1 Background

Opioid use is prevalent worldwide and causes significant burden of disease among the substance use disorders (SUDs). According to the United Nations Office on Drug and Crime (UNODC), in 2021, 60 million people had used opioids for non-medical purpose whereby more than half had used opiates mainly heroin [1]. In addition, opioid use accounted for most of the adverse effects of substance use including association with 71% of years of ‘healthy’ life lost due to SUD, 38% of those receiving SUD treatment and accounted for 69% of deaths due to SUD [1].

In Kenya, prevalence of opioid use varies depending on the population studied to range from 1.1% among patients of Human Immunodeficiency Virus (HIV) treatment to 8.2% among patients admitted at a psychiatric hospital [2]. The latest national survey on substance use, showed a lifetime prevalence of 0.5% among individuals aged 15–65 years in 2022 [3], which was an increase from 0.1% in a survey done five years prior [4] with a pattern of increasing use in different parts of the country [5]. This increase may be due to better surveillance used to measure the prevalence of opioid use in different regions [5]. Among individuals with opioid use disorder (OUD), majority use heroin whereby more than half use by injection [6]. In addition, opioid use is associated with negative effects such as risky sexual behaviour, depressive symptoms, Hepatitis-C Virus (HCV) infection and HIV-HCV co-infection [2].

Medications for opioid use disorder (MOUD) are the first line of treatment for OUD. These are cost‐effective therapies which improve retention to care and reduce risks associated with opioid use [7, 8]. MOUD, include methadone, buprenorphine and naltrexone of which methadone is the commonest [9]. Clients on methadone treatment report improving health, reduced risks of blood-borne infections, improved interpersonal relationships, and are less likely to engage with law enforcement [10, 11]. Despite the benefits to clients with OUD, there is poor retention in treatment [12]. A study on the experiences of clients on MOUD in a clinic in Kenya reported that clients experience personal and systemic barriers that hinder their engagement with care. These included poverty, lack of reliable means of transport, lack of babysitters, homelessness, engagement with the criminal justice system and prolonged wait times [13]. Barriers to MOUD treatment and retention include financial barriers, lack of awareness and negative attitude about methadone treatment, worries about methadone side effects, social stigma and access to the clinic [14,15,16].

Medications for opioid use disorders are recommended by World Health Organization as part of harm reduction for key population. This helps create a supportive environment that enables coordination of treatment for concurrent medical and mental health issues as well as provide psychosocial support [17]. Also, it is part of the recommended pharmacological treatment for substance use disorders in Kenya [18]. MOUD was started in Kenya 2014 as part of the national harm reduction strategy for HIV prevention in line with Kenya National HIV/AIDS Strategic plan [19]. The government through support of partners has set up eight public methadone treatment clinics in eight counties (out of 47 counties), with a plan to roll out the services to more areas [20].

There is growing research on the implementation of methadone treatment in Kenya although qualitative studies are few. These studies include (a) Cross-sectional studies assessing various outcomes [21,22,23,24,25,26]; (b) Qualitative studies among patients on methadone treatement most of which have been done on the same sample, [11, 27,28,29] (c) Two qualitative study report experiences of healthcare providers working at the methadone clinics whereby one study explored the challenges and successes of providing treatment at methodone clinics during the COVID-19 pandemic [30]; and a mixed method study among patients and clinicians at a methadone clinic that assessed effects of methadone treatment on psychosocial funtioning of patients on treatment [31]. Of note, these were carried out at a different methadone clinic other than the current study. (d) Two intervention studies evaluating psychosocial interventions among patients with one study testing use of motivational interviewing [32] and the other use of a text-message intervention [33].

The current study was part of a mixed method study that assessed factors associated with retention in treatment among patients on methadone treatment at a clinic in Nairobi [6]. The qualitative study among patients on methadone treatment enrolled 17 participants and identified four themes related to their experiences with methadone treatment. These themes focused on the impact of opioid use before starting methadone treatment and how the participants learned about the methadone treatment. Participants also reflected on the experiences with care at the methadone treatment clinic and the barriers they experienced that hindered optimal methadone treatment. These perspectives were shaped by sociodemographic factors, diverse determinants of health, the clients’ experiences, timeliness in seeking treatment, clinic characteristics including their interaction with health care providers [13]. This study builds up on this in recognition of a dearth of literature on the experiences and perspectives of health care providers caring for clients on methadone treatment. Therefore, this study aims to explore the experiences of healthcare providers who provide treatment to clients on methadone in Ngara Clinic and to identify facilitators, barriers and unexplored opportunities toward achieving optimal clinical outcomes. Understanding their perspective can be instrumental in appraising interventions that might be needed to improve treatment outcomes for clients on MOUD.

