Knowledge, Practice and Associated Factors of Catheter-Associated Urinary Tract Infection Prevention Among Nurses Working at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia, 2021

Background: Catheter-associated urinary tract infection is the source of about 20% of episodes of health-care acquired infections in acute care facilities and it is over 50% in long-term care facilities. To date, knowledge and practice of nurses towards catheter-associated urinary tract infection is still lower. However, in Ethiopia, there is no published scienti�c research describing the knowledge and practice of nurses on catheter-associated urinary tract infections prevention. Therefore, this study aimed to assess knowledge, practice and associated factors of catheter-associated urinary tract infection prevention among nurses working at university of Gondar comprehensive specialized hospital, northwest Ethiopia, 2021 Methods: Institutional based cross sectional study was conducted at University of Gondar Comprehensive Specialized Referral HospitalfromApril 01 to May01, 2021 among 423nurses. Simple random sampling technique was used. Data were collected by using self-administered questionnaire then coded and entered into EPI-Data version 4.6 and then exported to SPSS version 23. All variables with P-value <0.25 in the binarylogistic regression analyses were included in the multivariable regression analysis. The degree of association was interpreted by using the adjusted odds ratio with 95% con�dence intervals, and the signi�cance level was declared at P-value <0.05. The Hosmer–Lemeshow test was used to check the �tness of the model. Results: The knowledge and practice of nurses towards CAUTI prevention was 53% and 50% respectively. Good knowledge was associated with sex [AOR=1.84, 95% CI (1.09, 3.11)], work experience [AOR=2.36, 95% CI (1.09, 5.10)], working unit [AOR=6.9, 95% CI (2.11, 22.52)], received training [AOR=2.33, 95% CI (1.17, 4.65)] and had guideline [AOR=2.78, 95% CI (1.59, 4.88)]. Good practice was signi�cantly associated with sex, work experience, good attitude and good knowledge towards CAUTI prevention [AOR=2.19, 95% CI (1.


Background
Urinary tract infection (UTI) is one of the most common healthcare acquired infection caused by diseasecausing organisms in the ordinarily sterile urine or tissues of the genitourinary tract involving the urethra,bladder,and kidneys [1,2].Catheter associated urinary tract infection is resulted from introduction of indwelling catheter into the bladder and it is one of the most common health care acquired infections encountered in clinical practice which has been performed by unsterile technique, and by not taking adequate measures to maintain cleanliness of the urinary catheter during insertion, maintenance, and removal [3].
Globally urinary tract infection affecting more than 150 million people each year [4] and 70-80% of these urinary tract infections are attributed to catheter associated urinary tract infection [5].Catheter-associated urinary tract infection is the source of about 20% of episodes of health-care acquired infections in acute care facilities and it is over 50% in long-term care facilities [6].Additionally, the use of indwelling urethral catheters increases the risk of UTI occurrence in health-care settings by14-fold [7].Catheter-associated urinary tract infections are responsible for prolonged hospital lengths of stay, bacterial resistance, urosepsis, and even cause death [8].
In United states CAUTI accounted for 32% of all hospital acquired infections, making it the most frequent type of infection experienced in the hospital with approximately 449,000 CAUTI incidences with an estimated cost of 450 million dollar per year [9].In developing countries including Africa, the prevalence and extent of catheter-associated urinary tract infection remains high due to limited resources and de ciency in health care system.In Uganda, one-third of UTI is accounted for CAUTI [10].In Ethiopia, catheter associated urinary tract infection (CAUTI) is attributed 60.19 cases per 1000 persons-days [11].
Nurses play an important role in urinary catheter insertion, maintenance, and removal [12].Catheterassociated urinary tract infection is considered as the most frequent and preventable infections, if nurses take into consideration the recommended catheter placement indications and evidenced-based practice of catheter maintenance [13].Therefore, nurses should have adequate knowledge regarding infection control in the use of urethral catheters and their practice must be adhered to guidelines of catheter associated urinary tract infection prevention [14].
Even though 17% -69% of catheter-associated urinary tract infections can be prevented by applying infection prevention methods, the knowledge and practice level of many nurses are not well known regarding catheter insertion, maintenance and removal [15].According to the study conducted in Pakistan the adequate knowledge and practice level of nurses towards CAUTI prevention was 3.13% and 49% respectively [16].Another study in Saudi Arabia shows that only 0.73% of nurses have adequate knowledge and 55.7% of nurses have good practice regarding CAUTI prevention [17].
Factors such as advanced level of education and long years of work experience are found to behavinga positive impact on the level of nurse's knowledge and practice towards catheter-associated urinary tract infections prevention [15,18,19].
In recent years, certain measures have been taken to controlCAUTI.Center for disease control(CDC), Infectious Diseases Society of America (IDSA), world health organization (WHO), and department of health in Britain have published their efforts towards CAUTI prevention includingreducing inappropriate use of urinary catheters, Perform proper techniques for indwelling catheter insertion, implement proper urinary catheter maintenance procedures, and removing urinary catheters in a timely manner [20][21][22][23].
Ethiopia has been taken certain measures to tackle CAUTI through applying recommendations such as limiting use of indwelling urinary cathetersand applying practices guidelines for insertion, maintenance, and removal of catheter [24].
Even though many efforts have been made to prevent CAUTI, the burden continues to rise.As my best searching in Ethiopia there is no study conducted regarding nurse's knowledge and practice towards CAUTI prevention.Thus the current research is aimed to assess knowledge, practice and its associated factors towards CAUTI prevention among nurses at University of Gondar comprehensive specializedhospital.

