Navigating stigma: a qualitative study of barriers to opioid treatment engagement in Tanzania

Abstract

Background

Stigma related to drug use is a well-documented barrier to engaging and remaining on medication for opioid use disorder (MOUD), yet little is known about how stigma operates across multiple social and institutional settings in low-resource contexts.

Methods

This qualitative study draws on 40 in-depth interviews with current and former MOUD clients and four focus groups with 35 current clients at an opioid treatment clinic in Dar es Salaam, Tanzania. Transcripts were thematically analyzed to explore how stigma influenced MOUD adherence and retention.

Results

Five themes emerged: stigma encountered while using public transportation; employment-related stigma; lack of family support due to misinformation; institutional stigma within the treatment setting; and stigma management strategies, including altering appearance and distancing from peers. Gendered expectations intensified stigma for women, while assumptions of untrustworthiness shaped client interactions across settings. These experiences posed significant barriers to consistent treatment engagement.

Conclusions

To support MOUD retention, programs should integrate stigma reduction through expanded family engagement, more flexible clinic policies, and client-informed approaches. Public education efforts are also critical to addressing widespread misconceptions about MOUD and people who use drugs.

Background

Substance use disorders, particularly opioid use disorder, are among the most highly stigmatized health conditions globally. Widespread societal beliefs—such as the notion that drug use stems from personal failure—fuel stigma and serve as significant barriers to accessing and remaining engaged in care that supports clients’ health and well-being [1]. Medications for opioid use disorder (MOUD), including methadone maintenance treatment, are a cornerstone of evidence-based treatment [2]. Yet, stigma across individual, interpersonal, and structural levels continues to undermine engagement, adherence, and long-term treatment success—often resulting in treatment discontinuation and an increased use of substances that can increase risk of overdose [3–6].

Stigma related to drug use can take many forms, including direct discrimination (enacted stigma), fear of future mistreatment (anticipated stigma), and the internalization of negative societal messages (internalized stigma) [7–9]. These experiences may erode self-worth and confidence, especially when people begin to see themselves through the lens of harmful stereotypes—for example, as untrustworthy or morally deficient [3, 10].

People who use drugs may be rejected and feel misjudged by family, friends, and community members [10, 11], and may become socially isolated [12]. In response, many turn to networks of other PWUD for support [10, 13]. Although MOUD can reduce illegal opioid use and help restore relationships [14], its use itself may also stigmatized. People may perceive MOUD as substituting one addiction for another [4, 15]. These perceptions can discourage treatment engagement [16].

Stigma is also prevalent within healthcare settings. People with a history of drug use may experience discriminatory treatment or unwanted disclosure of their drug history or drug treatment status [4, 16]. Community-level stigma may also arise when drug treatment programs are visibly marked, or clients are publicly seen accessing care. These experiences can further reinforce negative beliefs and may contribute to treatment disengagement [5].

In many parts of Africa, where gender norms are strongly enforced, gender alone can add significant layers of stigma for individuals receiving MOUD. Women who use drugs often face heightened stigma due to societal expectations that frame drug use as incompatible with ideals of femininity, submissiveness, and caretaking [10]. Some women experience further marginalization through engagement in sex work or exposure to violence within male-dominated drug scenes, prompting them to avoid formal services and instead seek safer, more private spaces for support and care [14, 17]. These intersecting forms of stigma can compound feelings of isolation and pose substantial barriers to engaging with and remaining in treatment.

Objectives

While stigma has been widely acknowledged as a key barrier to effective treatment for opioid use disorder, few studies have examined how intersecting stigmas—related to drug use and gender—shape client experiences and retention in MOUD programs, particularly in low-resource settings. This study explores how stigma influences treatment trajectories by examining qualitative interview and focus group data. We focus on how stigma-related experiences—across individual, community, and healthcare contexts—impact clients’ adherence to MOUD and long-term treatment engagement.