2 Methods

2.1 Study design

This study adopted an exploratory qualitative study design to explore the experiences of healthcare providers based at a clinic in Nairobi County in line with the consolidated criteria for reporting qualitative research (COREQ) guidelines [34] (Supplementary material 1). Exploratory qualitative study design was chosen to provide insights through research into an issue that was not previously investigated [35].

2.2 Research team

Prior relationship with patients: Among the members of the team only SKK was an insider researcher as she in her capacity as a psychiatrist, worked with the clients as their clinician. To avoid any conflict of interest or power dynamics with the participants, SKK was not involved in the data collection for the study. The participants were aware that the data collection was part of a study. This was communicated as part of the informed consent.

2.3 Study setting

The study was carried out at Ngara methadone clinic in Nairobi County which was started in 2017 and at the time of study in 2020, served around 1000 clients. It is one of the eight public methadone clinics in Kenya and treatment is free. This is a low-threshold clinic whereby the aim is harm reduction. Patients are enrolled primarily through outreach clinics run by civil society organizations where they receive basic support, overdose treatment, and follow-up for those who are lost to follow up. Daily visits to the clinic are required and methadone is offered under direct observation by the clinicians. In addition to methadone, treatment for co-occurring disorders and psychosocial services is provided. Counselling services are available and recommended but not compulsory. Methadone dose titration is provided as needed and a urine drug screen is performed every three months. Adherence is not required to remain in treatment, but there are guidelines on managing those who discontinue treatment and enroll after a while [20].

2.4 Study participants and sampling

The study participants were healthcare providers caring for individuals on methadone treatment at the Ngara Clinic. At the time of study, there were 25 staff working at this clinic which comprised one psychiatrist, medical officers, clinical officers, pharmacists, psychologists and counsellors, nurses, and social workers. Purposive sampling was applied to recruit participants who met the inclusion criteria and were available at the time of the study. Participants needed to have worked in the clinic for at least six months and sign an informed consent to be included in the study. Purposive sampling was employed to ensure that participants were drawn from diverse professions.

2.5 Ethical consideration

This study was performed in accordance with the Declaration of Helsinki. Before the study began, ethical approval was obtained from the University of Nairobi/Kenyatta National Hospital Ethics Research Committee. Operational approval obtained from the Nairobi County Review Board. Participants signed informed consent form after reviewing the information on the study and being provided with an opportunity to ask questions. To ensure confidentiality, interviews were conducted in a private room within the clinic and no one apart from the research team had access to the raw and transcribed interviews.

2.6 Data collection

Individual semi- structured interviews were conducted face-to-face for the health care providers. A semi-structured interview guide was used to engage participants on their experiences, rewards, and challenges of providing care to clients on methadone treatment, noticeable benefits, barriers and unexplored opportunities to improve outcomes for clients on methadone treatment. The interview guide is attached as an appendix (Appendix 1). JM, a female undergraduate psychology student trained in qualitative research conducted the interviews which lasted between 30–40 min and were recorded with a digital voice recorder for transcription. Having been involved in the sister study with the clients on methadone treatment as the research assistant, the student was well primed for recruitment of participants, conducting interviews, transcribing, and analysis the data. GMM and SKK provided supervisory support to her throughout the study. The first two interviews were transcribed and shared with the research team before proceeding to collect the rest of the data. Saturation was achieved after eleven interviews. This was determined when there was no newer information that was being added from the subsequent interviews [36]. Among those approached for the interviews, none declined to be interviewed. There were no repeat interviews, and the transcripts were not taken back to the participants for review.

2.7 Data analysis

Thematic analysis was done by GMM, JM and SKK using the procedure described by Gale and colleagues [37]. The following steps were undertaken to perform data analysis.

Step 1: Familiarization with the transcripts: This was done by reading the transcripts severally to familiarize with the questioning and answering patterns of the interviews. Any word or phrase of interest was noted.

