Trapped but Trying: Stigma, Sexual Motivations, and the Everyday Struggles of Recovery from Psychoactive Substance Use Among Youth in Rural Ghana

Trapped but Trying: Stigma, Sexual Motivations, and the Everyday Struggles of Recovery from Psychoactive Substance Use Among Youth in Rural Ghana | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Trapped but Trying: Stigma, Sexual Motivations, and the Everyday Struggles of Recovery from Psychoactive Substance Use Among Youth in Rural Ghana Simon Nyarko, Julius Caesar Mahama, Abdul-Wadudu Faridu, Norbert Mantu Kipo, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8296597/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Psychoactive substance use among youth in rural Ghana is shaped by intertwined biopsychosocial factors, including cultural norms, gender expectations, relational dynamics, and structural disadvantage. Recovery for these young people extends beyond abstinence, comprising moral, social, and emotional efforts to rebuild dignity, belonging, and wellbeing. Despite rising substance use in Ghana, limited empirical work explores how youth understand their use and navigate recovery within rural contexts. This study examined the lived experiences of young people with current or prior psychoactive substance use in a rural Ghanaian community, focusing on how social, cultural, and relational contexts shape their substance use trajectories and recovery efforts. Methods A qualitative design grounded in a constructivist interpretivist approach was adopted. In-depth interviews were conducted with fifteen youth aged 19–33 years in a rural district in Ghana. Interviews explored participants’ experiences, motivations, struggles, and reflections on substance use and recovery. Data were audio-recorded, transcribed verbatim, and analyzed using reflexive thematic analysis to identify patterns of meaning and everyday struggles embedded in their social worlds. Results The findings indicate that recovery is a complex, fluid, and socially embedded process. Four interconnected dimensions shaped substance use and recovery: (1) personal motivations linked to sexual performance and masculine identity; (2) peer dynamics and the social ecology of drug availability; (3) stigma, exclusion, and the reinforcing cycle of dependence; and (4) structural barriers to care and community-based pathways to recovery. Participants described tramadol and similar substances as tools for demonstrating masculinity, enhancing sexual performance, and securing social validation. Stigma, shame, and fear of judgment, combined with limited access to mental healthcare and mistrust of institutions, impede help-seeking. Despite these barriers, participants expressed the need for community-based, compassionate, and non-judgmental recovery support that respects their vulnerabilities and strengths. Conclusions Substance use and recovery among rural Ghanaian youth are best understood holistically within a biopsychosocial framework that integrates individual experience with broader cultural, social, and structural contexts. Gender norms, stigma, and resource constraints significantly shape substance-use trajectories and recovery attempts. Effective interventions must therefore extend beyond biomedical models, incorporating gender-sensitive, community-grounded approaches that promote social inclusion, empathy, and sustainable wellbeing. Psychoactive substance use Recovery process stigma gender norm rural youth sexual motivations Ghana Figures Figure 1 Contributions to the literature Stigma, gender norms, and structural disadvantage profoundly shape young people’s experiences of psychoactive substance use and recovery in rural Ghana. Substances such as tramadol are commonly used to express masculinity, enhance sexual performance, and affirm social identity among peers. Recovery is viewed not merely as abstinence, but as a struggle to reclaim dignity, belonging, and social legitimacy amid stigma and moral judgment from families, communities, and health providers. Limited access to decentralized, affordable, and trustworthy services underscores the need for community-based, gender-responsive, and non-judgmental interventions integrated within primary health care to foster empathy, inclusion, and sustainable recovery. 1. Introduction Globally, psychoactive substance use among youth remains a major public health challenge (Armoon et al., 2023 ; Chen et al., 2025 ), attracting significant concern due to its wide-reaching impact on users in low- and middle-income countries (LMICs) (Kalungi et al., 2024 ). Psychoactive substance (psychoactive) is a broad term that covers any form of chemical substance, whether natural or synthetic, that can alter psychological functioning by affecting the central nervous system (CNS), resulting in a change in mood, perception, consciousness, or behaviour (Bonnet et al., 2020 ). Psychoactive drugs encompass a broad range of substances, including depressants such as alcohol and benzodiazepines; hallucinogens such as cannabis and lysergic acid diethylamide (LSD); stimulants such as amphetamines and cocaine; and opiates/opioids such as codeine and heroin. In LMICs, specifically Sub-Saharan African (SSA) nations, personal, structural, and systemic characteristics that exist predispose the youth to take up and show more interest in drug abuse and misuse. Recent evidence suggests that nearly one in five young people in SSA has used a psychoactive substance at least once in their lifetime (Ebrahim et al., 2024 ). This growing trend reflects a combination of structural factors, economic precarity, weak regulation, and limited access to health services, alongside interpersonal influences such as peer pressure, social identity formation, and the quest for belonging among youth (Mbuthia et al., 2020 ; Nawi et al., 2021 ). In Ghana, the issue has become increasingly visible through both scholarly and public discourse. Recent studies reveal that the use of substances such as alcohol, cannabis, tramadol, and codeine has risen among adolescents and young adults across both urban and rural settings (Kyei-Gyamfi et al., 2024 ; Osei-Tutu et al., 2025 ). Scholars attribute this rise in indiscriminate psychoactive substance use to a combination of socio-economic hardship, exposure to global youth cultures, and the easy availability of substances in informal markets (Adongo et al., 2024 ; Asamoah et al., 2024 ). For instance, Kabore et al ( 2019 ) found from their study that drug abuse is not even regarded as a disease in Ghana, pointing to one reason why less attention is paid to interventions (Kabore et al., 2019 ). Despite such growing recognition, most existing literature in Ghana has focused primarily on prevalence estimates, risk factors, or patterns of initiation, with relatively little attention to what follows: how young people who use substances attempt to recover, the meanings they attach to recovery, and the barriers they face in that process. More than just epidemiological data is needed to understand recovery among young people who use psychoactive substances (Eekhoudt et al., 2024 ); lived experience, meaning-making, and the social ecology in which recovery takes place must all be examined. Understanding the rural context, where acc​ess to formal treatment and harm reduction initiatives remains limited (Franz et al., 2024 ; Ibragimov et al., 2020 ),‌ is essential because recovery in‍ such an environment transcends clinical⁠ interventions and unfolds‌ as a continuous lived negotiation sha​ped by stigma​, gender norms, peer dynamics, and‍ economic pressures. Seldom does existing research in Ghana examine these interconnected issues from the viewpoint of people who are most impacted. As a result, less is known about the emotional, social, and relational aspects of recovery for the youth in rural communities. Nonetheless, this study addresses that gap by investigating the daily struggles of recovery from psychoactive substance use among youth in rural Ghanaian communities. It focuses on how stigma, gender norms, and sexual or relational motivations shape their efforts to stop or reduce use. In this context, recovery is understood as a socially ingrained process in which the desire to restore dignity, reclaim social approval, or embody accepted masculinity and femininity plays a significant role (Lamb & Kougiali, 2025 ). These gendered and relational dynamics are especially important in communities where manhood and social respect are frequently associated with sexual prowess, productivity, and self-control (Hammack & Manago, 2024 ). However, for many young people who have used substances, these same values become double-edged, motivating initiation through peer validation while limiting recovery through shame and marginalization (Earnshaw, 2020 ). The study shifts from a prevalence-based inquiry to a process-oriented approach that draws on the youth's own stories of struggle and agency. For this reason, the study contributes to a deeper comprehension of recovery as a social activity negotiated within complicated moral and relational environments, rather than just abstinence or treatment adherence. Such understanding is critical for developing community-based and gender-responsive interventions that are relevant to local realities rather than importing externally established paradigms. The strength of this study lies in the breadth and contextual richness of its qualitative nature, even though it was undertaken in one of Ghana's district capitals and cannot therefore be said to be statistically generalized. The study clarifies the paradoxes of resilience and reliance, showing how social criticism and stigma coexist with courage, ambition, and the desire to change. This work brings a fresh viewpoint to the literature on substance use and recovery in Sub-Saharan Africa, specifically Ghana, by highlighting the interconnected effects of sexual motivation, stigma, and masculinity. It provides theoretical and practical insights that are pertinent to practitioners, policymakers, and researchers who are interested in youth wellbeing and social inclusion. 2. Materials and Methods 2.1 Study Philosophy and Design This study employed a qualitative research design grounded in a constructivist and interpretivist paradigm, aiming to explore how the youth in rural Ghanaian communities experience and interpret their struggles trying to recover from psychoactive substance use (Bryman & Cramer, 2012). The study emphasized meaning-making and lived experience, which is congruent with the constructivist perspective of knowledge as co-constructed through social interaction and context (Do et al., 2023). 2.2 Study Setting The fieldwork was conducted in Yeji, a rural town and the administrative capital of the Pru East District in the Bono East Region of Ghana. Yeji is situated adjacent to the Volta Lake and serves as a trading centre and inland fishing settlement, drawing increasing numbers of young people migrating from cities, neighbouring towns, and surrounding villages (Setufe et al., 2022). With a population that reflects a mix of ethnic groups, Yeji is characterized by rich cultural diversity and changing social dynamics. In this context, the growing recognition of psychoactive substance use arises from a confluence of structural and social factors. Among these are robust informal social networks formed by migrant youth, relatively limited access to advanced educational opportunities, and persistent economic uncertainty amid livelihood pressures in formal government work, fishing, trading, and small-scale agriculture. The setting was selected because it typifies rural Ghanaian communities where access to formal mental health or rehabilitation services is limited, and where recovery often unfolds through informal, community-based processes rather than institutional care. 2.3 Study participants, sampling and sample size Participants were selected using purposive and snowball sampling strategies to ensure inclusion of individuals with varied experiences of substance use and recovery. In line with the Ghana Ministry of Youth and Sports’ definition of youth as persons aged 15 to 35 years (MoYS, 2013), participants within this age range were considered eligible. Additional inclusion criteria required that participants (a) had current or prior experience of psychoactive substance use, and (b) had resided in Yeji for at least one year. In total, fifteen participants (coded P01–P15) were interviewed. The sample size was determined a priori based on the principles of information power and thematic saturation, rather than statistical representativeness. By the twelfth interview, no new ideas emerged; three additional interviews were conducted to ensure conceptual completeness. 2.4 Data Collection Data were collected through face-to-face in-depth interviews, using semi-structured and open-ended questions designed to elicit rich narratives about recovery, stigma, and social experiences. A semi-structured interview guide, developed specifically for this study, was used to facilitate all interviews; the full English version is provided in Supplementary File S1 . Interviews were conducted in English, Gonja, Hausa, and Twi, depending on participants’ language preferences, and lasted 45-90 minutes. Each session took place at a private, convenient location chosen by the participant to ensure confidentiality and comfort. All interviews were audio-recorded with informed consent and transcribed verbatim. Field notes and reflexive memos were maintained to capture contextual details, emotional tones, and researcher reflections during and after data collection. The research lead later integrated these notes into the analytic process to enhance contextual understanding and reflexivity. Participants were appreciated with thirty Ghana Cedis (GHS 30.00) or an equivalent food package, for their time and participation 2.5 Data Analysis The recorded interviews were repeatedly reviewed to ensure a thorough familiarity with the data, and transcriptions were then produced. The data were analyzed using reflexive thematic analysis, following the six-phase framework developed by (Braun & Clarke, 2023). The process involved (1) familiarization with the data, (2) generation of initial codes, (3) searching for themes, (4) reviewing themes, (5) defining and naming themes, and (6) writing up the analysis. Coding was primarily inductive, allowing patterns and meanings to emerge from participants’ narratives rather than applying pre-existing theoretical categories. Two analysts independently coded the transcripts and met regularly to compare interpretations and resolve discrepancies. Codes were iteratively refined and grouped into subthemes and main themes in accordance with the research objectives. Reflexivity was maintained throughout the analysis via memoing and peer debriefing, enabling the researchers to document interpretive decisions, question assumptions, and maintain transparency in the analytic process. 2.6 Rigor and Trustworthiness of the Study To enhance the credibility, dependability, and confirmability of the findings, the study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist (Tong et al., 2007). Credibility was ensured through prolonged engagement with the data, analyst triangulation, and the use of verbatim quotations to substantiate interpretations. Dependability was achieved by maintaining an audit trail of coding decisions, theme development, and analytic memos. Confirmability was strengthened through reflexive journaling, while transferability was supported by providing thick, contextualized descriptions of the study setting and participants’ experiences (Enworo, 2023). 2.7 Researcher Reflexivity Reflexivity was integral to the research process. The lead researcher, a Ghanaian academic with experience in community-based health research, approached the study with both insider and outsider perspectives. Cultural familiarity and language proficiency facilitated rapport and nuanced understanding, while maintaining analytical distance ensured interpretive rigor. Throughout data collection and analysis, the team engaged in reflexive journaling, memo writing, and regular debriefings to examine assumptions and assess how their positionalities might shape interpretation. This reflective practice enhanced the study’s credibility and ethical transparency by grounding findings in participants’ lived experiences rather than researcher bias. 2.8 Ethics approval and consent to participate Clearance for this study was obtained from the Pru East District Assembly. An official request letter was submitted prior to data collection, and formal approval was granted (Ref: PEDA/01/10/08/001). Informed consent was obtained from all participants after explaining the purpose, procedures, and voluntary nature of participation. Participants were assured of confidentiality and their right to withdraw at any point without penalty. Pseudonyms and anonymized identifiers (P01–P15) were used in all transcripts and reports to protect privacy. Audio recordings and transcripts were securely stored and accessible only to the research team. 3. Results 3.1 Demographic Characteristics of Participants A total of fifteen (15) youth with current or prior experience with psychoactive substance use participated in the study. Participants ranged in age from 19 to 33 years, with a mean age of approximately 26 years. The majority were male (87%), while two were female (13%). Most participants were single (73%), and four were married (27%). In terms of education, levels of attainment ranged from no formal education to tertiary education. Three participants had tertiary education; two held diplomas; four completed senior high school; three completed junior high school; only one had primary education; and two had no formal education. Occupationally, participants engaged in diverse work, including trading, masonry, farming, sand supply, and casual labor, while five were unemployed at the time of data collection. The duration of substance use ranged from one to seven years, with most participants reporting two to five years of continuous use. Regarding recovery status, six participants were in recovery, six were contemplating change, and three were still in active use. Peer influence emerged as the most common mode of initiation, followed by curiosity, coping with stress, sexual motivation, and family exposure. Notably, several male participants cited sexual enhancement and performance as their initial motivation, while some female participants attributed their initiation to romantic partners or social gatherings. The characteristics of the study participants are summarized in Table 1 below. This table provides information on the duration of substance use, recovery status, and mode of initiation. Table 1. Demographic Characteristics of Study Participants (N = 15) Participant ID Sex Age (years) Marital Status Education Level Occupation/Job Duration of Substance Use (years) Recovery Status Mode of initiation P01 Male 26 Single Junior High School Sand supplier 3 Contemplating change Peer influence P02 Male 25 Single No formal Education Unemployed 5 Active use Influenced by friends P03 Male 30 Married Senior High School Mechanic 4 Contemplating change Sexual enhancement P04 Male 33 Married Diploma Mason 5 In recovery Coping with stress P05 Male 26 Single Senior High School Unemployed 6 Contemplating change Sexually motivated P06 Male 32 Single Junior High School Self-employed 4 In recovery To overcome family problems P07 Female 20 Single Senior High School Unemployed 1 Contemplating change Through social gatherings P08 Male 25 Single Diploma Student 2 In recovery Curiosity/experimentation P10 Male 19 Single Senior High School Gambler 2 Active use Curiosity and boredom P11 Female 23 Single Senior High School Unemployed 2 Contemplating change Introduced to it by my boyfriend P12 Male 29 Married Primary Farmer 7 Contemplating change Coping with stress P13 Male 26 Single Tertiary Trader 3 In recovery Family exposure P14 Male 22 Single Tertiary Unemployed 2 Contemplating change Peer influence P15 Male 24 Single Junior High School Casual work 2 In recovery For confidence and belongingness Source: Field Survey, 2025 3.2 Thematic Findings Four major themes emerged from the data, reflecting the social, behavioral, and structural dimensions of psychoactive substance use and recovery among participants: (1) Sexual Enhancement and the Quest for Masculine Identity; (2) Peer Influence, Availability, and the Social Ecology of Use; (3) Dependence, Stigma, and the Vicious Cycle of Use; and (4) Barriers to Care and Pathways to Recovery. Table 2 summarizes the themes, subthemes, codes, and verbatim quotes of participants. In sum, these themes illustrate how substance use is embedded in the gendered, relational, and moral landscapes of rural youth life, and how recovery is often constrained by social stigma and limited institutional support. Figure 1 provides a visual mapping of these themes. Unlike Table 2, it doesn’t present the participant quotes and thus serves as a summary. Table 2. Emergent themes, subthemes, codes, and participant quotes Theme Subtheme Codes Participant verbatim quotes Sexual Enhancement and the Quest for Masculine Identity Drug use for sexual performance Initiation for sexual pleasure; endurance during intercourse; peer narratives about sexual prowess “If you want to have an affair with a lady and you take that drug, it makes you stay longer in bed.” ( P05 ) “Some of us use it because when we are with ladies, we want to prove that we can do better, so we take it before we meet them.” ( P03 ) “Our boyfriends use these drugs. We love guys who can last ….. and that is why we also take the drugs to match their strength” ( P11 ) Perceived social prestige and masculinity Gaining respect through sexual ability; linking virility to manhood “They will say, ‘this boy is strong,’ so you too, you want to try and show them you are strong.” ( P02 ) “If you don’t take, they will tease you that you can’t satisfy a lady. So, I started.” ( P01 ) Peer Influence, Availability, and the Social Ecology of Use Peer pressure and normalization Friends introducing drugs; learning by observation; group bonding “It was my friends who introduced it to me… they said it makes you feel good and work hard.” ( P04 ) “When I saw my friend using it, I asked him what it was, then I also tried it and liked it.” ( P10 ) Easy access and local supply Local sellers; unregulated markets; dealer familiarity “The people selling know us. When you go there, they will even reduce the price for you.” ( P03 ) “It’s everywhere in the town; you can just buy it as buying a biscuit.” ( P14 ) Dependence, Stigma, and the Vicious Cycle of Use Physical and psychological dependence Withdrawal symptoms; body pains; inability to quit “When I wake up, my body will be hard, and I feel pains all over. I must take it before I can work.” ( P12 ) “Sometimes I say I will stop, but when the pain starts, I can’t.” ( P10 ) Social exclusion and stigma Family neglect; community rejection; feelings of dehumanization “They don’t see us as human beings anymore. Even my own family don’t want to eat with me.” ( P06 ) “People point at us and say, ‘those are the drug boys.’ It is shameful.” ( P05 ) Barriers to Care and Pathways to Recovery Barriers to seeking help Cost; fear of being judged; mistrust of authorities “I want to stop but where will I go? If you go to the hospital, they will ask you plenty questions and laugh at you.” ( P15 ) “Some of the sellers are even police people, so how can we report?” ( P10 ) Desired interventions and community-based solutions Free, non-judgmental care; rehabilitation; arrest of sellers; livelihood support “If the service is free and they won’t judge you, I will go.” ( P07 ) “They should catch those who sell to us and bring some work so that we stop.” ( P05 ) “If someone will help us small with farming or work, we won’t go there again.” ( P02 ) 3.2.1 Theme 1: Sexual Enhancement and the Quest for Masculine Identity This theme explores how psychoactive substance use among youth in rural Ghana is deeply entangled with constructions of masculinity, sexuality, and social validation. For many male participants, drug use was not merely about pleasure or dependence; it was a means to assert manhood, boost confidence, and perform sexual endurance that affirmed their social worth. Among female participants, substance use was often described as a relational act tied to their partners’ expectations and experiences. 3.2.1.1 Subtheme 1: Substance Use for Sexual Performance A dominant narrative across interviews was the use of psychoactive substances, particularly tramadol, to enhance sexual stamina and confidence during intercourse. Participants believed these drugs increased their ability to “stay longer” and satisfy their partners, which in turn boosted their self-esteem and social standing among peers. One participant explained: If you want to have an affair with a lady and you take that drug, it makes you stay longer in bed.” (P05, 26 years, single, unemployed) Another emphasized the social motivation behind this behavior: Some of us use it because when we are with ladies, we want to prove that we can do better, so we take it before we meet them. (P03, 30 years, married, mechanic) For these young men, sexual performance was both a private and public marker of masculinity. Their sense of accomplishment in sexual encounters became intertwined with peer recognition and social pride. This perception reinforced continued drug use as a mechanism to sustain the image of virility and sexual competence. The subtheme demonstrates that drug usage served as a symbolic tool of masculine expression, with sexual control and endurance representing dominance, confidence, and social prestige among male peer networks. The results are consistent with broader gender norms in Ghanaian communities, where masculinity is frequently linked with physical strength, sexual prowess, and emotional resilience. 3.2.1.1 Subtheme 2: Social Validation and Gendered Expectations In addition to enhancing sexual performance, substance use served as a strategy for social validation. Several participants reported that male peers ridiculed or excluded those who did not use drugs, framing abstinence as weakness or lack of sexual capability. This is how another participant shared his thoughts on being validated by peers concerning sexual satisfaction: If you don’t take, they will tease you that you can’t satisfy a lady. So, I started. (P01, 26 years, male, sand supplier) This peer pressure perpetuated a cycle of performance; young men took substances to fit in, gain respect, and avoid ridicule. With time, such social norms normalized psychoactive use as part of what it meant to be a “real man.” Interestingly, a female participant provided insight into how women’s attitudes indirectly perpetuated this culture: Our boyfriends use these drugs. We love guys who can last … and that is why we also take the drugs to match their strength. (P11, 23 years, female, unemployed) This perspective illustrates gendered complicity, in which women's desires and expectations helped males maintain drug use and, in some cases, prompted their own involvement. Sexual endurance has become a common currency of approbation and appeal in these social relationships. This subtheme focuses on how gendered power dynamics and cultural norms legitimize substance use in society. It reveals that recovery initiatives must address not only individual behaviours, but also underlying social narratives that link drug use to masculinity and acceptance. The prevalence of young, single males reflects how substance use and recovery are embedded within gendered constructions of masculinity and the pursuit of social validation among peers. The educational and occupational patterns highlight socio-economic precarity as a driver of both initiation and continued use, where psychoactive substances serve as coping mechanisms for stress and limited livelihood opportunities. Furthermore, the mixed recovery statuses, ranging from active use to contemplation and sustained recovery, illustrate a continuum of change shaped by stigma, resilience, and access to supportive networks. The reported modes of initiation highlight the powerful influence of peer dynamics, relational pressures, and community norms, aligning closely with the emerging themes on sexual motivation, social belonging, and barriers to recovery. These findings place psychoactive substance use among rural Ghanaian youths within the larger contexts of gender, socioeconomic vulnerability, and social ecology. 3.2.2 Theme 2: Peer Influence, Availability, and the Social Ecology of Use This theme explores how peer dynamics and access to psychoactive drugs influence the initiation and maintenance of substance use among young people. For many individuals, drug use was introduced and nurtured in social contexts, among friends, at work, or at community gatherings, where it was depicted as acceptable or even desirable. The local milieu, which provided easy access to uncontrolled drugs, reinforced the notion that substance use was a shared social practice rather than a solitary habit. 3.2.2.1 Subtheme 1: Peer Pressure and Normalization of Use Peer relationships emerged as the most powerful influence on participants’ initiation into psychoactive substance use. Most respondents traced their first encounter with substances to friends who encouraged them to experiment, often under the guise of improving mood, work energy, or social acceptance. Drug use was commonly introduced during informal social interactions, creating a permissive environment that normalized experimentation. One participant shared his experience: It was my friends who introduced it to me… they said it makes you feel good and work hard. (P04, 33 years, married, mason) In tandem to the above, Another added: When I saw my friend using it, I asked him what it was, then I also tried it and liked it. (P10, 19 years, single, gambler) Such narratives demonstrate how peer support of drug use served as both commencement and a means of belonging. Participants frequently feared social isolation if they declined to participate. Drug use became a symbol of group allegiance, strengthening social cohesion within peer groups. For some, the pressure was subtle, friends offering narcotics as harmless fun, but for others, it was blatant derision directed at people viewed as “too weak” or “unadventurous”. As a result, psychoactive substance use became firmly integrated in youth socialization processes, connecting identity, friendship, and acceptance within the peer network. 3.2.2.2 Subtheme 2: Substance Availability and Informal Markets The social normalization of substance use in this study was intensified by the easy availability of drugs within the local environment. Participants described how tramadol, cannabis, and other psychoactive substances were openly sold in the community, often by familiar vendors who extended credit or offered discounts. A participant mentioned how some of the sellers even reduce the prices for regular customers: The people selling know us. When you go there, they will even reduce the price for you. (P03, 30 years, married, mechanic) Another participant indicated how easy it is to get these substances: It’s everywhere in the town; you can just buy it like buying a biscuit. (P14, 22 years, single, unemployed) These narratives reflect a social ecology of drug supply in which accessibility and cost promote continuous usage. Participants' personal ties with dealers, along with the lack of effective regulation, created an enabling environment in which acquiring narcotics became as ordinary as buying food or home products. Furthermore, the combination of economic precarity and informal trade meant that drug sales were frequently accepted, if not protected, inside the community. Drug traffic thus became integrated into the local economic and social life, supporting the normalcy of use among young people. 3.2.3 Theme 3: Dependence, Stigma, and the Vicious Cycle of Use This theme depicts participants' experiences of physical and psychological dependence, which are exacerbated by intense social stigma and isolation. Over time, what began as experimentation or peer pressure became compulsion, with users unable to function regularly without the drug. The embarrassment and rejection they experienced from family and community members exacerbated their isolation and, irrationally, drove them back to ongoing usage. 3.2.3.1 Subtheme 1: Physical and Psychological Dependence Many participants described becoming physically dependent on psychoactive substances after prolonged use. They reported withdrawal symptoms such as pain, fatigue, restlessness, and loss of concentration whenever they tried to stop. For these young people, the drug gradually became part of daily functioning, taken not for pleasure, but to avoid discomfort and maintain productivity. A 29-year old farmer revealed: When I wake up, my body will be hard, and I feel pains all over. I must take it before I can work. (P12, 29 years, married, farmer) Another participant shared a similar struggle: Sometimes I say I will stop, but when the pain starts, I can’t. (P10, 19 years, single, gambler) Several participants also associated substance use with psychological relief. Some used drugs to suppress emotional distress, fear, or feelings of worthlessness. This interplay of physical and emotional dependence created a reinforcing cycle in which drugs were simultaneously the source of suffering and the only perceived escape. The narratives show that substance abuse among young people in rural Ghana goes beyond biological addiction; it is a coping technique within a larger environment of poverty, anxiety, and social expectations. 3.2.3.2 Subtheme 2: Social Exclusion and Stigmatization Beyond the physiological struggle, participants reported severe stigma and social rejection from family members, peers, and community leaders. They were frequently labeled as spoiled, lazy, or useless youth. This stigmatization resulted in a lack of trust, damaged relationships, and low self-esteem. One participant narrated his ordeal about how his family gave up on him: They don’t see us as human beings anymore. Even my own family don’t want to eat with me. (P06, 32 years, single, self-employed) Another participant buttressed this experience, stating: People point at us and say, ‘those are the drug boys.’ It is shameful. (P05, 26 years, single, unemployed) Such experiences of social devaluation frequently increased individuals' reliance on drugs as a method of emotional release. In many situations, stigma kept individuals from getting treatment or engaging in community activities. Some participants described being mocked or shunned from social gatherings, while others suffered outright hostility from neighbors who accused them of stealing or violence. As a result, the social environment encouraged dependence by both penalizing and pathologizing the user. The more individuals felt condemned or rejected, the more they turned to drugs to cope with their emotional wounds, establishing a self-perpetuating cycle of addiction and humiliation. 3.2.4 Theme 4: Barriers to Care and Pathways to Recovery This theme highlights the challenges that the youth who use psychoactive substances have when attempting to rehabilitate, as well as potential solutions. Participants' accounts show that recovery is a continuous moral, social, and institutional fight, not just a matter of personal willpower. Most individuals expressed a strong desire to stop using drugs, but their efforts were hindered by financial difficulties, stigma within health institutions, inadequate institutional support, and a lack of meaningful livelihood options. Despite this, their stories demonstrated a strong sense of agency, hope, and a willingness to change, provided enabling conditions were met. 3.2.4.1 Subtheme 1: Barriers to Seeking Help Participants reported that their recovery was hindered by structural and social obstacles that made seeking professional help difficult or undesirable. The most common barriers included financial constraints, fear of stigma, and distrust in formal health systems. For many, the cost of treatment and the distance to health facilities were prohibitive. Rehabilitation centers or psychiatric units were mostly located in urban areas far from their communities, making access nearly impossible without financial and family support. One participant explained: I want to stop, but where will I go? If you go to the hospital, they will ask you plenty questions and laugh at you. (P15, 24 years, single, casual worker) This quote reflects a broader concern that health professionals treat young people who use substances with judgment and ridicule rather than empathy. Others described the fear of being criminalized or publicly labeled as an “addict,” leading them to avoid medical services altogether. Another participant shared his worry: Some of the sellers are even police people, so how can we report? (P10, 19 years, single, gambler) Such statements reveal a pervasive climate of mistrust, not only in the healthcare system but also in law enforcement. Participants believed that even those responsible for enforcing regulations were complicit in the local drug trade. This perception reinforced a sense of futility about seeking formal help. The findings show that for many rural youths, recovery is hampered by both financial and moral challenges. Treatment is viewed as expensive, judgmental, and disconnected from their everyday experiences. As a result, the majority turned to self-managed attempts, informal advice, or spiritual healing, which gave moral support but rarely addressed dependence or relapse. 3.2.4.2 Subtheme 2: Desired Interventions and Community-Based Solutions Despite these challenges, participants demonstrated remarkable insight into what could facilitate recovery. They envisioned free, non-judgmental, and community-based rehabilitation services that offer counseling, education, and livelihood support. One participant emphasized the need for compassionate, stigma-free care: If the service is free and they won’t judge you, I will go. (P07, 20 years, single, unemployed) Another linked recovery to structural and economic interventions: “They should catch those who sell to us and bring some work so that we stop.” (P05, 26 years, single, unemployed) A third participant highlighted the role of employment and purpose in sustaining recovery: If someone will help us small with farming or work, we won’t go there again. (P02, 25 years, single, unemployed) These interviews highlight that, for participants, recovery entails more than just refraining from substances; it also means social reintegration, dignity, and self-sufficiency. Unemployment and boredom were typical triggers for substance abuse; therefore, livelihood options were considered crucial to stopping the cycle of recurrence. Participants also emphasized the importance of community education to change public attitudes and reduce stigma. They believed that if communities viewed substance use as a health issue rather than a moral failure, more young people would seek help without shame. In essence, their suggested solutions combined care, compassion, and capacity-building, reflecting an awareness that individual recovery depends on supportive social and economic structures. 4. Discussion Following our exploration of the lived experiences of youth in their use and decisions to seek recovery from psychoactive substance use in rural Ghana, the findings revealed that their struggles are shaped by intertwined social, cultural, and structural realities. The analysis, grounded in a constructivist lens, showed that recovery is not a linear or solely individual process but one negotiated through gender expectations, peer dynamics, stigma, and limited institutional support. Narratives of the youths highlighted how masculine ideals, peer belonging, and social marginalization collectively influence substance use and recovery pathways. Consistent with earlier African and global evidence, these findings underscore the social embeddedness of substance use and the need for context-responsive, gender-sensitive, and community-based approaches that go beyond punitive or biomedical interventions. The themes are discussed below in relation to existing literature and theory. 4.1 Sexual Enhancement and the Quest for Masculine Identity The findings, based on the social constructionist point of view, show that psychoactive substance use among young males in rural Ghana is significantly influenced by cultural expectations of masculinity, sexuality, and social validation. According to the participants' accounts, drug use, particularly tramadol use, was not only pleasurable but also served as a symbolic performance of manhood, power, and endurance. This lends credence to gender-relational interpretations that see substance use as a means by which men negotiate respect and belonging within peer networks (Courtenay, 2000; Sibanda & Batisai, 2021). Similar tendencies have been documented among young people in Africa, where sexual potency and dominance remain fundamental to masculine identity (Fiaveh, 2020; Khumalo et al., 2021; Maina et al., 2022). Several interviewees stated that utilizing psychoactive substances allowed them to prove their sexual capability while maintaining self-esteem. These accounts are consistent with the findings of a study, which found that young Nigerian men frequently associate sexual endurance with social prestige (Mensah, 2021). Within this moral economy of masculinity, pharmacological enhancement becomes a weapon for showing competence and managing female partners, reinforcing patriarchal narratives that prioritize virility over wellbeing. The narratives also illustrate the psychosocial mechanisms that support these practices, peer adulation, fear of scorn, and the seeking of confidence in intimate relationships. Female participants, on the other hand, revealed their own indirect role in perpetuating this culture, encouraging men who could last longer and occasionally utilizing drugs to equal their partners' performance levels. This corresponds to Butler's concept of gender performativity, in which femininity and masculinity are co-constituted through reciprocal behaviors that reproduce normative power relations (Butler, 1988). Comparable findings from literature suggest that women's expectations of male stamina help to normalize drug use for sexual enhancement among young males (Moore et al., 2020; Moyle et al., 2020). Thus, gendered complicity strengthens the social value associated with substance-enhanced sexual performance. These findings indicate that interventions focusing exclusively on the biomedical consequences of psychoactive substances may be ineffective if they disregard the cultural connotations associated with their use. Gender-transformative programs, such as community conversations on healthy masculinities and relationship dynamics, are more likely to question the long-held link between drug use, sexual prowess, and male identity (Ruane-Mcateer et al., 2020; Swartout & White, 2010). Recognizing the gendered reasons driving substance use is vital for building responsive prevention and treatment initiatives that resonate with the lived reality of young people in rural Ghana. 4.2 Peer Influence, Availability, and the Social Ecology of Use The study revealed that peers and the surrounding social environment played a crucial role in the initiation and maintenance of psychoactive substance use among young people. Most participants reported that friends introduced them to substances in contexts of leisure, work, or social gatherings, where use was presented as normal or even desirable. This finding aligns with the principles of social learning theory, which posit that behaviours are acquired and sustained through observation and reinforcement within peer groups (Bandura, 1977). Similar evidence from Nigeria confirms that peer approval and the desire for belonging are among the strongest motivators for youth substance use (Dumbili et al., 2022). Participants stated how drugs like tramadol and cannabis could be obtained cheaply and openly from familiar sellers, making drug use a part of ordinary social life. This is in sync with findings from studies (Feinberg & Osgood, 2023; Janulis et al., 2019) that noted that local supply networks and community complicity support a culture of acceptable drug use. Friendship, availability, and informal trade all contribute to an enabling environment in which psychedelic use becomes socially and economically rooted. The bottom line, thus, is that substance use among rural youth cannot be understood or addressed in isolation from their social ecology. Effective interventions should engage peer networks as part of the solution, promoting peer-led education and support groups that transform norms of belonging. Community surveillance, youth empowerment programmes, and livelihood initiatives can further weaken the social and economic conditions that make psychoactive substances accessible and socially acceptable. 