Rational Risk or Cultural Resistance: Co-Produced Findings on Structural Barriers to Drug and Alcohol Recovery Among South Asian Muslim Communities in England

Highlights

Public health relevance—How does this work relate to a public health issue?

• South Asian Muslim (SAM) communities in England experience a persistent drug and alcohol treatment gap driven by collective stigma, cultural misalignment in service design, and structural barriers to access, contributing to preventable health inequalities.
• Low engagement with mainstream recovery services reflects rational risk management in response to real social consequences including reputational harm to kinship networks through izzat (family honour and collective reputation) rather than cultural resistance or denial.

Public health significance—Why is this work of significance to public health?

• To the authors’ knowledge, this is among the first co-produced, empirically grounded study to move beyond documenting barriers toward generating practical solutions for D&A recovery service design with SAM communities, extending established stigma frameworks to collectivist, faith-based contexts.
• The Islamically adapted 12-step model demonstrates that mainstream recovery frameworks can be translated into religiously coherent pathways without compromising therapeutic fidelity, with relevance beyond SAM communities to other marginalised faith groups.

Public health implications—What are the key implications or messages for practitioners, policy makers and/or researchers in public health?

• Six co-produced, evidence-based design principles are proposed for commissioners (NHS/local authority officials responsible for planning and funding services) and service providers, covering confidentiality-first access, visibility-sensitive locations, flexible operational access, religiously coherent recovery options, gender-responsive provision, and recovery narratives that protect anonymity.
• Mainstream service adaptation, rather than parallel ‘Muslim-only’ provision, is the more equitable and stigma-conscious approach; this has immediate implications for NHS and local authority commissioning frameworks, including Core20PLUS5, targeting health inequalities in disadvantaged populations.

Abstract

Background: South Asian Muslim (SAM) communities remain significantly underserved by mainstream drug and alcohol (D&A) recovery services in England. Cultural and religious misalignment in service design creates structural barriers to engagement. Family members from SAM communities who support individuals with substance use disorders have identified structural, cultural, and religious barriers that hinder engagement with mainstream treatment services. This study builds on this body of evidence by working with service providers, commissioners and community stakeholders through participatory co-production to examine how these barriers can be addressed. Methods: Three participatory co-production workshops were held over a 12-week period. Data were also generated from a field visit to a culturally adapted recovery service and a content analysis of an Islamically adapted 12-step recovery workbook. Participants included commissioners, service providers, community ambassadors and service users (total n = 42 across three workshops; some participants attended more than one workshop). Results: Four interconnected themes that shaped recovery engagement were identified: (1) stigma and izzat operating as a collective structural risk management system; (2) confidentiality functioning as a precondition for engagement rather than a by-product of it; (3) service design, space and visibility as determinants of access; and (4) co-construction of religiously coherent recovery pathways. Low engagement among participants reflected rational risk management, in response to real social consequences, rather than cultural resistance. Conclusions: Findings suggest that inclusive recovery systems may benefit from the adaptation of mainstream services rather than the creation of parallel provision. Six evidence-based design principles are proposed for commissioners and service providers. Findings contribute to the evidence base for equitable health, culturally responsive D&A intervention design and have relevance beyond SAM communities to other marginalised faith communities across England.

1. Introduction

Drug and alcohol recovery services in England continue to be accessed predominantly by White populations, despite growing evidence that substance use occurs across all communities, including South Asian and Muslim (SAM) groups. Structural barriers arise when SAM communities are not considered or involved in decisions about service design, and when services fail to account for religious values, family obligations, and community norms [1,2]. Individuals are stigmatised by mainstream services, which may hold deficit assumptions about minority communities, as well as by their own communities, where drug and alcohol use is associated with shame, family dishonour, and collective reputational risk [1,2].

National policy evidence indicates that lower engagement among minority ethnic groups reflects unmet need rather than lower prevalence of substance use [3,4]. SAM communities in England are diverse populations shaped by shared religious and cultural identities, as well as shared experiences of racialisation, socioeconomic disadvantage, and marginalisation within healthcare systems [5,6,7]. Only 1% of individuals accessing D&A treatment services in England identify as British South Asian [1], a figure that is widely regarded as a significant underestimation, given the well-documented cultural and religious barriers to reporting and this reflects the alcohol harm paradox: the consistent finding that disadvantaged populations experience disproportionately higher rates of alcohol-related harm, despite often consuming less alcohol than more advantaged groups with national evidence documenting patterns of drug misuse, while literature links drug-related stigma with identity, power, discrimination and social exclusion [4,8,9].

