Suffering in silence: Stigma, healthcare barriers, and resilience during Sierra Leone’s 2025 clade IIb mpox outbreak—A multi-perspective qualitative study

Mpox was confirmed in Sierra Leone in January 2025, with a public health emergency declared shortly thereafter. By June 2025, the country reported over 4,000 confirmed cases caused by clade IIb. Limited qualitative research has explored the lived experiences of affected populations during mpox outbreaks in African settings. This study explored multi-stakeholder experiences of mpox, including illness trajectories, stigma manifestations, healthcare-seeking behaviours, and health system response challenges. We conducted a multi-perspective qualitative study using thematic framework analysis between March and August 2025 across four districts. Participants included mpox survivors (n = 42), healthcare workers (n = 38), community members (n = 36), and contact tracers (n = 24). Data were collected through 94 semi-structured interviews and 12 focus group discussions. Analysis was guided by a modified Social Ecological Model (SEM) integrating the Health Stigma and Discrimination Framework (HSDF). Five interconnected themes emerged: (1) illness characterised by physical suffering and lasting bodily changes; (2) multi-layered stigma operating across individual, interpersonal, community, and institutional levels; (3) healthcare-seeking shaped by fear of disclosure and economic constraints; (4) healthcare workers' moral distress and professional isolation; (5) adaptive health system response alongside coordination challenges. Stigma operated as a cross-cutting dimension that intersected with all other themes, shaping illness experience, care-seeking behaviour, professional practice, and system-level response simultaneously. It also permeated all dimensions of the mpox outbreak experience, delaying care-seeking, undermining contact tracing, and compounding healthcare worker distress. Compound trauma from sequential epidemic exposure emerged as a distinct burden among frontline workers. These findings point to the need for stigma-informed outbreak response strategies, sustained healthcare worker support mechanisms, and community-centred communication approaches in post-conflict, resource-constrained settings facing recurrent epidemics.