4.3 Dependence, Stigma, and the Vicious Cycle of Use The findings on this theme illuminate how dependence is not merely a physiological state, but rather a deeply relational and socially embedded one. Once youth become dependent on a psychoactive substance, they do not simply experience craving or withdrawal; they also bear the weight of stigma from family, community, and themselves (Connor et al., 2022; Hunt et al., 2024; Thomasius et al., 2022). This stigma constrains social support, undermines self-efficacy, and ultimately perpetuates the cycle of use. Our data aligns with evidence from similar resource-limited settings showing that stigma is a formidable barrier in recovery from substance use disorders. For example, a qualitative study in Tanzania found that drug-use stigma at multiple levels (individual, community, healthcare) shaped clients’ retention in methadone maintenance programmes (Admase et al., 2025). Similarly, scoping reviews of inpatient or residential treatment across Sub-Saharan Africa identify stigma and discrimination as pervasive non-structural barriers to access and retention (Janson et al., 2024). Furthermore, Ghana-specific photovoice work also documents stigma as a barrier at the community and organizational levels to accessing substance-use treatment (Kaboré et al., 2019). Together, these studies confirm that stigma is not only present but also operates in layered ways, internal, interpersonal, and institutional, in contexts where resources are limited and recovery pathways are fragile. Participants describe how being labelled “dependent” or “addict” shifts their social identity. It changes how family and peers relate to them, reduces their access to emotional or material support, and erodes motivation to attempt behaviour change. In effect, stigma becomes part of the mechanism that sustains use rather than simply an after-effect of addiction. One thing worth knowing is that, in Ghanaian communities, moral character, relational trust, and reputation are central to social standing. Labelled dependence disrupts those relational bonds. A young person seen as dependent may lose favour with family or neighbours, may be ostracized in informal peer networks, or may anticipate being judged. Cumulatively, internalized shame can erase the very motivation needed to attempt recovery efforts (Snoek et al., 2021). Additionally, because formal recovery services are scarce and socially distant from everyday life, youth may perceive little legitimacy in engaging formal care. They are left with their own social networks, yet these networks may view them through the lens of betrayal or moral failure. In other words, the social meaning of “addiction” in their community becomes fused with moral judgment, not only medical diagnosis. This suggests that conventional psychologically oriented or clinical models of dependence may underspecify the role of social identity repair, as previously mentioned in related studies (Blondé et al., 2024; Cruwys et al., 2020). Recovery may require not only reducing substance-use behaviour but reclaiming a socially acceptable self-identity in community and family settings. Programmes aiming to support recovery should include stigma-reduction components that go beyond individual counselling. Community dialogues, involving elders, families, or opinion-leaders, may help shift social perceptions of dependence from moral failure to a treatable condition. Peer recovery groups could provide safe spaces where youth can reframe their identity as someone in recovery rather than someone irrevocably “addicted.” This could help rebuild relational capital. Advocates and institutions might work toward framing substance-use dependence within health and psychosocial policy (rather than as deviance or criminality), reducing the moral burden placed on users and mitigating institutional stigma. 4.4 Barriers to Care and Pathways to Recovery This theme brings to light how participants not only perceive but live multiple, overlapping barriers when they attempt to access care, or to imagine recovery pathways. These include structural-economic constraints (distance, cost, service availability), sociocultural distrust of formal care, legal or social risk of seeking help, and limited awareness of services. At the same time, youth point toward informal or alternative recovery pathways embedded in their social world (family, peer networks, religious/spiritual actors). A qualitative synthesis of barriers and facilitators across low- and middle-income countries highlights common obstacles such as perceived cost, low motivation, lack of awareness, and weak service availability (Sarkar et al., 2021). In South Africa, treatment barriers among young adults include fragmented services, lack of resources, stigma, and concerns about confidentiality or privacy (Nyashanu & Visser, 2022). Moreover, a narrative review reveals that substance use treatment in Sub-Saharan Africa points to geographic concentration of centres in urban areas and limited infrastructure in rural places (Alayande et al., 2022). Also, in Ghana, a research similarly lists poverty, cost of treatment, lack of facilities, and stigma as barriers to accessing substance-use treatment services (Cadri et al., 2021). Against this backdrop, this study shows how the youth, negotiating recovery in rural Ghana, perceive these barriers as not only abstract obstacles, but as lived constraints: trust issues with providers, fear of social or legal consequences, reliance on informal networks, and preference for support that is socially proximate rather than clinical and distant. Key lessons noted after a critical look at the issues of barriers to seeking help include, first formal recovery or treatment infrastructure appears to be out of alignment with the lived realities of rural youth: physical distance matters, but so does relational distance and perceived legitimacy. If treatment is located far away, costly, or associated with judgment, many youth will not initiate help-seeking even if they “want” recovery. Second, informal or community-embedded pathways (such as family support, spiritual spaces, peer mentorship) fill part of that gap, but they often lack formal training, follow-up, or clinical oversight. Nevertheless, their social proximity makes them more accessible and trustworthy. In effect, recovery strategies emerge as adaptive bricolage: youth mix formal and informal sources, but often rely on what is nearest, known, and socially acceptable. Theoretically, this calls for recovery models that integrate embedded care, thus services delivered within or allied to trusted community settings (religious centres, peer groups, local leadership structures), rather than expecting youth to travel to distant clinics or to approach unfamiliar professional settings. Decentralizing recovery support through the integration of peer support or recovery-oriented counseling into primary-care or local community settings should be a consideration for interventions. Other considerations include partnerships with religious organizations, traditional authorities, non-governmental organizations, or peer-led groups that could help close the gap between official services and socially acceptable help-seeking behavior, as well as the possibility of reducing travel time, expenses, and social distance through mobile outreach units or satellite recovery support hubs within the communities. Informational outreach (what services are available, how they operate, and confidentiality guarantees) and trust-building activities (peer testimonies, public support from community leaders) may be beneficial to the youth. 4.5 Limitations of the Study While this study offers important insights into the lived realities of youth navigating psychoactive substance use and recovery within rural Ghana, certain limitations must be acknowledged. The study focused solely on young people in one rural community, and thus the findings may not reflect the perspectives of urban youth, older populations, or other key stakeholders such as family members, health workers, and community leaders. Moreover, as a qualitative study, it does not quantify the extent to which identified factors, such as stigma, gender norms, or peer influence, shape recovery trajectories. Participants were recruited through community networks rather than treatment facilities, which may have excluded individuals in advanced stages of recovery or formal rehabilitation. Future research could broaden the scope by including multiple communities, adopting mixed-methods or longitudinal designs, and incorporating perspectives from families, professionals, and community actors to enhance understanding and generalizability. 5.0 Conclusion and Implications Psychoactive substance use and recovery among young people in rural Ghana present complex challenges that transcend the biomedical domain, encompassing deep social, cultural, and structural dimensions. This study has shown that young adults’ engagement with psychoactive substances is intertwined with masculinity performance, peer socialization, stigma, and limited access to recovery services. Dependence is experienced not only as a physiological condition but as a moral and social identity that attracts discrimination and exclusion. Recovery, therefore, becomes an act of social negotiation, an effort to restore legitimacy, belonging, and self-worth within families and communities that often stigmatise substance use. These findings have important implications for mental health practice, policy, and community development. Evidence from this study demonstrates the need to reframe substance dependence as a public health and psychosocial issue rather than a moral failing or criminal act. Policymakers and service providers should prioritise the decentralisation of addiction care, especially in rural settings, by integrating recovery-oriented counselling and harm-reduction services into community health centres and primary healthcare systems. Such integration will ensure that young people and their families can access care without prohibitive costs or stigma. Moreover, the study highlights the necessity of community-driven approaches to recovery. Stakeholders, including the Department of Social Welfare, District Assemblies, and mental health professionals, should collaborate to establish peer-support groups and community rehabilitation forums where young people and their families can share experiences, build coping skills, and access psychosocial support. Religious and traditional leaders, who wield significant influence in rural Ghanaian communities, should also be engaged as allies in recovery promotion and stigma reduction. Integrating traditional healing practices with evidence-based mental health interventions could create culturally resonant and sustainable recovery pathways for affected youth. For mental health practitioners, the findings underscore the importance of cultural competence and empathy in practice. Training should emphasise relational and contextual understanding of dependence, enabling practitioners to communicate in ways that align with clients’ cultural values and lived experiences. This would foster trust and improve engagement between service users and providers. At the policy level, government agencies should develop sustainable social protection and rehabilitation schemes for young people experiencing substance dependence, with specific funding allocations for rural and underserved areas. Such interventions should also include family-based counselling, recognising that parents and caregivers experience significant emotional and economic strain due to their children’s substance use. In sum, addressing psychoactive substance use among Ghanaian youth requires a holistic approach that combines biomedical treatment, psychosocial rehabilitation, cultural sensitivity, and social reintegration. By embedding recovery efforts within community structures, reducing stigma, and strengthening support systems for both users and their families, stakeholders can help transform recovery from an individual struggle into a collective, socially supported process. This transformation will not only restore health and dignity to young people but also contribute to the broader goal of building resilient, inclusive, and mentally healthy communities in Ghana Abbreviations CNS Central Nervous System LSD Lysergic Acid Diethylamide LMICs Low- and Middle-Income Countries SSA Sub-Saharan Africa COREQ Consolidated Criteria for Reporting Qualitative Research Declarations Ethics approval and consent to participate This study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Ethical approval was obtained from the Pru East District Assembly (Ref: PEDA/01/10/08/001). All participants provided informed consent prior to participation. Participants were assured of confidentiality and informed of their right to withdraw from the study at any stage without consequence. Consent for publication This study does not include any person’s data in any form (including images, videos, or personal details). Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available but can be obtained from the corresponding author on reasonable request. Competing interests The authors declare that there are no conflicts of interest related to this work. Funding This study received no funding or financial support from any sponsor, grant, or funding agency. Acknowledgements The authors sincerely thank the PRU East District Assembly, particularly the District Chief Executive, Mr. Dauda Abdul Nasir, for their support of this study. We also appreciate the entire team at DRUGGS Ghana, a vibrant nonprofit organization dedicated to advocating against substance abuse, for their valuable partnership. Special thanks are due to the field assistants, Mugyi Tabata, Shadad, and Abdul Wahab, whose dedication and effort were vital to the successful completion of this work. Author contributions Simon Nyarko : Conceptualization, Methodology, Formal analysis, Data Curation, Writing – original draft, Writing – review & editing. Julius Caesar Mahama : Conceptualization, Data curation, Writing – review & editing. Abdul-Wadudu Faridu : Writing – review & editing. Norbert Mantu Kipo : Writing – review & editing. Michael Ayarika Issah : Writing – review & editing. Afumaa Erica : Writing – review & editing. Khadija Atchulo : Writing – review & editing. Martin Antuolkuu : Writing – review & editing References Admase, A., Cooney, E. E., Atkins, K., Winch, P. J., Mbwambo, J. K., Nkya, I. H., & Saleem, H. T. (2025). Navigating stigma: a qualitative study of barriers to opioid treatment engagement in Tanzania. Substance Abuse Treatment, Prevention, and Policy 2025 20:1 , 20 (1), 1–7. https://doi.org/10.1186/S13011-025-00660-Y Adongo, D. W., Adedia, D., Benneh, C. K., Tandoh, A., Amekyeh, H., Ntelah, E. K., Nanga, S., Asmah, R. H., & Woode, E. (2024). Psychoactive substance use and associated factors among students in a Ghanaian Tertiary Institution. Scientific African , 24 , e02250. https://doi.org/10.1016/j.sciaf.2024.e02250 Alayande, B., Chu, K. M., Jumbam, D. T., Kimto, O. E., Musa Danladi, G., Niyukuri, A., Anderson, G. A., El-Gabri, D., Miranda, E., Taye, M., Tertong, N., Yempabe, T., Ntirenganya, F., Byiringiro, J. C., Sule, A. Z., Kobusingye, O. C., Bekele, A., & Riviello, R. R. (2022). Disparities in Access to Trauma Care in Sub-Saharan Africa: a Narrative Review. Current Trauma Reports , 8 (3), 66. https://doi.org/10.1007/S40719-022-00229-1 Armoon, B., Griffiths, M. D., & Mohammadi, R. (2023). The Global Distribution and Epidemiology of Psychoactive Substance Use and Injection Drug Use Among Street-Involved Children and Youth: A Meta-Analysis. Substance Use and Misuse , 58 (6), 746–764. https://doi.org/10.1080/10826084.2023.2181036;REQUESTEDJOURNAL:JOURNAL:ISUM20;WGROUP:STRING:PUBLICATION Asamoah, P., Abokyi, S. N., & Fannam Nunfam, V. (2024). Challenges of parents of young adults misusing psychoactive substances in small-scale mining communities in Ghana. Cogent Mental Health , 3 (1), 1–37. https://doi.org/10.1080/28324765.2024.2382182;JOURNAL:JOURNAL:OAMH20;REQUESTEDJOURNAL:JOURNAL:OAMH20;WGROUP:STRING:PUBLICATION Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review , 84 (2), 191–215. https://doi.org/10.1037/0033-295X.84.2.191 Blondé, J., Falomir-Pichastor, J. M., & Desrichard, O. (2024). Unveiling the psychological mechanisms of mutual help groups for addiction recovery: The role of social identity factors. British Journal of Social Psychology , 63 (4), 2011–2030. https://doi.org/10.1111/BJSO.12771;JOURNAL:JOURNAL:20448309;WGROUP:STRING:PUBLICATION Bonnet, U., Specka, M., Soyka, M., Alberti, T., Bender, S., Grigoleit, T., Hermle, L., Hilger, J., Hillemacher, T., Kuhlmann, T., Kuhn, J., Luckhaus, C., Lüdecke, C., Reimer, J., Schneider, U., Schroeder, W., Stuppe, M., Wiesbeck, G. A., Wodarz, N., … Scherbaum, N. (2020). Ranking the Harm of Psychoactive Drugs Including Prescription Analgesics to Users and Others–A Perspective of German Addiction Medicine Experts. Frontiers in Psychiatry , 11 , 592199. https://doi.org/10.3389/FPSYT.2020.592199/BIBTEX Braun, V., & Clarke, V. (2023). Thematic analysis. APA Handbook of Research Methods in Psychology: Research Designs: Quantitative, Qualitative, Neuropsychological, and Biological (Vol. 2) (2nd Ed.). , 65–81. https://doi.org/10.1037/0000319-004 Bryman, A., & Cramer, D. (2012). Quantitative Data Analysis with IBM SPSS 17, 18 & 19 : A Guide for Social Scientists. Quantitative Data Analysis with IBM SPSS 17, 18 & 19 . https://doi.org/10.4324/9780203180990 Butler, J. (1988). Performative Acts and Gender Constitution: An Essay in Phenomenology and Feminist Theory. Theatre Journal , 40 (4), 519. https://doi.org/10.2307/3207893 Cadri, A., Nagumsi, B. A. A., Twi-Yeboah, A., Yeboah, L. D., Adomah-Afari, A., Ane-Loglo, M. G., & Aboagye, R. G. (2021). Facilitators and Barriers to Health Seeking among People Who Use Drugs in the Sunyani Municipality of Ghana: An Exploratory Study. BioMed Research International , 2021 , 2868953. https://doi.org/10.1155/2021/2868953 Chen, H., Liu, S., Wang, W., Shi, H., Gao, S., Yan, Y., Fang, J., Zhan, Y., Chen, H., & Liu, Z. (2025). Global burden of substance use disorders in adolescents and young adults aged 10–24 years from 1990 to 2021. Scientific Reports 2025 15:1 , 15 (1), 1–15. https://doi.org/10.1038/s41598-025-11266-6 Connor, J. P., Stjepanović, D., Budney, A. J., Le Foll, B., & Hall, W. D. (2022). Clinical management of cannabis withdrawal. Addiction , 117 (7), 2075–2095. https://doi.org/10.1111/ADD.15743;PAGE:STRING:ARTICLE/CHAPTER Courtenay, W. H. (2000). Constructions of masculinity and their influence on men’s well-being: A theory of gender and health. Social Science and Medicine , 50 (10), 1385–1401. https://doi.org/10.1016/S0277-9536(99)00390-1 Cruwys, T., Stewart, B., Buckley, L., Gumley, J., & Scholz, B. (2020). The recovery model in chronic mental health: A community-based investigation of social identity processes. Psychiatry Research , 291 , 113241. https://doi.org/10.1016/J.PSYCHRES.2020.113241 Do, H. N., Do, B. N., & Nguyen, M. H. (2023). 3How do constructivism learning environments generate better motivation and learning strategies? The Design Science Approach. Heliyon , 9 (12), e22862. https://doi.org/10.1016/J.HELIYON.2023.E22862 Dumbili, E. W., Okpan, S. O., Uwa-Robinson, K., & Azende, P. M. (2022). ‘If You Cannot Beat Them, You Join Them’: Friendship, Social Influence and Drinking to Belong Among Nigerian Youth. Alcohol, Age, Generation and the Life Course , 127–150. https://doi.org/10.1007/978-3-031-04017-7_6 Earnshaw, V. A. (2020). Stigma and substance use disorders: A clinical, research, and advocacy agenda. The American Psychologist , 75 (9), 1300. https://doi.org/10.1037/AMP0000744 Ebrahim, J., Adams, J., & Demant, D. (2024). Substance use among young people in sub-Saharan Africa: a systematic review and meta-analysis. Frontiers in Psychiatry , 15 , 1328318. https://doi.org/10.3389/FPSYT.2024.1328318/FULL Eekhoudt, C. R., Sandhu, M., Mniszak, C., Goodyear, T., Turuba, R., Marchand, K., Barbic, S., & Fast, D. (2024). Looking beyond drugs: A scoping review of recovery in the context of illicit substance use among adolescents and young adults. International Journal of Drug Policy , 133 , 104598. https://doi.org/10.1016/J.DRUGPO.2024.104598 Enworo, O. C. (2023). Application of Guba and Lincoln’s parallel criteria to assess trustworthiness of qualitative research on indigenous social protection systems. Qualitative Research Journal , 23 (4), 372–384. https://doi.org/10.1108/QRJ-08-2022-0116/FULL/PDF Feinberg, M. E., & Osgood, D. W. (2023). Teen Friendship networks, Development, and Risky Behavior. Teen Friendship Networks, Development, and Risky Behavior , 1–390. https://doi.org/10.1093/OSO/9780197602317.001.0001 Fiaveh, D. Y. (2020). Masculinity, Male Sexual Virility, and Use of Aphrodisiacs in Ghana. Journal of Men’s Studies , 28 (2), 165–182. https://doi.org/10.1177/1060826519887510;PAGE:STRING:ARTICLE/CHAPTER Franz, B., Cronin, C. E., Lindenfeld, Z., Pagan, J. A., Lai, A. Y., Krawczyk, N., Rivera, B. D., & Chang, J. E. (2024). Rural-urban disparities in the availability of hospital-based screening, medications for opioid use disorder, and addiction consult services. Journal of Substance Use and Addiction Treatment , 160 , 209280. https://doi.org/10.1016/J.JOSAT.2023.209280 Hammack, P. L., & Manago, A. M. (2024). The Psychology of Sexual and Gender Diversity in the 21st Century: Social Technologies and Stories of Authenticity. American Psychologist , 80 (3), 375–388. https://doi.org/10.1037/AMP0001366 Hunt, A., Merola, G. P., Carpenter, T., & Jaeggi, A. V. (2024). Evolutionary perspectives on substance and behavioural addictions: Distinct and shared pathways to understanding, prediction and prevention. Neuroscience & Biobehavioral Reviews , 159 , 105603. https://doi.org/10.1016/J.NEUBIOREV.2024.105603 Ibragimov, U., Young, A. M., & Cooper, H. L. F. (2020). Understanding rural risk environments for drug-related harms: Progress, challenges, and steps forward. The International Journal on Drug Policy , 85 , 102926. https://doi.org/10.1016/J.DRUGPO.2020.102926 Janson, S., Nyenga, L., Saleem, H., Mayo-Wilson, L. J., Mushy, S. E., Iseselo, M. K., van Draanen, J., Tucker, J., McPherson, M., & Conserve, D. F. (2024). Residential and inpatient treatment of substance use disorders in Sub-Saharan Africa: a scoping review. Substance Abuse Treatment, Prevention, and Policy , 19 (1). https://doi.org/10.1186/S13011-023-00589-0 Janulis, P., Birkett, M., Phillips, G., & Mustanski, B. (2019). Not getting high with a little help from your friends: Social versus drug network correlates of marijuana use among YMSM. Addictive Behaviors , 92 , 180–185. https://doi.org/10.1016/J.ADDBEH.2019.01.004 Kabore, A., Afriyie-Gyawu, E., Awuah, J., Hansen, A., Walker, A., Hester, M., Sié, M. A. W., Johnson, J., & Meda, N. (2019). Social ecological factors affecting substance abuse in Ghana (West Africa) using photovoice. PAMJ. 2019; 34:214 , 34 (214). https://doi.org/10.11604/PAMJ.2019.34.214.12851 Kaboré, A., Moussa, A., Sie, W., Awuah, J., Ouédraogo, M. O., Kaboré, I., & Meda, N. (2019). Barriers and Facilitators To Substance Abuse Treatment in Ghana (West Africa) Using Photovoice. International Journal of Development Research , 09 , 28454–28458. http://www.journalijdr.com Kalungi, H., Kamacooko, O., Lunkuse, J. F., Namutebi, J., Naluwooza, R., Price, M. A., Ruzagira, E., & Mayanja, Y. (2024). Prevalence and factors associated with illicit drug and high-risk alcohol use among adolescents living in urban slums of Kampala, Uganda. BMC Public Health 2024 24:1 , 24 (1), 1–11. https://doi.org/10.1186/S12889-024-19250-X Khumalo, S., Mabaso, M., Makusha, T., & Taylor, M. (2021). Intersections Between Masculinities and Sexual Behaviors Among Young Men at the University of KwaZulu-Natal, South Africa. SAGE Open , 11 (3). https://doi.org/10.1177/21582440211040114;WEBSITE:WEBSITE:SAGE;JOURNAL:JOURNAL:SGOA;REQUESTEDJOURNAL:JOURNAL:SGOA;WGROUP:STRING:PUBLICATION Kyei-Gyamfi, S., Kyei-Arthur, F., Alhassan, N., Agyekum, M. W., Abrah, P. B., & Kugbey, N. (2024). Prevalence, correlates, and reasons for substance use among adolescents aged 10–17 in Ghana: a cross-sectional convergent parallel mixed-method study. Substance Abuse Treatment, Prevention, and Policy 2024 19:1 , 19 (1), 1–9. https://doi.org/10.1186/S13011-024-00600-2 Lamb, R., & Kougiali, Z. G. (2025). Women and shame: narratives of recovery from alcohol dependence. Psychology and Health , 40 (10), 1736–1773. https://doi.org/10.1080/08870446.2024.2352191;ISSUE:ISSUE:DOI Maina, B. W., Sikweyiya, Y., Ferguson, L., & Kabiru, C. W. (2022). Conceptualisations of masculinity and sexual development among boys and young men in Korogocho slum in Kenya. Culture, Health and Sexuality , 24 (2), 226–240. https://doi.org/10.1080/13691058.2020.1829058;WGROUP:STRING:PUBLICATION Mbuthia, G., Wanzala, P., Ngugi, C. W., & Nyamogoba, H. D. N. (2020). A Qualitative Study on Alcohol and Drug Abuse among Undergraduate (University Students) in The Coastal Region of Kenya. African Journal of Health Sciences , 33 (1), 38–48. https://doi.org/10.4314/AJHS.V33I1 Mensah, E. O. (2021). To be a Man is Not a Day’s Job: The Discursive Construction of Hegemonic Masculinity by Rural Youth in Nigeria. Gender Issues 2021 38:4 , 38 (4), 438–460. https://doi.org/10.1007/S12147-020-09271-2 Moore, D., Hart, A., Fraser, S., & Seear, K. (2020). Masculinities, practices and meanings: A critical analysis of recent literature on the use of performance- and image-enhancing drugs among men. Health (United Kingdom) , 24 (6), 719–736. https://doi.org/10.1177/1363459319838595;PAGE:STRING:ARTICLE/CHAPTER Moyle, L., Dymock, A., Aldridge, A., & Mechen, B. (2020). Pharmacosex: Reimagining sex, drugs and enhancement. International Journal of Drug Policy , 86 , 102943. https://doi.org/10.1016/J.DRUGPO.2020.102943 MoYS. (2013). Report Ministerial Impact Assessment & Review Committee on Ghana Youth Employment and Enterpreneurial Agency ( Gyeeda ) . July . Nawi, A. M., Ismail, R., Ibrahim, F., Hassan, M. R., Manaf, M. R. A., Amit, N., Ibrahim, N., & Shafurdin, N. S. (2021). Risk and protective factors of drug abuse among adolescents: a systematic review. BMC Public Health 2021 21:1 , 21 (1), 1–15. https://doi.org/10.1186/S12889-021-11906-2 Nyashanu, T., & Visser, M. (2022). Treatment barriers among young adults living with a substance use disorder in Tshwane, South Africa. Substance Abuse Treatment, Prevention, and Policy , 17 (1). https://doi.org/10.1186/S13011-022-00501-2 Osei-Tutu, S., Owusu-Sarpong, O. J., Asante, F., Agyemang-Duah, W., Siaw, L. P., Darkwa, I. O., & Gyasi, R. M. (2025). The severity of Tramadol misuse among youth in urban informal settlements in Ghana: patterns, co-use, and sociodemographic factors. Archives of Public Health 2025 83:1 , 83 (1), 1–11. https://doi.org/10.1186/S13690-025-01634-Z Ruane-Mcateer, E., Gillespie, K., Amin, A., Aventin, Á., Robinson, M., Hanratty, J., Khosla, R., & Lohan, M. (2020). Gender-transformative programming with men and boys to improve sexual and reproductive health and rights: a systematic review of intervention studies. BMJ Global Health , 5 (10), e002997. https://doi.org/10.1136/BMJGH-2020-002997 Sarkar, S., Tom, A., & Mandal, P. (2021). Barriers and Facilitators to Substance Use Disorder Treatment in Low-and Middle-Income Countries: A Qualitative Review Synthesis. Substance Use & Misuse , 56 (7), 1062–1073. https://doi.org/10.1080/10826084.2021.1908359 Setufe, S. B., Amponsah, S. K. K., Henneh, S., & Acheampong, E. A. (2022). Pandemic risk, response, and resilience of fishermen in Ghana: a case study of fishing communities in Stratum VII, Volta Lake. Pandemic Risk, Response, and Resilience , 415. https://doi.org/10.1016/B978-0-323-99277-0.00025-5 Sibanda, A., & Batisai, K. (2021). The intersections of identity, belonging and drug use disorder: struggles of male youth in post-apartheid South Africa. International Journal of Adolescence and Youth , 26 (1), 143–157. https://doi.org/10.1080/02673843.2021.1899945;SUBPAGE:STRING:FULL Snoek, A., McGeer, V., Brandenburg, D., & Kennett, J. (2021). Managing shame and guilt in addiction: A pathway to recovery. Addictive Behaviors , 120 , 106954. https://doi.org/10.1016/J.ADDBEH.2021.106954 Swartout, K. M., & White, J. W. (2010). The relationship between drug use and sexual aggression in men across time. Journal of Interpersonal Violence , 25 (9), 1716–1735. https://doi.org/10.1177/0886260509354586 Thomasius, R., Paschke, K., & Arnaud, N. (2022). Substance-Use Disorders in Children and Adolescents. Deutsches Ärzteblatt International , 119 (25), 440. https://doi.org/10.3238/ARZTEBL.M2022.0122 Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care , 19 (6), 349–357. https://doi.org/10.1093/INTQHC/MZM042 Additional Declarations No competing interests reported. Supplementary Files SupplementaryS1.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8296597","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":556985940,"identity":"b7b1aafc-c433-4a60-a079-f56f3102dbb9","order_by":0,"name":"Simon Nyarko","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAUlEQVRIiWNgGAWjYJACxgYGBh4gzf7jg4ENiN94gFgtDJIzCtLAfKK0gIE0x4fDYAZeLeYSyc8+zqiok9Ft7z1gzGBw3m5t+2GgLTU20bi0WM5IM5654cxhHrMz5xKSCwxuJ287kwjUciwttwGHFoMbCcaMD9sO8JjdyDE4PAOoxewAUAtjw2E8WtI/A7XUgbQYNvMYnEs2O/+QkJYcY8aNbcwgLcbMPAYH7MxuELLlzJtixhlgv5wxY5xhkJxgdgNoSwI+vxxP38zYU1Fnb3a8x4zhwx87e7Pz6Q8ffKixwamFQSABlZ8IVpmAoQ4J8B9A5dvjUzwKRsEoGAUjEwAAiSFny3TQyYQAAAAASUVORK5CYII=","orcid":"","institution":"University of Ghana","correspondingAuthor":true,"prefix":"","firstName":"Simon","middleName":"","lastName":"Nyarko","suffix":""},{"id":556985944,"identity":"c7a4e78f-c1b8-499e-bad8-6568614767d5","order_by":1,"name":"Julius Caesar Mahama","email":"","orcid":"","institution":"Liverpool John Moores University","correspondingAuthor":false,"prefix":"","firstName":"Julius","middleName":"Caesar","lastName":"Mahama","suffix":""},{"id":556985949,"identity":"fcf8eb7d-9354-43e6-b20b-4191068258bf","order_by":2,"name":"Abdul-Wadudu Faridu","email":"","orcid":"","institution":"University for Development Studies","correspondingAuthor":false,"prefix":"","firstName":"Abdul-Wadudu","middleName":"","lastName":"Faridu","suffix":""},{"id":556985951,"identity":"d1863736-7a13-4e4f-88d5-5b3925f2a13f","order_by":3,"name":"Norbert Mantu Kipo","email":"","orcid":"","institution":"Tamale Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Norbert","middleName":"Mantu","lastName":"Kipo","suffix":""},{"id":556985958,"identity":"95f7bc65-7eeb-48aa-8567-dedaf5150c9b","order_by":4,"name":"Michael Ayarika Issah","email":"","orcid":"","institution":"Tamale Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Michael","middleName":"Ayarika","lastName":"Issah","suffix":""},{"id":556985962,"identity":"f7d42ca1-219b-46cd-8be3-60679aa7bfbc","order_by":5,"name":"Afumaa Erica","email":"","orcid":"","institution":"University of Ghana","correspondingAuthor":false,"prefix":"","firstName":"Afumaa","middleName":"","lastName":"Erica","suffix":""},{"id":556985964,"identity":"5d713b88-8b86-46a7-a8dd-e87e63166c34","order_by":6,"name":"Khadija Atchulo","email":"","orcid":"","institution":"Johns Hopkins University","correspondingAuthor":false,"prefix":"","firstName":"Khadija","middleName":"","lastName":"Atchulo","suffix":""},{"id":556985965,"identity":"ae4c60af-a99b-4397-90fd-81958f065934","order_by":7,"name":"Martin Antuolkuu","email":"","orcid":"","institution":"University of Allied Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Martin","middleName":"","lastName":"Antuolkuu","suffix":""}],"badges":[],"createdAt":"2025-12-06 19:38:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8296597/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8296597/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":97780878,"identity":"6be3bbaf-8224-416d-a883-b5bf063d8293","added_by":"auto","created_at":"2025-12-09 09:52:01","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":310275,"visible":true,"origin":"","legend":"","description":"","filename":"ManuscriptTrappedTryingPsychoactivesv1.1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8296597/v1/7a0c93da584255c1b99239ca.docx"},{"id":97780874,"identity":"e8c88012-e0ec-4946-8128-be65c9381fbd","added_by":"auto","created_at":"2025-12-09 09:52:01","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":10962,"visible":true,"origin":"","legend":"","description":"","filename":"5b26224f60ac4fca9a0b4b0bfe1da57c.json","url":"https://assets-eu.researchsquare.com/files/rs-8296597/v1/50d9d59aa913fb0e5f0de7ea.json"},{"id":97780879,"identity":"7e2b22c2-3441-4498-8b7e-4a0b7541bfa8","added_by":"auto","created_at":"2025-12-09 09:52:01","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":140850,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryS1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8296597/v1/5f1dc57f0f308f4ac613d597.pdf"},{"id":97780881,"identity":"3c5bf0af-ce2d-483a-a3d4-10595dced7ec","added_by":"auto","created_at":"2025-12-09 09:52:01","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":175542,"visible":true,"origin":"","legend":"","description":"","filename":"5b26224f60ac4fca9a0b4b0bfe1da57c1enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8296597/v1/2800dbc3808c055442b96a56.xml"},{"id":97897615,"identity":"948bd7ea-0572-4a0b-ab2a-31569d246103","added_by":"auto","created_at":"2025-12-10 15:37:59","extension":"png","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":217461,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8296597/v1/7d1d7e2dd79971ed462bd6ff.png"},{"id":97780876,"identity":"2797d517-ce91-4c79-9190-a433b5ff18ed","added_by":"auto","created_at":"2025-12-09 09:52:01","extension":"png","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":54667,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8296597/v1/dc7ca63f60ebbbc2bb7e6ffe.png"},{"id":97780883,"identity":"e847fb8e-4d12-488b-bb53-077c5bc2a19a","added_by":"auto","created_at":"2025-12-09 09:52:01","extension":"xml","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":172893,"visible":true,"origin":"","legend":"","description":"","filename":"5b26224f60ac4fca9a0b4b0bfe1da57c1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8296597/v1/7f276dbf8db4f1a8cf1a16b8.xml"},{"id":97780882,"identity":"f961e035-c0c5-4234-8bbe-a1b4b82b102d","added_by":"auto","created_at":"2025-12-09 09:52:01","extension":"html","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":182410,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8296597/v1/50812a40dd7769ce96ef0504.html"},{"id":97897790,"identity":"ddf656b4-72ba-49b3-bb5b-d82af60a1608","added_by":"auto","created_at":"2025-12-10 15:38:14","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":267928,"visible":true,"origin":"","legend":"\u003cp\u003eThematic Map of Psychoactive Substance Use and Recovery among Youth in a rural Ghanaian setting\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8296597/v1/28dfd58f36d43a986706d545.png"},{"id":100949359,"identity":"f34abf4a-835a-40a7-b046-a96cb5b94851","added_by":"auto","created_at":"2026-01-23 07:01:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1719179,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8296597/v1/042f661e-13d0-4919-a1b6-c88fad993aee.pdf"},{"id":97896760,"identity":"8167965d-4875-4af1-9031-655530693482","added_by":"auto","created_at":"2025-12-10 15:37:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":140850,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryS1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8296597/v1/19611ff037afc94ffc3aca04.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Trapped but Trying: Stigma, Sexual Motivations, and the Everyday Struggles of Recovery from Psychoactive Substance Use Among Youth in Rural Ghana","fulltext":[{"header":"Contributions to the literature","content":"\u003cul\u003e\n \u003cli\u003eStigma, gender norms, and structural disadvantage profoundly shape young people\u0026rsquo;s experiences of psychoactive substance use and recovery in rural Ghana.\u003c/li\u003e\n \u003cli\u003eSubstances such as tramadol are commonly used to express masculinity, enhance sexual performance, and affirm social identity among peers.\u003c/li\u003e\n \u003cli\u003eRecovery is viewed not merely as abstinence, but as a struggle to reclaim dignity, belonging, and social legitimacy amid stigma and moral judgment from families, communities, and health providers.\u003c/li\u003e\n \u003cli\u003eLimited access to decentralized, affordable, and trustworthy services underscores the need for community-based, gender-responsive, and non-judgmental interventions integrated within primary health care to foster empathy, inclusion, and sustainable recovery.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"1. Introduction","content":"\u003cp\u003eGlobally, psychoactive substance use among youth remains a major public health challenge (Armoon et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Chen et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), attracting significant concern due to its wide-reaching impact on users in low- and middle-income countries (LMICs) (Kalungi et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Psychoactive substance (psychoactive) is a broad term that covers any form of chemical substance, whether natural or synthetic, that can alter psychological functioning by affecting the central nervous system (CNS), resulting in a change in mood, perception, consciousness, or behaviour (Bonnet et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Psychoactive drugs encompass a broad range of substances, including depressants such as alcohol and benzodiazepines; hallucinogens such as cannabis and lysergic acid diethylamide (LSD); stimulants such as amphetamines and cocaine; and opiates/opioids such as codeine and heroin.\u003c/p\u003e\u003cp\u003eIn LMICs, specifically Sub-Saharan African (SSA) nations, personal, structural, and systemic characteristics that exist predispose the youth to take up and show more interest in drug abuse and misuse. Recent evidence suggests that nearly one in five young people in SSA has used a psychoactive substance at least once in their lifetime (Ebrahim et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). This growing trend reflects a combination of structural factors, economic precarity, weak regulation, and limited access to health services, alongside interpersonal influences such as peer pressure, social identity formation, and the quest for belonging among youth (Mbuthia et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Nawi et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn Ghana, the issue has become increasingly visible through both scholarly and public discourse. Recent studies reveal that the use of substances such as alcohol, cannabis, tramadol, and codeine has risen among adolescents and young adults across both urban and rural settings (Kyei-Gyamfi et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Osei-Tutu et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Scholars attribute this rise in indiscriminate psychoactive substance use to a combination of socio-economic hardship, exposure to global youth cultures, and the easy availability of substances in informal markets (Adongo et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Asamoah et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). For instance, Kabore et al (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) found from their study that drug abuse is not even regarded as a disease in Ghana, pointing to one reason why less attention is paid to interventions (Kabore et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Despite such growing recognition, most existing literature in Ghana has focused primarily on prevalence estimates, risk factors, or patterns of initiation, with relatively little attention to what follows: how young people who use substances attempt to recover, the meanings they attach to recovery, and the barriers they face in that process.\u003c/p\u003e\u003cp\u003eMore than just epidemiological data is needed to understand recovery among young people who use psychoactive substances (Eekhoudt et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2024\u003c/span\u003e); lived experience, meaning-making, and the social ecology in which recovery takes place must all be examined. Understanding the rural context, where acc​ess to formal treatment and harm reduction initiatives remains limited (Franz et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Ibragimov et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2020\u003c/span\u003e),\u0026zwnj; is essential because recovery in\u0026zwj; such an environment transcends clinical⁠ interventions and unfolds\u0026zwnj; as a continuous lived negotiation sha​ped by stigma​, gender norms, peer dynamics, and\u0026zwj; economic pressures. Seldom does existing research in Ghana examine these interconnected issues from the viewpoint of people who are most impacted. As a result, less is known about the emotional, social, and relational aspects of recovery for the youth in rural communities. Nonetheless, this study addresses that gap by investigating the daily struggles of recovery from psychoactive substance use among youth in rural Ghanaian communities. It focuses on how stigma, gender norms, and sexual or relational motivations shape their efforts to stop or reduce use. In this context, recovery is understood as a socially ingrained process in which the desire to restore dignity, reclaim social approval, or embody accepted masculinity and femininity plays a significant role (Lamb \u0026amp; Kougiali, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). These gendered and relational dynamics are especially important in communities where manhood and social respect are frequently associated with sexual prowess, productivity, and self-control (Hammack \u0026amp; Manago, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). However, for many young people who have used substances, these same values become double-edged, motivating initiation through peer validation while limiting recovery through shame and marginalization (Earnshaw, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe study shifts from a prevalence-based inquiry to a process-oriented approach that draws on the youth's own stories of struggle and agency. For this reason, the study contributes to a deeper comprehension of recovery as a social activity negotiated within complicated moral and relational environments, rather than just abstinence or treatment adherence. Such understanding is critical for developing community-based and gender-responsive interventions that are relevant to local realities rather than importing externally established paradigms.\u003c/p\u003e\u003cp\u003eThe strength of this study lies in the breadth and contextual richness of its qualitative nature, even though it was undertaken in one of Ghana's district capitals and cannot therefore be said to be statistically generalized. The study clarifies the paradoxes of resilience and reliance, showing how social criticism and stigma coexist with courage, ambition, and the desire to change. This work brings a fresh viewpoint to the literature on substance use and recovery in Sub-Saharan Africa, specifically Ghana, by highlighting the interconnected effects of sexual motivation, stigma, and masculinity. It provides theoretical and practical insights that are pertinent to practitioners, policymakers, and researchers who are interested in youth wellbeing and social inclusion.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003e2.1 Study Philosophy and Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study employed a qualitative research design grounded in a constructivist and interpretivist\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eparadigm, aiming to explore how the youth in rural Ghanaian communities experience and interpret their struggles trying to recover from psychoactive substance use (Bryman \u0026amp; Cramer, 2012). The study emphasized meaning-making and lived experience, which is congruent with the constructivist perspective of knowledge as co-constructed through social interaction and context (Do et al., 2023).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2 Study Setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe fieldwork was conducted in Yeji, a rural town and the administrative capital of the Pru East District in the Bono East Region of Ghana. Yeji is situated adjacent to the Volta Lake and serves as a trading centre and inland fishing settlement, drawing increasing numbers of young people migrating from cities, neighbouring towns, and surrounding villages (Setufe et al., 2022). With a population that reflects a mix of ethnic groups, Yeji is characterized by rich cultural diversity and changing social dynamics. \u0026nbsp; In this context, the growing recognition of psychoactive substance use arises from a confluence of structural and social factors. Among these are robust informal social networks formed by migrant youth, relatively limited access to advanced educational opportunities, and persistent economic uncertainty amid livelihood pressures in formal government work, fishing, trading, and small-scale agriculture. \u0026nbsp;The setting was selected because it typifies rural Ghanaian communities where access to formal mental health or rehabilitation services is limited, and where recovery often unfolds through informal, community-based processes rather than institutional care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3 Study participants, sampling and sample size\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants were selected using purposive and snowball sampling strategies to ensure inclusion of individuals with varied experiences of substance use and recovery. In line with the Ghana Ministry of Youth and Sports\u0026rsquo; definition of youth as persons aged 15 to 35 years (MoYS, 2013), participants within this age range were considered eligible. Additional inclusion criteria required that participants (a) had current or prior experience of psychoactive substance use, and (b) had resided in Yeji for at least one year. In total, fifteen participants (coded P01\u0026ndash;P15) were interviewed. The sample size was determined a priori based on the principles of information power and thematic saturation, rather than statistical representativeness. By the twelfth interview, no new ideas emerged; three additional interviews were conducted to ensure conceptual completeness.