Awareness, Knowledge, and Perceptions of Healthcare Professionals Regarding Antimicrobial Stewardship in Four Tertiary Hospitals in Freetown, Sierra Leone
While healthcare professionals in Freetown's tertiary hospitals hold overwhelmingly positive perceptions of antimicrobial stewardship, their actual awareness and knowledge remain moderate and are significantly hindered by critical deficits in training, policy, funding, and diagnostic infrastructure.
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In hospitals around the world, doctors and nurses rely on powerful medicines called antibiotics to fight bacterial infections. For decades, these drugs have saved countless lives, but a quiet crisis is growing. Bacteria are changing, learning to survive the very medicines designed to kill them. This phenomenon, known as antimicrobial resistance, turns once-treatable illnesses into deadly threats. The problem is made worse when antibiotics are used too often, for the wrong reasons, or for too long. To stop this, health systems are trying to implement a strategy called antimicrobial stewardship. Think of stewardship not as a new drug, but as a set of careful rules and habits: choosing the right medicine, giving the right dose, and stopping treatment as soon as it is no longer needed. The goal is to keep patients safe today while ensuring these life-saving drugs still work for future generations.
In Sierra Leone, a country in West Africa, the threat of resistant bacteria is severe, yet the systems needed to manage antibiotic use are often incomplete. A team of researchers set out to understand how the people who actually prescribe and administer these medicines feel about the new stewardship rules. They traveled to four major teaching hospitals in the capital city, Freetown, to speak with doctors, nurses, pharmacists, and laboratory staff. Their goal was to measure three things: how many people had heard of these stewardship rules, how well they understood the science behind them, and what they believed would make the rules work or fail in their daily work.
The researchers surveyed 339 healthcare workers across the four hospitals. They found a striking gap between knowing a word and understanding a concept. Nearly nine out of ten participants said they had heard the term "antimicrobial stewardship." Most had learned about it during their medical training or from colleagues. However, when the researchers asked specific questions to test their actual understanding, the numbers dropped significantly. Only about half of the staff could correctly answer a set of questions that measured a solid grasp of stewardship principles. For instance, while almost everyone knew that stewardship helps reduce drug resistance, fewer than two-thirds understood that antibiotics should be guided by local treatment guidelines rather than used broadly for every infection. Even more telling, only about one in three had received any formal training on these stewardship rules in the two years prior to the study.
The attitude of the staff, however, was overwhelmingly positive. Almost everyone agreed that stewardship programs are important and that they improve patient care. They were eager to participate and believed that training should be part of their professional education. This suggests that the resistance to change is not coming from the people themselves; they want to do the right thing. The barrier is not a lack of willingness, but a lack of support. When asked what stops them from following these best practices, the staff pointed to concrete, systemic failures. The most common obstacle was a lack of knowledge and training, cited by nearly 92 percent of respondents. This was followed closely by a lack of staff involvement, the absence of official hospital policies, and a shortage of funding.
Perhaps the most critical finding was the lack of diagnostic tools. More than 70 percent of the workers said that poor laboratory support was a major barrier. Without reliable lab tests to identify exactly which bacteria are causing an infection, doctors are forced to guess which antibiotic to use. They often have to choose a broad-spectrum drug that kills many types of bacteria, which accelerates the development of resistance. The study also revealed that the ability to follow stewardship rules varied by profession. Men were significantly more likely to have a good understanding of stewardship than women, but the researchers noted this was likely because men in this workforce were more often doctors or pharmacists, while women were more often nurses. Since nurses make up the largest group of healthcare workers in these hospitals, the study highlights a need to train everyone, not just the doctors.
The researchers concluded that while the people in these hospitals are ready and willing to improve antibiotic use, the system is not ready for them. The positive attitudes are a strong foundation, but they cannot stand alone. To turn good intentions into good practice, the hospitals need to build functional committees, create clear local guidelines, and, most urgently, invest in the laboratory capacity needed to diagnose infections accurately. Without these structural changes, the staff will continue to face a situation where they know what they should do but lack the tools to do it. The path forward requires training that includes every type of healthcare worker, from the nurse at the bedside to the pharmacist in the dispensary, and a commitment to fixing the broken links in the chain of care.
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