From Emergency Declaration to District-Level Delivery: A Theory-Guided Mixed-Methods Evaluation of Sierra Leone’s National KUSH Response (2024–2025)

From Emergency Declaration to District-Level Delivery: A Theory-Guided Mixed-Methods Evaluation of Sierra Leone’s National KUSH Response (2024–2025) | 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 From Emergency Declaration to District-Level Delivery: A Theory-Guided Mixed-Methods Evaluation of Sierra Leone’s National KUSH Response (2024–2025) Eric Nzirakaindi Ikoona, Foday Sahr, Mohamed A Vandi, Lucy Namulemo, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7870467/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 In April 2024, the President of Sierra Leone declared a national emergency over the synthetic street drug “KUSH,” linked primarily to nitazene-class synthetic opioids. In response, the government established a five-pillar national strategy coordinated by the newly formed National Task Force on Drug and Substance Abuse (NaTFDSA), modeled on the country’s prior COVID-19 coordination platform. This evaluation examines how the strategy transitioned from policy to practice during its first 18 months, what scaled, where implementation lagged, and what adaptations emerged under constraint. Methods We conducted a convergent mixed-methods implementation evaluation in four districts (Western Area Urban, Bo, Kenema, and Port Loko) between June and September 2025. Data sources included 52 in-depth interviews, eight focus group discussions with 67 participants, 18 facility observations, 127 strategy and monitoring documents, and routine implementation indicators. Qualitative data were analyzed using the Consolidated Framework for Implementation Research (CFIR). Quantitative indicators aligned with Proctor’s implementation outcomes. Triangulation matrices integrated data across sources. Ethical approval was obtained from the national research ethics committee. Findings: Treatment bed capacity expanded from 50 to 212 beds across six centers (4.24-fold increase; ±324%), surpassing the 180-bed national target. The Sierra Leone Psychiatric Teaching Hospital (SLPTH) expanded to 60 beds, and three regional centers opened. A total of 847 healthcare workers were trained, and 1,289 admissions occurred over the 18 months. Prevention efforts reached 1,186 communities (62% of the target). Reintegration services reached 678 discharged patients; among those with six-month follow-up data, 43% had returned to work or school. Law enforcement recorded 891 arrests and 189.7 kg of drug confiscations, while a perception survey (n = 220) estimated a 35% reduction in street-level availability. The Task Force held all 18 planned coordination meetings and mobilized US $ 2.23 million, with 78% budget execution. Reintegration received the lowest funding allocation. Interpretation: Sierra Leone achieved a rapid, multi-sectoral scale-up of substance use services under emergency conditions. This experience shows how crisis coordination architecture can accelerate implementation in low-resource settings. However, gaps in reintegration fidelity, rural equity, and sustainability highlight the need for institutionalization, routine financing, integration of indicators into health information systems, and expanded harm reduction. The next phase should prioritize peer-led recovery, gender-responsive reintegration, and diversion-to-treatment protocols to ensure enduring, equitable impact. Physical Medicine & Rehab Sierra Leone KUSH synthetic opioids nitazenes implementation science CFIR Proctor outcomes StaRI COREQ multisector governance crisis governance reintegration West Africa Figures Figure 1 Figure 2 Introduction KUSH refers to a street drug market in Sierra Leone, with laboratory evidence linking it primarily to nitazene-class synthetic opioids mixed with various psychoactive agents [1-3]. These compounds carry high overdose risk, especially in contexts with limited treatment infrastructure, surveillance, or harm-reduction systems [4–6]. In April 2024, the President of Sierra Leone declared a national emergency and announced a five-pillar response covering; prevention, care and treatment, social support, rehabilitation and reintegration, law enforcement, and community engagement; coordinated by a new National Task Force on Drug and Substance Abuse (NaTFDSA) modeled on the National COVID-19 Emergency Response Centre (NaCOVERC) established in 2020 to coordinate the prevention and control of COVID-19 [1,2]. In parallel, the National Public Health Agency, launched in December 2023, provided coordination infrastructure, including a situation room, operational dashboards, and district-facing logistics platforms [1]. The reuse of NaCOVERC architecture and the National Public Health Agency emergency preparedness and response infrastructure provides a unique test case of how emergency coordination structures can be adapted for substance use crises [1,2]. International agencies such as the World Health Organization (WHO) and the United Nations Office for Drugs and Crime (UNODC) recommend balanced responses to synthetic opioids, pairing treatment, harm reduction, and reintegration with proportionate enforcement [3,4,5]. Monitoring alerts have identified West Africa, including Sierra Leone, as a hotspot for nitazene-linked synthetic opioid diffusion [1-5]. However, implementation fidelity, system readiness, and adaptation remain under-examined in this context. Existing literature focuses primarily on the chemical composition of KUSH and media narratives [4–6]. Peer-reviewed studies have yet to document the fidelity, reach, or adaptation of Sierra Leone’s five-pillar response, nor analyzed the enabling role of emergency coordination infrastructures. No published evaluation applies implementation theory to explain how the presidential decree was translated into operational service delivery, nor how the system performed on reintegration, equity, and rural access [2,7]. This study addresses these gaps. We conducted a mixed-methods, theory-guided evaluation of Sierra Leone’s national KUSH response from April 2024 to October 2025. We used the Consolidated Framework for Implementation Research (CFIR) to analyze implementation determinants [8], Proctor’s taxonomy to measure implementation outcomes [9], and the FRAME framework to categorize adaptation types [10]. StaRI and COREQ guided reporting quality [11,12], while crisis and multi-sector governance theory provided an interpretive lens for understanding speed, equity, and institutionalization [13,14]. The objective of this evaluation was to assess fidelity, scale, and determinants of Sierra Leone’s KUSH response during the first 18 months of implementation. We asked: What scaled, where, and why? What implementation determinants shaped rollout? How did quantitative indicators and qualitative findings align or diverge? What strategies enabled adaptation under constraint? And what lessons follow for sustaining and equitably expanding services in crisis-affected, resource-limited contexts? Methods Design and Setting s: We employed a convergent mixed-methods design in four purposively selected districts: Western Area Urban, Bo, Kenema, and Port Loko, chosen to reflect geographic, urban–rural, and health system capacity diversity. The implementation window under review spanned April 2024 to October 2025. Data collection occurred between June and September 2025. Implementation Architecture : Figure 1 illustrates the coordination structure for Sierra Leone’s National Task Force on Drug and Substance Abuse (NaTFDSA). The Task Force was chaired by the Vice President and supported by a national coordinator, a strategic advisory group, and the National Public Health Agency (NPHA) (Figure 1). The NPHA housed the incident-management situation room and operationalized district-level implementation through five regional coordination hubs and district focal persons. Technical pillars included: (1) Risk Communication and Community Engagement (RCCE), (2) Care and Treatment, (3) Social Support and Reintegration, (4) Diagnostics and Surveillance, and (5) Safe and Dignified Burial. The operational support was led by the National Drug Law Enforcement Agency (NLDEA), the Ministry of Health, and partners through transport/logistics and security coordination. Guiding Frameworks : We applied three core implementation science frameworks to guide the evaluation [8,9,10]. The Consolidated Framework for Implementation Research (CFIR) was used to structure the analysis of implementation determinants across five domains: outer setting, inner setting, intervention characteristics, characteristics of individuals, and process [8]. Proctor’s taxonomy provided a basis for defining and measuring implementation outcomes, including fidelity, acceptability, feasibility, and sustainability [10]. To categorize changes in delivery approach, we used the FRAME (Framework for Reporting Adaptations and Modifications–Enhanced), distinguishing between fidelity-consistent adaptations (e.g., task-shifting, telepsychiatry) and transformative shifts (e.g., mobile clinics altering service geography) [7,8,9]. Implementation determinants reflected the CFIR domains [8]. Outer setting factors, such as political leadership and donor alignment, accelerated rollout, while inner setting challenges, including workforce shortages and fragile data systems, and limited fidelity [8]. FRAME-informed coding identified adaptive strategies that preserved core intervention functions under constraint [7]. Implementation outcomes were classified according to Proctor’s framework and aligned with the mixed-methods indicator set [10]. Together, these frameworks enabled structured analysis, triangulated interpretation, and comparison to other global implementation experiences. Selection of participants: The selection of participants for interviews and FGDs was purposive and targeted national policy makers, program coordinators, district focal persons, community representatives, staff of treatment facilities, Law enforcement officers, and development partners. Selection criteria: The study included participants who were involved in the implementation of the program at all levels. Inclusion Criteria: Informed consent, and persons who had been in Sierra Leone for at least 6 months before the study. Exclusion Criteria: Conflict of interest and lack of consent. Participants and Data Sources : We conducted 52 in-depth interviews with national policymakers, program coordinators, district focal persons, and development partners. Additionally, eight focus group discussions (FGDs) were held with 67 district-level implementers and community representatives. Structured observations were carried out in 18 treatment and prevention facilities across the four study districts. We reviewed 127 documents, including strategies, quarterly reports, financial records, training materials, and monitoring tools. Routine monitoring indicators were extracted from national dashboards and facility registers [1]. Routine Indicators : We abstracted monthly bed capacity, staffing, and admissions data from all six treatment centers, with 100% completeness. For reintegration outcomes, follow-up data on employment and educational status were available for 673 of 1,834 discharged patients (37%). Law enforcement indicators were compiled from NLDEA monthly reports, covering all districts. Arrests were classified as “high-level traffickers” when suspects possessed more than 5 kilograms of substances or had documented cross-border trafficking links. User Perception Survey : A structured street-intercept survey was conducted in September 2025 across the four study districts (n = 220; ~55 per district). Trained enumerators approached adults in market areas and transport hubs. After obtaining verbal informed consent, respondents were asked: “Compared to six months ago, how would you rate the availability of KUSH in your community?” Responses were recorded on a 5-point Likert scale ranging from “much less available” to “much more available.” Ethical Approval: Ethics approval was granted by the Sierra Leone Ethics and Scientific Review Committee (Protocol SLERC-2025-047). Verbal informed consent was obtained from all participants before interviews or FGDs, including consent for audio recording. All data were de-identified and stored on encrypted devices. The principle of good practice in accordance with the Declaration of Helsinki on involving human subjects in research was adhered to. Procedures and Analysis : Semi-structured interview and FGD guides were developed based on the CFIR and Proctor frameworks. Two trained analysts independently coded all qualitative transcripts using thematic analysis. A third analyst resolved discrepancies. Quantitative indicators covered inputs (infrastructure, human resources), outputs (service delivery), and process measures (coordination and financing). Fidelity scoring used equal weighting across achievement domains; sensitivity analysis demonstrated <5-point variation when weights were adjusted ±10%. Qualitative and quantitative data were integrated through triangulation matrices and joint displays to generate meta-inferences. Data validation occurred through stakeholder workshops and member checking at the national and district levels. Results Quantitative outcomes. Treatment capacity expanded from 50 to 212 beds across six centers (+324%), exceeding the national target of 180 beds (118%) [1]. The Sierra Leone Psychiatric Teaching Hospital was scaled to 60 beds, while three regional centers were opened. A total of 847 health workers were trained (77% of the 1,100 target), and 1,289 admissions occurred over 18 months (71.6/month). Prevention activities reached 1,186 communities (62% of the target), and reintegration services reached 678 discharged patients. Among 673 with six-month follow-up data, 43% had returned to work or school. Law