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.4 Data Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were collected through face-to-face in-depth interviews, using semi-structured and open-ended questions designed to elicit rich narratives about recovery, stigma, and social experiences. A semi-structured interview guide, developed specifically for this study, was used to facilitate all interviews; the full English version is provided in \u003cstrong\u003eSupplementary File S1\u003c/strong\u003e. Interviews were conducted in English, Gonja, Hausa, and Twi, depending on participants\u0026rsquo; language preferences, and lasted 45-90 minutes. Each session took place at a private, convenient location chosen by the participant to ensure confidentiality and comfort. All interviews were audio-recorded with informed consent and transcribed verbatim. Field notes and reflexive memos were maintained to capture contextual details, emotional tones, and researcher reflections during and after data collection. The research lead later integrated these notes into the analytic process to enhance contextual understanding and reflexivity. Participants were appreciated with thirty Ghana Cedis (GHS 30.00) or an equivalent food package, for their time and participation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.5 Data Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe recorded interviews were repeatedly reviewed to ensure a thorough familiarity with the data, and transcriptions were then produced. The data were analyzed using reflexive thematic analysis, following the six-phase framework developed by (Braun \u0026amp; Clarke, 2023). The process involved (1) familiarization with the data, (2) generation of initial codes, (3) searching for themes, (4) reviewing themes, (5) defining and naming themes, and (6) writing up the analysis. Coding was primarily inductive, allowing patterns and meanings to emerge from participants\u0026rsquo; narratives rather than applying pre-existing theoretical categories. Two analysts independently coded the transcripts and met regularly to compare interpretations and resolve discrepancies. Codes were iteratively refined and grouped into subthemes and main themes in accordance with the research objectives. Reflexivity was maintained throughout the analysis via memoing and peer debriefing, enabling the researchers to document interpretive decisions, question assumptions, and maintain transparency in the analytic process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.6 Rigor and Trustworthiness of the Study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo enhance the credibility, dependability, and confirmability of the findings, the study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist (Tong et al., 2007). Credibility was ensured through prolonged engagement with the data, analyst triangulation, and the use of verbatim quotations to substantiate interpretations. Dependability was achieved by maintaining an audit trail of coding decisions, theme development, and analytic memos. Confirmability was strengthened through reflexive journaling, while transferability was supported by providing thick, contextualized descriptions of the study setting and participants\u0026rsquo; experiences (Enworo, 2023).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.7 Researcher Reflexivity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eReflexivity was integral to the research process. The lead researcher, a Ghanaian academic with experience in community-based health research, approached the study with both insider and outsider perspectives. Cultural familiarity and language proficiency facilitated rapport and nuanced understanding, while maintaining analytical distance ensured interpretive rigor. Throughout data collection and analysis, the team engaged in reflexive journaling, memo writing, and regular debriefings to examine assumptions and assess how their positionalities might shape interpretation. This reflective practice enhanced the study\u0026rsquo;s credibility and ethical transparency by grounding findings in participants\u0026rsquo; lived experiences rather than researcher bias.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.8 Ethics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClearance for this study was obtained from the Pru East District Assembly. An official request letter was submitted prior to data collection, and formal approval was granted (Ref: PEDA/01/10/08/001). Informed consent was obtained from all participants after explaining the purpose, procedures, and voluntary nature of participation. Participants were assured of confidentiality and their right to withdraw at any point without penalty. Pseudonyms and anonymized identifiers (P01\u0026ndash;P15) were used in all transcripts and reports to protect privacy. Audio recordings and transcripts were securely stored and accessible only to the research team.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003e\u003cstrong\u003e3.1 Demographic Characteristics of Participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of fifteen (15) youth with current or prior experience with psychoactive substance use participated in the study. Participants ranged in age from 19 to 33 years, with a mean age of approximately 26 years. The majority were male (87%), while two were female (13%). Most participants were single (73%), and four were married (27%). In terms of education, levels of attainment ranged from no formal education to tertiary education. Three participants had tertiary education; two held diplomas; four completed senior high school; three completed junior high school; only one had primary education; and two had no formal education. Occupationally, participants engaged in diverse work, including trading, masonry, farming, sand supply, and casual labor, while five were unemployed at the time of data collection. The duration of substance use ranged from one to seven years, with most participants reporting two to five years of continuous use. Regarding recovery status, six participants were in recovery, six were contemplating change, and three were still in active use. Peer influence emerged as the most common mode of initiation, followed by curiosity, coping with stress, sexual motivation, and family exposure. Notably, several male participants cited sexual enhancement and performance as their initial motivation, while some female participants attributed their initiation to romantic partners or social gatherings. The characteristics of the study participants are summarized in \u003cstrong\u003eTable 1\u0026nbsp;\u003c/strong\u003ebelow. This table provides information on the duration of substance use, recovery status, and mode of initiation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Demographic Characteristics of Study Participants (N = 15)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"890\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.3255%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipant ID\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.07071%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.07071%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.51964%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2132%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation Level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5903%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOccupation/Job\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4377%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration of Substance Use (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.009%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRecovery Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7632%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMode of initiation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.3255%;\"\u003e\n \u003cp\u003eP01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.07071%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.07071%;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.51964%;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2132%;\"\u003e\n \u003cp\u003eJunior High School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5903%;\"\u003e\n \u003cp\u003eSand supplier\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4377%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.009%;\"\u003e\n \u003cp\u003eContemplating change\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7632%;\"\u003e\n \u003cp\u003ePeer influence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.3255%;\"\u003e\n \u003cp\u003eP02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.07071%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.07071%;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.51964%;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2132%;\"\u003e\n \u003cp\u003eNo formal Education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5903%;\"\u003e\n \u003cp\u003eUnemployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4377%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.009%;\"\u003e\n \u003cp\u003eActive use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7632%;\"\u003e\n \u003cp\u003eInfluenced by friends\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.3255%;\"\u003e\n \u003cp\u003eP03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.07071%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.07071%;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.51964%;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2132%;\"\u003e\n \u003cp\u003eSenior High School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5903%;\"\u003e\n \u003cp\u003eMechanic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4377%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.009%;\"\u003e\n \u003cp\u003eContemplating change\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7632%;\"\u003e\n \u003cp\u003eSexual enhancement\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.3255%;\"\u003e\n \u003cp\u003eP04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.07071%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.07071%;\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.51964%;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2132%;\"\u003e\n \u003cp\u003eDiploma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5903%;\"\u003e\n \u003cp\u003eMason\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4377%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.009%;\"\u003e\n \u003cp\u003eIn recovery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7632%;\"\u003e\n \u003cp\u003eCoping with stress\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.3255%;\"\u003e\n \u003cp\u003eP05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.07071%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.07071%;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.51964%;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2132%;\"\u003e\n \u003cp\u003eSenior High School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5903%;\"\u003e\n \u003cp\u003eUnemployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4377%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.009%;\"\u003e\n \u003cp\u003eContemplating change\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7632%;\"\u003e\n \u003cp\u003eSexually motivated\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.3255%;\"\u003e\n \u003cp\u003eP06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.07071%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.07071%;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.51964%;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2132%;\"\u003e\n \u003cp\u003eJunior High School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5903%;\"\u003e\n \u003cp\u003eSelf-employed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4377%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.009%;\"\u003e\n \u003cp\u003eIn recovery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7632%;\"\u003e\n \u003cp\u003eTo overcome family problems\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.3255%;\"\u003e\n \u003cp\u003eP07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.07071%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.07071%;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.51964%;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2132%;\"\u003e\n \u003cp\u003eSenior High School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5903%;\"\u003e\n \u003cp\u003eUnemployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4377%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.009%;\"\u003e\n \u003cp\u003eContemplating change\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7632%;\"\u003e\n \u003cp\u003eThrough social gatherings\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.3255%;\"\u003e\n \u003cp\u003eP08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.07071%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.07071%;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.51964%;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2132%;\"\u003e\n \u003cp\u003eDiploma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5903%;\"\u003e\n \u003cp\u003eStudent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4377%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.009%;\"\u003e\n \u003cp\u003eIn recovery\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7632%;\"\u003e\n \u003cp\u003eCuriosity/experimentation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.3255%;\"\u003e\n \u003cp\u003eP10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.07071%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.07071%;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.51964%;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2132%;\"\u003e\n \u003cp\u003eSenior High School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5903%;\"\u003e\n \u003cp\u003eGambler\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4377%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.009%;\"\u003e\n \u003cp\u003eActive use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7632%;\"\u003e\n \u003cp\u003eCuriosity and boredom\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.3255%;\"\u003e\n \u003cp\u003eP11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.07071%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.07071%;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.51964%;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2132%;\"\u003e\n \u003cp\u003eSenior High School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5903%;\"\u003e\n \u003cp\u003eUnemployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4377%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.009%;\"\u003e\n \u003cp\u003eContemplating change\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7632%;\"\u003e\n \u003cp\u003eIntroduced to it by my boyfriend\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.3255%;\"\u003e\n \u003cp\u003eP12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.07071%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.07071%;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.51964%;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2132%;\"\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5903%;\"\u003e\n \u003cp\u003eFarmer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4377%;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.009%;\"\u003e\n \u003cp\u003eContemplating change\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7632%;\"\u003e\n \u003cp\u003eCoping with stress\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.3255%;\"\u003e\n \u003cp\u003eP13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.07071%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.07071%;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.51964%;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2132%;\"\u003e\n \u003cp\u003eTertiary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5903%;\"\u003e\n \u003cp\u003eTrader\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4377%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.009%;\"\u003e\n \u003cp\u003eIn recovery\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7632%;\"\u003e\n \u003cp\u003eFamily exposure\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.3255%;\"\u003e\n \u003cp\u003eP14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.07071%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.07071%;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.51964%;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2132%;\"\u003e\n \u003cp\u003eTertiary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5903%;\"\u003e\n \u003cp\u003eUnemployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4377%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.009%;\"\u003e\n \u003cp\u003eContemplating change\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7632%;\"\u003e\n \u003cp\u003ePeer influence\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10.3255%;\"\u003e\n \u003cp\u003eP15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.07071%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.07071%;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.51964%;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2132%;\"\u003e\n \u003cp\u003eJunior High School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5903%;\"\u003e\n \u003cp\u003eCasual work\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4377%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.009%;\"\u003e\n \u003cp\u003eIn recovery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7632%;\"\u003e\n \u003cp\u003eFor confidence and belongingness\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSource: Field Survey, 2025\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2 Thematic Findings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFour major themes emerged from the data, reflecting the social, behavioral, and structural dimensions of psychoactive substance use and recovery among participants: (1) Sexual Enhancement and the Quest for Masculine Identity; (2) Peer Influence, Availability, and the Social Ecology of Use; (3) Dependence, Stigma, and the Vicious Cycle of Use; and (4) Barriers to Care and Pathways to Recovery. \u003cstrong\u003eTable 2\u003c/strong\u003e summarizes the themes, subthemes, codes, and verbatim quotes of participants. In sum, these themes illustrate how substance use is embedded in the gendered, relational, and moral landscapes of rural youth life, and how recovery is often constrained by social stigma and limited institutional support.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 1\u003c/strong\u003e provides a visual mapping of these themes. Unlike Table 2, it doesn\u0026rsquo;t present the participant quotes and thus serves as a summary.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Emergent themes, subthemes, codes, and participant quotes\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"649\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSubtheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCodes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipant verbatim quotes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eSexual Enhancement and the Quest for Masculine Identity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eDrug use for sexual performance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eInitiation for sexual pleasure; endurance during intercourse; peer narratives about sexual prowess\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026ldquo;If you want to have an affair with a lady and you take that drug, it makes you stay longer in bed.\u0026rdquo; (\u003cstrong\u003eP05\u003c/strong\u003e)\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u0026ldquo;Some of us use it because when we are with ladies, we want to prove that we can do better, so we take it before we meet them.\u0026rdquo; (\u003cstrong\u003eP03\u003c/strong\u003e)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;Our boyfriends use these drugs. We love guys who can last \u0026hellip;.. and that is why we also take the drugs to match their strength\u0026rdquo; (\u003cstrong\u003eP11\u003c/strong\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003ePerceived social prestige and masculinity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eGaining respect through sexual ability; linking virility to manhood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026ldquo;They will say, \u0026lsquo;this boy is strong,\u0026rsquo; so you too, you want to try and show them you are strong.\u0026rdquo; (\u003cstrong\u003eP02\u003c/strong\u003e)\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u0026ldquo;If you don\u0026rsquo;t take, they will tease you that you can\u0026rsquo;t satisfy a lady. So, I started.\u0026rdquo; (\u003cstrong\u003eP01\u003c/strong\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003ePeer Influence, Availability, and the Social Ecology of Use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003ePeer pressure and normalization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eFriends introducing drugs; learning by observation; group bonding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026ldquo;It was my friends who introduced it to me\u0026hellip; they said it makes you feel good and work hard.\u0026rdquo; (\u003cstrong\u003eP04\u003c/strong\u003e)\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u0026ldquo;When I saw my friend using it, I asked him what it was, then I also tried it and liked it.