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

Background/Objectives: Children under five years of age in Sierra Leone are frequently exposed to antibiotics, yet little is known about the prescribers who make these decisions. We assessed the knowledge, attitudes, and determinants of antibiotic prescribing among paediatric prescribers in three Sierra Leonean hospitals. Methods: In a convergent mixed-methods study at three hospitals (May–August 2025), 102 doctors and community health officers (CHOs) completed a questionnaire, and 18 participated in in-depth interviews. Quantitative data were analysed using non-parametric tests, correlation, and Firth logistic regression, and qualitative interviews with Braun and Clarke Reflexive thematic analysis guided by the Teixeira prescribing behaviour framework and the capability, opportunity, motivation–behaviour (COM-B) model. The two strands were integrated at interpretation. Results: The median knowledge score was 14/16 (IQR 12.25–15.00), and attitude domain scores were positive (80.0–95.0% of maximum). Doctors (AOR 12.72; 95% CI 4.05–46.98) and female prescribers (AOR 2.85; 95% CI 1.10–8.10) had higher odds of good knowledge; among the attitude domains, profession was associated only with ignorance. Clinical judgement (66.7%) was the most frequently reported determinant, and laboratory results (24.5%) and parental requests (5.9%) were among the least. Qualitative interviews identified five themes: diagnostic uncertainty and limitations, health-system and resource constraints, professional influences, and caregiver and community influences, as well as participants’ suggestions for stewardship. Conclusions: Prescribers had good knowledge and positive attitudes but described diagnostic, supply, and affordability constraints that may limit appropriate prescribing. Stewardship in Sierra Leone should combine diagnostic strengthening, local guidelines, cadre-specific training and mentorship, and caregiver education.