enforcement reported 891 kush-related arrests and 189.7 kg of seizures, including 47 high-level trafficker arrests. A perception survey in September 2025 (n=220) reported a 35% reduction in street-level availability. The Task Force met all 18 times as planned and mobilized US$2.23 million, executing 78% of the budget. Reintegration was the lowest-spending pillar. Key indicators appear in Table 1, and Figure 2 summarizes pillar-level progress against targets. Table 1: Key implementation indicators by pillar (April 2024–October 2025) Pillars Baseline 18 ‑ Month Result Target % Achieved PILLAR 1: PREVENTION & RISK COMMUNICATION Communities reached 0 1,186 1,900 62% Radio programs aired 0 247 N/S N/A School programs established 0 34 schools N/S N/A PILLAR 2: CARE & TREATMENT Treatment bed capacity 50 (1 center) 212 (6 centers) 180 beds 118% Facilities operational 1 (SLPTH only) 6 (all regions) 6 centers 100% Health workers trained 0 847 1,100 77% Cumulative admissions 0* 1,289 (71.6/month) N/S N/A Average length of stay N/A 28 days N/S N/A PILLAR 3: SOCIAL REINTEGRATION Patients accessing services 0 678 of 1,834 discharged N/S N/A Return to work/school (6‑mo) N/A 43% (289 of 673 eligible) 70% of served 61% Vocational training provided 0 412 patients N/S N/A Economic empowerment grants 0 79 patients N/S N/A PILLAR 4: LAW ENFORCEMENT Total arrests 247 (full year, 2023) 891 (18 months) N/S N/A Seizures (kg) 47.3 189.7 N/S N/A High‑level trafficker arrests 8 47 N/S N/A Street availability reduction 0% 35% (surveys) 80% reduction 44% PILLAR 5: COMMUNITY ENGAGEMENT District focal persons recruited 0 16 16 (all) 100% Community advisory committees 0 42 N/S N/A Traditional/religious leaders engaged Sporadic 347 N/S N/A COORDINATION & FINANCING Task Force meetings 0 18 (monthly) 18 100% Budget mobilized (USD) $0 $2.23 million N/S N/A – Government contribution N/A $0.78 million (35%) N/S N/A – Donor contribution N/A $1.45 million (65%) N/S N/A Budget execution rate N/A 78% ($1.74M spent) ≥80% 98% Notes: N/S = Not specified in original plan; N/A = Not applicable; SLPTH = Sierra Leone Psychiatric Teaching Hospital. Baseline for cumulative admissions indicates no NaTFDSA baseline before the April 2024 emergency declaration. Data sources by category: Prevention & RCCE indicators: RCCE activity logs and community registers ; Care & Treatment indicators: Facility registers and training databases; Social Reintegration indicators: Discharge registers and follow-up tracking systems ; Law Enforcement indicators: NLDEA monthly reports; Community Engagement indicators: District focal person reports; Coordination & Financing: NaTFDSA quarterly reports (Q2 2024-Q4 2025) and financial records. Table 2. Illustrative qualitative quotes (by CFIR domain/pillar). Domain/Pillar Role/Level Theme Illustrative quote Outer setting/Stigma Social Worker, Kenema Stigma deters care and reintegration “People see KUSH users as criminals, not patients. Families hide their relatives, and employers refuse to hire them.” Outer setting/Structural determinants Reintegration Coordinator, National Unemployment undermines recovery “We discharge clients into the same conditions—no jobs, no income—and relapse follows despite best efforts.” Inner setting/Workforce Regional Coordinator, Eastern Specialist scarcity “We have no psychiatrists at regional centers. Task‑shifting helps, but complex cases need specialists.” Inner setting/Supplies Facility Administrator, Port Loko Stock‑outs and infrastructure gaps “We run out of essential medications monthly and sometimes operate without reliable power or water.” Intervention characteristics Ministry of Health Official, National Holistic design as a strength “Unlike past approaches, the five‑pillar strategy tackles prevention, treatment, reintegration, enforcement, and community engagement together.” Characteristics of individuals Nurse, Kenema Center Training depth “Two days of training introduced the basics, but complex cases still feel daunting without mentorship.” Process/Coordination Program Manager, Treatment Phased roll‑out and adaptation “We started where capacity existed and adapted as we learned, rather than waiting for perfect conditions.” Process/Monitoring District Focal Person, Kenema Feedback loops “We submit reports monthly, but response and data feedback from the national level come slowly.” Health–enforcement interface Facility Administrator, SLPTH Deterrence by arrest risk “Patients fear arrest near facilities. Clear non‑arrest zones and diversion protocols change that dynamic.” Youth engagement Youth Leader, Kenema Voice and ownership “The Task Force talks about us more than with us. Youth advisory roles improve message fit and uptake.” Community leadership Paramount Chief, Bo Cultural legitimacy “When chiefs and imams speak about recovery, communities listen. That opens doors for services.” Motivation & Burnout Counselor, Kenema Provider well‑being “Daily exposure to severe cases drains staff. We need support to keep going without burning out.” Table 3: Illustrative qualitative quotes by CFIR domain and pillar CFIR domain Pillar Theme Illustrative quote (de ‑ identified) Source (role/level/district) Outer setting Prevention (RCCE) Stigma deters care Families hide relatives who use Kush out of shame; people avoid clinics because they fear judgment. Social worker, Kenema Outer setting Reintegration Structural barriers We train people in skills, but there are no jobs. Without income, relapse risk stays high. Reintegration coordinator, National Outer setting Law enforcement Supply chain resilience We arrest street sellers, but the network replaces them within days. Traffickers stay upstream. NLDEA regional commander, Southern Outer setting Community engagement Traditional leaders as allies When the chief speaks, people listen. His endorsement opens doors for outreach teams. Community leader, Bo Inner setting Care & treatment Workforce scarcity We run a 50‑bed center without a psychiatrist. Nurses carry complex cases after a two‑day course. Facility administrator, Port Loko Inner setting Care & treatment Medication gaps Guidelines mention buprenorphine, but we don’t have it. We rely on supportive care. Medical officer, Port Loko Inner setting Data & M&E Weak data systems Paper registers get lost. Districts send late reports, so national dashboards stay incomplete. National M&E coordinator Inner setting Coordination District resourcing I coordinate a whole district with no vehicle and an irregular fuel budget. District focal person, Kenema Characteristics of individuals Care & treatment Training depth Two days gave me the basics, but I need mentoring for dual diagnosis and pregnancy cases. Nurse, Kenema center Characteristics of individuals Care & treatment Burnout Daily exposure to severe cases is draining. Some staff request transfers after a few months. Counselor, Western Area Urban Characteristics of individuals Community engagement Youth voice Adults design messages for us without us. Youth seats on committees change the tone. Youth representative, Bo Characteristics of individuals Prevention (RCCE) Language fit Most posters are in English. Rural communities respond when messages use local idioms. Regional coordinator, Northern Process Coordination High‑level leadership Monthly reviews chaired by the Vice President push ministries to deliver assigned actions. Ministry of Health representative, National Process Procurement Delays and workarounds Government procurement takes months. We bridged gaps with partner emergency stocks. Supply chain manager, National Process Adaptation Task‑shifting in practice We shifted counseling tasks to CHOs and paired them with tele‑consults from Freetown. Program manager, Treatment Process Law enforcement-health interface Diversion to treatment Non‑arrest zones around facilities reduce fear. Officers now call focal persons for referrals. Police supervisor, Western Area Urban Outer setting Coordination & governance NPHA platform NPHA’s situation room gives a backbone—data flow, convening power, and escalation routes. NaTFDSA pillar lead, National Process Community engagement Contact‑based RCCE Recovery testimonials shift attitudes more than lectures; communities trust lived experience. RCCE coordinator, National Inner setting Reintegration Financing predictability Reintegration stalls when district funds arrive late. Spending floors help planning. District focal person, Bo Outer setting Prevention (RCCE) Faith networks Friday sermons and Sunday messages carry prevention content to audiences that radio does not reach. Imam, Bo Outer setting Access Rural transport Mobile clinics and transport vouchers doubled attendance from remote chiefdoms. District focal person, Port Loko Inner setting Care & treatment Quality variation Freetown runs near full capacity with complete teams; regional centers still fill gaps. Regional coordinator, Eastern Process Monitoring Monthly review calls Monthly district‑to‑national calls surface problems early; quick fixes follow. NPHA analyst, Situation Room Outer setting Youth engagement Co‑design Co‑design in the local language cuts message resistance; youth groups now lead school events. Youth Brigade Lead, Western Area Urban Illustrative qualitative quotations by the CFIR domain and pillar . 1. Prevention/ Risk Communication and Community Engagement ( RCCE ) – acceptability and fit . “We mount the most aggressive public education campaign since Ebola. Awareness rises everywhere.” Said a National coordinator (Western Area Urban). “The messages from Freetown don’t fit our context; they ignore why young people use KUSH.” Said a District focal person (Port Loko) 2. Care and treatment – feasibility and fidelity . “We move from zero trained staff to hundreds in months.” Said a Training Lead (National) “Two days of training help, but complex cases still worry me.” Said a Nurse (in Kenema) “We train on buprenorphine, but the drug isn’t available here.” Said a Doctor (in Port Loko) 3. Reintegration – penetration and sustainability . “We discharge into the same conditions that led to KUSH use.” Said the Reintegration coordinator (National) “Former users can’t get jobs; stigma blocks them.” Said a District focal person (in Bo) 4. Law enforcement–health interface – appropriateness . “We arrest dealers; networks replace them within days.” Said the NLDEA leadership (at National) “Fear of arrest near facilities keeps people away from care.” Said a Facility administrator (SLPTH) 5. Community engagement – process and participation . “Paramount chiefs shift community attitudes when they speak.” Said the Community Engagement Lead (National). “Young people are not at the table; our voices are missing.” Said a Youth leader (in Kenema) 6. Coordination/governance – I nner S etting . “Before the Task Force, everyone worked alone; now we share data and decide together.” Said a Ministry of Health representative (National) “I coordinate five districts with no budget and no vehicle.” Said the Regional coordinator (Eastern) 7. Financing and sustainability . “Financial reporting is transparent, but procurement delays and slows delivery.” Said a Development partner, Program manager (treatment) Operational adaptations: To address early constraints, programs implemented task-shifting from psychiatrists to nurses and community health officers, supported by short courses and supervised through a national tele-consultation roster. Procurement delays were mitigated through emergency stock mobilization, standardized formularies, and consolidated district orders. Monitoring systems were strengthened using simplified registers, a community feedback tool, core indicator sets, and monthly district-national review calls led by the National Public Health Agency. RCCE campaigns featured recovery testimonials, provider language training, and community engagement with faith and traditional leaders. Rural access improved via mobile clinics and transport vouchers. Youth engagement was enhanced through advisory roles, youth brigades, and co-designed prevention messaging in local languages. Law enforcement piloted diversion-to-treatment protocols and non-arrest zones. Financing for reintegration stabilized through paired donor–domestic funding and quarterly district-level spending floors. CFIR-based qualitative determinants: The outer setting factors, Political leadership, and donor alignment enabled the rapid rollout [1]. Stigma, unemployment, and criminalization fears, however, limited reintegration. Youth participants in a companion study reported feeling judged by providers and unsafe near enforcement officers [20]. Inner setting challenges included staff shortages, unreliable transport, infrastructure gaps, and weak data systems in rural areas [1]. The five-pillar strategy was seen as appropriate for problem complexity but required high coordination capacity. Guidelines lacked adaptation for nitazene-class substances [1,3]. While short trainings improved staff confidence for routine cases, many felt unprepared for co-occurring psychiatric or medical conditions. Burnout was widely reported. Adaptive strategies: Teams adopted multiple strategies to preserve core intervention functions under pressure. These included: supervised task-shifting to nurses and community health workers; telepsychiatry consultations via WhatsApp; mobilization of emergency stockpiles; consolidated procurement systems; contact-based anti-stigma outreach; youth advisory groups and co-developed communications; and diversion protocols replacing punitive enforcement practices. These adaptations are considered fidelity-consistent per the FRAME framework [7,8]. Mixed-methods integration: Triangulation across interviews, focus groups, facility observations, documents, and routine data confirmed strong convergence in treatment fidelity and divergence in reintegration coverage. Quantitative gains in beds, workforce, and admissions