\u0026rdquo; (\u003cstrong\u003eP10\u003c/strong\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eEasy access and local supply\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eLocal sellers; unregulated markets; dealer familiarity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026ldquo;The people selling know us. When you go there, they will even reduce the price for you.\u0026rdquo; (\u003cstrong\u003eP03\u003c/strong\u003e)\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u0026ldquo;It\u0026rsquo;s everywhere in the town; you can just buy it as buying a biscuit.\u0026rdquo; (\u003cstrong\u003eP14\u003c/strong\u003e)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eDependence, Stigma, and the Vicious Cycle of Use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003ePhysical and psychological dependence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eWithdrawal symptoms; body pains; inability to quit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026ldquo;When I wake up, my body will be hard, and I feel pains all over. I must take it before I can work.\u0026rdquo; (\u003cstrong\u003eP12\u003c/strong\u003e)\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u0026ldquo;Sometimes I say I will stop, but when the pain starts, I can\u0026rsquo;t.\u0026rdquo; (\u003cstrong\u003eP10\u003c/strong\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eSocial exclusion and stigma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eFamily neglect; community rejection; feelings of dehumanization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026ldquo;They don\u0026rsquo;t see us as human beings anymore. Even my own family don\u0026rsquo;t want to eat with me.\u0026rdquo; (\u003cstrong\u003eP06\u003c/strong\u003e)\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u0026ldquo;People point at us and say, \u0026lsquo;those are the drug boys.\u0026rsquo; It is shameful.\u0026rdquo; (\u003cstrong\u003eP05\u003c/strong\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eBarriers to Care and Pathways to Recovery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eBarriers to seeking help\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eCost; fear of being judged; mistrust of authorities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026ldquo;I want to stop but where will I go? If you go to the hospital, they will ask you plenty questions and laugh at you.\u0026rdquo; (\u003cstrong\u003eP15\u003c/strong\u003e)\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u0026ldquo;Some of the sellers are even police people, so how can we report?\u0026rdquo; (\u003cstrong\u003eP10\u003c/strong\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eDesired interventions and community-based solutions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eFree, non-judgmental care; rehabilitation; arrest of sellers; livelihood support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026ldquo;If the service is free and they won\u0026rsquo;t judge you, I will go.\u0026rdquo; (\u003cstrong\u003eP07\u003c/strong\u003e)\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u0026ldquo;They should catch those who sell to us and bring some work so that we stop.\u0026rdquo; (\u003cstrong\u003eP05\u003c/strong\u003e)\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u0026ldquo;If someone will help us small with farming or work, we won\u0026rsquo;t go there again.\u0026rdquo; (\u003cstrong\u003eP02\u003c/strong\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2.1 Theme 1: Sexual Enhancement and the Quest for Masculine Identity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis theme explores how psychoactive substance use among youth in rural Ghana is deeply entangled with constructions of masculinity, sexuality, and social validation. For many male participants, drug use was not merely about pleasure or dependence; it was a means to assert manhood, boost confidence, and perform sexual endurance that affirmed their social worth. Among female participants, substance use was often described as a relational act tied to their partners\u0026rsquo; expectations and experiences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2.1.1 Subtheme 1: Substance Use for Sexual Performance\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA dominant narrative across interviews was the use of psychoactive substances, particularly tramadol, to enhance sexual stamina and confidence during intercourse. Participants believed these drugs increased their ability to \u0026ldquo;stay longer\u0026rdquo; and satisfy their partners, which in turn boosted their self-esteem and social standing among peers.\u003c/p\u003e\n\u003cp\u003eOne participant explained:\u003c/p\u003e\n\u003cp\u003eIf you want to have an affair with a lady and you take that drug, it makes you stay longer in bed.\u0026rdquo;\u003cem\u003e\u0026nbsp;\u003c/em\u003e(P05, 26 years, single, unemployed)\u003c/p\u003e\n\u003cp\u003eAnother emphasized the social motivation behind this behavior:\u003c/p\u003e\n\u003cp\u003eSome of us use it because when we are with ladies, we want to prove that we can do better, so we take it before we meet them. (P03, 30 years, married, mechanic)\u003c/p\u003e\n\u003cp\u003eFor these young men, sexual performance was both a private and public marker of masculinity. Their sense of accomplishment in sexual encounters became intertwined with peer recognition and social pride. This perception reinforced continued drug use as a mechanism to sustain the image of virility and sexual competence.\u003c/p\u003e\n\u003cp\u003eThe subtheme demonstrates that drug usage served as a symbolic tool of masculine expression, with sexual control and endurance representing dominance, confidence, and social prestige among male peer networks. The results are consistent with broader gender norms in Ghanaian communities, where masculinity is frequently linked with physical strength, sexual prowess, and emotional resilience.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2.1.1 Subtheme 2: Social Validation and Gendered Expectations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn addition to enhancing sexual performance, substance use served as a strategy for social validation. Several participants reported that male peers ridiculed or excluded those who did not use drugs, framing abstinence as weakness or lack of sexual capability.\u003c/p\u003e\n\u003cp\u003eThis is how another participant shared his thoughts on being validated by peers concerning sexual satisfaction:\u003c/p\u003e\n\u003cp\u003eIf you don\u0026rsquo;t take, they will tease you that you can\u0026rsquo;t satisfy a lady. So, I started. (P01, 26 years, male, sand supplier)\u003c/p\u003e\n\u003cp\u003eThis peer pressure perpetuated a cycle of performance; young men took substances to fit in, gain respect, and avoid ridicule. With time, such social norms normalized psychoactive use as part of what it meant to be a \u0026ldquo;real man.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eInterestingly, a female participant provided insight into how women\u0026rsquo;s attitudes indirectly perpetuated this culture:\u003c/p\u003e\n\u003cp\u003eOur boyfriends use these drugs. We love guys who can last \u0026hellip; and that is why we also take the drugs to match their strength. (P11, 23 years, female, unemployed)\u003c/p\u003e\n\u003cp\u003eThis perspective illustrates gendered complicity, in which women\u0026apos;s desires and expectations helped males maintain drug use and, in some cases, prompted their own involvement. Sexual endurance has become a common currency of approbation and appeal in these social relationships.\u0026nbsp;\u003cbr\u003e\u0026nbsp;This subtheme focuses on how gendered power dynamics and cultural norms legitimize substance use in society. It reveals that recovery initiatives must address not only individual behaviours, but also underlying social narratives that link drug use to masculinity and acceptance. The prevalence of young, single males reflects how substance use and recovery are embedded within gendered constructions of masculinity and the pursuit of social validation among peers. The educational and occupational patterns highlight socio-economic precarity as a driver of both initiation and continued use, where psychoactive substances serve as coping mechanisms for stress and limited livelihood opportunities. Furthermore, the mixed recovery statuses, ranging from active use to contemplation and sustained recovery, illustrate a continuum of change shaped by stigma, resilience, and access to supportive networks. The reported modes of initiation highlight the powerful influence of peer dynamics, relational pressures, and community norms, aligning closely with the emerging themes on sexual motivation, social belonging, and barriers to recovery. These findings place psychoactive substance use among rural Ghanaian youths within the larger contexts of gender, socioeconomic vulnerability, and social ecology.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2.2 Theme 2: Peer Influence, Availability, and the Social Ecology of Use\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis theme explores how peer dynamics and access to psychoactive drugs influence the initiation and maintenance of substance use among young people. For many individuals, drug use was introduced and nurtured in social contexts, among friends, at work, or at community gatherings, where it was depicted as acceptable or even desirable. The local milieu, which provided easy access to uncontrolled drugs, reinforced the notion that substance use was a shared social practice rather than a solitary habit.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2.2.1 Subtheme 1: Peer Pressure and Normalization of Use\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePeer relationships emerged as the most powerful influence on participants\u0026rsquo; initiation into psychoactive substance use. Most respondents traced their first encounter with substances to friends who encouraged them to experiment, often under the guise of improving mood, work energy, or social acceptance. Drug use was commonly introduced during informal social interactions, creating a permissive environment that normalized experimentation.\u003c/p\u003e\n\u003cp\u003eOne participant shared his experience:\u003c/p\u003e\n\u003cp\u003eIt was my friends who introduced it to me\u0026hellip; they said it makes you feel good and work hard. (P04, 33 years, married, mason)\u003c/p\u003e\n\u003cp\u003eIn tandem to the above, Another added:\u003c/p\u003e\n\u003cp\u003eWhen I saw my friend using it, I asked him what it was, then I also tried it and liked it. (P10, 19 years, single, gambler)\u003c/p\u003e\n\u003cp\u003eSuch narratives demonstrate how peer support of drug use served as both commencement and a means of belonging. Participants frequently feared social isolation if they declined to participate. Drug use became a symbol of group allegiance, strengthening social cohesion within peer groups.\u0026nbsp;\u003cbr\u003e\u0026nbsp;For some, the pressure was subtle, friends offering narcotics as harmless fun, but for others, it was blatant derision directed at people viewed as \u0026ldquo;too weak\u0026rdquo; or \u0026ldquo;unadventurous\u0026rdquo;. As a result, psychoactive substance use became firmly integrated in youth socialization processes, connecting identity, friendship, and acceptance within the peer network.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2.2.2 Subtheme 2: Substance Availability and Informal Markets\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe social normalization of substance use in this study was intensified by the easy availability of drugs within the local environment. Participants described how tramadol, cannabis, and other psychoactive substances were openly sold in the community, often by familiar vendors who extended credit or offered discounts.\u003c/p\u003e\n\u003cp\u003eA participant mentioned how some of the sellers even reduce the prices for regular customers:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe people selling know us. When you go there, they will even reduce the price for you. (P03, 30 years, married, mechanic)\u003c/p\u003e\n\u003cp\u003eAnother participant indicated how easy it is to get these substances:\u003c/p\u003e\n\u003cp\u003eIt\u0026rsquo;s everywhere in the town; you can just buy it like buying a biscuit. (P14, 22 years, single, unemployed)\u003c/p\u003e\n\u003cp\u003eThese narratives reflect a social ecology of drug supply in which accessibility and cost promote continuous usage. Participants\u0026apos; personal ties with dealers, along with the lack of effective regulation, created an enabling environment in which acquiring narcotics became as ordinary as buying food or home products. Furthermore, the combination of economic precarity and informal trade meant that drug sales were frequently accepted, if not protected, inside the community. Drug traffic thus became integrated into the local economic and social life, supporting the normalcy of use among young people.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2.3 Theme 3: Dependence, Stigma, and the Vicious Cycle of Use\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis theme depicts participants\u0026apos; experiences of physical and psychological dependence, which are exacerbated by intense social stigma and isolation. Over time, what began as experimentation or peer pressure became compulsion, with users unable to function regularly without the drug. The embarrassment and rejection they experienced from family and community members exacerbated their isolation and, irrationally, drove them back to ongoing usage.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2.3.1 Subtheme 1: Physical and Psychological Dependence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMany participants described becoming physically dependent on psychoactive substances after prolonged use. They reported withdrawal symptoms such as pain, fatigue, restlessness, and loss of concentration whenever they tried to stop. For these young people, the drug gradually became part of daily functioning, taken not for pleasure, but to avoid discomfort and maintain productivity.\u003c/p\u003e\n\u003cp\u003eA 29-year old farmer revealed:\u003c/p\u003e\n\u003cp\u003eWhen I wake up, my body will be hard, and I feel pains all over. I must take it before I can work. (P12, 29 years, married, farmer)\u003c/p\u003e\n\u003cp\u003eAnother participant shared a similar struggle:\u003c/p\u003e\n\u003cp\u003eSometimes I say I will stop, but when the pain starts, I can\u0026rsquo;t. (P10, 19 years, single, gambler)\u003c/p\u003e\n\u003cp\u003eSeveral participants also associated substance use with psychological relief. Some used drugs to suppress emotional distress, fear, or feelings of worthlessness. This interplay of physical and emotional dependence created a reinforcing cycle in which drugs were simultaneously the source of suffering and the only perceived escape.\u003c/p\u003e\n\u003cp\u003eThe narratives show that substance abuse among young people in rural Ghana goes beyond biological addiction; it is a coping technique within a larger environment of poverty, anxiety, and social expectations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2.3.2 Subtheme 2: Social Exclusion and Stigmatization\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBeyond the physiological struggle, participants reported severe stigma and social rejection from family members, peers, and community leaders. They were frequently labeled as spoiled, lazy, or useless youth. This stigmatization resulted in a lack of trust, damaged relationships, and low self-esteem.\u003c/p\u003e\n\u003cp\u003eOne participant narrated his ordeal about how his family gave up on him:\u003c/p\u003e\n\u003cp\u003eThey don\u0026rsquo;t see us as human beings anymore. Even my own family don\u0026rsquo;t want to eat with me. (P06, 32 years, single, self-employed)\u003c/p\u003e\n\u003cp\u003eAnother participant buttressed this experience, stating:\u003c/p\u003e\n\u003cp\u003ePeople point at us and say, \u0026lsquo;those are the drug boys.\u0026rsquo; It is shameful. (P05, 26 years, single, unemployed)\u003c/p\u003e\n\u003cp\u003eSuch experiences of social devaluation frequently increased individuals\u0026apos; reliance on drugs as a method of emotional release. In many situations, stigma kept individuals from getting treatment or engaging in community activities. Some participants described being mocked or shunned from social gatherings, while others suffered outright hostility from neighbors who accused them of stealing or violence. As a result, the social environment encouraged dependence by both penalizing and pathologizing the user. The more individuals felt condemned or rejected, the more they turned to drugs to cope with their emotional wounds, establishing a self-perpetuating cycle of addiction and humiliation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2.4 Theme 4: Barriers to Care and Pathways to Recovery\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis theme highlights the challenges that the youth who use psychoactive substances have when attempting to rehabilitate, as well as potential solutions. Participants\u0026apos; accounts show that recovery is a continuous moral, social, and institutional fight, not just a matter of personal willpower. Most individuals expressed a strong desire to stop using drugs, but their efforts were hindered by financial difficulties, stigma within health institutions, inadequate institutional support, and a lack of meaningful livelihood options. Despite this, their stories demonstrated a strong sense of agency, hope, and a willingness to change, provided enabling conditions were met.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2.4.1 Subtheme 1: Barriers to Seeking Help\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants reported that their recovery was hindered by structural and social obstacles that made seeking professional help difficult or undesirable. The most common barriers included financial constraints, fear of stigma, and distrust in formal health systems.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor many, the cost of treatment and the distance to health facilities were prohibitive. Rehabilitation centers or psychiatric units were mostly located in urban areas far from their communities, making access nearly impossible without financial and family support. One participant explained:\u003c/p\u003e\n\u003cp\u003eI want to stop, but where will I go? If you go to the hospital, they will ask you plenty questions and laugh at you. (P15, 24 years, single, casual worker)\u003c/p\u003e\n\u003cp\u003eThis quote reflects a broader concern that health professionals treat young people who use substances with judgment and ridicule rather than empathy. Others described the fear of being criminalized or publicly labeled as an \u0026ldquo;addict,\u0026rdquo; leading them to avoid medical services altogether. Another participant shared his worry:\u003c/p\u003e\n\u003cp\u003eSome of the sellers are even police people, so how can we report? (P10, 19 years, single, gambler)\u003c/p\u003e\n\u003cp\u003eSuch statements reveal a pervasive climate of mistrust, not only in the healthcare system but also in law enforcement. Participants believed that even those responsible for enforcing regulations were complicit in the local drug trade. This perception reinforced a sense of futility about seeking formal help.\u003c/p\u003e\n\u003cp\u003eThe findings show that for many rural youths, recovery is hampered by both financial and moral challenges. Treatment is viewed as expensive, judgmental, and disconnected from their everyday experiences. As a result, the majority turned to self-managed attempts, informal advice, or spiritual healing, which gave moral support but rarely addressed dependence or relapse.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2.4.2 Subtheme 2: Desired Interventions and Community-Based Solutions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDespite these challenges, participants demonstrated remarkable insight into what could facilitate recovery. They envisioned free, non-judgmental, and community-based rehabilitation services that offer counseling, education, and livelihood support.\u003c/p\u003e\n\u003cp\u003eOne participant emphasized the need for compassionate, stigma-free care:\u003c/p\u003e\n\u003cp\u003eIf the service is free and they won\u0026rsquo;t judge you, I will go. (P07, 20 years, single, unemployed)\u003c/p\u003e\n\u003cp\u003eAnother linked recovery to structural and economic interventions:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;They should catch those who sell to us and bring some work so that we stop.\u0026rdquo; (P05, 26 years, single, unemployed)\u003c/p\u003e\n\u003cp\u003eA third participant highlighted the role of employment and purpose in sustaining recovery:\u003c/p\u003e\n\u003cp\u003eIf someone will help us small with farming or work, we won\u0026rsquo;t go there again. (P02, 25 years, single, unemployed)\u003c/p\u003e\n\u003cp\u003eThese interviews highlight that, for participants, recovery entails more than just refraining from substances; it also means social reintegration, dignity, and self-sufficiency. Unemployment and boredom were typical triggers for substance abuse; therefore, livelihood options were considered crucial to stopping the cycle of recurrence.\u003c/p\u003e\n\u003cp\u003eParticipants also emphasized the importance of community education to change public attitudes and reduce stigma. They believed that if communities viewed substance use as a health issue rather than a moral failure, more young people would seek help without shame. In essence, their suggested solutions combined care, compassion, and capacity-building, reflecting an awareness that individual recovery depends on supportive social and economic structures.\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eFollowing our exploration of the lived experiences of youth in their use and decisions to seek recovery from psychoactive substance use in rural Ghana, the findings revealed that their struggles are shaped by intertwined social, cultural, and structural realities. The analysis, grounded in a constructivist lens, showed that recovery is not a linear or solely individual process but one negotiated through gender expectations, peer dynamics, stigma, and limited institutional support. Narratives of the youths highlighted how masculine ideals, peer belonging, and social marginalization collectively influence substance use and recovery pathways. Consistent with earlier African and global evidence, these findings underscore the social embeddedness of substance use and the need for context-responsive, gender-sensitive, and community-based approaches that go beyond punitive or biomedical interventions. The themes are discussed below in relation to existing literature and theory.