Methods

This study was conducted at an opioid treatment clinic in Dar es Salaam, Tanzania. The clinic is embedded within a large public hospital and offers MOUD, specifically methadone maintenance treatment, as well as psychosocial services, tuberculosis, HIV and hepatitis B testing and treatment, hepatitis C screening, social services, and occupational therapy at no cost to clients. Methadone is dispensed daily through the clinic pharmacy during limited hours in the morning. We conducted a total of 40 in-depth interviews with clients over the age of 18 years receiving MOUD, specifically methadone maintenance treatment, and clients over the age of 18 years who had disengaged from MOUD care with the past six months. Four focus group interviews with a total of 35 current clients over the age of 18 years (6 to 10 participants per focus group) were also conducted between January and April 2020. Current clients on MOUD were recruited through the opioid treatment clinic. Disengaged clients who had previously been enrolled in MOUD were recruited through community outreach workers affiliated with the opioid treatment clinic and local community-based organizations who provide harm reduction services to people who use drugs. Focus groups were stratified by gender: two focus groups with only men and two focus groups with only women. Informed consent was obtained from all participants prior to the interview or focus group. We did not collect personally identifiable information from participants. Trained local interviewers fluent in both Swahili and English administered the in-depth interviews and focus groups using semi-structured guides. Interview and focus group guides included questions on barriers and facilitators to adhering to and remaining on MOUD with specific probes on stigma. In-depth individual interviews lasted about 60 min and focus groups lasted about 90 min. All interviews and focus groups were audio-recorded. Participants were compensated 10,000 Tanzanian shillings (approximately 4 USD) for their participation.

Data analysis

All interviews and focus groups were transcribed verbatim in Swahili and then translated to English. For the primary analysis of the parent study, the study team developed a codebook that included deductive codes derived from study objectives and interview and focus group topics, in addition to inductive codes that emerged from the data. Two coders then coded all transcripts using the codebook. To ensure consistency, two coders independently coded an initial sample of transcripts, resolving discrepancies through discussion with the larger research team. Once consistency was established, the coders proceeded to independently code the remaining transcripts. Data management and coding were conducted using NVivo (QSR International, Melbourne, Australia).

For the current analysis, we conducted a second cycle of pattern coding in line with an adaptive approach to multistage coding [18]. This allowed us to group codes and associated data to identify broader themes relevant to stigma based on the Health Stigma and Discrimination Framework [19]. Specifically, we identified themes on stigma experiences (individual perceptions and encounters with stigma), stigma practices (actions and behaviors reflecting stigma), and stigma markings (social labeling and associated consequences). These broader stigma-related themes were grounded in the data and generated through team discussion. We then used a theoretical coding process of organizing the themes, which allowed us to examine how overlapping experiences of drug use stigma shaped MOUD adherence and retention.

Results

The in-depth interview sample consisted of 40 participants, with a slightly higher proportion of males (n = 23) than females (n = 17). Participants ranged in age from 20 to over 50 years, with the majority (53%) between 40 and 49 years old. Most participants were current methadone clients (n = 29), while a smaller number had discontinued treatment (n = 11). The focus group sample consisted of 35 participants, 20 current male clients, and 15 current female clients. We did not collect age data on focus group participants.

Five key themes related to stigma emerged from participant narratives, with each highlighting how layered forms of stigma influenced their experiences with opioid treatment and shaped their ability to remain engaged in care. These themes include: [1] transport denial and social judgment as barriers to accessing MOUD; [2] employment stigma as a barrier to economic stability and treatment retention; [3] lack of family support due to persistent stigma and misinformation; [4] stigma embedded in the treatment environment itself; and [5] strategies of stigma management through self-presentation. Female participants more often reported experiences of stigma, underscoring the additional pressures created by gendered norms around drug use. Participants described how both anticipated and enacted stigma—across community, family, and clinic contexts—impacted their sense of dignity, motivation to continue treatment, and access to resources needed to support recovery. Participants often invoked narratives that reflected internalized shame, mistrust of peers, and efforts to counter stigma through behavior and appearance. Each of these themes, along with their relationship to stigma drivers, manifestations, and treatment implications, is discussed below.

Transport denial and social judgment as barriers to MOUD access

Most clients reported relying on public minibuses, known as daladalas, to reach the clinic to receive their daily methadone doses. Some participants, particularly male participants, reported that daladala conductors occasionally denied them bus entry because of their history of drug use. One participant reported that:

“…there are other conductors who see that even if they pick you [the client] up, they [think you] might steal from their customers. So, he can refuse to allow you to board his bus.” (Current male client).