Collective stigma, operating through kinship and family-honour networks, is central to explaining this persistent gap [5,10]. Drawing on the broader health stigma literature, stigma can be understoodas a social process involving enacted, anticipated and internalised mechanisms, whereby individuals or groups who use substances may be devalued based on perceived attributes, characteristics or behaviours [5,8,9]. Stigma (negative beliefs and perceptions) leads to prejudice (negative emotional response) and discrimination (treating people differently), leading to social exclusion [2,10]. Stigma is a multifaceted phenomenon operating across several interconnected levels: interpersonal interactions, where it is enacted towards people in everyday encounters; structural contexts, where it is embedded within institutional policies and practices; and internalised processes, whereby individuals know about, identify with and then accept and reproduce negative societal beliefs about themselves [6,7,11]. While the stigma frameworks developed by Goffman [11], Link and Phelan [2] primarily address individuals, theories accounting for the collectivist approach within SAM faith-based communities are lacking. This is particularly the case with regard to stigma risk shared across kinship networks, a phenomenon not previously theorised in the drug and alcohol recovery literature. This study addresses that gap.

Stigma is the central theoretical lens through which to understand low engagement with D&A recovery services among SAM communities. We draw on two complementary stigma frameworks, namely Goffman’s foundational conceptualization [11] and Link and Phelan’s modified labelling theory [2]. This study explains why not only individuals, but also entire family and kinship networks, avoid services. Goffman defined stigma as a deeply discrediting attribute that reduces a person’s status from that of a ‘whole and usual’ individual to that of a ‘tainted and discounted’ one [11,12]. For SAM communities, the concern is less about a known identity than about preventing information about substance use from becoming visible to the community. This explains why confidentiality functions not as a reassuring feature of service delivery, but as a structural precondition for engagement; encountering a known community member in a waiting room or appearing on a GP referral pathway can trigger irreversible social consequences for the individual and their family.

Link and Phelan’s [2] modified labelling theory extends Goffman’s framework in two directly relevant ways. First, anticipated stigma: the expectation of negative social consequences before any label has been formally applied, is sufficient to suppress help-seeking behaviour even in the absence of prior experience of discrimination. Second, Link and Phelan [2] show how stigma operates as a social structure rather than merely an individual psychological experience; it is embedded in community norms, institutional practices and cultural meanings that shape behaviour at a collective level.

This collective dimension is particularly significant for SAM communities, where the concept of ‘izzat’, meaning family honour and collective reputation, means that the social consequences of stigma extend far beyond the individual to their entire kinship network. If a family member’s D&A use is disclosed, it risks damaging siblings’ marriage prospects, undermining parents’ social standing, and destabilising the community relationships on which families depend economically and socially. In this context, stigma functions as a collective reputational risk management system, in which families engage in active information management to protect shared social capital. Knott, Khokher and Shaw explain that izzat, translated as ‘honour’, ‘dignity’ and ‘collective reputation’, is defined as social capital in South Asian communities that is culturally specific [13,14]. This extends Link and Phelan’s [2] framework, which was developed primarily at the individual level, to kinship networks and community structures—a theoretical contribution not previously made in the D&A recovery literature.

Problematic drug and alcohol use (D&A) represents a major public health challenge in England. More than 20% of adults consumed more than the UK Chief Medical Officers’ recommended safe limit of 14 units of alcohol per week [4], while drug-related deaths increased by 15% in 2023 [4,15]. Among community recovery services, Alcoholics Anonymous has been shown to increase abstinence rates, reduce relapse rates, and improve psychological well-being [4,16].

The 12-step framework developed by Alcoholics Anonymous is one of the most widely used D&A recovery models internationally and in England [17]. However, this framework was developed within a Christian theological tradition, and its foundational concepts—powerlessness, surrender to a ‘higher power’, and permanent self-identification as an ‘alcoholic’—are not universally applicable across religious or cultural contexts [17,18]. Broader reviews of the relationship between Islam and alcohol use confirm that the religious prohibition does not eliminate consumption or harm within Muslim communities, but does shape how such problems are disclosed and addressed [19]. For Muslim individuals, surrendering to a ‘higher power’ is potentially compatible with the Islamic concept of tawakkul (reliance on Allah). However, the idea of permanently identifying as an ‘alcoholic’ is a fixed stigma, as theorised by Goffman [10], and is incompatible with Islamic concepts such as karamah (inherent human dignity) and fitrah (the innate human capacity for moral change and spiritual return) [20]. This study explores the extent to which the 12-step framework can be adapted to align with Islamic values while retaining its core therapeutic principles.

For SAM communities, the cumulative effect of structural barriers to accessing treatment means that, when harm occurs, it is less likely to be identified, treated or resolved [1,3]. The existing evidence base on SAM communities’ engagement with D&A services is limited. Where research exists, it suggests that many Muslims facing alcohol-related problems in the family turn to informal, internet-based sources of advice rather than formal services [21] consistent with the barriers documented below. Recently, Sattar et al. (2024) conducted the first systematic qualitative study to document the perceived barriers to engagement among SAM communities in north-east England, identifying stigma, concerns about confidentiality and cultural misalignment in service design as the main reasons why people do not seek help [1]. This study is a direct follow-up, shifting the focus from documenting barriers to actively co-producing solutions. Through three participatory workshops involving commissioners, service providers, community ambassadors, and service users, this study examines how mainstream recovery models, specifically the 12-step framework, can be adapted to incorporate Islamic values and generates practical recommendations for service design and commissioning. There is no other co-produced, empirically grounded study of this nature for SAM communities in England, which represents a significant gap in the evidence base.

