Psychosocial determinants of antibiotic stewardship decisions among Chinese clinicians across hospital tiers: a longitudinal study

Inappropriate antibiotic use contributes to antimicrobial resistance, yet much stewardship evidence is cross-sectional and intention-based. We conducted a two-wave longitudinal survey of clinicians in Chinese hospitals approximately 11 months apart (baseline September–October 2024; follow-up August–September 2025) to examine whether baseline psychosocial factors predicted follow-up stewardship-aligned responses to four clinical vignettes and whether associations varied by hospital level. Among 1,420 clinicians with linked responses, higher follow-up vignette scores were independently associated with stronger reasoned-action beliefs, fewer perceived barriers, greater self-efficacy, stronger knowledge and skills, greater social support, and higher perceived patient-centred benefits in both structural equation modelling and robust regression analyses. TPB-related beliefs were not independently associated after mutual adjustment. Hospital level moderated the association between reasoned-action beliefs and follow-up vignette responses, with stronger associations in tertiary than primary hospitals. Stewardship interventions may therefore need to address capability, confidence, supportive environments, and institutional context in addition to attitudes.