In this instance, the daladala conductors show a fear of theft, a form of social judgment that serves as a driver of stigma. Clients mentioned that this shaped their ability to arrive on time and receive their daily dose of MOUD.

Employment stigma as a barrier to economic stability and MOUD retention

Participants consistently expressed a desire for the opioid treatment clinic to provide job search support. Many clients, both male and female, described significant challenges in securing employment due to stigma associated with current or past heroin use. Employers were often perceived as unwilling to hire people with a history of drug use, viewing them as untrustworthy or prone to theft. As one shared:

“…one [employer] can perceive you as ‘these [clients] are really thieves…She must steal, they are all the same.’ Therefore, there are a lot of challenges [with finding employment].” (Current female client).

Unemployment was frequently identified as a barrier to MOUD retention, as participants needed income to meet basic needs and cover transportation or other costs associated with daily clinic attendance. Stigmatizing attitudes from potential employers were seen as a major obstacle to achieving the stability needed to support ongoing treatment.

Lack of family support due to stigma as a barrier to MOUD adherence and long-term retention

While many participants reported that their relationships with their family members improved after they enrolled in the opioid treatment clinic and started receiving MOUD, other participants, particularly women, reported continuing to face strained relationships because their family members believed taking MOUD, specifically methadone, was not any different from using heroin.

One female participant, whose in-laws pressured her to discontinue opioid treatment in favor of fulfilling traditional caregiving roles, described an instance when her in-laws refused to acknowledge her efforts toward recovery. Reflecting on her in-laws’ continued suspicion and rejection, she recalled:

“There is a day we sat [and the family members said]: ‘…make sure you don’t kill our relative with your syringes’…You know it hurts…you know when you have been a drug addict you have no value.” (Former female client who had discontinued treatment).

In this account, the participant’s in-laws invoked the image of a syringe—a powerful symbol of heroin use—to frame her as a persistent threat to her husband’s safety, regardless of her current enrollment in treatment. Her reference to herself as a “drug addict,” despite her efforts to stop using heroin, may reflect internalized stigma and a sense of diminished self-worth. This participant’s experience underscores a broader theme across participant narratives: the lack of family support was frequently cited as a significant barrier to MOUD adherence and long-term retention.

Stigma and the treatment environment

Participants’ experiences revealed that stigma was not limited to public or community spaces but was also embedded within the treatment environment itself. Several participants, particularly former clients who had discontinued opioid treatment, described instances of feeling disrespected, dismissed, or surveilled while receiving methadone services at the clinic. These experiences often centered on the roles and behaviors of peer clinic leaders—clients who are appointed to assist with administrative responsibilities, such as distributing health cards and enforcing clinic policies. While the inclusion of peers in clinic operations was designed to enhance service delivery, some participants perceived certain leaders as exercising their authority in ways that felt punitive or stigmatizing. For example, some leaders were said to photograph clients who lingered at the clinic after dispensing hours, even though this practice was not part of their formal responsibilities. One participant reflected:

“…there are some of the leaders, just a small mistake and [they] can shout at you…so...due to those actions, there are times when you start thinking that if it wasn’t for the illicit drug use, you wouldn’t have been there, and we would be respecting one another…there are times that I say, ‘If I would have known all about that then, then I would never have enrolled in this treatment.’” (Current female client).

Beyond interactions with peer leaders, some participants also reported feeling discouraged when denied methadone doses after arriving late. In these situations, clinic staff often required formal documentation to validate the reason for tardiness—such as a doctor’s note—without which clients were sometimes turned away. These policies are intended to promote accountability and clinical oversight, and many current clients in the study described them as helpful to their recovery. However, some participants—particularly those who had discontinued opioid treatment—perceived the same policies as reflecting mistrust or blanket assumptions about client dishonesty. As one male participant who was currently enrolled in opioid treatment explained:

“Because most of us are liars, we are the ones who destruct our own service because most of us [do] not tell the truth even if we have a truly emergency.” (Current male client).

This participant’s statement not only reflects broader community and institutional narratives of distrust but also illustrates internalized or self-stigma—accepting and reproducing negative stereotypes about people who use drugs and people with a history of drug use. These accounts reflect how institutional practices and the interpersonal climate within the clinic can inadvertently reinforce stigma, even within a setting intended to support recovery. The treatment environment—shaped by both policy and culture—emerged as a critical site where respect, trust, and a sense of belonging could either be fostered or eroded. For some clients, these experiences affected not only their emotional well-being but also their continued engagement in care.