Study period and area
This studywas conducted from April 01 to May 01, 2021 in University of Gondar comprehensive specializedhospital.The hospital is found in Gondar town which is 727 km from Addis Ababa, the capital of Ethiopia and 180 km from Bahir Dar, the capital of Amhara region.The hospital is used as the referral center for more than 5 million catchment populations.It has more than 1000-bed capacity and provides service to over 200,000 patients annually [25].It provides both specialty and subspecialty services including pediatrics, surgery, gynecology and obstetrics, internal medicine, psychiatry, and ophthalmology in its in-patient and outpatient services.There are around 495 nurses who are working in the hospital.The nurse's patient-ratio varied within working units and nurses are performing comprehensive cares in each working unit

Study design
Institutional based cross sectional study design was employed in University ofGondar Comprehensive Specialized Hospital

Source population
All nurses working at University of Gondar Comprehensive Specialized Hospital

Study population
All nurses working at University of Gondar Comprehensive Specialized Hospitalwho were available at the time of data collection period

Inclusion and exclusion criteria Inclusion criteria
All nurses who were working in university of Gondar Comprehensive Specialized Hospital Sample size determination Sample size was determined by using single population proportion formula by taking the proportion of knowledge and practice (p) 50%(because there was no study conducted in our country regarding this title)with expected margin of error (d) 5% just to maximize the sample size and improve the precision of study, 95% con dence interval and non-response rate 10%.The total number of sample size was obtained from university of Gondar comprehensive specialized hospital in all inpatient and outpatient services.Study participants were selected by using simple random sampling method and were assigned randomly by lottery method.There are a total 495 of nurses in University of Gondar comprehensive specialized hospital.70 nurses from medical units, 59 from pediatric units, 83 from surgical units, 27 from ICUs, 13 from dialysis unit, 34 from OR units, 31 from recovery units, 20 from stula unit, 38 from emergency OPD, and 48 from outpatient department nurses were selected by using proportional allocation.And the total sample size was 423.

Data collectiontool and procedure
A structured English version self-administered questionnairewas used as instrument to collect data which is adopted from different literatures.The data were collected by three trained BScunemployed nursesfor duration of one month and supervised by one midwifery professional [13,17,26].The questionnaire had vesections.The rst section dealing with demographic characteristics of respondents, the second deals with work related characteristics, and thethird sectionwas about personal factors towards CAUTI prevention.
The fourth section was about 10 questions related to catheter indications, maintenance,care, removal, risk factors for CAUTI, and complications of CAUTI to assess nurses' knowledge towards CAUTI prevention andeach correct answer was scored one and each wrong answer was scored zero.The total score for correct answers from all of the items was computed and classi ed as follows; good knowledge when study participants respond equal and abovefrom the mean score of knowledge questions towards CAUTI prevention and poor knowledge when study participants respond below the mean score from knowledge questions towards CAUTI prevention The fth section deals the extent of nurses' practices toward prevention of CAUTI.It included 15 questions; ve items for practices of nurses before catheter insertion, two items for practices of nurses during catheter insertion, and eight items for practices of nurses after catheter insertion.Study participants were asked to choose the appropriate answer for each item in the questionnaire.Every correct answer was given one point and wrong answerwas given zero.The total score for correct answers from all of the items was computed and classi ed as follows; good practice when study participants respond equal and abovefrom the mean score of practice questions towards CAUTI prevention and poor practice when study participants respond below the mean score from practice questions towards CAUTI prevention The questionnaire was validated by following face validity method.To test the reliability of the tool, Cronbach alpha were calculated after a pre-test by taking 5% of the sample size at Tibebe Ghion specialized hospital and the value was 0.79, 0.83 and 0.89 for knowledge, attitude and practice tools respectivelythatwere in acceptable ranges.The participants involved in the pre-test study were not included in the present study.