Step 2: Line by line coding of the interviews: open coding was performed independently by the analysist on a paper transcript. Two rich transcripts were identified to assist in the development of the coding framework. They were read at least two times and words, statements and phrases that were deemed to be interesting, relevant or important were flagged. A list of these words was compiled, and then cleaned up to merge similar or repetitive phrases into categories were later designated as codes. Further categorization was done to manage those nodes that were either too large or unspecified.

Step 3: Reconciling the codes-: GMM and SKK compared the nodes created and harmonized them by grouping similar ones. Overarching labels were given to those that could be loosely grouped together which were further refined to develop a coding framework.

Step 4: Coding on NVIVO-12: A coding framework was created on NVIVO which was applied to the interviews. Additional free nodes were added as the coding unfolded to include those that were not captured by the coding framework. A coding framework was developed by organizing the nodes in a logical manner and then applied into NVIVO to guide coding. Nodes that were not captured in the framework were added as free nodes and later on incorporated into the existing ones.

2.8 Factors considered to ensure trustworthiness of the data

To ensure credibility, the recorded data was transcribed word for word and shared among the authors. In addition, the authors have included some verbatim responses from participants in the results section. Second, for transferability, a detailed description of the study methods and context is provided and the questions in the semi-structured interview guide have been shared (as an appendix) to facilitate understanding what was done in the study. Third, for confirmability of the study findings, the authors kept all documents used in data collection and these were used during the data analysis process to ensure that the interpretation of data was guided by the raw data. JM kept a reflexive journal during the data collection. In this journal, she recorded reflections and interesting insights she obtained during the data collection and analysis, further enriching the interpretation of the data. Also, the authors provide an elaborate description of data collection and analysis, to allow the readers understand the processes in the study. This description includes how the themes were developed and identified. Lastly, to ensure dependability, the authors kept an audit trail by documenting all aspects of how data was collected and analyzed with frequent discussion throughout the analysis process [38, 39]. Member checking was not undertaken because it was not practical to trace the participants as we did not include contact information as a way to ensure confidentiality and de-linking of possible identifying data with the participants. All authors agreed to the published results.

3 Results

There were 11 participants enrolled in the study. The participants’ sociodemographic characteristics are presented in Table 1.

Table 1 Sociodemographic characteristics of participants
Full size table

Following the thematic analysis of the interviews, the following themes were identified. These are (a) The impact of methadone treatment on clients (b) Threats to client recovery and (c) Thinking outside the box (Supplementary material 2).

3.1 Theme 1: impact of methadone treatment on clients

This theme focuses on healthcare providers’ reflection on how the clients they cared for benefitted from the methadone treatment. These observations are largely based on their interactions with patients receiving care at the clinic. Participants noted that with consistent methadone use, there was a reduction in substance use among the patients. They believed that the reduction in injection drug use, which was occasioned by stabilization of cravings and withdrawal symptoms resulted in in turn resulted in reduction in risks for infections such as HIV and Hepatitis.

“Some say they have benefitted but the only benefit we have seen in most of the patients is that they do not continue injecting, so we can say that methadone helps them not to inject”. (Staff, 2)

Attending the methadone clinic provided an opportunity to address other conditions that the clients presented with. Because the clinic provides comprehensive services such as medical, (HIV, Hepatitis and tuberculosis (TB) treatment). psychiatric and counselling services, they tended to improve overall health outcomes.

“Because it's combined with apart from just receiving methadone in case they have other comorbidities at least they can be attended to, so it is like a one-stop-shop for them. It is supposed to be a one-stop-shop because there is HIV service, there is just regular clinical follow-up in case one has clinical issues, in case they have TB we can offer treatment, so it’s a one-stop-shop for them which is very good and also a plus for the patients, they do not have to come here then go to another place for another service.” (Staff, 5)

Complex conditions whose services were not available were referred to the heath settings that offered specialized services. Participants understood the complex health needs of these clients. Therefore, seeing positive changes, improvement, and success in the recovery, however little is very encouraging to the providers as they feel vindicated for the hard work they do with the clients.

