“Feeling unseen, not judged”: Provider stigma, clinical non-recognition, and KUSH treatment access in Sierra Leone

J Subst Use Addict Treat. 2026 Nov 9:210152. doi: 10.1016/j.josat.2026.210152. Online ahead of print.

ABSTRACT

INTRODUCTION: Provider-related barriers to substance use treatment are often framed as attitudinal stigma. In rapid synthetic drug epidemics, patients also experience clinical non-recognition: encounters in which providers hear the account but do not translate it into condition-specific assessment, explanation, management, or referral. Because patient-experienced competence shapes return, avoidance, and peer referral, we treat clinical non-recognition as an access-relevant quality signal distinct from direct provider testing. This study examined whether barrier forms differed across Sierra Leone’s KUSH service contexts. KUSH is the local name for a synthetic drug preparation of variable composition.

METHODS: We conducted a focused secondary comparative qualitative analysis of a four-district dataset. All 250 participants reported KUSH use histories and joined focus group discussions; 90 of these participants also completed semi-structured interviews. We returned to provider-related transcript segments and NVivo memos, extracted 115 accounts, and analyzed them through two pre-specified sub-types: attitudinal enacted stigma and patient-experienced clinical non-recognition. Peer-network reputation effects and disconfirming enabling encounters were coded separately. Findings are participant-reported experiences, not direct provider assessment.

RESULTS: Provider-related barriers appeared across all sites. In Western Area, accounts more often described attitudinal enacted stigma (26/43 accounts) than clinical non-recognition (11/43), including public labelling, moralistic language, and confidentiality breach. In Bombali, Bo, and Kenema, accounts more often described clinical non-recognition (15/22, 18/26, and 17/24 accounts, respectively): health workers listened without obvious judgement, but the encounter did not produce KUSH-specific assessment, management, or referral. Negative and positive facility reputations circulated through peer networks before attendance. Enabling accounts showed that competent, respectful recognition within resource constraints also travelled through networks.

CONCLUSION: Similar provider-barrier frequencies concealed different mechanisms. Specialist-center responses need stronger confidentiality, reception, and anti-stigma practice; district-hospital responses need KUSH- and opioid-type withdrawal recognition, initial management, and referral training. Patient-experienced competence is a quality signal for treatment access. Monitoring should extend beyond attender satisfaction surveys to capture community-level facility reputation effects.

PMID:43003233 | DOI:10.1016/j.josat.2026.210152