were consistent with qualitative themes of urgency, reuse of COVID-era platforms, and visible political commitment. Reintegration shortfalls aligned with qualitative reports of stigma, economic hardship, and enforcement-related fears [1,14,15,16,17]. While enforcement efforts intensified, both data and interviews suggested only a modest impact on perceived drug availability, reinforcing known supply chain adaptation dynamics [1–3,18]. Discussions Principal findings: Sierra Leone's national KUSH response, evaluated from April 2024 to October 2025, achieved rapid multi-sectoral scale-up through five coordinated technical pillars (Figure 1). Treatment capacity expanded from 50 to 212 beds (+324%) across six facilities, three regional centers were launched, and 847 health workers were trained (Figure 2). The National Task Force on Drug and Substance Abuse (NaTFDSA), modeled after the NaCOVERC coordination system from COVID-19, leveraged proven emergency routines. The newly launched National Public Health Agency (December 2023) provided situation room capabilities, data systems, and operational coordination [1,13]. This architecture enabled implementation at a pace rarely seen in low-resource settings. However, some significant inequities emerged. The reintegration services reached just 678 of 1,834 discharged patients (37%), and only 43% of those with follow-up had returned to work or school (Table 1). Rural districts, particularly Port Loko, showed 40% lower bed occupancy and 60% fewer trained staff per capita than Western Area Urban, with similar gaps in prevention reach and reintegration coverage [1-3]. Relationship to existing literature: This case supports crisis governance theory, where focusing on events and institutional memory accelerates implementation [13,14]. Clear authority structures, such as vice-presidential chairmanship and donor alignment, reduced fragmentation and supported fast rollout [14]. Health-led strategies are more effective than enforcement-heavy approaches, yet despite 891 arrests, only a 35% perceived reduction in drug availability occurred [3,15,19]. This reflects resilience and displacement within supply chains, well documented in the literature [15]. Stigma emerged as a persistent barrier, confirming research on its deterrent effects on care-seeking and recovery [16,17]. A companion youth study (n=104) reported avoidance of care due to provider judgment, fear of arrest, and economic instability [20]. The Consolidated Framework for Implementation Research analysis identified outer setting accelerators such as political leadership, unified messaging, and donor harmonization as critical enablers [8,9,14]. Routine reactivation of incident management, data reporting, and expedited procurement reduced friction (Table 2). Inner setting constraints, such as limited budget, authority at the district level, weak transport systems, and paper-based reporting, compromised reach and equity [1]. The FRAME framework distinguished fidelity-consistent adaptations, like task-shifting with supervision, from transformative adaptations such as mobile clinics, which restructured rural service delivery [7,8,9]. Adaptive implementation strategies: Context-specific innovations addressed implementation barriers. Nurses and Community Health Officers (CHOs) managed routine cases under telepsychiatry supervision. Emergency pharmaceutical stocks bridged three-month procurement gaps (Table 1). One-page registers replaced complex forms, improving data completeness from 45% to 85%. RCCE programs featured contact-based strategies using recovered users as peer educators. Clinic space was negotiated with paramount chiefs for mobile outreach, reducing rural travel burdens by 75%. Youth brigades co-designed prevention messaging in local languages, elevating engagement from tokenistic consultation to genuine partnership. Police trained in diversion protocols tripled facility referrals [1,3]. These responses illustrate how adaptive design can maintain fidelity under constraints [8]. Equity and reintegration gaps: Reintegration outcomes highlight systemic neglect of social determinants. Only 79 individuals received economic grants despite unemployment being a leading relapse trigger. No facilities had dedicated services for women, and none provided private spaces for counselling, on-site childcare during treatment sessions, or protocols for intimate partner violence screening and referral. Rural-urban disparity worsened throughout implementation, with Port Loko and other rural districts receiving 65% less per capita funding than urban centers (Table 3). Youth described relapse cycles driven by hopelessness, stigma, and fear of criminalization [20]. These are not delivery failures; they reflect structural exclusion and underline the need to treat addiction as a social issue, not a criminal one [16,17,20,21]. Policy and practice implications: To sustain progress, NaTFDSA must transition from emergency operation to institutionalized coordination within the National Public Health Agency. DHIS2 should include substance-use indicators for routine monitoring. Funding for peer-led roles, reintegration staff, and youth programs must be formalized in recurrent budgets, not project cycles. Diversion-to-treatment must be scaled nationwide, supported by enforcement reforms that protect confidentiality and reduce deterrents to care [1-3,14,19,20,21]. Gender-responsive service design, including female-only treatment hours, childcare provision, and trauma-informed care, must move from peripheral to central elements of national strategy. Without these transitions, current gains will erode when emergency funding expires. Strengths and limitations: Strengths include theory-guided analysis, methodological triangulation across five data sources, and adherence to StaRI and COREQ standards [9-12]. Limitations include a cross-sectional design, partial data completeness (37%) for reintegration follow-up, and an implementer-focused perspective, although partially balanced by the companion youth study [20]. The 18-month evaluation captures early implementation but not long-term sustainability. Future evaluations should track longitudinal outcomes, center user experience in design, and measure population-level impact beyond facility-based metrics [18]. Lessons for other contexts: Countries facing synthetic drug crises can accelerate implementation by adapting existing emergency infrastructure, not reinventing systems. High-level leadership, pooled donor funding, and routine performance forums are critical. However, retrofit equity strategies consistently fail; designing for rural access and youth engagement from the outset is essential. Reintegration cannot be an afterthought; economic pathways must be embedded from day one. Safe zones and diversion protocols should be standard practice, not pilot projects. Accountability can be enhanced through public dashboards, community feedback loops, and meaningful youth participation in governance structures [1-3,13,14,19]. Conclusion Sierra Leone's response demonstrates that crisis-driven implementation is possible in low-resource settings when leadership, coordination, and adaptability converge. The successful adaptation of COVID-era systems through NaTFDSA, operationalized by the National Public Health Agency (NPHA), offers a replicable model. But speed must be matched by equity. Without institutionalization, dedicated financing, and focus on lived experiences, gains will remain fragile. Recovery successes must be measured not only through infrastructure metrics but through dignity restored, stigma challenged, and sustained reintegration for those navigating addiction and its consequences. Research in context: Evidence before this study. Reports describe nitazene‑dominant KUSH markets in West Africa and rapid diffusion in Sierra Leone, while global monitoring warns about potent synthetic opioids entering new markets. National statements in April 2024 announced a five‑pillar emergency response. Before this evaluation, no peer‑reviewed implementation study documented how the response scaled, with what fidelity, and why [1,2,4–6]. Added value of this study. This study provides the first mixed‑methods, theory‑guided evaluation of Sierra Leone’s national KUSH response. It explains how leadership, pre‑existing emergency architecture, and partner alignment enabled rapid scale‑up; why reintegration and rural coverage lagged; and where to target strategy in the next phase [1,3,9–12,13,14]. Implications of all the available evidence. Emergency architecture can accelerate delivery, but sustained results require institutionalization, routine financing, strong data systems, anti‑stigma and harm‑reduction practices, and clear protocols that link enforcement to care [3,14–17,19]. Abbreviations CFIR Consolidated Framework for Implementation Research COREQ Consolidated Criteria for Reporting Qualitative Research DHIS2 District Health Information Software 2 FGD Focus Group Discussion HCW HealthCare Worker IDI In‑Depth Interview NaCOVERC National COVID‑19 Emergency Response Center NaTFDSA National Task Force on Drug and Substance Abuse NPHA National Public Health Agency RCCE Risk Communication and Community Engagement STAGE Scientific Technical Advisory Group for Emergencies StaRI Standards for Reporting Implementation Studies. Declarations Ethics, data sharing, and reporting: This study was approved by the Sierra Leone Ethics and Scientific Review Committee (Protocol SLERC-2025-047). All participants provided verbal informed consent. De-identified qualitative data and aggregated implementation indicators are available upon reasonable request from the corresponding author, subject to ethical clearance. Reporting aligns with StaRI and COREQ [1,11,12]. Acknowledgments: We acknowledge with many thanks the support from Connaught Teaching Hospital Complex, partner organizations, and government agencies for the information that contributed to this manuscript. Ethics approval: This study was reviewed and approved by the Sierra Leone Research and Ethics Review Board of the Ministry of Health (Approval ID: SLREB/2024/0001). Informed consent was obtained from all participants through a detailed consent form explaining the study's purpose, procedures, risks, and benefits. Participants were assured that their responses would remain confidential and that they could withdraw from the study at any time without any penalty. To further ensure participant privacy, all data were anonymized, and no identifying information was linked to individual responses. Additionally, the study was conducted in accordance with the Declaration of Helsinki on research involving human subjects. Consent to Participate: All participants provided informed consent to participate in this study. Consent for publication: All participants consented to the publication of this information. Authors’ Contributions: Study conceptualization and design were conducted by ENI, FS, MAV, DLK, and LN. ENI, LN, FS, MAV, and DLK performed data collection and analysis. Manuscript drafting was conducted by ENI and DLK. Critical review and editing involved all authors. All authors approved the final version of this manuscript. Conflict of Interests : All authors declare no conflicts of interest. Data Availability : All data related to this manuscript are available upon a reasonable request to the corresponding author. Funding/Support : There was no external research funding for this study. Authors' Information: Dr. Eric Nzirakaindi Ikoona (ENI) is at National Public Health Agency, Freetown, Sierra Leone; Prof. Foday Sahr (FS) is at National Public Health Agency, Freetown, Sierra Leone; Dr. Mohamed A Vandi (MAV) is at National Public Health Agency, Freetown, Sierra Leone; Dr. Lucy Namulemo (LN) is at Foothills Community-Based interventions, Monticello, Kentucky, USA; Dr. Ronald Kaluya (RK) is at Uganda Counseling and Support Services, Kampala, Uganda; Mr. Fatmata Kanja Jalloh (FKJ) is at Uganda Counseling and Support Services, Kampala, Uganda; Dr. Mame Awe Toure is at ICAP at the University of Columbia, Freetown, Sierra Leone; Prof. David Lagoro Kitara (DLK) is a Takemi fellow of Harvard University and a Professor at Gulu University, Faculty of Medicine, Department of Surgery, Gulu City, Uganda. References National Task Force on Drug and Substance Abuse (NaTFDSA) and National Public Health Agency, Sierra Leone. From Policy to Practice: A CFIR-Based Evaluation of Sierra Leone's Rapid Scale-Up of the National Kush Response (2024–2025). Unpublished evaluation report; 2025. National Taskforce on Drugs and Substance Abuse Convenes to Address Sierra Leone’s Drug Crisis Reuters. Sierra Leone declares a national emergency on drug abuse. 5 Apr 2024. Available at: https://www.reuters.com/world/africa/sierra-leone-declares-national-emergency-drug-abuse-2024-04-05/ UNODC & WHO. International Standards for the Treatment of Drug Use Disorders. Geneva/Vienna: UNODC/WHO; 2020. United Nations Office on Drugs and Crime. World Drug Report 2024: Key findings and conclusions. Vienna: UNODC; 2024. United Nations Office on Drugs and Crime. World Drug Report 2025: Key findings. Vienna: UNODC; 2025. Clingendael Institute & Global Initiative Against Transnational Organized Crime. Kush in Sierra Leone: West Africa's growing synthetic drugs challenge. 25 Feb 2025. Clingendael Institute & Global Initiative Against Transnational Organized Crime. Kush in Sierra Leone: West Africa's growing synthetic drugs challenge. 25 Feb 2025. - Search Stirman SW, Baumann AA, Miller CJ. The FRAME: an expanded framework for reporting adaptations and modifications to evidence-based interventions. Implementation Science. 2019;14(1):58. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation Science. 2009;4:50. Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Administration and Policy in Mental Health and Mental Health Services Research. 