Operational de nition
Knowledge: is awareness and understanding of nurses regarding CAUTI prevention Good Knowledge: Refers to those study participants who scored point greater than or equal to the mean score of knowledge questions towardsCAUTI prevention [13].
Poor knowledge: Refers to those study participants who scored point less than the mean score of knowledge questions towardsCAUTI prevention [13].
Practice: In this study it refers to the nurses actions regarding CAUTI prevention Good Practice:Refers to those study participants who scored point greater than or equal to the mean score of practice questions towardsCAUTI prevention [17].
Poor Practice:Refers to those study participants who scored point less than the mean score of practice questions towardsCAUTI prevention [17].

Data processing and analysis
The data were coded and entered into Epi-dataversion 4.6 and then exported to statistical package for social science (SPSS) version 23 for analysis.The data were cleaned thenfrequencies and crosstabulationwere computed before regression analysis.Descriptive statistics was computed, and the result was summarized by texts, tables, and charts and presented in terms of mean and standard deviation.The Hosmer-Lemeshow test was used to check themodel tness.Binary logistic regression model was used to test the association between dependent and each independent variable.All variables with P-value <0.25in the bivariable logistic regression analyses were included in the multivariable regression analysis.In the multivariable logistic regression analysis the degree of association was interpreted by using the adjusted odds ratio with 95% con dence intervals, and the signi cance level was declared at P-value <0.05.

Data quality assurance
Data quality was ensured by providing half day training to data collectors about the research objective, participant selection method, eligible study subjects, data collection tools, and procedures.The data collection toolwasadopted from different literatures which was developed in English language and was checkedfor its consistency in the meaning of words.A pretest was done on ve percent (22)from the total sample size at Tibebe Ghion specializedhospital two weeks before the actual data collection period.Based on the result of the pretest, necessary corrections and amendments were taken on the data collection tools (i.e.knowledge related question).Regular supervision was held during the data collection period and the collected data were checked on daily basis for completeness.

Socio-demographic characteristics of nurses
A total of 406 participants were included in this study with a response rate of 96%.Among respondents 221 (54.4%) were female.In this study the mean age of the participants was 31.36 years +4.03SD.Most of the participants 306(75.4%)were orthodox Christian and 239(58.8%)were married and 380(93.6%)had more than 5000 birr income and 307(75.6%)nurses had a bachelor's degree(Table 1).Nurses' Knowledge regarding to prevention of CAUTI Participants were asked 10 questions to assess their knowledge on CAUTI prevention, and they were categorized into two groups based on their score in relation to the mean.The mean score was 5.64 (SD = 2.49).More than half 215(53 %) of the respondents were found to have good knowledge, while 191(47 %) of the respondents were found to have poor knowledge towards CAUTI prevention (Table 4).
Nurses' practice regarding to prevention of CAUTI By using 15 practice based questions, the mean practice score of the respondents was found to be 10.22 (SD = 3.27).Half 203(50 %) of the respondents had good practice; whereas the remaining 203(50 %) respondents had poor practice of CAUTI prevention (Table 5).

