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Keywords: Sierra Leone, Multidrug-Resistant Tuberculosis, Implementation Research, Treatment Adherence, Socio-Ecological Model

Background: Sierra Leone's health system has been weakened by centuries of structural violence: the transatlantic slave trade, colonial exploitation, a decade-long civil war, and an Ebola epidemic have undermined the country's health care delivery capacity. Tuberculosis, a disease synonymous with poverty, thrives in Sierra Leone. The WHO estimates Sierra Leone's TB incidence at 372 cases per 100,000 people, ranking it among the 30 highest-burden countries, though inadequate diagnostic capacity means the true burden likely exceeds reported figures. MDR-TB presents an even greater challenge, requiring complex, prolonged treatment with more limited options and profound community implications given airborne transmission. The establishment of Sierra Leone's national MDR-TB program through a partnership between the Ministry of Health and Partners In Health Sierra Leone (PIH SL) was transformative, providing lifesaving therapy to patients who had languished for years. Today, treatment is delivered across three hospitals, and shorter regimens have enabled more patients to receive care at home. Yet social and economic forces such as poverty, malnutrition, weak infrastructure, and fragmented funding, shape whether people living with MDR-TB  succeed or struggle on treatment. These factors have not yet been systematically examined.

Objectives:

1. Document the lived experiences of people living with MDR-TB in Sierra Leone to understand how individual, interpersonal, and structural factors shape their treatment outcomes
2. Examine how health system and structural forces (including infrastructure, supply chains, financing, and human resources) shape the delivery of MDR-TB services, through in-depth interviews with clinical, programmatic, and policy stakeholders

Design: A qualitative, two-aim implementation research study will be conducted at Lakka Government Hospital (urban) and Koidu Government Hospital (rural) in Sierra Leone. Aim 1 will involve semi-structured in-depth interviews with up to 30 MDR-TB patients, purposively sampled into low-adherence (n=15) and good-adherence (n=15) cohorts. Patient narratives will be analyzed through the Socio-Ecological Model (SEM). Aim 2 will involve individual interviews with up to 20 stakeholders including clinicians, community health workers, Ministry of Health officials, National TB Program leadership, and NGO leaders. Stakeholder interviews will be structured and analyzed using the Consolidated Framework for Implementation Research (CFIR). Oral informed consent will be obtained for both aims. Chart abstraction of non-identifiable clinical variables will be conducted by treating physicians at each site to contextualize interview data.

Impact/Effectiveness: This project is currently in the IRB submission phase, with dual review planned through the UCLA Behavioral Social Science IRB and the Sierra Leone Ethics and Scientific Review Committee (SLESRC). Findings will be shared with the Ministry of Health, National TB Program, and participating hospital and district health leadership. Results are expected to identify actionable barriers at multiple levels of the socio-ecological framework, informing future program design, community-based care expansion, and policy recommendations for MDR-TB services in Sierra Leone, and beyond.

Lessons Learned: Designing an IRB submission for qualitative implementation research in an impoverished, post-conflict setting requires sustained collaboration across multiple institutional partners. This protocol was iteratively developed with input from PIH Sierra Leone clinical and program leadership, the Sierra Leonean Ministry of Health and National TB Program, and UCLA faculty mentorship, each bringing distinct priorities, contextual knowledge, and regulatory requirements to the process. Aligning these perspectives was essential for arriving at study procedures that are rigorous, ethical, and operationally achievable.

Summary: This project applies a multi-level implementation research framework to characterize the structural and systemic forces shaping MDR-TB treatment in Sierra Leone. By integrating the narratives of people living with MDR-TB with stakeholder perspectives across clinical, administrative, and policy levels, the study aims to generate evidence that can directly strengthen MDR-TB services and inform health systems investment in one of the world's highest-burden settings.