2011;38(2):65–76. Kirk MA, Moore JE, Wiltsey Stirman S, Birken SA. Towards a comprehensive model for understanding adaptations' impact: the model for adaptation design and impact (MADI). Implementation Science. 2020;15(1):56. Pinnock H, Barwick M, Carpenter CR, Eldridge S, Grandes G, Griffiths CJ, et al. Standards for Reporting Implementation Studies (StaRI) Statement. BMJ. 2017;356:i6795. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care. 2007;19(6):349–357. Boin A, Lodge M. Designing resilient institutions for transboundary crisis management: a time for public administration. Public Administration. 2016;94(2):289–298. Rasanathan K, Bennett S, Atkins V, Beschel R, Carrasquilla G, Charles J, et al. Governing multi-sectoral action for health in low- and middle-income countries. PLoS Medicine. 2017;14(4):e1002285. Harm Reduction International. The Global State of Harm Reduction 2024. London: Harm Reduction International; 2024. Link BG, Phelan JC. Conceptualizing stigma. Annual Review of Sociology. 2001;27:363–385. Livingston JD, Milne T, Fang ML, Amari E. The effectiveness of interventions for reducing stigma related to substance use disorders: a systematic review. Addiction. 2012;107(1):39–50. Chambers DA, Glasgow RE, Stange KC. The dynamic sustainability framework: addressing the paradox of sustainment amid ongoing change. Implementation Science. 2013;8(1):117. WHO. Community management of opioid overdose. Geneva: World Health Organization; 2014. Ikoona EN, Namulemo L, Kaluya R, Vandi MA, Sahr F, Kitara DL. Lived Experiences and Recovery Challenges of Youth Facing the KUSH Crisis in Sierra Leone: A Qualitative Study. SSRN; 2025. doi:10.2139/ssrn.5543304. Oyat FWD, Oloya JN, Atim P, Ikoona EN, Aloyo J, Kitara DL. The psychological impact, risk factors, and coping strategies of the COVID-19 pandemic on healthcare workers in sub-Saharan Africa: a narrative review of existing literature. BMC Psychol.;10(1):284. Additional Declarations The authors declare no competing interests. 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. 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(2024–2025)\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eKUSH refers to a street drug market in Sierra Leone, with laboratory evidence linking it primarily to nitazene-class synthetic opioids mixed with various psychoactive agents [1-3]. These compounds carry high overdose risk, especially in contexts with limited treatment infrastructure, surveillance, or harm-reduction systems [4\u0026ndash;6]. In April 2024, the President of Sierra Leone declared a national emergency and announced a five-pillar response covering; prevention, care and treatment, social support, rehabilitation and reintegration, law enforcement, and community engagement; coordinated by a new National Task Force on Drug and Substance Abuse (NaTFDSA) modeled on the National COVID-19 Emergency Response Centre (NaCOVERC) established in 2020 to coordinate the prevention and control of COVID-19 [1,2].\u003c/p\u003e\n\u003cp\u003eIn parallel, the National Public Health Agency, launched in December 2023, provided coordination infrastructure, including a situation room, operational dashboards, and district-facing logistics platforms [1]. The reuse of NaCOVERC architecture and the National Public Health Agency emergency preparedness and response infrastructure provides a unique test case of how emergency coordination structures can be adapted for substance use crises [1,2].\u003c/p\u003e\n\u003cp\u003eInternational agencies such as the World Health Organization (WHO) and the United Nations Office for Drugs and Crime (UNODC) recommend balanced responses to synthetic opioids, pairing treatment, harm reduction, and reintegration with proportionate enforcement [3,4,5]. Monitoring alerts have identified West Africa, including Sierra Leone, as a hotspot for nitazene-linked synthetic opioid diffusion [1-5]. However, implementation fidelity, system readiness, and adaptation remain under-examined in this context.\u003c/p\u003e\n\u003cp\u003eExisting literature focuses primarily on the chemical composition of KUSH and media narratives [4\u0026ndash;6]. Peer-reviewed studies have yet to document the fidelity, reach, or adaptation of Sierra Leone\u0026rsquo;s five-pillar response, nor analyzed the enabling role of emergency coordination infrastructures. No published evaluation applies implementation theory to explain how the presidential decree was translated into operational service delivery, nor how the system performed on reintegration, equity, and rural access [2,7].\u003c/p\u003e\n\u003cp\u003eThis study addresses these gaps. We conducted a mixed-methods, theory-guided evaluation of Sierra Leone\u0026rsquo;s national KUSH response from April 2024 to October 2025. We used the Consolidated Framework for Implementation Research (CFIR) to analyze implementation determinants [8], Proctor\u0026rsquo;s taxonomy to measure implementation outcomes [9], and the FRAME framework to categorize adaptation types [10]. StaRI and COREQ guided reporting quality [11,12], while crisis and multi-sector governance theory provided an interpretive lens for understanding speed, equity, and institutionalization [13,14].\u003c/p\u003e\n\u003cp\u003eThe objective of this evaluation was to assess fidelity, scale, and determinants of Sierra Leone\u0026rsquo;s KUSH response during the first 18 months of implementation. We asked: What scaled, where, and why? What implementation determinants shaped rollout? How did quantitative indicators and qualitative findings align or diverge? What strategies enabled adaptation under constraint? And what lessons follow for sustaining and equitably expanding services in crisis-affected, resource-limited contexts?\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eDesign and Setting\u003c/strong\u003e\u003cstrong\u003es:\u0026nbsp;\u003c/strong\u003eWe employed a convergent mixed-methods design in four purposively selected districts: Western Area Urban, Bo, Kenema, and Port Loko, chosen to reflect geographic, urban\u0026ndash;rural, and health system capacity diversity. The implementation window under review spanned April 2024 to October 2025. Data collection occurred between June and September 2025.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplementation Architecture\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eFigure 1 illustrates the coordination structure for Sierra Leone\u0026rsquo;s National Task Force on Drug and Substance Abuse (NaTFDSA). The Task Force was chaired by the Vice President and supported by a national coordinator, a strategic advisory group, and the National Public Health Agency (NPHA) (Figure 1). The NPHA housed the incident-management situation room and operationalized district-level implementation through five regional coordination hubs and district focal persons.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTechnical pillars included:\u003c/strong\u003e (1) Risk Communication and Community Engagement (RCCE), (2) Care and Treatment, (3) Social Support and Reintegration, (4) Diagnostics and Surveillance, and (5) Safe and Dignified Burial. The operational support was led by the National Drug Law Enforcement Agency (NLDEA), the Ministry of Health, and partners through transport/logistics and security coordination.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGuiding Frameworks\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eWe applied three core implementation science frameworks to guide the evaluation [8,9,10]. The Consolidated Framework for Implementation Research (CFIR) was used to structure the analysis of implementation determinants across five domains: outer setting, inner setting, intervention characteristics, characteristics of individuals, and process [8]. Proctor\u0026rsquo;s taxonomy provided a basis for defining and measuring implementation outcomes, including fidelity, acceptability, feasibility, and sustainability [10].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo categorize changes in delivery approach, we used the FRAME (Framework for Reporting Adaptations and Modifications\u0026ndash;Enhanced), distinguishing between fidelity-consistent adaptations (e.g., task-shifting, telepsychiatry) and transformative shifts (e.g., mobile clinics altering service geography) [7,8,9]. Implementation determinants reflected the CFIR domains [8]. Outer setting factors, such as political leadership and donor alignment, accelerated rollout, while inner setting challenges, including workforce shortages and fragile data systems, and limited fidelity [8].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFRAME-informed coding identified adaptive strategies that preserved core intervention functions under constraint [7]. Implementation outcomes were classified according to Proctor\u0026rsquo;s framework and aligned with the mixed-methods indicator set [10]. Together, these frameworks enabled structured analysis, triangulated interpretation, and comparison to other global implementation experiences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSelection of participants:\u0026nbsp;\u003c/strong\u003eThe selection of participants for interviews and FGDs was purposive and targeted national policy makers, program coordinators, district focal persons, community representatives, staff of treatment facilities, Law enforcement officers, and development partners.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSelection criteria:\u0026nbsp;\u003c/strong\u003eThe study included participants who were involved in the implementation of the program at all levels.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion Criteria:\u0026nbsp;\u003c/strong\u003eInformed consent, and persons who had been in Sierra Leone for at least 6 months before the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion Criteria:\u0026nbsp;\u003c/strong\u003eConflict of interest and lack of consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants and Data Sources\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eWe conducted 52 in-depth interviews with national policymakers, program coordinators, district focal persons, and development partners. Additionally, eight focus group discussions (FGDs) were held with 67 district-level implementers and community representatives. Structured observations were carried out in 18 treatment and prevention facilities across the four study districts. We reviewed 127 documents, including strategies, quarterly reports, financial records, training materials, and monitoring tools. Routine monitoring indicators were extracted from national dashboards and facility registers [1].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRoutine Indicators\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eWe abstracted monthly bed capacity, staffing, and admissions data from all six treatment centers, with 100% completeness. For reintegration outcomes, follow-up data on employment and educational status were available for 673 of 1,834 discharged patients (37%). Law enforcement indicators were compiled from NLDEA monthly reports, covering all districts. Arrests were classified as \u0026ldquo;high-level traffickers\u0026rdquo; when suspects possessed more than 5 kilograms of substances or had documented cross-border trafficking links.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUser Perception Survey\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eA structured street-intercept survey was conducted in September 2025 across the four study districts (n = 220; ~55 per district). Trained enumerators approached adults in market areas and transport hubs. After obtaining verbal informed consent, respondents were asked: \u0026ldquo;Compared to six months ago, how would you rate the availability of KUSH in your community?\u0026rdquo; Responses were recorded on a 5-point Likert scale ranging from \u0026ldquo;much less available\u0026rdquo; to \u0026ldquo;much more available.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval:\u0026nbsp;\u003c/strong\u003eEthics approval was granted by the Sierra Leone Ethics and Scientific Review Committee (Protocol SLERC-2025-047). Verbal informed consent was obtained from all participants before interviews or FGDs, including consent for audio recording. All data were de-identified and stored on encrypted devices. The principle of good practice in accordance with the Declaration of Helsinki on involving human subjects in research was adhered to.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProcedures and Analysis\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eSemi-structured interview and FGD guides were developed based on the CFIR and Proctor frameworks. Two trained analysts independently coded all qualitative transcripts using thematic analysis. A third analyst resolved discrepancies. Quantitative indicators covered inputs (infrastructure, human resources), outputs (service delivery), and process measures (coordination and financing).\u003c/p\u003e\n\u003cp\u003eFidelity scoring used equal weighting across achievement domains; sensitivity analysis demonstrated \u0026lt;5-point variation when weights were adjusted \u0026plusmn;10%. Qualitative and quantitative data were integrated through triangulation matrices and joint displays to generate meta-inferences. Data validation occurred through stakeholder workshops and member checking at the national and district levels.\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003eQuantitative outcomes.