From healthcare encounters to policy: Patient and stakeholder perspectives on how stigma undermines care for people with substance use disorders and multiple disadvantages.

Abstract

ObjectivesStigma is a well-documented barrier to care for people with substance use disorders (SUDs), but little is known about how it affects individuals with SUDs who also experience multiple disadvantages such as homelessness, poverty and unmet health care needs. This article explores how stigma is experienced by service users, staff, and system-level stakeholders of outreach services tailored to this cohort, and how it shapes interactions with health care services, treatment engagement, and service implementation.MethodsNinety-eight semi-structured interviews were conducted with service users, staff, and stakeholders of three outreach-based services for people with SUDs and multiple disadvantages in England. Data were analysed using the iterative categorisation technique. The analysis was guided by a framework informed by a sociological model of stigma and a typology of stigma and discrimination in mental health.ResultsFour themes were identified: (1) stigmatising language and discriminatory practices in primary and acute health care encounters; (2) self-stigma and its impact on help-seeking behaviour; (3) the influence of stigma on the commissioning and sustainability of services tailored to this cohort; and (4) the key role of specialist services, such as outreach services and acute hospital alcohol care teams, in reducing stigma.ConclusionsStigma operates across interpersonal and structural levels, undermining equitable care for people with SUDs and multiple disadvantages. Addressing these barriers requires stigma-informed training for acute and primary health care providers, as well as advocacy skills for specialist services.