This study aimed to document the barriers to engagement in recovery programmes experienced by SAM communities, to examine how these programmes are experienced in relation to culture and religion, and to co-produce practical recommendations for adapting and commissioning services. The focus throughout is on the means and pathways used to access or design culturally appropriate care, rather than on evaluating recovery outcomes. The solutions co-produced by participants, culminating in six evidence-based design principles, are the primary contribution of this study.

2. Methods

This paper presents the findings of a participatory, co-produced qualitative research project [1,22]. Involvement and engagement principles are part of co-production work, and the work here included and went beyond these principles when community members worked alongside the research team, being involved equally in decision making throughout the duration of the research project [22]. Four complementary data sources were employed: workshop discussions, co-produced reflections, observations from a field visit to a culturally adapted recovery service in a city in the Midlands, and a content analysis of an Islamically adapted 12-step recovery workbook. This multi-source approach was designed to capture contextual meanings, lived experiences, and practical knowledge that may be overlooked by more conventional research designs.

2.1. Study Design

A participatory, co-produced qualitative research design comprising three sequential workshops delivered over 12 weeks was adopted. Co-production was chosen because of its ability to include historically marginalised communities as equal partners in knowledge generation within research processes [23,24]. The design progressed from service mapping in Workshop 1, to learning from an established, culturally adapted model in Workshop 2, to co-producing practical recommendations in Workshop 3. This study is a direct follow-up to 2024 study by Sattar et al. [1], which used semi-structured interviews to document perceived barriers to D&A service engagement among SAM communities. While Sattar et al. [1] in 2024 established the nature and scope of the problem, this study moved from documentation to a co-produced solution design, examining how mainstream recovery models could be adapted to incorporate Islamic values, generating practical recommendations for commissioners and service providers.

Recruitment

Participants were recruited through community ambassadors—individuals recognized and trusted within the SAM community—who approached and invited community members to take part in the study. Public participants (community ambassadors) received remuneration in the form of shopping vouchers in recognition of their time and expertise. Lived experience was represented through service users and community members: no lived-experience service providers were included among participants. Some public participants also held a dual role as community ambassadors, contributing both as research participants and as trusted community facilitators.

2.2. Methodological Framework

Participatory Action Research (PAR) principles were adopted to amplify community expertise and generate contextually grounded knowledge based on lived experience [24]. This approach provides an understanding of how the world is shaped by diverse thoughts and behaviours defined by culture and language, making it well suited to studies exploring the culturally specific experiences of accessing health services. This is particularly important given evidence that Muslims experiencing alcohol-related problems often rely on informal or online sources of advice in the absence of trusted, culturally responsive formal support [25], underscoring the value of engaging community stakeholders directly. The framework for analysing findings, based on the concept of stigma, is detailed in Section 2 above.

2.3. Positionality

The lead researcher occupies an insider–outsider position in relation to SAM communities, having grown up within the community. This position provided access to the culture and language of the communities and an acute awareness of the sensitivities surrounding disclosure and stigma, including the concept of ‘izzat’ and the fear of reputational consequences, which shaped participants’ accounts. Workshops were facilitated by the research team (ZS, SS and AS). Two of the research members including the lead researcher (ZS and SS) attended all three workshops to facilitate discussion and collect data, and held no professional connection to any of the services discussed by participants. Reflexivity was maintained throughout the research process by regularly reflecting critically on how this positionality may have shaped the generation and interpretation of data [26]. Participants were aware of the researcher’s community background, which fostered an atmosphere of trust and openness during the workshops.

2.4. Workshop Design

Three workshops were delivered sequentially over 12 weeks, with Workshops 1 and 3 taking place in Newcastle and Workshop 2 taking place in a city in the Midlands. Workshop 1 involved mapping the current provision, Workshop 2 involved observing a culturally adapted recovery service in the field, and Workshop 3 involved co-producing draft recommendations. Full participant profiles are presented in

Table 1. Characteristics of participants across co-design workshops.

Workshop	Location	Community Ambassadors	Service Providers	Commissioners	Service Users/ Community Members	Total Participants
Workshop 1	City in North of England	2	9	1	3	15
Workshop 2	Midlands	4	8	3	0	15
Workshop 3	City in North of England	2	7	1	2	12
Total	—	8	24	5	5	42

Note: Participants included statutory, third-sector and community stakeholders, alongside members of South Asian and Muslim (SAM) communities. Participants (n = 42) reflect total workshop attendance rather than unique individuals, as some participants attended more than one workshop. Community Ambassadors: individuals recognised and trusted within the SAM community, who help build trust and facilitate communication between community members and D&A services. Commissioners: NHS/local authority staff responsible for planning and funding D&A services.

below. Workshop questions were developed in collaboration with the Public Involvement and Community Engagement (PICE) group: some individuals involved in this process also took part in the workshops themselves and, in some cases, held a community ambassador role.