Discussion
Catheter associated urinary tract infection (CAUTI) is one of major global health concern, which places a huge burden on the health care system.Nurses are expected to play a signi cant role in the prevention of CAUTIs [27].
The result of this study showed that 53%with 95%CI (48.3, 57.6) of study participants had good knowledge about catheter associated urinary tract infection prevention.This nding is in line with study conducted in Pakistan in which (51.8%) of the respondents had good knowledge [28].Even though, there is difference in socioeconomic status and level of health sector development, the possible reason of similarity between the current study and study in Pakistan might be using a similar study population (staff nurse), study unit and study design.
The result of this study also lower than the study conducted in Sri Lanka (63.9%) [29], in India (56.7%) [30].and in Rwanda (64.52%) [13].The possible reason for this difference might be due to difference in study unit and study settings.On this study nurses working in inpatient and outpatient services were included in only one hospital; whereas in study done in Rwanda the study subject was nurses working only in ICUs at two different referral hospital.
However, the result of this study was higher than the study conducted in India 16.7% [31], in Saudi Arabia (37.23%) [17], and in another study in India (46.7%) [32].The possible justi cation might be due to differences in study design, differences in study setting, and the differences in result rating;for example, in Saudi Arabia study,the knowledge was rated as Good, moderate, and poor.As well, the result rating in India's study is quite different; it was rate as high, moderate and low.This may differ from the gurative interpretation of this study as good and poor knowledge.
For males the odds of good knowledge towards catheter associated urinary tract infection prevention was 1.84 times that of females [AOR = 1.84, 95% CI (1.09, 3.11)].This nding was inconsistent with the study conducted in Turkey [33].The possible explanation might be because males are more exposed to different sociocultural and social activities than females in the Ethiopian context.Furthermore, females have extraordinary activities as compared with males such as cooking, washing, and preparing for daily home consumption.Therefore, they might have less time to read and scale up their knowledge [34].
The odds of good knowledge towards catheter associated UTI prevention among nurses with 5 to 10 years work experience was 2.36 times that of nurses with <5 years of work experience [AOR = 2.36, 95 % CI (1.09, 5.10)].Similar nding was reported in study conducted in India; where years of experience were signi cantly associated with knowledge [32].Another study has conducted in Rwanda revealed that, the greater the working experience the higher the knowledge gained [13].The reason might be nurses with more years of work experience have more chance to work with different professionals so that they can learn from their coworker's experience.Moreover, in the fact that the participants working for extended period of time in their professions, they could obtain various exposures that increase their knowledge towards CAUTI prevention related to their day to day activities.
The odds of good knowledge towards catheter associated UTI prevention among nurses who took training related to catheter associated UTI was 2.33 times that of nurses who had not taken [AOR = 2.33, 95 % CI (1.17, 4.65)].This nding was consistent with the study conducted in India [32], Egypt [35].The possible explanation might be due to that training can enhance an individual's body of knowledge regarding CAUTI prevention.
The odds of good knowledge towards catheter associated UTI prevention among nurses working in emergency OPD was 6.9 times that of working in medical units [AOR 6.Half of 203(50%) with 95% CI (45.3, 54.7) of study participants had good practice towards prevention of catheter associated urinary tract infection.This result was lower than the studies conducted in India (86.5%) [30], Sri Lanka (79.5%) [29], Saudi Arabia (55.7%), [17], and Rwanda (79.9%) [13].The possible justi cation might be due to difference in socioeconomic status, level of health sector development, study setting, study design, and difference in tool used to rating the outcome.
On the other hand, this study nding was higher than the study conducted in Pakistan (49%) [19].The reason behind this difference might be difference in studysetting and the difference in instrument (tool) used to assess nurses' practice towards prevention of catheter associated urinary tract infection.
In a multivariable logistic regression analysis, variables like sex, work experience, having good attitude and, good knowledge were found to have signi cantly associated with the practice of nurses towards catheter associated UTI prevention For males the odds of good practice towards catheter associated UTI prevention was 2.19 times that offemales[AOR = 2.19, 95% CI (1.23, 3.88)].This nding was inconsistent with the study conducted in Rwanda [13].The possible explanation might be in Ethiopia, most of the home-based activities such as food preparation and food serving, child feeding, cloth hygiene, and home-based sanitation are left for women.Therefore, women may not get time to practice CAUTI prevention because of being busy taking care of the family members compared with men. .Similar nding was reported in studies conducted in India [37], Pakistan [16].The nding might be justi ed as nurses' experience increased; they become familiar with the subject matter thereby acquire good practice to carry out the procedure with safety and precision.
The odds of good practice towards catheter associated UTI prevention among nurses having good knowledge was 5.28 times that of nurses having poor knowledge [AOR = 5.28, 95 % CI (2.86, 9.76)].This nding was consistent with the study conducted in India [38], Iran [39] and Saudi Arabia [17].The possible explanation could be because of the more knowledgeable to a particular subject matter the more skillful to a particular activity.
The odds of good practice towards catheter associated UTI prevention among nurses having favorableattitude was 3.06 times that of nurses having unfavorableattitude[AOR = 3.06, 95 % CI (1.65, 5.67)].This nding was in line with the study conducted in Tamil Nadu, India [40].The possible explanation might beindividuals with good attitude towards CAUTI prevention havegood practice level towards CAUTI prevention.

