Antimicrobial Stewardship Knowledge Gaps among Healthcare Professionals at a Ghanaian Tertiary Hospital: A Cross-Sectional Study

Despite having generally positive attitudes and appropriate self-reported practices regarding antimicrobial stewardship, healthcare professionals at Komfo Anokye Teaching Hospital in Ghana exhibit significant knowledge deficits, highlighting an urgent need for role-tailored, competency-based training to bridge the gap between favorable attitudes and evidence-based behaviors.

The Gist

Imagine a hospital as a massive, busy kitchen where the chefs (doctors), the sous-chefs (nurses), and the quality control inspectors (pharmacists) are all responsible for cooking up the right "medicine meals" to cure infections. However, there's a dangerous ingredient called Antimicrobial Resistance (AMR). Think of AMR like a super-villain that makes the bacteria immune to the medicine, turning a simple infection into a life-threatening monster. To stop this villain, the kitchen needs a strict set of rules called Antimicrobial Stewardship (AMS)—a plan to ensure the right medicine is used, in the right amount, for the right amount of time.

This study took a look inside the Komfo Anokye Teaching Hospital in Ghana to see how well the kitchen staff understands these rules, how much they care about them, and how well they actually follow them.

Here is what the researchers found, broken down into simple concepts:

1. The "Heart" vs. The "Brain"

The study discovered a funny disconnect between what the staff feels and what they know.

• The Heart (Attitude): Almost everyone (96%) had a great attitude. They all agreed that following the stewardship rules is important. It's like everyone in the kitchen saying, "Yes, we definitely want to stop the super-villain bacteria!"
• The Brain (Knowledge): However, when asked specific questions about how to stop the villain, only a tiny fraction (19%) knew the answers. It's as if everyone wants to save the day, but most of the chefs don't actually know the secret recipe or the specific steps to defeat the enemy.

2. The "Practice" Gap

Even though the knowledge was low, the staff reported that they were doing a pretty good job following the rules (77% said they had "good practice").

• The Metaphor: Imagine a group of people who think they are driving safely because they have a good attitude, but they don't actually know the traffic laws. They might be lucky enough to avoid accidents for a while, but without knowing the rules, they are taking risks. The study suggests that while people say they are following the rules, they might be missing the technical details on how to do it correctly.

3. Who Knows What? (The Experience Factor)

The researchers looked at who had the best "knowledge scores" and found two main helpers:

• Experience: Chefs who had been working for a while (5–15+ years) knew more than the new hires.
• Training: The single biggest booster of knowledge was formal training. If a staff member had taken a specific class on how to fight antibiotic resistance, they were much more likely to know the rules.
• The Twist: Interestingly, just having a training session last year didn't automatically make someone an expert. It seems that one-off, short classes aren't enough; you need deep, structured training to really learn the material.

4. The Role of the Kitchen Crew

Different jobs had different strengths:

• Pharmacists (The Inspectors): They were the most likely to report doing the right things. They are naturally trained to check the ingredients, so they are good at the stewardship game.
• Nurses (The Sous-Chefs): They were less likely to report "good practice" compared to doctors. The study suggests this might be because the rules for nurses aren't always clear, or they don't feel empowered to speak up in the decision-making process.
• Doctors (The Head Chefs): They were in the middle, but the study highlights that without specific training, even the head chefs are missing key knowledge.

The Bottom Line

The study concludes that the hospital staff in Ghana want to do the right thing (great attitude), and they think they are doing it (good self-reported practice), but they are missing the technical knowledge to do it perfectly.

The Solution Proposed:
The authors suggest that the hospital needs to stop just telling people "it's important" and start giving them role-specific training.

• Think of it like this: You wouldn't teach a chef how to fix a car engine; you'd teach them how to use a specific knife. Similarly, doctors, nurses, and pharmacists need training tailored exactly to their specific jobs.
• They also need regular updates and practical tools (like checklists or guides) to help them turn their good intentions into actual, evidence-based actions.

In short: The team has the heart, but they need the manual and the practice to win the battle against super-bacteria.