\u003c/h2\u003e\n\u003cp\u003eTreatment capacity expanded from 50 to 212 beds across six centers (+324%), exceeding the national target of 180 beds (118%) [1]. The Sierra Leone Psychiatric Teaching Hospital was scaled to 60 beds, while three regional centers were opened. A total of 847 health workers were trained (77% of the 1,100 target), and 1,289 admissions occurred over 18 months (71.6/month). Prevention activities reached 1,186 communities (62% of the target), and reintegration services reached 678 discharged patients. Among 673 with six-month follow-up data, 43% had returned to work or school. Law enforcement reported 891 kush-related arrests and 189.7 kg of seizures, including 47 high-level trafficker arrests. A perception survey in September 2025 (n=220) reported a 35% reduction in street-level availability. The Task Force met all 18 times as planned and mobilized US$2.23 million, executing 78% of the budget. Reintegration was the lowest-spending pillar. Key indicators appear in Table 1, and Figure 2 summarizes pillar-level progress against targets.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Key implementation indicators by pillar (April 2024\u0026ndash;October 2025)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"716\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePillars\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e18\u003c/strong\u003e\u003cstrong\u003e‑\u003c/strong\u003e\u003cstrong\u003eMonth Result\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTarget\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e% Achieved\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 716px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePILLAR 1: PREVENTION \u0026amp; RISK COMMUNICATION\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eCommunities reached\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e1,186\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e1,900\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e62%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eRadio programs aired\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e247\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eN/S\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eSchool programs established\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e34 schools\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eN/S\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 716px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePILLAR 2: CARE \u0026amp; TREATMENT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eTreatment bed capacity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e50 (1 center)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e212 (6 centers)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e180 beds\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e118%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eFacilities operational\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e1 (SLPTH only)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e6 (all regions)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e6 centers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eHealth workers trained\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e847\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e1,100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e77%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eCumulative admissions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e0*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e1,289 (71.6/month)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eN/S\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eAverage length of stay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e28 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eN/S\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 716px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePILLAR 3: SOCIAL REINTEGRATION\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003ePatients accessing services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e678 of 1,834 discharged\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eN/S\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eReturn to work/school (6‑mo)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e43% (289 of 673 eligible)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e70% of served\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e61%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eVocational training provided\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e412 patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eN/S\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eEconomic empowerment grants\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e79 patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eN/S\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 716px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePILLAR 4: LAW ENFORCEMENT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eTotal arrests\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e247 (full year, 2023)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e891 (18 months)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eN/S\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eSeizures (kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e47.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e189.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eN/S\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eHigh‑level trafficker arrests\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eN/S\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eStreet availability reduction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e35% (surveys)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e80% reduction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e44%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 716px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePILLAR 5: COMMUNITY ENGAGEMENT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eDistrict focal persons recruited\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e16 (all)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eCommunity advisory committees\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eN/S\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eTraditional/religious leaders engaged\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eSporadic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e347\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eN/S\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 716px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCOORDINATION \u0026amp; FINANCING\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eTask Force meetings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e18 (monthly)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eBudget mobilized (USD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e$0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e$2.23 million\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eN/S\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026ndash; Government contribution\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e$0.78 million (35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eN/S\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026ndash; Donor contribution\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e$1.45 million (65%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eN/S\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 258px;\"\u003e\n \u003cp\u003eBudget execution rate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e78% ($1.74M spent)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026ge;80%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003e98%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNotes: N/S = Not specified in original plan; N/A = Not applicable; SLPTH = Sierra Leone Psychiatric Teaching Hospital. Baseline for cumulative admissions indicates no NaTFDSA baseline before the April 2024 emergency declaration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData sources by category:\u0026nbsp;\u003c/strong\u003ePrevention \u0026amp; RCCE indicators: RCCE activity logs and community registers\u003cstrong\u003e;\u0026nbsp;\u003c/strong\u003eCare \u0026amp; Treatment indicators: Facility registers and training databases; Social Reintegration indicators: Discharge registers and follow-up tracking systems\u003cstrong\u003e;\u0026nbsp;\u003c/strong\u003eLaw Enforcement indicators: NLDEA monthly reports;\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eCommunity Engagement indicators: District focal person reports;\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eCoordination \u0026amp; Financing: NaTFDSA quarterly reports (Q2 2024-Q4 2025) and financial records.\u003c/p\u003e\n\u003cp\u003eTable 2. Illustrative qualitative quotes (by CFIR domain/pillar).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"713\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDomain/Pillar\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRole/Level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIllustrative quote\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eOuter setting/Stigma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eSocial Worker, Kenema\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eStigma deters care and reintegration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026ldquo;People see KUSH users as criminals, not patients. Families hide their relatives, and employers refuse to hire them.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eOuter setting/Structural determinants\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eReintegration Coordinator, National\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eUnemployment undermines recovery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026ldquo;We discharge clients into the same conditions\u0026mdash;no jobs, no income\u0026mdash;and relapse follows despite best efforts.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eInner setting/Workforce\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eRegional Coordinator, Eastern\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eSpecialist scarcity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026ldquo;We have no psychiatrists at regional centers. Task‑shifting helps, but complex cases need specialists.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eInner setting/Supplies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eFacility Administrator, Port Loko\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eStock‑outs and infrastructure gaps\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026ldquo;We run out of essential medications monthly and sometimes operate without reliable power or water.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eIntervention characteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eMinistry of Health Official, National\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eHolistic design as a strength\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026ldquo;Unlike past approaches, the five‑pillar strategy tackles prevention, treatment, reintegration, enforcement, and community engagement together.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eCharacteristics of individuals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eNurse, Kenema Center\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eTraining depth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026ldquo;Two days of training introduced the basics, but complex cases still feel daunting without mentorship.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eProcess/Coordination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eProgram Manager, Treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003ePhased roll‑out and adaptation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026ldquo;We started where capacity existed and adapted as we learned, rather than waiting for perfect conditions.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eProcess/Monitoring\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eDistrict Focal Person, Kenema\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eFeedback loops\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026ldquo;We submit reports monthly, but response and data feedback from the national level come slowly.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eHealth\u0026ndash;enforcement interface\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eFacility Administrator, SLPTH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eDeterrence by arrest risk\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026ldquo;Patients fear arrest near facilities. Clear non‑arrest zones and diversion protocols change that dynamic.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eYouth engagement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eYouth Leader, Kenema\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eVoice and ownership\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026ldquo;The Task Force talks about us more than with us. Youth advisory roles improve message fit and uptake.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eCommunity leadership\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eParamount Chief, Bo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eCultural legitimacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026ldquo;When chiefs and imams speak about recovery, communities listen. That opens doors for services.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eMotivation \u0026amp; Burnout\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eCounselor, Kenema\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 150px;\"\u003e\n \u003cp\u003eProvider well‑being\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u0026ldquo;Daily exposure to severe cases drains staff. We need support to keep going without burning out.