world-making and decomposition today.Some readers may wonder if the adjective ‘postdigital’ is really necessary. Perhaps not, but words do things. By flagging the attempt to overcome a troublesome binary that still dominates public and academic discussions of technology and education, this adjective opens up what Tsing  has callThree implications for research conclude this piece. First, the economy of knowledge, including citational practices, mean that universalising titles are picked up and circulated more easily than writings which explore, e.g. the complex noise that make it ‘impossible for the bottom line to be one single statement’ Haraway : 105. ThSecond, patchwork ethnographies (Tsing) or ethnographies of the particular (Abu-Lughod) are only one set of methodologies emerging from these theories that will be important for future studies of datafication and education. This is not only about following policy or educational technologies into classrooms but also about what we notice when we look into classrooms. The broader implication for research is to attend to the heterogeneity. I suggested some ideas above which draw on interviews, observations and analysis of documents, software and infrastructure.Third, none of the three concepts offers the redemption, solutions or ways out of our contemporary conundrum that educational researchers are often expected to provide. By analysing heterogeneity, however, we might avoid the seductions of abstractions about the digital and find new ways of noticing and weaving together the terrible, the terrifying, the strange and the wonderful of the postdigital.