Workshop 1 (city in the North of England) involved mapping the current D&A provision and examining existing service pathways. It also involved identifying gaps and barriers to engagement for SAM communities. Workshop 2 (a city in the Midlands) involved observing a culturally tailored recovery service that was initially designed for SAM communities but was later opened to wider populations, as well as reviewing a culturally adapted recovery workbook. Workshop 3 (city in the North of England) synthesised learning from the previous sessions and collaboratively developed draft recommendations for a framework, toolkit or checklist to guide the adaptation of services to be more culturally responsive. A number of participants were involved across all three workshops, providing continuity of perspective and enabling the co-production process to build cumulatively on prior discussions and shared learning.

2.5. Data Collection

Data were generated from four complementary sources. Each workshop was facilitated by the research team, with discussions producing co-constructed knowledge [27] through participatory activities, group dialogue, and reflective exercises. Participant-generated outputs were documented on flip chart paper, while facilitator notes were recorded and retained for analysis. Notes were generated from the second workshop’s field visit to a city in the Midlands, covering the physical environment, service delivery practices, and participants’ responses to the culturally adapted service model. A content analysis of the Islamically adapted 12-step workbook was conducted to document the integration of Islamic theological concepts, Arabic terminology and faith-based practices at each stage of the programme.

2.6. Data Analysis

Reflexive thematic analysis [28] was conducted iteratively across all four data sources, rather than sequentially, to enable cross-validation of themes. Data were thematically analysed by the research team, comprising three researchers. Emerging themes were subsequently presented back to Public Involvement and Community Engagement (PICE) members to confirm that the themes reflected what had been discussed in the workshops, and to establish whether they agreed with the co-produced findings, consistent with established approaches to enhancing trustworthiness in qualitative research [29]. The analysis was informed by stigma frameworks [2,11] paying particular attention to how anticipated stigma, collective stigma (izzat), and fear of disclosure shaped the participants’ accounts. Initial codes were generated inductively from participant-generated outputs and facilitator notes, before being reviewed against the theoretical framework to identify patterns of collective stigma, confidentiality and service access. Themes were developed iteratively across all four data sources, with each workshop’s outputs interrogated in relation to those preceding it. The Islamically adapted workbook was analysed using a framework content analysis approach, whereby each adapted step was mapped against the generic 12-step equivalent in order to identify theological substitutions, retained elements, and linguistic adaptations. Four interconnected themes were identified through this process.

2.7. Ethics

Ethical approval for this study was obtained from the University Ethics Committee reference number 11104. Participants were given a project information sheet and asked to provide written informed consent before taking part. Data was anonymised at the point of collection and stored securely in accordance with GDPR requirements. Participants were free to withdraw at any time.

3. Results

In line with the study’s aim of examining the means through which SAM communities access and shape culturally appropriate recovery care, an analysis of workshop discussions and field visit observations, as well as the Islamically adapted 12-step recovery workbook, identified four interconnected themes that shape recovery engagement within SAM communities. These were (1) stigma and izzat as collective structural risk management, encompassing deterministic community narratives and the management of discreditable stigma across kinship networks; (2) confidentiality as a structural precondition for engagement, including anticipated stigma and trust as a prerequisite rather than an outcome of service contact; (3) service design, space and visibility as access determinants, including inflexible access pathways, stigmatising identity labels, and gender as a structural barrier; and (4) co-constructing religiously coherent recovery pathways, including the incompatibility of mainstream recovery language with Islamic values and the adaptation of the 12-step framework through Islamic theological concepts. These themes are presented in thematic order, rather than in the order of the workshops, to reflect the iterative and cumulative nature of the co-production process. In line with the theoretical framework, the findings are interpreted through the lens of stigma as a collective structural force operating through izzat and family honour networks, rather than as an individual psychological experience.

3.1. Theme 1: Stigma and Izzat as Collective Structural Risk Management

Participants consistently described stigma as a collective, structural force operating through family honour networks, rather than as a personal feeling of shame. Substance use was perceived as affecting not only the individual, but also the reputation, relationships, and future prospects of their entire extended family.

As one participant explained:

“If people find out, it’s not just me—it’s my whole family that gets talked about.”

(Service user)

This reflects what Goffman [11] identifies as discreditable stigma: managing information about an attribute that is not yet known, but which could become so. In SAM communities, the consequences of this information becoming public knowledge can affect siblings’ marriage prospects, parents’ social standing, and the stability of community relationships on which families depend materially and socially.