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003eTable 3: Illustrative qualitative quotes by CFIR domain and pillar\u003c/h2\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"762\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCFIR domain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePillar\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIllustrative quote (de\u003c/strong\u003e\u003cstrong\u003e‑\u003c/strong\u003e\u003cstrong\u003eidentified)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSource (role/level/district)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003eOuter setting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003ePrevention (RCCE)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eStigma deters care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eFamilies hide relatives who use Kush out of shame; people avoid clinics because they fear judgment.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eSocial worker, Kenema\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003eOuter setting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eReintegration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eStructural barriers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eWe train people in skills, but there are no jobs. Without income, relapse risk stays high.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eReintegration coordinator, National\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003eOuter setting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eLaw enforcement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eSupply chain resilience\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eWe arrest street sellers, but the network replaces them within days. Traffickers stay upstream.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eNLDEA regional commander, Southern\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003eOuter setting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eCommunity engagement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eTraditional leaders as allies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eWhen the chief speaks, people listen. His endorsement opens doors for outreach teams.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eCommunity leader, Bo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003eInner setting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eCare \u0026amp; treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eWorkforce scarcity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eWe run a 50‑bed center without a psychiatrist. Nurses carry complex cases after a two‑day course.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eFacility administrator, Port Loko\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003eInner setting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eCare \u0026amp; treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eMedication gaps\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eGuidelines mention buprenorphine, but we don\u0026rsquo;t have it. We rely on supportive care.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eMedical officer, Port Loko\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003eInner setting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eData \u0026amp; M\u0026amp;E\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eWeak data systems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003ePaper registers get lost. Districts send late reports, so national dashboards stay incomplete.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eNational M\u0026amp;E coordinator\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003eInner setting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eCoordination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eDistrict resourcing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eI coordinate a whole district with no vehicle and an irregular fuel budget.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eDistrict focal person, Kenema\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003eCharacteristics of individuals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eCare \u0026amp; treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eTraining depth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eTwo days gave me the basics, but I need mentoring for dual diagnosis and pregnancy cases.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eNurse, Kenema center\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003eCharacteristics of individuals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eCare \u0026amp; treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eBurnout\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eDaily exposure to severe cases is draining. Some staff request transfers after a few months.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eCounselor, Western Area Urban\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003eCharacteristics of individuals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eCommunity engagement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eYouth voice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eAdults design messages for us without us. Youth seats on committees change the tone.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eYouth representative, Bo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003eCharacteristics of individuals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003ePrevention (RCCE)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eLanguage fit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eMost posters are in English. Rural communities respond when messages use local idioms.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eRegional coordinator, Northern\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003eProcess\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eCoordination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eHigh‑level leadership\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eMonthly reviews chaired by the Vice President push ministries to deliver assigned actions.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eMinistry of Health representative, National\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003eProcess\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eProcurement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eDelays and workarounds\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eGovernment procurement takes months. We bridged gaps with partner emergency stocks.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eSupply chain manager, National\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003eProcess\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eAdaptation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eTask‑shifting in practice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eWe shifted counseling tasks to CHOs and paired them with tele‑consults from Freetown.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eProgram manager, Treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003eProcess\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eLaw enforcement-health interface\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eDiversion to treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eNon‑arrest zones around facilities reduce fear. Officers now call focal persons for referrals.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003ePolice supervisor, Western Area Urban\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003eOuter setting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eCoordination \u0026amp; governance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eNPHA platform\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eNPHA\u0026rsquo;s situation room gives a backbone\u0026mdash;data flow, convening power, and escalation routes.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eNaTFDSA pillar lead, National\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003eProcess\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eCommunity engagement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eContact‑based RCCE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eRecovery testimonials shift attitudes more than lectures; communities trust lived experience.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eRCCE coordinator, National\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003eInner setting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eReintegration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eFinancing predictability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eReintegration stalls when district funds arrive late. Spending floors help planning.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eDistrict focal person, Bo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003eOuter setting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003ePrevention (RCCE)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eFaith networks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eFriday sermons and Sunday messages carry prevention content to audiences that radio does not reach.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eImam, Bo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003eOuter setting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eAccess\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eRural transport\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eMobile clinics and transport vouchers doubled attendance from remote chiefdoms.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eDistrict focal person, Port Loko\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003eInner setting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eCare \u0026amp; treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eQuality variation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eFreetown runs near full capacity with complete teams; regional centers still fill gaps.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eRegional coordinator, Eastern\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003eProcess\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eMonitoring\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eMonthly review calls\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eMonthly district‑to‑national calls surface problems early; quick fixes follow.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eNPHA analyst, Situation Room\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003eOuter setting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 106px;\"\u003e\n \u003cp\u003eYouth engagement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eCo‑design\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eCo‑design in the local language cuts message resistance; youth groups now lead school events.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eYouth Brigade Lead, Western Area Urban\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eIllustrative qualitative quotations by the CFIR domain and pillar\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e\u003cem\u003e\u003cbr\u003e\u003c/em\u003e\u003cstrong\u003e1.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ePrevention/\u003c/strong\u003e\u003cstrong\u003eRisk Communication and Community Engagement\u003c/strong\u003e (\u003cstrong\u003eRCCE\u003c/strong\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u0026ndash; acceptability and fit\u003c/strong\u003e.\u003cbr\u003e\u0026nbsp;\u0026ldquo;We mount the most aggressive public education campaign since Ebola. Awareness rises everywhere.\u0026rdquo; \u0026nbsp;Said a National coordinator (Western Area Urban).\u003cbr\u003e\u0026nbsp;\u0026ldquo;The messages from Freetown don\u0026rsquo;t fit our context; they ignore why young people use KUSH.\u0026rdquo; Said a District focal person (Port Loko)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eCare and treatment \u0026ndash; feasibility and fidelity\u003c/strong\u003e.\u003cbr\u003e\u0026nbsp;\u0026ldquo;We move from zero trained staff to hundreds in months.\u0026rdquo; Said a Training Lead (National)\u003cbr\u003e\u0026nbsp;\u0026ldquo;Two days of training help, but complex cases still worry me.\u0026rdquo; Said a Nurse (in Kenema)\u003cbr\u003e\u0026nbsp;\u0026ldquo;We train on buprenorphine, but the drug isn\u0026rsquo;t available here.\u0026rdquo; Said a Doctor (in Port Loko)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eReintegration \u0026ndash; penetration and sustainability\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u0026ldquo;We discharge into the same conditions that led to KUSH use.\u0026rdquo; Said the Reintegration coordinator (National)\u003cbr\u003e\u0026nbsp;\u0026ldquo;Former users can\u0026rsquo;t get jobs; stigma blocks them.\u0026rdquo; Said a District focal person (in Bo)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eLaw enforcement\u0026ndash;health interface \u0026ndash; appropriateness\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;\u0026ldquo;We arrest dealers; networks replace them within days.\u0026rdquo; Said the NLDEA leadership (at National)\u003cbr\u003e\u0026nbsp;\u0026ldquo;Fear of arrest near facilities keeps people away from care.\u0026rdquo; Said a Facility administrator (SLPTH)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e5.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eCommunity engagement \u0026ndash; process and participation\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u0026ldquo;Paramount chiefs shift community attitudes when they speak.\u0026rdquo; Said the Community Engagement Lead (National).\u003cbr\u003e\u0026nbsp;\u0026ldquo;Young people are not at the table; our voices are missing.