Tell people and lose what I have: Care-seeking, concealment, and disclosure during Sierra Leone’s 2025 clade IIb mpox outbreak

During Sierra Leone’s 2025 clade IIb mpox outbreak, care-seeking occurred in a social context where formal presentation could expose symptoms, sexualised assumptions, and private relationships to families, workplaces, neighbours, and surveillance systems. We conducted a focused thematic analysis nested within a broader qualitative study across Western Area Urban, Western Area Rural, Bo, and Kenema from 10 March to 28 August 2025. The focused dataset held 70 transcripts. All 42 survivor interviews formed the primary evidence. The remaining 28 were contextual transcripts, drawn from interviews and focus group discussions with healthcare workers, contact tracers, and community members. Analysis used the Framework Method, dual coding, reflexive memos, matrix charting, and member checking with survivor participants. We identified four linked processes: protective misrecognition through socially safer diagnostic categories; disclosure risk as the point where stigma, cost, distance, relationship risk, and service trust converged; health system co-production of delay through early diagnostic uncertainty, referral gaps, and limited diagnostic access; and enabling conditions that made care-seeking safer, especially trusted intermediaries and visible confidentiality practices. Twenty-eight of the 42 survivor accounts met the criteria for pathway classification: 16 supported disclosure pathways and 12 forced concealment pathways, including three transitional cases that shifted after a trusted intermediary emerged. The other 14 survivor accounts lacked one or more pathway criteria and contributed contextual survivor evidence. Gender, intimate partnership risk, contact tracing visibility, and memories of Ebola and COVID-19 shaped disclosure decisions. The framework specifies how disclosure operates as a convergence point in high-stigma outbreak care-seeking. Outbreak preparedness should design confidentiality, intermediary, and contact-tracing systems that make disclosure safe enough to perform.