Limitation of the study
n= (Z α/2 ) 2 p (1-p)/d 2 n= (1.96) 2 .0.5(1-0.5)/(0.05) 2 n= 384 Non response rate = (384) (10%) = 38.4Total sample (n) = 384+38.4=423 Where n= minimum sample size required to the study d= margin of error p= prevalence of knowledge and practice Z α/2 = value of standard normal distribution Sampling technique and procedure Dependent variables Knowledge of nurses towards CAUTI prevention Practice of nurses towards CAUTI prevention Independent variables Socio-demographic variables Age, sex, religion, ethnicity, level of education, marital status, monthly income Work related variables Work experience, working unit, training on CAUTI prevention, number of attending training on CAUTI prevention, availability of CAUTI prevention guidelines, usage of CAUTI prevention guidelines Personal related variables Attitude of nurses towards CAUTI prevention Favorable attitude:Refers to those study participants who scored point greater than or equal to the mean score of attitude questions about CAUTI prevention[26].Unfavorableattitude:Refers to those study participants who scored point less than the mean score of attitude questions about CAUTI prevention[26].
The odds of good practice towards catheter associated UTI prevention among nurses with >10 years work experience was 5.44 times that of nurses with <5 years of work experience [AOR = 5.44, 95 % CI (1.66, 17.84)], Moreover the odds of good practice towards catheter associated UTI prevention among nurses with 5 to 10 years work experience was3.59times that of nurses with <5 years of work experience [AOR = 3.59, 95 % CI (1.46, 8.87)]

Table 1 :
Socio-demographic characteristics of nurses to assess knowledge, practice and associated factors towards CAUTI prevention among nurses at UoGCSH, Northwest Ethiopia, 2021 (N = 406).
training program on catheter associated UTI prevention more than once.More than half of study participants 218(53.7%)hadCAUTIprevention guidelines in their working unit (Table2).Table 2: work related factors to assess knowledge, practice and associated factors towards CAUTI prevention among nurses at UoGCSH, Northwest Ethiopia, 2021 (N= 406).

Table 3 :
Frequency distribution of participants response of Attitude towards CAUTI prevention among nurses at UoGCSH, Northwest Ethiopia, 2021 (N = 406).

Table 4 :
Frequency distribution of participants response of knowledge towards CAUTI prevention among nurses at UoGCSH, Northwest Ethiopia, 2021 (N = 406).

Table 5 :
Frequency distribution of participants response of practice towards CAUTI prevention among associated UTI prevention among nurses who took training related to catheter associated UTI was 2.33 times that of nurses who had not taken [AOR = 2.33, 95 % CI (1.17, 4.65)].For nurses who had catheter associated UTI prevention guidelines the odds of good knowledge towards CAUTI prevention was 2.78 times that of nurses who had not[AOR=2.78;95%CI(1.59,4.88)] (Table6).
was 1.84 times that of females [AOR = 1.84, 95% CI (1.09, 3.11)].The odds of good knowledge towards catheter associated UTI prevention among nurses with 5 to 10 years work experience was 2.36 times that of nurses with <5 years of work experience [AOR = 2.36, 95 % CI (1.09, 5.10)].The odds of good knowledge towards catheter associated UTI prevention among nurses working in emergency OPD was 6.9 times that of working in medical units [AOR 6.9, 95% CI (2.11, 22.52)].The odds of good knowledge towards catheter
[17]5% CI(2.11, 22.52)].This nding was consistent with the study conducted in Saudi Arabia[17].The possible explanation might be because of the prevalence of violence and none violence causality emergency cases occurred more in emergency units than the medical units.Therefore, nurses who are working in emergency ward face patients who need immediate intervention and treatments.They may lead them to read and update themselves.
presence of guideline will advocate the art and science of CAUTI prevention.Availability of CAUTI prevention guideline is likely improving nurses' knowledge and providing continuity of care.