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.1 Sexual Enhancement and the Quest for Masculine Identity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe findings, based on the social constructionist point of view, show that psychoactive substance use among young males in rural Ghana is significantly influenced by cultural expectations of masculinity, sexuality, and social validation. According to the participants\u0026apos; accounts, drug use, particularly tramadol use, was not only pleasurable but also served as a symbolic performance of manhood, power, and endurance. This lends credence to gender-relational interpretations that see substance use as a means by which men negotiate respect and belonging within peer networks (Courtenay, 2000; Sibanda \u0026amp; Batisai, 2021). Similar tendencies have been documented among young people in Africa, where sexual potency and dominance remain fundamental to masculine identity (Fiaveh, 2020; Khumalo et al., 2021; Maina et al., 2022).\u003c/p\u003e\n\u003cp\u003eSeveral interviewees stated that utilizing psychoactive substances allowed them to prove their sexual capability while maintaining self-esteem. These accounts are consistent with the findings of a study, which found that young Nigerian men frequently associate sexual endurance with social prestige (Mensah, 2021). Within this moral economy of masculinity, pharmacological enhancement becomes a weapon for showing competence and managing female partners, reinforcing patriarchal narratives that prioritize virility over wellbeing. The narratives also illustrate the psychosocial mechanisms that support these practices, peer adulation, fear of scorn, and the seeking of confidence in intimate relationships.\u003c/p\u003e\n\u003cp\u003eFemale participants, on the other hand, revealed their own indirect role in perpetuating this culture, encouraging men who could last longer and occasionally utilizing drugs to equal their partners\u0026apos; performance levels. This corresponds to Butler\u0026apos;s concept of gender performativity, in which femininity and masculinity are co-constituted through reciprocal behaviors that reproduce normative power relations (Butler, 1988). Comparable findings from literature suggest that women\u0026apos;s expectations of male stamina help to normalize drug use for sexual enhancement among young males (Moore et al., 2020; Moyle et al., 2020). Thus, gendered complicity strengthens the social value associated with substance-enhanced sexual performance.\u003c/p\u003e\n\u003cp\u003eThese findings indicate that interventions focusing exclusively on the biomedical consequences of psychoactive substances may be ineffective if they disregard the cultural connotations associated with their use. Gender-transformative programs, such as community conversations on healthy masculinities and relationship dynamics, are more likely to question the long-held link between drug use, sexual prowess, and male identity (Ruane-Mcateer et al., 2020; Swartout \u0026amp; White, 2010). Recognizing the gendered reasons driving substance use is vital for building responsive prevention and treatment initiatives that resonate with the lived reality of young people in rural Ghana.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.2 Peer Influence, Availability, and the Social Ecology of Use\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study revealed that peers and the surrounding social environment played a crucial role in the initiation and maintenance of psychoactive substance use among young people. Most participants reported that friends introduced them to substances in contexts of leisure, work, or social gatherings, where use was presented as normal or even desirable. This finding aligns with the principles of social learning theory, which posit that behaviours are acquired and sustained through observation and reinforcement within peer groups (Bandura, 1977). Similar evidence from Nigeria confirms that peer approval and the desire for belonging are among the strongest motivators for youth substance use (Dumbili et al., 2022). Participants stated how drugs like tramadol and cannabis could be obtained cheaply and openly from familiar sellers, making drug use a part of ordinary social life. This is in sync with findings from studies (Feinberg \u0026amp; Osgood, 2023; Janulis et al., 2019) that noted that local supply networks and community complicity support a culture of acceptable drug use. Friendship, availability, and informal trade all contribute to an enabling environment in which psychedelic use becomes socially and economically rooted. The bottom line, thus, is that substance use among rural youth cannot be understood or addressed in isolation from their social ecology. Effective interventions should engage peer networks as part of the solution, promoting peer-led education and support groups that transform norms of belonging. Community surveillance, youth empowerment programmes, and livelihood initiatives can further weaken the social and economic conditions that make psychoactive substances accessible and socially acceptable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.3 Dependence, Stigma, and the Vicious Cycle of Use\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe findings on this theme illuminate how dependence is not merely a physiological state, but rather a deeply relational and socially embedded one. Once youth become dependent on a psychoactive substance, they do not simply experience craving or withdrawal; they also bear the weight of stigma from family, community, and themselves (Connor et al., 2022; Hunt et al., 2024; Thomasius et al., 2022). This stigma constrains social support, undermines self-efficacy, and ultimately perpetuates the cycle of use. Our data aligns with evidence from similar resource-limited settings showing that stigma is a formidable barrier in recovery from substance use disorders. For example, a qualitative study in Tanzania found that drug-use stigma at multiple levels (individual, community, healthcare) shaped clients\u0026rsquo; retention in methadone maintenance programmes (Admase et al., 2025). Similarly, scoping reviews of inpatient or residential treatment across Sub-Saharan Africa identify stigma and discrimination as pervasive non-structural barriers to access and retention (Janson et al., 2024). Furthermore, Ghana-specific photovoice work also documents stigma as a barrier at the community and organizational levels to accessing substance-use treatment (Kabor\u0026eacute; et al., 2019). Together, these studies confirm that stigma is not only present but also operates in layered ways, internal, interpersonal, and institutional, in contexts where resources are limited and recovery pathways are fragile.\u003c/p\u003e\n\u003cp\u003eParticipants describe how being labelled \u0026ldquo;dependent\u0026rdquo; or \u0026ldquo;addict\u0026rdquo; shifts their social identity. It changes how family and peers relate to them, reduces their access to emotional or material support, and erodes motivation to attempt behaviour change. In effect, stigma becomes part of the mechanism that sustains use rather than simply an after-effect of addiction. One thing worth knowing is that, in Ghanaian communities, moral character, relational trust, and reputation are central to social standing. Labelled dependence disrupts those relational bonds. A young person seen as dependent may lose favour with family or neighbours, may be ostracized in informal peer networks, or may anticipate being judged. Cumulatively, internalized shame can erase the very motivation needed to attempt recovery efforts (Snoek et al., 2021).\u003c/p\u003e\n\u003cp\u003eAdditionally, because formal recovery services are scarce and socially distant from everyday life, youth may perceive little legitimacy in engaging formal care. They are left with their own social networks, yet these networks may view them through the lens of betrayal or moral failure. In other words, the social meaning of \u0026ldquo;addiction\u0026rdquo; in their community becomes fused with moral judgment, not only medical diagnosis. This suggests that conventional psychologically oriented or clinical models of dependence may underspecify the role of social identity repair, as previously mentioned in related studies (Blond\u0026eacute; et al., 2024; Cruwys et al., 2020). Recovery may require not only reducing substance-use behaviour but reclaiming a socially acceptable self-identity in community and family settings.\u003c/p\u003e\n\u003cp\u003eProgrammes aiming to support recovery should include stigma-reduction components that go beyond individual counselling. Community dialogues, involving elders, families, or opinion-leaders, may help shift social perceptions of dependence from moral failure to a treatable condition. Peer recovery groups could provide safe spaces where youth can reframe their identity as someone in recovery rather than someone irrevocably \u0026ldquo;addicted.\u0026rdquo; This could help rebuild relational capital. Advocates and institutions might work toward framing substance-use dependence within health and psychosocial policy (rather than as deviance or criminality), reducing the moral burden placed on users and mitigating institutional stigma.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.4 Barriers to Care and Pathways to Recovery\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis theme brings to light how participants not only perceive but live multiple, overlapping barriers when they attempt to access care, or to imagine recovery pathways. These include structural-economic constraints (distance, cost, service availability), sociocultural distrust of formal care, legal or social risk of seeking help, and limited awareness of services. At the same time, youth point toward informal or alternative recovery pathways embedded in their social world (family, peer networks, religious/spiritual actors). A qualitative synthesis of barriers and facilitators across low- and middle-income countries highlights common obstacles such as perceived cost, low motivation, lack of awareness, and weak service availability (Sarkar et al., 2021). In South Africa, treatment barriers among young adults include fragmented services, lack of resources, stigma, and concerns about confidentiality or privacy (Nyashanu \u0026amp; Visser, 2022).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMoreover, a narrative review reveals that substance use treatment in Sub-Saharan Africa points to geographic concentration of centres in urban areas and limited infrastructure in rural places (Alayande et al., 2022). Also, in Ghana, a research similarly lists poverty, cost of treatment, lack of facilities, and stigma as barriers to accessing substance-use treatment services (Cadri et al., 2021). Against this backdrop, this study shows how the youth, negotiating recovery in rural Ghana, perceive these barriers as not only abstract obstacles, but as lived constraints: trust issues with providers, fear of social or legal consequences, reliance on informal networks, and preference for support that is socially proximate rather than clinical and distant.\u003c/p\u003e\n\u003cp\u003eKey lessons noted after a critical look at the issues of barriers to seeking help include, first\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eformal recovery or treatment infrastructure appears to be out of alignment with the lived realities of rural youth: physical distance matters, but so does relational distance and perceived legitimacy. If treatment is located far away, costly, or associated with judgment, many youth will not initiate help-seeking even if they \u0026ldquo;want\u0026rdquo; recovery. Second, informal or community-embedded pathways (such as family support, spiritual spaces, peer mentorship) fill part of that gap, but they often lack formal training, follow-up, or clinical oversight. Nevertheless, their social proximity makes them more accessible and trustworthy. In effect, recovery strategies emerge as adaptive bricolage: youth mix formal and informal sources, but often rely on what is nearest, known, and socially acceptable. Theoretically, this calls for recovery models that integrate embedded care, thus services delivered within or allied to trusted community settings (religious centres, peer groups, local leadership structures), rather than expecting youth to travel to distant clinics or to approach unfamiliar professional settings. Decentralizing recovery support through the integration of peer support or recovery-oriented counseling into primary-care or local community settings should be a consideration for interventions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOther considerations include partnerships with religious organizations, traditional authorities, non-governmental organizations, or peer-led groups that could help close the gap between official services and socially acceptable help-seeking behavior, as well as the possibility of reducing travel time, expenses, and social distance through mobile outreach units or satellite recovery support hubs within the communities. Informational outreach (what services are available, how they operate, and confidentiality guarantees) and trust-building activities (peer testimonies, public support from community leaders) may be beneficial to the youth.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.5 Limitations of the Study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhile this study offers important insights into the lived realities of youth navigating psychoactive substance use and recovery within rural Ghana, certain limitations must be acknowledged. The study focused solely on young people in one rural community, and thus the findings may not reflect the perspectives of urban youth, older populations, or other key stakeholders such as family members, health workers, and community leaders. Moreover, as a qualitative study, it does not quantify the extent to which identified factors, such as stigma, gender norms, or peer influence, shape recovery trajectories. Participants were recruited through community networks rather than treatment facilities, which may have excluded individuals in advanced stages of recovery or formal rehabilitation. Future research could broaden the scope by including multiple communities, adopting mixed-methods or longitudinal designs, and incorporating perspectives from families, professionals, and community actors to enhance understanding and generalizability.\u003c/p\u003e"},{"header":"5.0 Conclusion and Implications","content":"\u003cp\u003ePsychoactive substance use and recovery among young people in rural Ghana present complex challenges that transcend the biomedical domain, encompassing deep social, cultural, and structural dimensions. This study has shown that young adults\u0026rsquo; engagement with psychoactive substances is intertwined with masculinity performance, peer socialization, stigma, and limited access to recovery services. Dependence is experienced not only as a physiological condition but as a moral and social identity that attracts discrimination and exclusion. Recovery, therefore, becomes an act of social negotiation, an effort to restore legitimacy, belonging, and self-worth within families and communities that often stigmatise substance use.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThese findings have important implications for mental health practice, policy, and community development. Evidence from this study demonstrates the need to reframe substance dependence as a public health and psychosocial issue rather than a moral failing or criminal act. Policymakers and service providers should prioritise the decentralisation of addiction care, especially in rural settings, by integrating recovery-oriented counselling and harm-reduction services into community health centres and primary healthcare systems. Such integration will ensure that young people and their families can access care without prohibitive costs or stigma. Moreover, the study highlights the necessity of community-driven approaches to recovery. Stakeholders, including the Department of Social Welfare, District Assemblies, and mental health professionals, should collaborate to establish peer-support groups and community rehabilitation forums where young people and their families can share experiences, build coping skills, and access psychosocial support. Religious and traditional leaders, who wield significant influence in rural Ghanaian communities, should also be engaged as allies in recovery promotion and stigma reduction. Integrating traditional healing practices with evidence-based mental health interventions could create culturally resonant and sustainable recovery pathways for affected youth. For mental health practitioners, the findings underscore the importance of cultural competence and empathy in practice. Training should emphasise relational and contextual understanding of dependence, enabling practitioners to communicate in ways that align with clients\u0026rsquo; cultural values and lived experiences. This would foster trust and improve engagement between service users and providers. At the policy level, government agencies should develop sustainable social protection and rehabilitation schemes for young people experiencing substance dependence, with specific funding allocations for rural and underserved areas. Such interventions should also include family-based counselling, recognising that parents and caregivers experience significant emotional and economic strain due to their children\u0026rsquo;s substance use.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn sum, addressing psychoactive substance use among Ghanaian youth requires a holistic approach that combines biomedical treatment, psychosocial rehabilitation, cultural sensitivity, and social reintegration. By embedding recovery efforts within community structures, reducing stigma, and strengthening support systems for both users and their families, stakeholders can help transform recovery from an individual struggle into a collective, socially supported process. This transformation will not only restore health and dignity to young people but also contribute to the broader goal of building resilient, inclusive, and mentally healthy communities in Ghana\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eCNS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 420px;\"\u003e\n \u003cp\u003eCentral Nervous System\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eLSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 420px;\"\u003e\n \u003cp\u003eLysergic Acid Diethylamide\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eLMICs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 420px;\"\u003e\n \u003cp\u003eLow- and Middle-Income Countries\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eSSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 420px;\"\u003e\n \u003cp\u003eSub-Saharan Africa\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eCOREQ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 420px;\"\u003e\n \u003cp\u003eConsolidated Criteria for Reporting Qualitative Research\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Ethical approval was obtained from the Pru East District Assembly (Ref: PEDA/01/10/08/001). All participants provided informed consent prior to participation. Participants were assured of confidentiality and informed of their right to withdraw from the study at any stage without consequence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study does not include any person\u0026rsquo;s data in any form (including images, videos, or personal details).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available but can be obtained from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there are no conflicts of interest related to this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received no funding or financial support from any sponsor, grant, or funding agency.