Participants also described deterministic community narratives that framed substance misuse as a fixed, permanent identity rather than a behaviour that could change. These narratives reinforced hopelessness and suppressed help-seeking further:

“In our community it’s like, once an addict, always an addict—people don’t believe you can change.”

(Community member)

This framing of addiction as an unchangeable, permanent state was described by participants as undermining motivation to seek help in the first place, since recovery itself was perceived by the community as impossible. Unlike family-honour-related stigma, which centres on concealment, this narrative operated by removing hope of change altogether. This account illustrates how stigma functions as a collective liability. The anticipation of being labelled, as theorised by Link and Phelan [2] can deter engagement independently of any actual experience of discrimination. These dynamics imply that the SAM community acts as a reputational risk management system in which delayed or avoided help-seeking is a rational response to real social consequences, rather than being evidence of denial or cultural resistance. These dynamics also have implications for understanding the recovery gap underpinning the alcohol harm paradox.

3.2. Theme 2: Confidentiality as a Structural Precondition for Engagement

Participants consistently distinguish between confidentiality as a service policy and confidentiality as an experience based on trust. In close-knit communities with dense social networks, formal assurances of confidentiality were considered insufficient because the risk of recognition and disclosure was seen as inherent rather than manageable through procedures.

As one participant stated:

“It’s not that people don’t want help, it’s that they’re scared of being seen asking for it.”

(Community ambassador)

Another participant explicitly stated that the risk of being seen to access services could outweigh the perceived benefit:

“You may want support, but walking into the wrong building could cause more problems than it solves.”

(Service user)

A further participant highlighted the limitations of formal confidentiality assurances:

“People know people. You can’t just walk into a service and expect no one to notice.”

(Community ambassador)

These accounts reflect the operation of anticipated stigma, as theorised by Link and Phelan [2]. It is the rational expectation of social consequences, rather than the experience of them, that suppresses engagement. Crucially, participants emphasised that trust in confidentiality must be established prior to engagement, rather than developing through contact with services. This challenges the conventional service model assumption that trust is built during the therapeutic relationship. For SAM communities, confidentiality is not a feature of good service delivery; it is a precondition for any engagement to take place at all.

3.3. Theme 3: Service Design, Space and Visibility as Access Determinants

Participants identified a range of practical and structural features of mainstream D&A services that exacerbated stigma-driven barriers to access. Service locations that were visible, community-facing or associated with stigmatised identities were perceived as deterrents, as being seen entering such a building could result in the disclosure of discreditable stigma.

Participants identified a range of features they perceived as structural barriers to access, including inflexible appointment times, GP referral requirements, and complex (including digital) entry pathways [note: the majority of participants were not current or former service users of local D&A treatment]. These were seen as particularly challenging for SAM community members with significant caregiving responsibilities, many of whom felt existing health and support services were not designed with their circumstances in mind.

“If you work or have kids, those appointment times just don’t work—so people give up.”

(Service user)

Participants expressed significant discomfort with identity-reducing labels such as ‘addict’ or ‘alcoholic’, which they encountered both in broader social contexts and within mainstream recovery settings. These labels were felt to be incompatible with Islamic values of inherent human dignity and the capacity for moral change and were seen as foreclosing the possibility of growth and redemption rather than supporting it.

“Being called an addict feels like that’s all you are—there’s no space to move on from it.”

(Community ambassador)

This discomfort reflects the theoretical mechanism identified by Link and Phelan whereby the stigma label itself becomes a barrier because accepting it means accepting a fixed and discredited identity, which has permanent social consequences. Gender emerged as a cross-cutting structural dimension. Women described intensified stigma and heightened confidentiality concerns, reflecting patriarchal surveillance within SAM communities [30]. Participants identified gender-segregated provision not as a cultural preference, but as a structural necessity for women’s access. This is consistent with intersectional analyses of gender and religious identity in health service engagement [31].

3.4. Theme 4: Co-Constructing Religiously Coherent Recovery Pathways

Participants identified tensions between mainstream recovery language and Islamic understandings of human nature, agency, and change, which some experienced as a barrier to engagement. The medical framing of addiction as chronic, biologically fixed and irreversible was experienced as incompatible with Islamic concepts such as ikhtiyar (human agency), karamah (inherent dignity) and fitrah (the innate capacity for moral change) [20,32].

As one service provider stated:

“When recovery is explained using Islamic ideas, it actually makes sense to people.”

(Service provider)

A content analysis of the Islamically adapted 12-step recovery workbook revealed that mainstream recovery principles can be maintained when translated into a theologically coherent framework. The workbook retains the core structure of the 12 steps while integrating Islamic theological concepts, Arabic terminology, and faith-based practices at each stage.

Table 2. Adaptation of the Twelve-Step recovery model using Islamic concepts identified during co-design workshops.