“Over the four years that I’ve been in a methadone clinic I have seen successes; you know there is nothing good than supporting even that one client to be a better person. Generally, it’s a journey, seeing that person from the first day, [struggling in all areas of their lives] to someone you can even sit and reason with. Because ideally, the basic indicator of recovery is how you look. If you look better than you came that means there is a process of recovery, which is a journey it’s a cycle…” (Staff, 1).

Besides the health benefits of methadone treatment, participants also observed social benefits. Stable clients were restored to their families and reintegration into society was possible while others were enabled to engage in meaningful economic activities.

“Because many when they are coming here, they come when everything in their life is finished but when they come here to join the program, some are not working, they have stopped even working but when they start taking methadone, they go back to work, they start understanding themselves. Those whose families are broken they start reuniting, and everything comes to normal. .... So those are the benefits, you start knowing yourself understanding yourself, and go back to normal life.” (Staff, 4)

Reduction in engagement with the criminal justice system was another benefit that was thought to accrue from engaging in methadone treatment. Before then, clients with OUD were said to engage in criminal activities to finance their drug dependency.

“So many, in terms of the social aspect, we’ve been able to reintegrate the patients back in the community, that is the most important thing, we have also noticed that patient crime rates have gone down because they are on care.” (Staff, 8)

Although the benefits of consistent adherence to methadone were obvious for all to see, participants underscored the commitment and determination of the clients to improve.

“There are those who are ready to change, in methadone, the clients we are dealing with are self-focused, it's upon you as a client the way I have learnt about it. Some clients are not ready to change, but for those who are ready to change we see a very big change in them.” (Staff, 3)

Methadone treatment was deemed to be an effective remedy for OUD that provided the stability the clients needed to reintegrate into society, engage in gainful employment and reduce crimes. Seeing this transformation provided an added incentive and encouragement to support the clients in realizing the full benefits of treatment.

3.2 Theme 2: threats to client recovery

This theme describes provider and client-related factors that threatened the recovery of clients on methadone treatment. These factors can be categorized into individual and systemic level challenges. One of the main individual-level challenges related to the perceived lack of knowledge and skills required in the management of patients with opioid use disorder. Since the clinic was established recently, a significant number of participants did not have extensive experience or prior training in managing clients with mental health and addiction. This limited their ability to experience proficiency in caring for clients with complex needs such as those presented at the clinic.

“It was a new experience, a field I have never worked in, so it was a bit challenging but with time, with practice, you begin to understand the concept of the program.” (Staff, 2)

With time, inexperienced providers were offered in-house training to bridge the gap in knowledge and skills they needed to be safe providers. However, over time they reported to have improved skills.

“We’ve learnt a lot about it being a new program there are many challenges, the first one is how to handle the methadone clients because it is a challenge to handle them, a very big challenge. To understand them, dealing with them, tolerance, it needs a lot of tolerance and patience.” (Staff, 3)

On a system level, participants reported that inadequate staff to provide psychosocial treatment hindered the provision of quality care to the clients receiving methadone treatment. Providers understood clients on MOUD needed support to modify their behaviors and adopt healthy ones. Although psychologists/counsellors were working at the clinic, the numbers were low compared to the number of patients being seen.

“I think this place needs more psychologists than any other person because if we just provide methadone and we are not doing intense psychosocial support, we are not helping these people, and that is why they keep dropping off and coming back! Very little success rate.” (Staff, 5)

Another system-level barrier emanated from the current practice guidelines on methadone treatment in Kenya which requires clients to come to the clinic daily which was further limited by narrow operating hours. This resulted in patients missing doses which has an impact on the treatment outcome.

“When patients are on methadone, it has a timeline, the opening and closing hours, when you close your methadone facility at 1:00 pm, that is for weekdays and noon for weekends and public holidays sometimes you end up missing out, and then you understand the dynamics of Nairobi, you could have a traffic jam on some roads so the patients could end up missing out on their daily dosage that is a gap on our side but that is the standard operational procedure which is there and the guideline that has been put operational which is somehow limiting.” (Staff, 8)

Another challenge that the staff experienced was dealing with behavioral issues that clients often presented with. Staff reported that some clients exhibited aggressive behavior and others had a history of interaction with the criminal justice system. Such clients often proved difficult and challenging to care for, especially for providers who did not have training in conflict management.