Stigma management through self-presentation and its role in MOUD adherence

In response to stigmatizing experiences within the treatment environment, as well as broader societal judgment, clients described employing personal strategies to manage how they were perceived. In response to prevailing stereotypes that depict people who use drugs as unkempt or irresponsible, some participants, particularly female participants, deliberately modified their appearance and behavior to manage how they were perceived by others. These efforts to resist or preempt stigma were not only about social acceptance but also served as motivation to remain adherent to MOUD. For example, one participant described how concerns about judgment—particularly from potential employers—shaped her ongoing commitment to treatment:

“I only try as much as I can to make sure that I take my medication [MOUD] accordingly, changing my behavior and appearance so that even when a person intends to judge me, him/herself will feel shy.” (Current female client).

This theme highlights how stigma management strategies are intertwined with participants’ sense of identity and their efforts to remain engaged in opioid treatment despite external and internalized stigma.

Discussion

Stigma related to drug use was a pervasive theme in participants’ experiences with accessing and engaging in opioid treatment. This paper explored how various forms of stigma—perceived from community members, family, employers, transportation systems, and even within the clinic environment—shaped client experiences and influenced MOUD adherence and retention. Although more male participants were included in the study, female participants more frequently described experiences of stigma, highlighting the added burden of gendered expectations surrounding drug use. This difference may reflect the persistence of strong gender norms, as well as the possibility that men may be less likely to disclose experiences that could diminish their social status [20]. These layered experiences of stigma not only shaped participants’ daily interactions but also had tangible consequences for their ability to consistently access and adhere to MOUD and remain in treatment.

Perceptions of untrustworthiness frequently emerged in participants’ accounts of attempting to access public transportation and secure employment. Given that clients must commute daily to receive MOUD, stigmatizing encounters—particularly on public transportation—often led to delays that jeopardized timely arrival during the limited morning methadone dispensing hours. Expanding methadone dispensing hours at the clinic could help mitigate the effects of such delays caused by offering greater flexibility for clients navigating stigma-related barriers. The clinic currently offers take-away doses to clients who meet certain stability criteria, such as sustained treatment adherence, negative toxicology screens, and a demonstrated ability to safely store and self-administer methadone [21]. Expanding eligibility for take-away dosing—while maintaining appropriate safeguards—could further reduce the frequency of clinic visits, thereby lessening clients’ exposure to stigma and improving MOUD adherence and retention. Employment stigma similarly affected clients’ ability to generate income and afford daily transportation. Since these data were collected, the clinic has implemented a job training program for clients who meet certain stability criteria, such as consistent treatment adherence and negative toxicology results. However, participation in the program has thus far been limited to a small number of clients. Securing additional government funding to expand access to job training opportunities should be prioritized, as strengthening clients’ economic stability could play a critical role in supporting long-term treatment retention. Prior research has demonstrated that employment or having a stable source of income can improve MOUD outcomes, including treatment retention [22–24]. In parallel, community outreach efforts that raise awareness and address misconceptions about MOUD remain essential to reducing stigma and improving access, particularly as clients navigate transit systems and broader structural barriers to sustained treatment engagement. Further research is warranted on effective communication strategies to combat public stigma toward people who use drugs and people receiving opioid treatment.

In addition to public stigma, family support—or lack thereof—emerged as an important factor influencing clients’ ability to adhere to MOUD, which has been previously reported in the literature [25, 26]. Many participants reported strained family relationships fueled by ongoing stigma toward drug use and misunderstanding about MOUD. Family stigma is often influenced by broader community skepticism about the effectiveness of MOUD as a pathway to recovery [8] and can contribute to clients’ internal doubts and negative feelings about their transition away from illicit drug use through MOUD [15]. Involving families in treatment discussions and providing education about the purpose, effectiveness, and expected duration of MOUD could help to address these misconceptions, strengthen family support networks, and ultimately improve clients’ ability sustain long-term treatment engagement. While the clinic currently employs social workers who engage family members, this support is often limited to a single person identified as a treatment supporter. Expanding family engagement efforts beyond just one designated supporter to include broader family networks could help address misconceptions about MOUD, strengthen trust, and improve clients’ ability to sustain long-term treatment engagement [27].