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors sincerely thank the PRU East District Assembly, particularly the District Chief Executive, Mr. Dauda Abdul Nasir, for their support of this study. We also appreciate the entire team at DRUGGS Ghana, a vibrant nonprofit organization dedicated to advocating against substance abuse, for their valuable partnership. Special thanks are due to the field assistants, Mugyi Tabata, Shadad, and Abdul Wahab, whose dedication and effort were vital to the successful completion of this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSimon Nyarko\u003c/strong\u003e: Conceptualization, Methodology, Formal analysis, Data Curation, Writing \u0026ndash; original draft, Writing \u0026ndash; review \u0026amp; editing. \u003cstrong\u003eJulius Caesar Mahama\u003c/strong\u003e: Conceptualization, Data curation, Writing \u0026ndash; review \u0026amp; editing. \u003cstrong\u003eAbdul-Wadudu Faridu\u003c/strong\u003e: Writing \u0026ndash; review \u0026amp; editing. \u003cstrong\u003eNorbert Mantu Kipo\u003c/strong\u003e: Writing \u0026ndash; review \u0026amp; editing. \u003cstrong\u003eMichael Ayarika Issah\u003c/strong\u003e: Writing \u0026ndash; review \u0026amp; editing. \u003cstrong\u003eAfumaa Erica\u003c/strong\u003e: Writing \u0026ndash; review \u0026amp; editing. \u003cstrong\u003eKhadija Atchulo\u003c/strong\u003e: Writing \u0026ndash; review \u0026amp; editing. \u003cstrong\u003eMartin Antuolkuu\u003c/strong\u003e: Writing \u0026ndash; review \u0026amp; editing\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAdmase, A., Cooney, E. E., Atkins, K., Winch, P. J., Mbwambo, J. K., Nkya, I. H., \u0026amp; Saleem, H. T. (2025). Navigating stigma: a qualitative study of barriers to opioid treatment engagement in Tanzania. \u003cem\u003eSubstance Abuse Treatment, Prevention, and Policy 2025 20:1\u003c/em\u003e, \u003cem\u003e20\u003c/em\u003e(1), 1\u0026ndash;7. https://doi.org/10.1186/S13011-025-00660-Y\u003c/li\u003e\n \u003cli\u003eAdongo, D. W., Adedia, D., Benneh, C. K., Tandoh, A., Amekyeh, H., Ntelah, E. K., Nanga, S., Asmah, R. H., \u0026amp; Woode, E. (2024). Psychoactive substance use and associated factors among students in a Ghanaian Tertiary Institution. \u003cem\u003eScientific African\u003c/em\u003e, \u003cem\u003e24\u003c/em\u003e, e02250. https://doi.org/10.1016/j.sciaf.2024.e02250\u003c/li\u003e\n \u003cli\u003eAlayande, B., Chu, K. M., Jumbam, D. T., Kimto, O. E., Musa Danladi, G., Niyukuri, A., Anderson, G. A., El-Gabri, D., Miranda, E., Taye, M., Tertong, N., Yempabe, T., Ntirenganya, F., Byiringiro, J. C., Sule, A. Z., Kobusingye, O. C., Bekele, A., \u0026amp; Riviello, R. R. (2022). Disparities in Access to Trauma Care in Sub-Saharan Africa: a Narrative Review. \u003cem\u003eCurrent Trauma Reports\u003c/em\u003e, \u003cem\u003e8\u003c/em\u003e(3), 66. https://doi.org/10.1007/S40719-022-00229-1\u003c/li\u003e\n \u003cli\u003eArmoon, B., Griffiths, M. D., \u0026amp; Mohammadi, R. (2023). The Global Distribution and Epidemiology of Psychoactive Substance Use and Injection Drug Use Among Street-Involved Children and Youth: A Meta-Analysis. \u003cem\u003eSubstance Use and Misuse\u003c/em\u003e, \u003cem\u003e58\u003c/em\u003e(6), 746\u0026ndash;764. https://doi.org/10.1080/10826084.2023.2181036;REQUESTEDJOURNAL:JOURNAL:ISUM20;WGROUP:STRING:PUBLICATION\u003c/li\u003e\n \u003cli\u003eAsamoah, P., Abokyi, S. N., \u0026amp; Fannam Nunfam, V. (2024). Challenges of parents of young adults misusing psychoactive substances in small-scale mining communities in Ghana. \u003cem\u003eCogent Mental Health\u003c/em\u003e, \u003cem\u003e3\u003c/em\u003e(1), 1\u0026ndash;37. https://doi.org/10.1080/28324765.2024.2382182;JOURNAL:JOURNAL:OAMH20;REQUESTEDJOURNAL:JOURNAL:OAMH20;WGROUP:STRING:PUBLICATION\u003c/li\u003e\n \u003cli\u003eBandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. \u003cem\u003ePsychological Review\u003c/em\u003e, \u003cem\u003e84\u003c/em\u003e(2), 191\u0026ndash;215. https://doi.org/10.1037/0033-295X.84.2.191\u003c/li\u003e\n \u003cli\u003eBlond\u0026eacute;, J., Falomir-Pichastor, J. M., \u0026amp; Desrichard, O. (2024). Unveiling the psychological mechanisms of mutual help groups for addiction recovery: The role of social identity factors. \u003cem\u003eBritish Journal of Social Psychology\u003c/em\u003e, \u003cem\u003e63\u003c/em\u003e(4), 2011\u0026ndash;2030. https://doi.org/10.1111/BJSO.12771;JOURNAL:JOURNAL:20448309;WGROUP:STRING:PUBLICATION\u003c/li\u003e\n \u003cli\u003eBonnet, U., Specka, M., Soyka, M., Alberti, T., Bender, S., Grigoleit, T., Hermle, L., Hilger, J., Hillemacher, T., Kuhlmann, T., Kuhn, J., Luckhaus, C., L\u0026uuml;decke, C., Reimer, J., Schneider, U., Schroeder, W., Stuppe, M., Wiesbeck, G. A., Wodarz, N., \u0026hellip; Scherbaum, N. (2020). Ranking the Harm of Psychoactive Drugs Including Prescription Analgesics to Users and Others\u0026ndash;A Perspective of German Addiction Medicine Experts. \u003cem\u003eFrontiers in Psychiatry\u003c/em\u003e, \u003cem\u003e11\u003c/em\u003e, 592199. https://doi.org/10.3389/FPSYT.2020.592199/BIBTEX\u003c/li\u003e\n \u003cli\u003eBraun, V., \u0026amp; Clarke, V. (2023). Thematic analysis. \u003cem\u003eAPA Handbook of Research Methods in Psychology: Research Designs: Quantitative, Qualitative, Neuropsychological, and Biological (Vol. 2) (2nd Ed.).\u003c/em\u003e, 65\u0026ndash;81. https://doi.org/10.1037/0000319-004\u003c/li\u003e\n \u003cli\u003eBryman, A., \u0026amp; Cramer, D. (2012). Quantitative Data Analysis with IBM SPSS 17, 18 \u0026amp; 19 : A Guide for Social Scientists. \u003cem\u003eQuantitative Data Analysis with IBM SPSS 17, 18 \u0026amp; 19\u003c/em\u003e. https://doi.org/10.4324/9780203180990\u003c/li\u003e\n \u003cli\u003eButler, J. (1988). Performative Acts and Gender Constitution: An Essay in Phenomenology and Feminist Theory. \u003cem\u003eTheatre Journal\u003c/em\u003e, \u003cem\u003e40\u003c/em\u003e(4), 519. https://doi.org/10.2307/3207893\u003c/li\u003e\n \u003cli\u003eCadri, A., Nagumsi, B. A. A., Twi-Yeboah, A., Yeboah, L. D., Adomah-Afari, A., Ane-Loglo, M. G., \u0026amp; Aboagye, R. G. (2021). Facilitators and Barriers to Health Seeking among People Who Use Drugs in the Sunyani Municipality of Ghana: An Exploratory Study. \u003cem\u003eBioMed Research International\u003c/em\u003e, \u003cem\u003e2021\u003c/em\u003e, 2868953. https://doi.org/10.1155/2021/2868953\u003c/li\u003e\n \u003cli\u003eChen, H., Liu, S., Wang, W., Shi, H., Gao, S., Yan, Y., Fang, J., Zhan, Y., Chen, H., \u0026amp; Liu, Z. (2025). Global burden of substance use disorders in adolescents and young adults aged 10\u0026ndash;24 years from 1990 to 2021. \u003cem\u003eScientific Reports 2025 15:1\u003c/em\u003e, \u003cem\u003e15\u003c/em\u003e(1), 1\u0026ndash;15. https://doi.org/10.1038/s41598-025-11266-6\u003c/li\u003e\n \u003cli\u003eConnor, J. P., Stjepanović, D., Budney, A. J., Le Foll, B., \u0026amp; Hall, W. D. (2022). Clinical management of cannabis withdrawal. \u003cem\u003eAddiction\u003c/em\u003e, \u003cem\u003e117\u003c/em\u003e(7), 2075\u0026ndash;2095. https://doi.org/10.1111/ADD.15743;PAGE:STRING:ARTICLE/CHAPTER\u003c/li\u003e\n \u003cli\u003eCourtenay, W. H. (2000). Constructions of masculinity and their influence on men\u0026rsquo;s well-being: A theory of gender and health. \u003cem\u003eSocial Science and Medicine\u003c/em\u003e, \u003cem\u003e50\u003c/em\u003e(10), 1385\u0026ndash;1401. https://doi.org/10.1016/S0277-9536(99)00390-1\u003c/li\u003e\n \u003cli\u003eCruwys, T., Stewart, B., Buckley, L., Gumley, J., \u0026amp; Scholz, B. (2020). The recovery model in chronic mental health: A community-based investigation of social identity processes. \u003cem\u003ePsychiatry Research\u003c/em\u003e, \u003cem\u003e291\u003c/em\u003e, 113241. https://doi.org/10.1016/J.PSYCHRES.2020.113241\u003c/li\u003e\n \u003cli\u003eDo, H. N., Do, B. N., \u0026amp; Nguyen, M. H. (2023). 3How do constructivism learning environments generate better motivation and learning strategies? The Design Science Approach. \u003cem\u003eHeliyon\u003c/em\u003e, \u003cem\u003e9\u003c/em\u003e(12), e22862. https://doi.org/10.1016/J.HELIYON.2023.E22862\u003c/li\u003e\n \u003cli\u003eDumbili, E. W., Okpan, S. O., Uwa-Robinson, K., \u0026amp; Azende, P. M. (2022). \u0026lsquo;If You Cannot Beat Them, You Join Them\u0026rsquo;: Friendship, Social Influence and Drinking to Belong Among Nigerian Youth. \u003cem\u003eAlcohol, Age, Generation and the Life Course\u003c/em\u003e, 127\u0026ndash;150. https://doi.org/10.1007/978-3-031-04017-7_6\u003c/li\u003e\n \u003cli\u003eEarnshaw, V. A. (2020). Stigma and substance use disorders: A clinical, research, and advocacy agenda. \u003cem\u003eThe American Psychologist\u003c/em\u003e, \u003cem\u003e75\u003c/em\u003e(9), 1300. https://doi.org/10.1037/AMP0000744\u003c/li\u003e\n \u003cli\u003eEbrahim, J., Adams, J., \u0026amp; Demant, D. (2024). Substance use among young people in sub-Saharan Africa: a systematic review and meta-analysis. \u003cem\u003eFrontiers in Psychiatry\u003c/em\u003e, \u003cem\u003e15\u003c/em\u003e, 1328318. https://doi.org/10.3389/FPSYT.2024.1328318/FULL\u003c/li\u003e\n \u003cli\u003eEekhoudt, C. R., Sandhu, M., Mniszak, C., Goodyear, T., Turuba, R., Marchand, K., Barbic, S., \u0026amp; Fast, D. (2024). Looking beyond drugs: A scoping review of recovery in the context of illicit substance use among adolescents and young adults. \u003cem\u003eInternational Journal of Drug Policy\u003c/em\u003e, \u003cem\u003e133\u003c/em\u003e, 104598. https://doi.org/10.1016/J.DRUGPO.2024.104598\u003c/li\u003e\n \u003cli\u003eEnworo, O. C. (2023). Application of Guba and Lincoln\u0026rsquo;s parallel criteria to assess trustworthiness of qualitative research on indigenous social protection systems. \u003cem\u003eQualitative Research Journal\u003c/em\u003e, \u003cem\u003e23\u003c/em\u003e(4), 372\u0026ndash;384. https://doi.org/10.1108/QRJ-08-2022-0116/FULL/PDF\u003c/li\u003e\n \u003cli\u003eFeinberg, M. E., \u0026amp; Osgood, D. W. (2023). Teen Friendship networks, Development, and Risky Behavior. \u003cem\u003eTeen Friendship Networks, Development, and Risky Behavior\u003c/em\u003e, 1\u0026ndash;390. https://doi.org/10.1093/OSO/9780197602317.001.0001\u003c/li\u003e\n \u003cli\u003eFiaveh, D. Y. (2020). Masculinity, Male Sexual Virility, and Use of Aphrodisiacs in Ghana. \u003cem\u003eJournal of Men\u0026rsquo;s Studies\u003c/em\u003e, \u003cem\u003e28\u003c/em\u003e(2), 165\u0026ndash;182. https://doi.org/10.1177/1060826519887510;PAGE:STRING:ARTICLE/CHAPTER\u003c/li\u003e\n \u003cli\u003eFranz, B., Cronin, C. E., Lindenfeld, Z., Pagan, J. A., Lai, A. Y., Krawczyk, N., Rivera, B. D., \u0026amp; Chang, J. E. (2024). Rural-urban disparities in the availability of hospital-based screening, medications for opioid use disorder, and addiction consult services. \u003cem\u003eJournal of Substance Use and Addiction Treatment\u003c/em\u003e, \u003cem\u003e160\u003c/em\u003e, 209280. https://doi.org/10.1016/J.JOSAT.2023.209280\u003c/li\u003e\n \u003cli\u003eHammack, P. L., \u0026amp; Manago, A. M. (2024). The Psychology of Sexual and Gender Diversity in the 21st Century: Social Technologies and Stories of Authenticity. \u003cem\u003eAmerican Psychologist\u003c/em\u003e, \u003cem\u003e80\u003c/em\u003e(3), 375\u0026ndash;388. https://doi.org/10.1037/AMP0001366\u003c/li\u003e\n \u003cli\u003eHunt, A., Merola, G. P., Carpenter, T., \u0026amp; Jaeggi, A. V. (2024). Evolutionary perspectives on substance and behavioural addictions: Distinct and shared pathways to understanding, prediction and prevention. \u003cem\u003eNeuroscience \u0026amp; Biobehavioral Reviews\u003c/em\u003e, \u003cem\u003e159\u003c/em\u003e, 105603. https://doi.org/10.1016/J.NEUBIOREV.2024.105603\u003c/li\u003e\n \u003cli\u003eIbragimov, U., Young, A. M., \u0026amp; Cooper, H. L. F. (2020). Understanding rural risk environments for drug-related harms: Progress, challenges, and steps forward. \u003cem\u003eThe International Journal on Drug Policy\u003c/em\u003e, \u003cem\u003e85\u003c/em\u003e, 102926. https://doi.org/10.1016/J.DRUGPO.2020.102926\u003c/li\u003e\n \u003cli\u003eJanson, S., Nyenga, L., Saleem, H., Mayo-Wilson, L. J., Mushy, S. E., Iseselo, M. K., van Draanen, J., Tucker, J., McPherson, M., \u0026amp; Conserve, D. F. (2024). Residential and inpatient treatment of substance use disorders in Sub-Saharan Africa: a scoping review. \u003cem\u003eSubstance Abuse Treatment, Prevention, and Policy\u003c/em\u003e, \u003cem\u003e19\u003c/em\u003e(1). https://doi.org/10.1186/S13011-023-00589-0\u003c/li\u003e\n \u003cli\u003eJanulis, P., Birkett, M., Phillips, G., \u0026amp; Mustanski, B. (2019). Not getting high with a little help from your friends: Social versus drug network correlates of marijuana use among YMSM. \u003cem\u003eAddictive Behaviors\u003c/em\u003e, \u003cem\u003e92\u003c/em\u003e, 180\u0026ndash;185. https://doi.org/10.1016/J.ADDBEH.2019.01.004\u003c/li\u003e\n \u003cli\u003eKabore, A., Afriyie-Gyawu, E., Awuah, J., Hansen, A., Walker, A., Hester, M., Si\u0026eacute;, M. A. W., Johnson, J., \u0026amp; Meda, N. (2019). Social ecological factors affecting substance abuse in Ghana (West Africa) using photovoice. \u003cem\u003ePAMJ. 2019; 34:214\u003c/em\u003e, \u003cem\u003e34\u003c/em\u003e(214). https://doi.org/10.11604/PAMJ.2019.34.214.12851\u003c/li\u003e\n \u003cli\u003eKabor\u0026eacute;, A., Moussa, A., Sie, W., Awuah, J., Ou\u0026eacute;draogo, M. O., Kabor\u0026eacute;, I., \u0026amp; Meda, N. (2019). Barriers and Facilitators To Substance Abuse Treatment in Ghana (West Africa) Using Photovoice. \u003cem\u003eInternational Journal of Development Research\u003c/em\u003e, \u003cem\u003e09\u003c/em\u003e, 28454\u0026ndash;28458. http://www.journalijdr.com\u003c/li\u003e\n \u003cli\u003eKalungi, H., Kamacooko, O., Lunkuse, J. F., Namutebi, J., Naluwooza, R., Price, M. A., Ruzagira, E., \u0026amp; Mayanja, Y. (2024). Prevalence and factors associated with illicit drug and high-risk alcohol use among adolescents living in urban slums of Kampala, Uganda. \u003cem\u003eBMC Public Health 2024 24:1\u003c/em\u003e, \u003cem\u003e24\u003c/em\u003e(1), 1\u0026ndash;11. https://doi.org/10.1186/S12889-024-19250-X\u003c/li\u003e\n \u003cli\u003eKhumalo, S., Mabaso, M., Makusha, T., \u0026amp; Taylor, M. (2021). Intersections Between Masculinities and Sexual Behaviors Among Young Men at the University of KwaZulu-Natal, South Africa. \u003cem\u003eSAGE Open\u003c/em\u003e, \u003cem\u003e11\u003c/em\u003e(3). https://doi.org/10.1177/21582440211040114;WEBSITE:WEBSITE:SAGE;JOURNAL:JOURNAL:SGOA;REQUESTEDJOURNAL:JOURNAL:SGOA;WGROUP:STRING:PUBLICATION\u003c/li\u003e\n \u003cli\u003eKyei-Gyamfi, S., Kyei-Arthur, F., Alhassan, N., Agyekum, M. W., Abrah, P. B., \u0026amp; Kugbey, N. (2024). Prevalence, correlates, and reasons for substance use among adolescents aged 10\u0026ndash;17 in Ghana: a cross-sectional convergent parallel mixed-method study. \u003cem\u003eSubstance Abuse Treatment, Prevention, and Policy 2024 19:1\u003c/em\u003e, \u003cem\u003e19\u003c/em\u003e(1), 1\u0026ndash;9. https://doi.org/10.1186/S13011-024-00600-2\u003c/li\u003e\n \u003cli\u003eLamb, R., \u0026amp; Kougiali, Z. G. (2025). Women and shame: narratives of recovery from alcohol dependence. \u003cem\u003ePsychology and Health\u003c/em\u003e, \u003cem\u003e40\u003c/em\u003e(10), 1736\u0026ndash;1773. https://doi.org/10.1080/08870446.2024.2352191;ISSUE:ISSUE:DOI\u003c/li\u003e\n \u003cli\u003eMaina, B. W., Sikweyiya, Y., Ferguson, L., \u0026amp; Kabiru, C. W. (2022). Conceptualisations of masculinity and sexual development among boys and young men in Korogocho slum in Kenya. \u003cem\u003eCulture, Health and Sexuality\u003c/em\u003e, \u003cem\u003e24\u003c/em\u003e(2), 226\u0026ndash;240. https://doi.org/10.1080/13691058.2020.1829058;WGROUP:STRING:PUBLICATION\u003c/li\u003e\n \u003cli\u003eMbuthia, G., Wanzala, P., Ngugi, C. W., \u0026amp; Nyamogoba, H. D. N. (2020). A Qualitative Study on Alcohol and Drug Abuse among Undergraduate (University Students) in The Coastal Region of Kenya. \u003cem\u003eAfrican Journal of Health Sciences\u003c/em\u003e, \u003cem\u003e33\u003c/em\u003e(1), 38\u0026ndash;48. https://doi.org/10.4314/AJHS.V33I1\u003c/li\u003e\n \u003cli\u003eMensah, E. O. (2021). To be a Man is Not a Day\u0026rsquo;s Job: The Discursive Construction of Hegemonic Masculinity by Rural Youth in Nigeria. \u003cem\u003eGender Issues 2021 38:4\u003c/em\u003e, \u003cem\u003e38\u003c/em\u003e(4), 438\u0026ndash;460. https://doi.org/10.1007/S12147-020-09271-2\u003c/li\u003e\n \u003cli\u003eMoore, D., Hart, A., Fraser, S., \u0026amp; Seear, K. (2020). Masculinities, practices and meanings: A critical analysis of recent literature on the use of performance- and image-enhancing drugs among men. \u003cem\u003eHealth (United Kingdom)\u003c/em\u003e, \u003cem\u003e24\u003c/em\u003e(6), 719\u0026ndash;736. https://doi.org/10.1177/1363459319838595;PAGE:STRING:ARTICLE/CHAPTER\u003c/li\u003e\n \u003cli\u003eMoyle, L., Dymock, A., Aldridge, A., \u0026amp; Mechen, B. (2020). Pharmacosex: Reimagining sex, drugs and enhancement. \u003cem\u003eInternational Journal of Drug Policy\u003c/em\u003e, \u003cem\u003e86\u003c/em\u003e, 102943. https://doi.org/10.1016/J.DRUGPO.2020.102943\u003c/li\u003e\n \u003cli\u003eMoYS. (2013). \u003cem\u003eReport Ministerial Impact Assessment \u0026amp; Review Committee on Ghana Youth Employment and Enterpreneurial Agency ( Gyeeda )\u003c/em\u003e. \u003cem\u003eJuly\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eNawi, A. M., Ismail, R., Ibrahim, F., Hassan, M. R., Manaf, M. R. A., Amit, N., Ibrahim, N., \u0026amp; Shafurdin, N. S. (2021). Risk and protective factors of drug abuse among adolescents: a systematic review. \u003cem\u003eBMC Public Health 2021 21:1\u003c/em\u003e, \u003cem\u003e21\u003c/em\u003e(1), 1\u0026ndash;15. https://doi.org/10.1186/S12889-021-11906-2\u003c/li\u003e\n \u003cli\u003eNyashanu, T., \u0026amp; Visser, M. (2022). Treatment barriers among young adults living with a substance use disorder in Tshwane, South Africa. \u003cem\u003eSubstance Abuse Treatment, Prevention, and Policy\u003c/em\u003e, \u003cem\u003e17\u003c/em\u003e(1). https://doi.org/10.1186/S13011-022-00501-2\u003c/li\u003e\n \u003cli\u003eOsei-Tutu, S., Owusu-Sarpong, O. J., Asante, F., Agyemang-Duah, W., Siaw, L. P., Darkwa, I. O., \u0026amp; Gyasi, R. M. (2025). The severity of Tramadol misuse among youth in urban informal settlements in Ghana: patterns, co-use, and sociodemographic factors. \u003cem\u003eArchives of Public Health 2025 83:1\u003c/em\u003e, \u003cem\u003e83\u003c/em\u003e(1), 1\u0026ndash;11. https://doi.org/10.1186/S13690-025-01634-Z\u003c/li\u003e\n \u003cli\u003eRuane-Mcateer, E., Gillespie, K., Amin, A., Aventin, \u0026Aacute;., Robinson, M., Hanratty, J., Khosla, R., \u0026amp; Lohan, M. (2020). Gender-transformative programming with men and boys to improve sexual and reproductive health and rights: a systematic review of intervention studies. \u003cem\u003eBMJ Global Health\u003c/em\u003e, \u003cem\u003e5\u003c/em\u003e(10), e002997. https://doi.org/10.1136/BMJGH-2020-002997\u003c/li\u003e\n \u003cli\u003eSarkar, S., Tom, A., \u0026amp; Mandal, P. (2021). Barriers and Facilitators to Substance Use Disorder Treatment in Low-and Middle-Income Countries: A Qualitative Review Synthesis. \u003cem\u003eSubstance Use \u0026amp; Misuse\u003c/em\u003e, \u003cem\u003e56\u003c/em\u003e(7), 1062\u0026ndash;1073. https://doi.org/10.1080/10826084.2021.1908359\u003c/li\u003e\n \u003cli\u003eSetufe, S. B., Amponsah, S. K. K., Henneh, S., \u0026amp; Acheampong, E. A. (2022). Pandemic risk, response, and resilience of fishermen in Ghana: a case study of fishing communities in Stratum VII, Volta Lake. \u003cem\u003ePandemic Risk, Response, and Resilience\u003c/em\u003e, 415. https://doi.org/10.1016/B978-0-323-99277-0.00025-5\u003c/li\u003e\n \u003cli\u003eSibanda, A., \u0026amp; Batisai, K. (2021). The intersections of identity, belonging and drug use disorder: struggles of male youth in post-apartheid South Africa. \u003cem\u003eInternational Journal of Adolescence and Youth\u003c/em\u003e, \u003cem\u003e26\u003c/em\u003e(1), 143\u0026ndash;157. https://doi.org/10.1080/02673843.2021.1899945;SUBPAGE:STRING:FULL\u003c/li\u003e\n \u003cli\u003eSnoek, A., McGeer, V., Brandenburg, D., \u0026amp; Kennett, J. (2021). Managing shame and guilt in addiction: A pathway to recovery. \u003cem\u003eAddictive Behaviors\u003c/em\u003e, \u003cem\u003e120\u003c/em\u003e, 106954. https://doi.org/10.1016/J.ADDBEH.2021.106954\u003c/li\u003e\n \u003cli\u003eSwartout, K. M., \u0026amp; White, J. W. (2010). The relationship between drug use and sexual aggression in men across time. \u003cem\u003eJournal of Interpersonal Violence\u003c/em\u003e, \u003cem\u003e25\u003c/em\u003e(9), 1716\u0026ndash;1735. https://doi.org/10.1177/0886260509354586\u003c/li\u003e\n \u003cli\u003eThomasius, R., Paschke, K., \u0026amp; Arnaud, N. (2022). Substance-Use Disorders in Children and Adolescents. \u003cem\u003eDeutsches \u0026Auml;rzteblatt International\u003c/em\u003e, \u003cem\u003e119\u003c/em\u003e(25), 440. https://doi.org/10.3238/ARZTEBL.M2022.0122\u003c/li\u003e\n \u003cli\u003eTong, A., Sainsbury, P., \u0026amp; Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. \u003cem\u003eInternational Journal for Quality in Health Care\u003c/em\u003e, \u003cem\u003e19\u003c/em\u003e(6), 349\u0026ndash;357. https://doi.org/10.1093/INTQHC/MZM042\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Psychoactive substance use, Recovery process, stigma, gender norm, rural youth, sexual motivations, Ghana","lastPublishedDoi":"10.21203/rs.3.rs-8296597/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8296597/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003ePsychoactive substance use among youth in rural Ghana is shaped by intertwined biopsychosocial factors, including cultural norms, gender expectations, relational dynamics, and structural disadvantage. Recovery for these young people extends beyond abstinence, comprising moral, social, and emotional efforts to rebuild dignity, belonging, and wellbeing. Despite rising substance use in Ghana, limited empirical work explores how youth understand their use and navigate recovery within rural contexts. This study examined the lived experiences of young people with current or prior psychoactive substance use in a rural Ghanaian community, focusing on how social, cultural, and relational contexts shape their substance use trajectories and recovery efforts.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA qualitative design grounded in a constructivist interpretivist approach was adopted. In-depth interviews were conducted with fifteen youth aged 19\u0026ndash;33 years in a rural district in Ghana. Interviews explored participants\u0026rsquo; experiences, motivations, struggles, and reflections on substance use and recovery. Data were audio-recorded, transcribed verbatim, and analyzed using reflexive thematic analysis to identify patterns of meaning and everyday struggles embedded in their social worlds.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe findings indicate that recovery is a complex, fluid, and socially embedded process. Four interconnected dimensions shaped substance use and recovery: (1) personal motivations linked to sexual performance and masculine identity; (2) peer dynamics and the social ecology of drug availability; (3) stigma, exclusion, and the reinforcing cycle of dependence; and (4) structural barriers to care and community-based pathways to recovery. Participants described tramadol and similar substances as tools for demonstrating masculinity, enhancing sexual performance, and securing social validation. Stigma, shame, and fear of judgment, combined with limited access to mental healthcare and mistrust of institutions, impede help-seeking. Despite these barriers, participants expressed the need for community-based, compassionate, and non-judgmental recovery support that respects their vulnerabilities and strengths.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eSubstance use and recovery among rural Ghanaian youth are best understood holistically within a biopsychosocial framework that integrates individual experience with broader cultural, social, and structural contexts. Gender norms, stigma, and resource constraints significantly shape substance-use trajectories and recovery attempts. Effective interventions must therefore extend beyond biomedical models, incorporating gender-sensitive, community-grounded approaches that promote social inclusion, empathy, and sustainable wellbeing.\u003c/p\u003e","manuscriptTitle":"Trapped but Trying: Stigma, Sexual Motivations, and the Everyday Struggles of Recovery from Psychoactive Substance Use Among Youth in Rural Ghana","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-09 09:51:57","doi":"10.21203/rs.3.rs-8296597/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d4524a25-62d8-4188-8535-0cd47892bd8d","owner":[],"postedDate":"December 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-22T00:09:03+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-09 09:51:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8296597","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8296597","identity":"rs-8296597","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}