“… you find that these clients come from very difficult and diverse backgrounds, I have come to learn that there are clients here who have criminal histories such as robbing banks, murder etc…… I think it's because of the addiction sometimes they tend to use language that is coarse towards the staff, they can be aggressive, and it is not something that they are conscious about, because today they may be aggressive but tomorrow they will still come to seek that service and they will forget how they were the previous day”. (Staff, 11)

Because there are no conditions set for clients to access methadone treatment, clients can expect to receive care despite the struggles that they continue to present in their recovery journeys. Nevertheless, healthcare providers often experience mixed emotions as they watch the clients wrestle with recovery challenges such as continued substance use during treatment.

“…we deal with men who came here ready to transform their lives, but not all of them transform because even though they want to stop taking heroin, some of them have continued using heroin. So you feel that you want them to be helped, you want them to have a life that is free from drugs, as you talk to them, even as you counsel them you find that some are still taking heroin, and you don’t feel good because when you are here, you want to help them come out of addiction” (Staff 4).

As a low-threshold clinic, patients are not sanctioned for using substances while on treatment. Nevertheless, such a practice frustrates healthcare providers because it is a likely impediment to their recovery. In addition, a significant number of clients believed that drugs like cannabis and nicotine are not harmful drugs and therefore can be used alongside methadone therapy. This attitude is largely informed by their lack of knowledge of how using other substances may negatively impact their recovery process.

“My experience is not bad, but most of our clients continue using these other drugs that cause addiction such as cannabis, nicotine, and others. To them, they believe these substances are not drugs because what brought them here is to stop heroin and that’s why they are here. So, you will find most of them still use cannabis and nicotine as well as tobacco.” (Staff 10).

Despite the challenges that the clients presented at the methadone clinic, providers were deeply aware of the socioeconomic challenges that the clients faced that hindered their ability to adhere to treatment regimens. The daily commutes to the clinic to receive methadone doses were not sustainable because a majority of the clients lived in poverty or had limited economic abilities. This created a huge barrier and a burden that the clients could not sustain.

“Some of them come from far, all corners of Nairobi, there is a transport challenge because they need fare to ensure they are here, and because they come daily that’s a lot of money. Sometimes they lack the fare to come and take methadone daily, you find that someone has lacked fare maybe for a week or three days, especially for those who come from as far as Thika, Rongai, and Westlands (10-30 km away). So, there is that challenge.” (Staff 3)

A significant number of them were homeless and experienced other diverse social determinants of health such as lack of social support, poor working conditions, and poor access to health services. The lack of continuity of care i.e. inpatient services for clients in the acute phase of treatment meant that clients returned to the same environment with drugs easily accessible, hence having a negative impact on recovery and retention in treatment.

“The fact that there is a lack of continual healthcare, you take your medicine and go back to where you came from, so you are still exposed. …that’s the main gap. After taking methadone they just go back to the same environment and get exposed.” (Staff, 2)

Numerous staff, systemic and patient’ factors were identified as significant barriers to overall recovery of clients on methadone treatment. These barriers presented with opportunities for the decision makers to explore opportunities to improve overall outcome for clients on MOUD.

3.3 Theme 3: thinking outside the box.

Participants pointed out that patients needed counseling services as an adjunct to the methadone therapy. Participants believe that adequate psychosocial support services can increase retention to care and as such, the clinic, though limited with resources could explore a way to optimize the available counsellors.

“…we need to strengthen the system of having them to see counselors, so I don’t know maybe we can have days where we are pushing them to see a counselor is at the top of like incentivize them to see counselors so that whatever issues that they have that still pull them back to addiction can be sorted out at that level. Then if there are any other things that these clients could be going through on an individual level, they can be tackled at that level with the counselor.” (Staff, 12).

Most of the clients receiving care for OUD are underemployed or not in gainful employment and as such, they are unable to adhere to the treatment requirement that demands a daily commute to the clinic. To support clients being financially stable, healthcare providers proposed a partnership between the MOUD program and other stakeholders to offer them skills and job opportunities that would keep them busy and provide much-needed resources to meet the financial demands of the MOUD program. It would also assist in their reintegration into society.