\u0026rdquo; Said a Youth leader (in Kenema)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eCoordination/governance \u0026ndash;\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eI\u003c/strong\u003e\u003cstrong\u003enner\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eS\u003c/strong\u003e\u003cstrong\u003eetting\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u0026ldquo;Before the Task Force, everyone worked alone; now we share data and decide together.\u0026rdquo; Said a \u0026nbsp;Ministry of Health representative (National)\u003cbr\u003e\u0026nbsp;\u0026ldquo;I coordinate five districts with no budget and no vehicle.\u0026rdquo; Said the Regional coordinator (Eastern)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e7.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eFinancing\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eand\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003esustainability\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u0026ldquo;Financial reporting is transparent, but procurement delays and slows delivery.\u0026rdquo; Said a Development partner, Program manager (treatment)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOperational adaptations: To address early constraints, programs implemented task-shifting from psychiatrists to nurses and community health officers, supported by short courses and supervised through a national tele-consultation roster. Procurement delays were mitigated through emergency stock mobilization, standardized formularies, and consolidated district orders. Monitoring systems were strengthened using simplified registers, a community feedback tool, core indicator sets, and monthly district-national review calls led by the National Public Health Agency. RCCE campaigns featured recovery testimonials, provider language training, and community engagement with faith and traditional leaders. Rural access improved via mobile clinics and transport vouchers. Youth engagement was enhanced through advisory roles, youth brigades, and co-designed prevention messaging in local languages. Law enforcement piloted diversion-to-treatment protocols and non-arrest zones. Financing for reintegration stabilized through paired donor\u0026ndash;domestic funding and quarterly district-level spending floors.\u003c/p\u003e\n\u003cp\u003eCFIR-based qualitative determinants: The outer setting factors, Political leadership, and donor alignment enabled the rapid rollout [1]. Stigma, unemployment, and criminalization fears, however, limited reintegration. Youth participants in a companion study reported feeling judged by providers and unsafe near enforcement officers [20]. Inner setting challenges included staff shortages, unreliable transport, infrastructure gaps, and weak data systems in rural areas [1]. The five-pillar strategy was seen as appropriate for problem complexity but required high coordination capacity. Guidelines lacked adaptation for nitazene-class substances [1,3]. While short trainings improved staff confidence for routine cases, many felt unprepared for co-occurring psychiatric or medical conditions. Burnout was widely reported.\u003c/p\u003e\n\u003cp\u003eAdaptive strategies: Teams adopted multiple strategies to preserve core intervention functions under pressure. These included: supervised task-shifting to nurses and community health workers; telepsychiatry consultations via WhatsApp; mobilization of emergency stockpiles; consolidated procurement systems; contact-based anti-stigma outreach; youth advisory groups and co-developed communications; and diversion protocols replacing punitive enforcement practices. These adaptations are considered fidelity-consistent per the FRAME framework [7,8].\u003c/p\u003e\n\u003cp\u003eMixed-methods integration: Triangulation across interviews, focus groups, facility observations, documents, and routine data confirmed strong convergence in treatment fidelity and divergence in reintegration coverage. Quantitative gains in beds, workforce, and admissions were consistent with qualitative themes of urgency, reuse of COVID-era platforms, and visible political commitment. Reintegration shortfalls aligned with qualitative reports of stigma, economic hardship, and enforcement-related fears [1,14,15,16,17]. While enforcement efforts intensified, both data and interviews suggested only a modest impact on perceived drug availability, reinforcing known supply chain adaptation dynamics [1\u0026ndash;3,18].\u003c/p\u003e"},{"header":"Discussions","content":"\u003cp\u003e\u003cstrong\u003ePrincipal findings:\u0026nbsp;\u003c/strong\u003eSierra Leone's national KUSH response, evaluated from April 2024 to October 2025, achieved rapid multi-sectoral scale-up through five coordinated technical pillars (Figure 1). Treatment capacity expanded from 50 to 212 beds (+324%) across six facilities, three regional centers were launched, and 847 health workers were trained (Figure 2). The National Task Force on Drug and Substance Abuse (NaTFDSA), modeled after the NaCOVERC coordination system from COVID-19, leveraged proven emergency routines. The newly launched National Public Health Agency (December 2023) provided situation room capabilities, data systems, and operational coordination [1,13]. This architecture enabled implementation at a pace rarely seen in low-resource settings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHowever, some significant inequities emerged. The reintegration services reached just 678 of 1,834 discharged patients (37%), and only 43% of those with follow-up had returned to work or school (Table 1). Rural districts, particularly Port Loko, showed 40% lower bed occupancy and 60% fewer trained staff per capita than Western Area Urban, with similar gaps in prevention reach and reintegration coverage [1-3].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRelationship to existing literature:\u0026nbsp;\u003c/strong\u003eThis case supports crisis governance theory, where focusing on events and institutional memory accelerates implementation [13,14]. Clear authority structures, such as vice-presidential chairmanship and donor alignment, reduced fragmentation and supported fast rollout [14]. Health-led strategies are more effective than enforcement-heavy approaches, yet despite 891 arrests, only a 35% perceived reduction in drug availability occurred [3,15,19]. This reflects resilience and displacement within supply chains, well documented in the literature [15]. Stigma emerged as a persistent barrier, confirming research on its deterrent effects on care-seeking and recovery [16,17]. A companion youth study (n=104) reported avoidance of care due to provider judgment, fear of arrest, and economic instability [20].\u003c/p\u003e\n\u003cp\u003eThe Consolidated Framework for Implementation Research analysis identified outer setting accelerators such as political leadership, unified messaging, and donor harmonization as critical enablers [8,9,14]. Routine reactivation of incident management, data reporting, and expedited procurement reduced friction (Table 2). Inner setting constraints, such as limited budget, authority at the district level, weak transport systems, and paper-based reporting, compromised reach and equity [1]. The FRAME framework distinguished fidelity-consistent adaptations, like task-shifting with supervision, from transformative adaptations such as mobile clinics, which restructured rural service delivery [7,8,9].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdaptive implementation strategies:\u0026nbsp;\u003c/strong\u003eContext-specific innovations addressed implementation barriers. Nurses and Community Health Officers (CHOs) managed routine cases under telepsychiatry supervision. Emergency pharmaceutical stocks bridged three-month procurement gaps (Table 1). One-page registers replaced complex forms, improving data completeness from 45% to 85%. RCCE programs featured contact-based strategies using recovered users as peer educators. Clinic space was negotiated with paramount chiefs for mobile outreach, reducing rural travel burdens by 75%. Youth brigades co-designed prevention messaging in local languages, elevating engagement from tokenistic consultation to genuine partnership. Police trained in diversion protocols tripled facility referrals [1,3]. These responses illustrate how adaptive design can maintain fidelity under constraints [8].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEquity and reintegration gaps:\u0026nbsp;\u003c/strong\u003eReintegration outcomes highlight systemic neglect of social determinants. Only 79 individuals received economic grants despite unemployment being a leading relapse trigger. No facilities had dedicated services for women, and none provided private spaces for counselling, on-site childcare during treatment sessions, or protocols for intimate partner violence screening and referral. Rural-urban disparity worsened throughout implementation, with Port Loko and other rural districts receiving 65% less per capita funding than urban centers (Table 3). Youth described relapse cycles driven by hopelessness, stigma, and fear of criminalization [20]. These are not delivery failures; they reflect structural exclusion and underline the need to treat addiction as a social issue, not a criminal one [16,17,20,21].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePolicy and practice implications:\u0026nbsp;\u003c/strong\u003eTo sustain progress, NaTFDSA must transition from emergency operation to institutionalized coordination within the National Public Health Agency. DHIS2 should include substance-use indicators for routine monitoring. Funding for peer-led roles, reintegration staff, and youth programs must be formalized in recurrent budgets, not project cycles. Diversion-to-treatment must be scaled nationwide, supported by enforcement reforms that protect confidentiality and reduce deterrents to care [1-3,14,19,20,21]. Gender-responsive service design, including female-only treatment hours, childcare provision, and trauma-informed care, must move from peripheral to central elements of national strategy. Without these transitions, current gains will erode when emergency funding expires.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths and limitations:\u0026nbsp;\u003c/strong\u003eStrengths include theory-guided analysis, methodological triangulation across five data sources, and adherence to StaRI and COREQ standards [9-12]. Limitations include a cross-sectional design, partial data completeness (37%) for reintegration follow-up, and an implementer-focused perspective, although partially balanced by the companion youth study [20]. The 18-month evaluation captures early implementation but not long-term sustainability. Future evaluations should track longitudinal outcomes, center user experience in design, and measure population-level impact beyond facility-based metrics [18].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLessons for other contexts:\u0026nbsp;\u003c/strong\u003eCountries facing synthetic drug crises can accelerate implementation by adapting existing emergency infrastructure, not reinventing systems. High-level leadership, pooled donor funding, and routine performance forums are critical. However, retrofit equity strategies consistently fail; designing for rural access and youth engagement from the outset is essential. Reintegration cannot be an afterthought; economic pathways must be embedded from day one. Safe zones and diversion protocols should be standard practice, not pilot projects.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAccountability can be enhanced through public dashboards, community feedback loops, and meaningful youth participation in governance structures [1-3,13,14,19].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eSierra Leone's response demonstrates that crisis-driven implementation is possible in low-resource settings when leadership, coordination, and adaptability converge. The successful adaptation of COVID-era systems through NaTFDSA, operationalized by the National Public Health Agency (NPHA), offers a replicable model. But speed must be matched by equity. Without institutionalization, dedicated financing, and focus on lived experiences, gains will remain fragile. Recovery successes must be measured not only through infrastructure metrics but through dignity restored, stigma challenged, and sustained reintegration for those navigating addiction and its consequences.\u003c/p\u003e\n\u003cp\u003eResearch in context: Evidence before this study. Reports describe nitazene‑dominant KUSH markets in West Africa and rapid diffusion in Sierra Leone, while global monitoring warns about potent synthetic opioids entering new markets. National statements in April 2024 announced a five‑pillar emergency response. Before this evaluation, no peer‑reviewed implementation study documented how the response scaled, with what fidelity, and why [1,2,4\u0026ndash;6].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdded value of this study.\u003c/strong\u003e This study provides the first mixed‑methods, theory‑guided evaluation of Sierra Leone\u0026rsquo;s national KUSH response. It explains how leadership, pre‑existing emergency architecture, and partner alignment enabled rapid scale‑up; why reintegration and rural coverage lagged; and where to target strategy in the next phase [1,3,9\u0026ndash;12,13,14].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications of all the available evidence.\u003c/strong\u003e Emergency architecture can accelerate delivery, but sustained results require institutionalization, routine financing, strong data systems, anti‑stigma and harm‑reduction practices, and clear protocols that link enforcement to care [3,14\u0026ndash;17,19].