Technical Summary

Technical Summary: Antimicrobial Stewardship Knowledge Gaps among Healthcare Professionals at a Ghanaian Tertiary Hospital

Problem Statement
Antimicrobial resistance (AMR) poses a critical threat to global health systems, particularly in low- and middle-income countries (LMICs) where diagnostic capacity and resource availability are often limited. A primary driver of AMR is the inappropriate use of antimicrobials, including initiation without indication, broad-spectrum selection, and incorrect dosing. While Antimicrobial Stewardship (AMS) programs offer a coordinated framework to optimize prescribing, dispensing, and administration, there is a scarcity of local data regarding the Knowledge, Attitudes, and Practices (KAP) of healthcare professionals in Ghana. Understanding these dynamics is essential for designing realistic, role-specific interventions to translate national AMR policies into tangible hospital-level improvements.

Methodology
This study employed a descriptive cross-sectional survey design conducted at Komfo Anokye Teaching Hospital (KATH), a tertiary referral center in Kumasi, Ghana.

• Population: The study targeted medical doctors, pharmacists, and nurses directly involved in antimicrobial decision-making.
• Sample: A target sample of 350 was calculated using Cochran's formula; 349 valid responses were analyzed (91 doctors, 101 pharmacists, 157 nurses).
• Instrument: Data were collected via a structured questionnaire adapted from established AMS/AMR KAP tools. The instrument covered socio-demographics, knowledge of AMS interventions, attitudes toward AMS, and self-reported practices.
• Scoring: Scores were converted to percentages and dichotomized as "good" (≥60%) or "poor" (<60%).
• Analysis: Associations were tested using Chi-square tests. Multivariable logistic regression was used to identify predictors of good KAP, reporting Adjusted Odds Ratios (AOR) with 95% confidence intervals. Significance was set at p < 0.05.

Key Results
The study revealed a distinct disparity between the attitudes of healthcare professionals and their actual knowledge levels:

• Knowledge: Only 18.6% of participants demonstrated good knowledge of AMS. This was significantly associated with having formal AMS/AMR training (AOR 2.94) and greater years of practice (5–9 years: AOR 2.32; ≥15 years: AOR 2.77).
• Attitudes: Attitudes were overwhelmingly positive, with 95.7% of participants categorized as having a "good" attitude. Formal training was the only significant predictor of good attitudes (AOR 5.19).
• Practices: Self-reported practices were generally good (77.4%). However, professional designation significantly influenced practice outcomes. Compared to medical doctors, nurses had significantly lower odds of good practice (AOR 0.29), while pharmacists had higher odds (AOR 1.41). Additionally, participants with 10–14 years of experience had the highest odds of good practice (AOR 3.18).
• Training Impact: While formal training was associated with better knowledge and attitudes, "updated training in the last year" was not independently associated with improved KAP outcomes, suggesting that the content, duration, or reinforcement of recent training may be insufficient.

Key Contributions

• Multidisciplinary Assessment: Unlike studies focusing on single cadres, this research evaluates KAP across the three primary professional groups (doctors, nurses, pharmacists) central to the antimicrobial care pathway in a major Ghanaian tertiary hospital.
• Identification of Specific Gaps: The study highlights a critical "knowledge-attitude-practice" gap. While professionals recognize the importance of stewardship (high attitude), they lack the specific technical knowledge (low knowledge) required to implement it effectively.
• Role-Specific Insights: The findings delineate specific vulnerabilities, noting that nurses face significant barriers to good stewardship practice compared to doctors and pharmacists, likely due to role ambiguity and hierarchical constraints.

Significance and Claims
The paper concludes that despite favorable attitudes and generally good self-reported practices, marked knowledge deficits exist among healthcare professionals at KATH. The authors assert that these deficits hinder the consistent integration of stewardship tools into clinical decision-making.

The study claims that to translate positive attitudes into evidence-based behaviors, interventions must move beyond general awareness-raising. Specifically, the authors recommend:

1. Role-tailored, competency-based training: Interventions must address the specific needs of different professional groups, particularly nurses who showed lower practice scores.
2. Regular updates and reinforcement: Training should not be a one-time event but must be supported by practical stewardship tools and multidisciplinary structures.
3. Implementation of enabling interventions: The findings support the WHO practical toolkit approach, emphasizing the need for governance, multidisciplinary teams, and context-appropriate monitoring systems to sustain rational antimicrobial use.

The authors maintain a modest stance, acknowledging the limitation of self-reported data (potential social desirability bias) but affirming that the identified gaps provide a clear priority for targeted training and support strategies within the hospital setting.