“Because you go back to the community and there are social obligations which you must meet, you have financial obligations. If there is a plan to maybe act on their skills, act on those who can do some good crafts or link with other organizations maybe for training so that as much as they move out of here, they leave with some skills that can enable them to hustle, get some few shillings to get something on the table….” (Staff, 1)

Addiction to substances such as heroin has been reported to cause a significant strain on the family and other familial relationships, leading to family dysfunction, and as such, at the time the clients begin receiving care for OUD, they have limited support services to support their recovery. Providing mechanisms to help clients regain the trust lost due to substance use is important to support their recovery journey. Such an endeavor can assist clients to reintegrate into the community as part of the recovery cascade.

“…even re-integrating with other people is a great challenge because there are those gaps they missed, so coming into terms is also a challenge” (Staff, 7).

In addition to supporting client reintegration into the community, participants recognized the value of community linkage, sensitization, and education. Strengthening linkages to society, social support and rehabilitation services is critical since a comprehensive approach is crucial to educating families about the benefits of MOUD which can increase communal support and buy-in from families.

“Yes, community linkages, sensitization, education, because even the public is not aware of what we do here, the issue of drugs is not known, and people also shy away from it. So, it's better if we created awareness and showed people that this issue can be tackled in a dignified way so that people can embrace the project” (Staff, 2).

Participants suggested some strategies that can be incorporated in the treatment guidelines to overcome some of the barriers noted by the patients. These include having take-home methadone doses and alternate day dosing so that patients don’t have to come daily to the clinic. Providing a mobile van to deliver methadone to patients staying far to the clinic was also a recommendation and was reported as something that was in consideration at the time of the study.

“We are exploring on the aspect of a mobile van and this is going to advantage some of the patients who are not able to come for methadone daily, so we’ve had approval for the mobile van, the only challenge we are facing is human resource. We are already operational in some areas of Nairobi where the patients will be able to get their methadone in different areas, rather than come to the clinic daily.” (Staff, 8)

The perspectives provided by the providers regarding unexplored opportunities to improve retention of care and outcome for clients on methadone treatment. They draw attention to the need for innovative sustainable solutions to support these vulnerable clients on their recovery journey.

4 Discussion

The present study was completed after a similar study among patients attending treatment at the clinic and whose findings are published [13]. We, therefore, sought to understand the experiences of healthcare providers working with patients on methadone treatment and their perception of the benefits, barriers and opportunities that affect patients’ ability to meet their treatment goals.

The findings showed that healthcare providers were encouraged to witness patients making progress in their recovery, a common predisposition reported in past research [40]. The biggest changes that the clients exhibited tended to follow a consistent engagement with MOUD care, with methadone addressing withdrawal and craving symptoms that affect persons with OUD [27], patients could then spend their resources to pursue endeavors that promote their well-being. Bearing witness to this transformation is inspirational to healthcare providers because being in a practitioner in SUD treatment can sometimes be emotionally stressful and draining [41]. The qualitative interview among patients also revealed similar findings whereby patients reported methadone treatment to have contributed to changes in health and other areas of life [13].

Participants acknowledged the immense difficulties they faced in providing care to individuals with OUD. These difficulties emanate from both client and clinical factors that impact on treatment outcome of patients on methadone treatment goal i.e., to provide stability, pursuit of self-care and well-being [42]. Their perspectives provide a window to interrogate the determinants of health that impact the treatment and recovery of the patients under their care. Income and employment opportunities are significant determinants of health that impact patients’ ability to be retained on treatment or experience positive health outcomes [43, 44]. Financial factors were also cited by the patients at the clinic as a challenge given that a majority of them worked as casual laborers and struggled to afford bus fare to travel to the clinic for daily methadone treatment [13] a challenge commonly reported in similar settings [14, 15]. Moreover, a significant number are homeless or live on the streets, which impacts on treatment outcomes [13, 44, 45].

Another determinant of health that significantly impacts the recovery of the individuals on MOUD is social support and coping skills. Participants alluded that substance use may have caused family estrangement or stigma which prevents the family members to rally behind them and support their recovery. This has been reported by healthcare providers in other settings [46, 47] and by patients on methadone treatment [13].

