Service User and Healthcare-Worker Perspectives on Substance Use Disorder Treatment Journeys, Relapse, and Recovery in Sub-Saharan Africa: Evidence from Uganda

IntroductionSubstance Use Disorders (SUDs) pose significant public health challenges in sub-Saharan Africa. However, there is limited evidence on how service users (SUs) and front-line health care workers (HCWs) experience SUD treatment and recovery within resource constrained settings. This study explored the perspectives of SUs and HCWs to understand treatment trajectories and to identify multilevel barriers and facilitators influencing recovery outcomes. MethodsWe conducted a qualitative study at two public treatment facilities in Uganda; the Alcohol and Drug Unit at Butabika National Referral Mental Hospital and the Mental Health Unit at Gulu Regional Referral Hospital. Using purposive sampling, we interviewed 10 HCWs directly involved in SUD care (five per site) and randomly selected 43 SUs from a parent cohort of 439 adults treated for SUDs at the same sites. We transcribed all audio recordings verbatim and translated them into English where necessary. We coded SUs and HCWs data separately and then applied integrative mapping to generate cross-cutting meta-themes. ResultsWe identified four interrelated meta-themes that described how individual, social, community and health system factors influenced treatment journey and recovery outcomes. Both SUs and HCWs highlighted resource constrained service environments characterized by shortages of specialist staff, medications and secure infrastructure, which compelled clinicians to improvise and resulted in fragmented care. Human resource gaps contributed to rushed assessments, minimal psychosocial engagement, and limited follow-up. Treatment pathways were described as heavily biomedical, with services centred on detoxification and management of acute withdrawal, while psychosocial needs, and contextual stressors insufficiently addressed. Outside the treatment facility, individual, social and community barriers like stigma, strained family relationships, peer pressure, poverty, alcohol-dependent livelihoods, and untreated mental or physical comorbidities made recovery difficult, as SUs returned to the same environments that precipitated their substance use. Despite these challenges, participants identified opportunities to strengthen recovery pathways, including integration of family and spiritual support, involvement of "expert-client" models, anti-stigma interventions, and task-sharing with community health workers. ConclusionSustained recovery from SUDs in Uganda is constrained by fragmented clinical services, systemic resource shortages, stigma, and unsupportive social contexts. Improving recovery therefore demands a multilevel response including strengthening psychosocial support, integrating family and spiritual support, peer role models, anti-stigma initiatives and task-sharing with community health workers to strengthen recovery pathways and sustain long-term treatment outcomes.