Stigma at the institutional level—including stigma directed at clients from clinic staff, such as peer leaders and providers, as well as punitive clinic policies—aligns with findings from prior studies. Research has shown that discriminatory experiences in healthcare settings can damage patient-provider relationships and, when such experiences are anticipated to persist, may contribute to clients discontinuing MOUD altogether [4, 28]. Treatment discontinuation can increase the risk of returning to illicit drug use and overdosing [3–6]. While participants acknowledged that strict policies were important for maintaining clinic standards, the use of stereotypical language—such as referring to clients as “liars”—as justification for these policies suggests a need for greater dialogue between clinic staff and clients. Such communication could help clarify the purpose of clinic policies and reduce the potential for reinforcing stigma. Clinics can approach stigmatizing practices within their environments through offering opportunities for clients to voice their perspectives on clinic policies and the treatment they receive within the clinic. These opportunities, which can include advisory boards made up of clients, can help administrators better understand instances of stigma and establish accountability mechanisms to reduce discriminatory practices by clinic staff [16].

Prior studies have explored how people who use drugs manage anticipated stigma by choosing not to disclose their opioid treatment status [16]. In the current study, participants indicated that disassociating from other clients and altering one’s appearance were additional strategies used to limit stigmatizing practices by community members. While clients enrolled in opioid treatment are prone to facing heightened stigma and discrimination due to their history of illicit drug use [29], associations with drug use are also linked to social marginalization and isolation [10]. Thus, altering one’s appearance and distancing from other clients can serve as strategies to avoid negative social consequences. These actions reflect efforts to cultivate a more positive social identity. Opioid treatment programs can strengthen support for clients by facilitating connections to peers who have been navigating recovery well. These peer relationships can provide clients with constructive models for navigating recovery and rebuilding their lives [16].

This study is subject to limitations. The results of this study are drawn from transcripts that were translated into English for coding and analysis by the American first author. Therefore, the results may not capture cultural nuances or interpretations evident in the Swahili version of the transcripts. The participants recruited for the parent study may also have different experiences from those who chose not to engage in the study, introducing the possibility that there are different, unidentified experiences between those who chose to be involved in the study and those who did not. Additionally, the research question of focus of this study was a secondary question. Topics of substance use stigmas and MOUD adherence and retention may have been more fully addressed had they been the primary aim of the study.

Conclusions

This study highlights how stigma—across community, family, and institutional settings—shapes access to and retention in opioid treatment. Gendered expectations, economic insecurity, and negative stereotypes about people who use drugs compound these challenges. While some support mechanisms exist, findings point to the need for expanded family engagement, more flexible clinic policies, and opportunities for clients to provide input on their care. Public education and structural interventions that directly address stigma are critical to supporting long-term recovery. Integrating stigma reduction into opioid treatment programming is essential not only for improving MOUD adherence and retention, but also for promoting dignity and equity in care.

Author contributions

H.T.S. acquired funding. J.K.M., I.H.K., and H.T.S. collaborated to collect the data used in the manuscript. H.T.S. shared study data with A.A. A.A. and H.T.S. conceived the research question. A.A., E.E.C., and H.T.S. reviewed the theoretical framework for the study. A.A. conducted a formal analysis of the data and drafted the manuscript. E.E.C., K.A., P.J.W., I.H.K, and H.T.S. provided feedback for the manuscript. A.A., E.E.C., and H.T.S. contributed to the final version of the manuscript.

Funding

This research was supported by the National Institute on Drug Abuse through grant number K01DA047142. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Data availability

Due to the sensitive nature of interview transcripts, the datasets used for the current study are available on reasonable request and with permission from the corresponding authors.

Declarations

Ethics approval and consent to participate

The study received IRB approvals from the Johns Hopkins Bloomberg School of Public Health and Muhimbili University of Health and Allied Sciences. All participants provided oral informed consent before being enrolled in the study. Confidential information was de-identified, and pseudonyms were used in lieu of participant names for the data analysis process.

Consent for publication

Not Applicable.

Competing interests

The authors declare no competing interests.