Twelve-Step Principle	Islamically Adapted Equivalent *
Admitting powerlessness over addiction	Recognition of dependence and need for Allah’s guidance
Belief in a Higher Power	Tawhid (belief in the oneness of Allah)
Turning one’s will and life over to God	Reliance on Allah (tawakkul) and submission to divine guidance
Moral self-inventory	Muhasabah (self-reflection and accountability)
Admitting wrongs	Tawbah (repentance and acknowledgement of wrongdoing)
Readiness for change	Intentional commitment to personal reform (niyyah)
Asking for shortcomings to be removed	Seeking Allah’s forgiveness and support for transformation
Making a list of those harmed	Recognition of responsibilities towards family and community
Making amends	Restoring relationships and fulfilling obligations
Continued personal inventory	Ongoing self-accountability and spiritual reflection
Prayer and meditation	Salah, dhikr, du’a and spiritual contemplation
Helping others in recovery	Service to community, mentoring and mutual support

* Source: Adapted from Alcoholics Anonymous [15] and the Islamic recovery literature [20,33] Table reflects adaptation based on the published literature and field visit observations. Formal content analysis of the Islamically adapted workbook was conducted as part of this study.

provides a comparative analysis of the generic 12-step framework and its Islamically adapted equivalent.

Table 3. Key Islamic concepts identified as relevant to culturally adapted recovery services.

Concept *	Definition	Relevance to Recovery
Tawhid	Belief in the oneness of Allah	Provides spiritual foundation and sense of purpose
Tawbah	Repentance and return to Allah	Supports behavioural change and recovery from relapse
Muhasabah	Self-reflection and self-accountability	Encourages recognition of harmful behaviours and personal growth
Tawakkul	Reliance upon Allah	Supports resilience and coping during recovery
Sabr	Patience and perseverance	Encourages sustained engagement with recovery processes
Rahmah	Mercy and compassion	Promotes non-judgemental support and recovery environments
Karamah	Human dignity	Challenges stigma and affirms self-worth
Fitrah	Innate human goodness and potential	Reinforces hope and capacity for change
Ummah	Community and collective responsibility	Supports peer support and community-based recovery
Ibadah	Worship and devotion	Provides structure, routine and spiritual wellbeing

* Source: Haque [20]; Kamal and Loewenthal (2002) [33]; Badri (2013) [34]; field visit observations, Midlands recovery service.

shows the core Islamic concepts integrated into the workbook and their relevance to recovery.

The field visit to a city in the Midlands (Workshop 2) provided practice-based illustration of what religiously coherent recovery provision can look like in practice, although the model has not yet been formally evaluated. Islamic concepts such as tawbah (repentance), dhikr (remembrance of God), du’a (supplication) and sadaqah (charitable giving) were meaningfully integrated into the recovery process. However, participants consistently emphasised that the Midlands model cannot be directly transferred to the North of England city: the communities are demographically different; the model has not been formally evaluated; and local adaptation, rather than replication, is essential. Observations and participant responses from the field visit were not analysed as a standalone dataset: rather, they were integrated across the four cross-cutting themes reported above most directly informing this theme, where participants’ reactions to seeing Islamic concepts embedded in a real service directly shaped the theme’s content.

3.5. Co-Produced Design Principles

Based on findings from three co-produced workshops, six evidence-based design principles have been proposed to help commissioners and service providers develop inclusive D&A recovery services for SAM communities. These principles were developed and validated with participants, reflecting the priorities of community members, service users, commissioners and providers, rather than being imposed externally. Their co-produced origin gives them a degree of community legitimacy that externally designed frameworks cannot claim. Although these principles were developed in a SAM context, they are also relevant to other marginalised faith communities and disadvantaged populations, as structural and cultural misalignment in mainstream services creates comparable barriers to engagement for these groups.

Principle 1: Confidentiality-First Access. Standard procedures should be established for anonymous initial contact, including telephone, online and social media options, as well as drop-in services and low-registration entry points. These procedures should include clear explanations of who will know what and when. Trust must be built before engagement occurs; it cannot be assumed to develop during engagement. This principle addresses the finding that confidentiality is a structural precondition rather than a service feature.

Principle 2: Visibility-Sensitive Service Design. Discreet, neutral locations should be prioritised in the early stages of recovery, with the option of moving into community-based spaces as the recovery identity is established. Service locations should not be situated in spaces associated with high community visibility, such as mosques and community centres, during the initial engagement period, as these directly amplify the risk of discreditable stigma.

Principle 3: Flexible Operational Access. Extended opening hours, alternatives to GP referral, simplified pathways and rapid entry options should be implemented. Services that require advance booking during standard working hours structurally exclude shift workers, carers, and those in precarious employment—groups that are disproportionately represented in SAM communities.

Principle 4: Religiously Coherent Recovery Options. Services should provide support for the theological reframing of recovery principles, train staff in respectful Islamic literacy and partner with credible faith and community intermediaries. The language of recovery must be compatible with Islamic understandings of human agency, inherent dignity, and the capacity for moral change. The Islamically adapted 12-step framework provides a promising model for this approach, though formal evaluation is still needed.

