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    Awareness, Knowledge, and Perceptions of Healthcare Professionals Regarding Antimicrobial Stewardship in Four Tertiary Hospitals in Freetown, Sierra Leone
    (Springer Science and Business Media LLC, 2026-09-14) Barrie, Umaru
    Background Antimicrobial resistance (AMR) is among the most consequential threats to contemporary health systems, and its burden is borne disproportionately by low- and middle-income countries. Sierra Leone records one of the highest AMR-associated mortality rates worldwide, yet antimicrobial stewardship (AMS) remains fragmented and, in most facilities, unformalised. Because stewardship is ultimately enacted through the routine decisions of frontline clinicians, this study assessed the awareness, knowledge, perceptions and perceived barriers relating to AMS among healthcare professionals (HCPs) in four tertiary hospitals in Freetown. Methods A hospital-based analytical cross-sectional study was conducted between 1 June and 30 August 2025 at Ola During Children’s Teaching Hospital, Connaught Teaching Hospital, Princess Christian Maternity Hospital and the Dr. Julius Maada Bio Paediatric Centre of Excellence. The sample size was derived using Cochran’s formula with finite population correction against an eligible workforce of 1,478 and an allowance of 10% for non-response, yielding 339 participants, who were selected by stratified random sampling with proportional allocation by facility and professional cadre. A structured, pre-tested, self-administered questionnaire measured awareness (four items), knowledge (six items) and perception (five items); composite scores were classified using pre-specified thresholds. Data were analysed in IBM SPSS Statistics version 27 using descriptive statistics, the chi-square test and bivariate followed by multivariable logistic regression, with variables at p < 0.20 in bivariate analysis entered into the adjusted model. Significance was set at p < 0.05, and reporting follows the STROBE statement for cross-sectional studies. Results Of the 339 respondents, 211 (62.2%) were female and 179 (52.8%) were nurses. Although 301 (88.8%) reported having heard of AMS, only 178 (52.5%) achieved a good composite awareness score and 186 (54.9%) were familiar with the WHO Access, Watch and Reserve (AWaRe) classification. Good knowledge was demonstrated by 206 (60.8%) participants, moderate knowledge by 120 (35.4%) and poor knowledge by 13 (3.8%), and 329 (97.1%) held positive perceptions of stewardship. The barriers most frequently endorsed were limited knowledge and training (311, 91.9%), limited staff involvement (273, 80.5%), absence of an AMS policy or guideline (271, 80.0%), lack of dedicated funding (247, 72.9%), poor laboratory diagnostic support (241, 71.1%) and weak infection prevention and control infrastructure (233, 68.7%); 209 (61.7%) had received no formal AMS training in the preceding two years. In the multivariable model, male sex (versus female: adjusted odds ratio \[AOR\] 3.92, 95% confidence interval \[CI\] 1.46–10.49, p = 0.007) and good knowledge (versus poor knowledge: AOR 7.45, 95% CI 1.72–32.36, p = 0.007) were independently associated with good composite AMS awareness, whereas perception was not (AOR 0.39, 95% CI 0.07–2.14, p = 0.278). Conclusions Exposure to antimicrobial stewardship terminology was high in Freetown’s tertiary hospitals, and attitudes towards stewardship were overwhelmingly favourable; however, composite awareness and knowledge remained substantially lower than simple exposure, while implementation was constrained by deficits in training, governance, diagnostics and financing. Attitudes are overwhelmingly favourable, but composite awareness and applied knowledge remain moderate and implementation is constrained by deficits in training, governance, diagnostics and financing. Favourable attitudes constitute a usable foundation; converting them into practice will require institutionalised AMS committees and guidelines, cadre-inclusive continuing education, and investment in microbiological diagnostic capacity.