Healthcare providers reported experiencing aggression from clients especially those that were still actively using substances. This aggression may be due to frustration at the way the clinic is run, wait times, issues with the limitations imposed upon them such as having to come to the clinic daily for methadone ingestion. The impact of the behavioral issues that the clients exhibit is common at methadone clinics and may raise safety issues and may be attributed to unmet needs or disease process [40, 48]. It is possible that the providers may not have received adequate training and experience in conflict resolution or de-escalation techniques involving clients with substance use disorders. This needs to be offered to the providers [48]. It may also be necessary to explore training the healthcare providers on treatment approaches for individuals with SUDs including training on other components of recovery other than focusing entirely on abstinence including harm reduction among individuals with OUD [14, 49, 50] as a way to improve outcomes at the methadone clinic.

Another challenge reported by the participants was lack of adequate human resource to provide psychosocial interventions at the clinic as the few psychologists at the clinic were not able to adequately meet the needs given the high patient/psychologist ratio which was similar to what was reported by the patients receiving treatment at the clinic [13]. This is in line with the recommendation for combined psychosocial and pharmacotherapy for OUD [51]. Several studies report on effectiveness of different psychosocial interventions among individuals with OUD although the findings show mixed effects [52,53,54]. Of note is that most of these studies have been conducted in high income countries. This shows need for further research to evaluate the effectiveness of psychosocial intervention in low and middle-income country setting such as where this study was conducted.

Although the clinic was under-resourced, participants suggested practical interventions that could be explored to improve methadone treatment at the clinic. These include staffing the clinic with more helping professionals, assisting clients to reintegrate into the community and obtain gainful employment, and provision of communal transport system for clients to access clinic appointments. Another strategy to understaffing is use of peer support that has been shown to help improve outcomes among patients with OUD [55, 56]. Peers can be utilized to assist with tasks that do not require high level of clinical skills such as psychosocial support, clerical jobs and care navigation hence would relieve the few staff available to commit to core task of clinical care to the many clients that need to be served daily. In addition, the providers suggested that the clients need to be assisted to restore strained familial relationships occasioned by substance use. These suggestions are like what has been suggested in past studies.

It is important to note that since the study was carried out, several services have been rolled out at the clinic to improve access to methadone such as mobile van that delivers methadone to several places around the catchment area hence patients don’t have to travel far to the clinic and delivery of methadone to individuals who are in prison and require the treatment. There is also plan to provide buprenorphine in addition to methadone, hence increasing MOUD access to patients [20].

The perspectives provided by the health care providers regarding their care for patients on MOUD provide important insights about factors that may impact patients’ treatment outcomes. They can help clarify the implementation of methadone treatment to ensure that patients are supported in every way to reach their recovery goals.

4.1 Strength and limitations

The strength of this study is that it is among the first studies to describe the experiences of healthcare providers offering care to individuals on methadone treatment in Kenya and gives insight into this area with limited research in the region.

The limitations of the study include, being carried out in one methadone clinic hence results may not be generalizable to other clinics and settings. In addition, inclusion of a researcher who worked at the clinic at the time of study may have affected the objectivity of the findings, although this person was not involved with data collection process and trustworthiness was ensured as discussed in methods section. However, insider researcher could have an advantage over outside researcher such as better understanding of the responses as they are familiar with the language and have a better understanding of the specific context of the comments [57, 58]. Also, purposive sampling and a low sample size inadvertently increased the likelihood of selection bias and as such the diversity of experiences to draw from are limited. Of note is that this was partly influenced by the number of staff at the clinic during the study period. However, the findings provide insight to the experiences of staff and can be used to guide policy to improve implementation of MOUD provision.

5 Conclusions

The study provides an insight into the perspectives of health care providers caring for individuals on OUD treatment. Even though the program is relatively young, and with many providers having limited experiences in this field, they seemed to be acutely aware of the complexities that clients needing MOUD present with that act as barriers to their recovery journey. Despite the limited resources at their disposal, heath care providers are also well-versed with the opportunities and investment needed to support the recovery of the clients. These findings highlight healthcare providers’ perspectives on MOUD provision and when combined with the findings from the patient interviews [13], can help guide policy to improve methadone treatment in Kenya. Also, solutions can be explored such as capacity building and increasing the number of staff working in the clinic to improve treatment outcomes. In addition, further research in the other methadone treatment clinics is recommended to compare the experiences of health care providers in the different settings and to also explore possible implementation of the strategies suggested to assess if they can apply in the setting and/ effective in improving treatment outcomes among individuals with MOUD.