Principle 5: Gender-Responsive Provision. Safe pathways for women, including gender-segregated options where required, should be designed and staffed to minimise exposure to surveillance and stigma. Gender segregation should be viewed as a structural necessity to improve women’s access to services, rather than as a cultural preference. This approach is consistent with an intersectional analysis of gender and religious identity in health service engagement [30,31].

Principle 6: Recovery Narratives Without Reputational Harm. Culturally safe mechanisms that make recovery visible while protecting individual anonymity should be developed, such as anonymised storytelling, digital campaigns led by trusted community intermediaries, and peer speakers from outside the area. Visible recovery narratives are essential to breaking the feedback loop between stigma-driven concealment, deterministic community narratives about addiction and hopelessness.

4. Discussion

4.1. Reframing Low Engagement: Rational Actors Navigating Structural Risk

The key findings of this study reveal that South Asian Muslim individuals and families affected by substance misuse are rational and strategic decision-makers who consider the costs and benefits of seeking help in the context of real and foreseeable social consequences. The potential benefits of accessing recovery support are weighed against factors such as protecting family honour (izzat), maintaining kinship relationships, preserving marriage prospects for siblings, and sustaining community standing. These findings suggest that low SAM community engagement with D&A services reflects structural and social factors, rather than cultural resistance, a lack of insight or community-level dysfunction. Evidence generated through collaboration with community members, service users, and providers suggests that stigma acts as a collective structural force through family honour networks, building on the work of Goffman and Link and Phelan in ways not previously theorised in the D&A recovery literature. These ideas are most evident in Themes 1 and 2, where participants openly discussed the risk assessments they perform when deciding whether to seek help, as well as the types of structural changes that would make engagement feel safer and more achievable. These accounts support Corrigan et al.’s [35] assertion that stigma-related avoidance is a rational response to discrimination rather than a lack of motivation.

This reframing has significant implications for service design. If low engagement reflects rational risk management rather than a cultural pathology, the appropriate response is to change the structural conditions that make engagement risky rather than increasing community awareness campaigns that leave these conditions unchanged.

4.2. Theoretical Contributions

This study makes four interconnected theoretical contributions. Firstly, it expands upon Goffman’s concept [11] of discreditable stigma, demonstrating that information management in SAM communities occurs at the level of kinship networks rather than the individual. The unit of stigma risk is the family, not the individual—a finding that has not previously been theorised in the D&A recovery literature. Secondly, it broadens Link and Phelan’s [2] modified labelling theory by showing that anticipated stigma acts as a collective structural force within SAM communities, discouraging the entire family network from seeking help rather than just individuals. This represents a significant advancement in existing stigma frameworks, which were primarily developed in relation to individual psychology and behaviour. Third, it builds on Sattar et al. [1] by theorising confidentiality not as a governance requirement or service feature, but as a structural precondition for engagement, thus reversing the assumption embedded in conventional service models that trust develops during the therapeutic relationship. Fourthly, this study suggests how the intersection of gender and religion increases stigma risk in ways that existing frameworks do not account for. The accounts of women in Theme 3, for whom gender-segregated provision is a structural necessity rather than a cultural preference, extend the intersectional analysis of stigma and health service access [31,36] to the specific context of D&A recovery.

Together, these contributions suggest that existing theoretical frameworks for understanding D&A service access require significant expansion to encompass the experiences of collectivist, faith-based communities, in which stigma, honour, and religious identity operate as structural rather than individual forces. Both the Islamically adapted 12-step workbook and the Midlands Recovery Service provide practice-based evidence that mainstream recovery models can be adapted to incorporate Islamic values while retaining their structural and therapeutic integrity. Analysis of the workbook demonstrates that Islamically coherent recovery language does not require the abandonment of evidence-based principles, but rather their translation. This is consistent with the broader literature on the cultural adaptation of psychological and health interventions, which suggests that both surface-level and deep-level adaptations can increase engagement and relevance without compromising therapeutic fidelity [37,38]. The Islamic concepts integrated into the workbook—tawbah (repentance), tawakkul (reliance on God) and muhasabah (self-examination)—map onto the core mechanisms of the 12-step process, locating them within a theologically coherent framework. However, three critical limitations apply. Firstly, the Midlands model has not been formally evaluated, and its effectiveness therefore remains undemonstrated in the research literature. Secondly, SAM communities in North of England and in the city in the Midlands are demographically distinct, meaning that findings from one context cannot be assumed to transfer directly to the other. Thirdly, local adaptation rather than direct replication is essential. These limitations have important implications for commissioning. Evidence-based adaptation requires investment in local co-production and evaluation rather than the simple adoption of models developed elsewhere.

