"Knowledge, Attitudes, and Determinants of Antibiotic Prescribing among Paediatric Prescribers in Three Hospitals in Sierra Leone: A Mixed-Methods Study"

Children under five years of age in Sierra Leone carry one of the highest burdens of infectious disease and mortality in the world, and they receive antibiotics frequently. Yet little is known about the clinicians who make these prescribing decisions. Because physicians are scarce, much paediatric care in Sierra Leone is delivered by community health officers (CHOs), mid-level non-physician clinicians who diagnose and prescribe under a task-shifting model. To our knowledge, this is the first study in Sierra Leone to examine paediatric prescribers, including CHOs, and the first to combine survey and interview data to explore why good knowledge may not translate into appropriate prescribing for children. We conducted a convergent mixed-methods study at the national tertiary paediatric hospital and at regional and district hospitals. A census of eligible prescribers achieved a 92.7% response rate (102 of 110), and 18 prescribers took part in in-depth interviews. Prescribers had good knowledge and positive attitudes overall, and doctors had substantially higher odds of good knowledge than CHOs in Firth penalised regression. Interviews showed that prescribing was shaped mainly by limited microbiology, antibiotic stock-outs, costs to families, workload, and caregiver practices before the child reached hospital. Integrating both strands within the Teixeira prescribing behaviour framework and the COM-B model points to diagnostic strengthening, locally adapted paediatric guidelines and dosing support, structured mentorship for CHOs and junior doctors, and caregiver education as priorities for paediatric antimicrobial stewardship.