\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCFIR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eConsolidated Framework for Implementation Research\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCOREQ\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eConsolidated Criteria for Reporting Qualitative Research\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDHIS2\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDistrict Health Information Software 2\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eFGD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eFocus Group Discussion\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHCW\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHealthCare Worker\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIDI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIn‑Depth Interview\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNaCOVERC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNational COVID‑19 Emergency Response Center\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNaTFDSA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNational Task Force on Drug and Substance Abuse\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNPHA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNational Public Health Agency\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRCCE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRisk Communication and Community Engagement\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSTAGE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eScientific Technical Advisory Group for Emergencies\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eStaRI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eStandards for Reporting Implementation Studies.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics, data sharing, and reporting: This study was approved by the Sierra Leone Ethics and Scientific Review Committee (Protocol SLERC-2025-047). All participants provided verbal informed consent. De-identified qualitative data and aggregated implementation indicators are available upon reasonable request from the corresponding author, subject to ethical clearance. Reporting aligns with StaRI and COREQ [1,11,12].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003eWe acknowledge with many thanks the support from Connaught Teaching Hospital Complex, partner organizations, and government agencies for the information that contributed to this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval:\u0026nbsp;\u003c/strong\u003eThis study was reviewed and approved by the Sierra Leone Research and Ethics Review Board of the Ministry of Health (Approval ID: SLREB/2024/0001). Informed consent was obtained from all participants through a detailed consent form explaining the study\u0026apos;s purpose, procedures, risks, and benefits. Participants were assured that their responses would remain confidential and that they could withdraw from the study at any time without any penalty. To further ensure participant privacy, all data were anonymized, and no identifying information was linked to individual responses. Additionally, the study was conducted\u0026nbsp;in accordance with the Declaration of Helsinki on research involving human subjects.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate:\u0026nbsp;\u003c/strong\u003eAll participants provided informed consent to participate in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e All participants consented to the publication of this information.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions:\u0026nbsp;\u003c/strong\u003eStudy conceptualization and design were conducted by ENI, FS, MAV, DLK, and LN. ENI, LN, FS, MAV, and DLK performed data collection and analysis. Manuscript drafting was conducted by ENI and DLK. Critical review and editing involved all authors. All authors approved the final version of this manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interests\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eAll authors declare no conflicts of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eAll data related to this manuscript are available upon a reasonable request to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding/Support\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eThere was no external research funding for this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; Information:\u003c/strong\u003e Dr. Eric Nzirakaindi Ikoona (ENI) is at National Public Health Agency, Freetown, Sierra Leone; Prof. Foday Sahr (FS) is at National Public Health Agency, Freetown, Sierra Leone; Dr. Mohamed A Vandi (MAV) is at National Public Health Agency, Freetown, Sierra Leone; \u0026nbsp;Dr. Lucy Namulemo (LN) is at Foothills Community-Based interventions, Monticello, Kentucky, USA; Dr. Ronald Kaluya (RK) is at Uganda Counseling and Support Services, Kampala, Uganda; Mr. Fatmata Kanja Jalloh (FKJ) is at Uganda Counseling and Support Services, Kampala, Uganda; Dr. Mame Awe Toure is at ICAP at the University of Columbia, Freetown, Sierra Leone; Prof. David Lagoro Kitara (DLK) is a Takemi fellow of Harvard University and a Professor at Gulu University, Faculty of Medicine, Department of Surgery, Gulu City, Uganda.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eNational Task Force on Drug and Substance Abuse (NaTFDSA) and National Public Health Agency, Sierra Leone. From Policy to Practice: A CFIR-Based Evaluation of Sierra Leone\u0026apos;s Rapid Scale-Up of the National Kush Response (2024\u0026ndash;2025). Unpublished evaluation report; 2025. National Taskforce on Drugs and Substance Abuse Convenes to Address Sierra Leone\u0026rsquo;s Drug Crisis\u003c/li\u003e\n\u003cli\u003eReuters. Sierra Leone declares a national emergency on drug abuse. 5 Apr 2024. Available at: https://www.reuters.com/world/africa/sierra-leone-declares-national-emergency-drug-abuse-2024-04-05/\u003c/li\u003e\n\u003cli\u003eUNODC \u0026amp; WHO. International Standards for the Treatment of Drug Use Disorders. Geneva/Vienna: UNODC/WHO; 2020.\u003c/li\u003e\n\u003cli\u003eUnited Nations Office on Drugs and Crime. World Drug Report 2024: Key findings and conclusions. Vienna: UNODC; 2024.\u003c/li\u003e\n\u003cli\u003eUnited Nations Office on Drugs and Crime. World Drug Report 2025: Key findings. Vienna: UNODC; 2025.\u003c/li\u003e\n\u003cli\u003eClingendael Institute \u0026amp; Global Initiative Against Transnational Organized Crime. Kush in Sierra Leone: West Africa\u0026apos;s growing synthetic drugs challenge. 25 Feb 2025. Clingendael Institute \u0026amp; Global Initiative Against Transnational Organized Crime. Kush in Sierra Leone: West Africa\u0026apos;s growing synthetic drugs challenge. 25 Feb 2025. - Search\u003c/li\u003e\n\u003cli\u003eStirman SW, Baumann AA, Miller CJ. The FRAME: an expanded framework for reporting adaptations and modifications to evidence-based interventions. Implementation Science. 2019;14(1):58.\u003c/li\u003e\n\u003cli\u003eDamschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation Science. 2009;4:50.\u003c/li\u003e\n\u003cli\u003eProctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Administration and Policy in Mental Health and Mental Health Services Research. 2011;38(2):65\u0026ndash;76.\u003c/li\u003e\n\u003cli\u003eKirk MA, Moore JE, Wiltsey Stirman S, Birken SA. Towards a comprehensive model for understanding adaptations\u0026apos; impact: the model for adaptation design and impact (MADI). Implementation Science. 2020;15(1):56.\u003c/li\u003e\n\u003cli\u003ePinnock H, Barwick M, Carpenter CR, Eldridge S, Grandes G, Griffiths CJ, et al. Standards for Reporting Implementation Studies (StaRI) Statement. BMJ. 2017;356:i6795.\u003c/li\u003e\n\u003cli\u003eTong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care. 2007;19(6):349\u0026ndash;357.\u003c/li\u003e\n\u003cli\u003eBoin A, Lodge M. Designing resilient institutions for transboundary crisis management: a time for public administration. Public Administration. 2016;94(2):289\u0026ndash;298.\u003c/li\u003e\n\u003cli\u003eRasanathan K, Bennett S, Atkins V, Beschel R, Carrasquilla G, Charles J, et al. Governing multi-sectoral action for health in low- and middle-income countries. PLoS Medicine. 2017;14(4):e1002285.\u003c/li\u003e\n\u003cli\u003eHarm Reduction International. The Global State of Harm Reduction 2024. London: Harm Reduction International; 2024.\u003c/li\u003e\n\u003cli\u003eLink BG, Phelan JC. Conceptualizing stigma. Annual Review of Sociology. 2001;27:363\u0026ndash;385.\u003c/li\u003e\n\u003cli\u003eLivingston JD, Milne T, Fang ML, Amari E. The effectiveness of interventions for reducing stigma related to substance use disorders: a systematic review. Addiction. 2012;107(1):39\u0026ndash;50.\u003c/li\u003e\n\u003cli\u003eChambers DA, Glasgow RE, Stange KC. The dynamic sustainability framework: addressing the paradox of sustainment amid ongoing change. Implementation Science. 2013;8(1):117.\u003c/li\u003e\n\u003cli\u003eWHO. Community management of opioid overdose. Geneva: World Health Organization; 2014.\u003c/li\u003e\n\u003cli\u003eIkoona EN, Namulemo L, Kaluya R, Vandi MA, Sahr F, Kitara DL. Lived Experiences and Recovery Challenges of Youth Facing the KUSH Crisis in Sierra Leone: A Qualitative Study. SSRN; 2025. doi:10.2139/ssrn.5543304.\u003c/li\u003e\n\u003cli\u003eOyat FWD, Oloya JN, Atim P, Ikoona EN, Aloyo J, Kitara DL. The psychological impact, risk factors, and coping strategies of the COVID-19 pandemic on healthcare workers in sub-Saharan Africa: a narrative review of existing literature. BMC Psychol.;10(1):284. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"NATIONAL PUBLIC HEALTH AGENCY, FREETOWN, SIERRA LEONE","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"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":"Sierra Leone, KUSH, synthetic opioids, nitazenes, implementation science, CFIR, Proctor outcomes, StaRI, COREQ, multisector governance, crisis governance, reintegration, West Africa","lastPublishedDoi":"10.21203/rs.3.rs-7870467/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7870467/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eIn April 2024, the President of Sierra Leone declared a national emergency over the synthetic street drug \u0026ldquo;KUSH,\u0026rdquo; linked primarily to nitazene-class synthetic opioids. In response, the government established a five-pillar national strategy coordinated by the newly formed National Task Force on Drug and Substance Abuse (NaTFDSA), modeled on the country\u0026rsquo;s prior COVID-19 coordination platform. This evaluation examines how the strategy transitioned from policy to practice during its first 18 months, what scaled, where implementation lagged, and what adaptations emerged under constraint.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe conducted a convergent mixed-methods implementation evaluation in four districts (Western Area Urban, Bo, Kenema, and Port Loko) between June and September 2025. Data sources included 52 in-depth interviews, eight focus group discussions with 67 participants, 18 facility observations, 127 strategy and monitoring documents, and routine implementation indicators. Qualitative data were analyzed using the Consolidated Framework for Implementation Research (CFIR). Quantitative indicators aligned with Proctor\u0026rsquo;s implementation outcomes. Triangulation matrices integrated data across sources. Ethical approval was obtained from the national research ethics committee.\u003c/p\u003e\u003ch2\u003eFindings:\u003c/h2\u003e\u003cp\u003eTreatment bed capacity expanded from 50 to 212 beds across six centers (4.24-fold increase; \u0026plusmn;324%), surpassing the 180-bed national target. The Sierra Leone Psychiatric Teaching Hospital (SLPTH) expanded to 60 beds, and three regional centers opened. A total of 847 healthcare workers were trained, and 1,289 admissions occurred over the 18 months. Prevention efforts reached 1,186 communities (62% of the target). Reintegration services reached 678 discharged patients; among those with six-month follow-up data, 43% had returned to work or school. Law enforcement recorded 891 arrests and 189.7 kg of drug confiscations, while a perception survey (n\u0026thinsp;=\u0026thinsp;220) estimated a 35% reduction in street-level availability. The Task Force held all 18 planned coordination meetings and mobilized US\u003cspan\u003e$\u003c/span\u003e2.23\u0026nbsp;million, with 78% budget execution. Reintegration received the lowest funding allocation.\u003c/p\u003e\u003ch2\u003eInterpretation:\u003c/h2\u003e\u003cp\u003eSierra Leone achieved a rapid, multi-sectoral scale-up of substance use services under emergency conditions. This experience shows how crisis coordination architecture can accelerate implementation in low-resource settings. However, gaps in reintegration fidelity, rural equity, and sustainability highlight the need for institutionalization, routine financing, integration of indicators into health information systems, and expanded harm reduction. The next phase should prioritize peer-led recovery, gender-responsive reintegration, and diversion-to-treatment protocols to ensure enduring, equitable impact.\u003c/p\u003e","manuscriptTitle":"From Emergency Declaration to District-Level Delivery: A Theory-Guided Mixed-Methods Evaluation of Sierra Leone’s National KUSH Response (2024–2025)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-17 12:46:53","doi":"10.21203/rs.3.rs-7870467/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":"17cb2919-4f4a-49c4-91d3-988abcceeac5","owner":[],"postedDate":"October 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":56474568,"name":"Physical Medicine \u0026 Rehab"}],"tags":[],"updatedAt":"2025-10-17T12:46:53+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-17 12:46:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7870467","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7870467","identity":"rs-7870467","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}