4.3. Mainstreaming Versus Parallel Provision

The findings support the argument for adapting mainstream services to better meet the needs of SAM communities, rather than creating separate, parallel provision. Theme 2 shows that a design prioritising confidentiality must be embedded in mainstream access pathways, rather than being offered through a separate ‘Muslim service’, which would itself function as a visibility marker and stigma amplifier. Theme 3 suggests that flexibility in access, location, and language must be standard features of mainstream services, not extras available only through designated services. The creation of separate parallel provision risks exacerbating the very marginalisation it seeks to address by visibly identifying users as belonging to a stigmatised group [39,40]. The adaptation of mainstream services, as advocated by the NHS Core20PLUS5 framework, is a more equitable, sustainable and stigma-conscious approach. This argument aligns with the broader health equity literature, which identifies parallel or targeted provision as a risk factor for exacerbating rather than alleviating health inequalities [12,41].

4.4. Limitations

This study has several limitations that should be considered when interpreting the findings. Firstly, the study is geographically specific to a city in the North of England and a city in the Midlands, so the findings may not be directly transferable to SAM communities in other regions. Self-selection among participants may mean that those facing the greatest barriers to engagement were not represented in the workshops. Additionally, some individuals held multiple overlapping roles across the study, contributing to the Public Involvement and Community Engagement (PICE) group that helped shape the workshops questions, while also participating in the workshops themselves and, in some cases, acting as community ambassadors. Consistent with the participatory and co-produced ethos of this study, and with the approach taken in related by this research team, these overlapping roles are made explicit rather than treated as a hidden weakness. However, the lack of independence between those who helped generate the workshop questions and those who subsequently answered them cannot be ruled out as a source of bias, and is noted here as a limitation. As the study has no longitudinal follow-up, it cannot assess whether the co-produced recommendations were implemented or effective. SAM communities are not homogeneous, so the findings should not be assumed to apply uniformly to communities with different national heritages, generational profiles, or religious practices. This study examined the mechanisms and means participants used or proposed for accessing culturally appropriate care; it did not assess treatment outcomes or effectiveness, which remains an important direction for future research.

4.5. Synthesis

The findings across this discussion are connected by a single underlying mechanism: the consistent failure of mainstream D&A services to consider the collective, relational and structural nature of stigma in SAM communities. These frameworks help explain the findings presented above: anticipated and discreditable stigma explain why confidentiality must be established before engagement begins. Collective stigma operating through izzat explains why the visibility and location of services carry such high stakes; and stigma labelling also explains why recovery language framed around fixed identity labels is incompatible with the Islamic values of karamah (inherent dignity) and fitrah (the innate capacity for moral change) [20,34] Therefore, religiously coherent recovery pathways are not merely a cultural preference, but a structural response to the stigmatising identity constructions embedded in mainstream recovery models.

Current frameworks theorise stigma at an individual level, services are designed around individual disclosure and trust-building, and policy responses target individual awareness and behaviour change. The findings of this study suggest that these approaches are not merely inadequate, but actively counterproductive in collectivist, faith-based contexts, where the unit of risk is the family rather than the individual. This has a direct implication that goes beyond service design. It suggests that health equity frameworks are more broadly needed to consider how structural stigma operates differently in different cultural contexts involving notions of personhood, honour and social capital. The six design principles proposed here are not merely practical recommendations, but an operationalisation of what it means to address collective stigma as a structural rather than individual issue.

4.6. Future Directions

Priorities for future work include a formal evaluation of the Islamically adapted Midlands model using realist evaluation methodology, examining Context, Mechanism and Outcome (CMO) configurations [42], particularly well-suited to capturing the context-sensitive nature of culturally adapted recovery interventions; the development of a commissioner toolkit; the routine collection of ethnicity and religion data in care planning; and a larger, funded research programme to establish the evidence base for co-produced, culturally responsive recovery interventions across England.

5. Conclusions

The aim of this study was to document the barriers to engagement with D&A recovery services faced by SAM communities, to examine how recovery models are experienced in relation to culture and religion, and to co-produce practical recommendations for adapting and commissioning services. The findings indicate that, among participants, low engagement reflected rational risk management in the face of real structural consequences, rather than cultural resistance, denial or a lack of motivation. The study suggests that stigma operates as a collective structural force through family honour networks that confidentiality is a prerequisite for engagement and that religious coherence is a structural access requirement rather than a cultural preference.

These findings contribute to the growing body of evidence for the design of culturally responsive D&A interventions for SAM communities in England. The six design principles proposed here provide commissioners and service providers with an evidence-based framework for adapting mainstream services to accommodate diverse recovery pathways, without creating parallel provision that could further marginalise those it seeks to help.

The findings are relevant not only to SAM communities but also to other marginalized faith communities and disadvantaged populations, for whom cultural, religious and structural misalignment in mainstream services creates comparable barriers to engagement. Future works should build on these co-produced principles through formal evaluation and wider implementation to strengthen the evidence base for culturally responsive recovery services.