INTRODUCTION:

A key measure of patient safety and care quality, healthcare-associated infections (HAIs) are those that emerge during a patient's stay in a hospital or other healthcare setting. By definition, the infection must not have been present or in its incubation period upon admission¹ The economic burden is staggering; HAIs extend hospital stays, require additional diagnostic tests and therapeutic interventions, and lead to long-term disability and excess deaths². For instance, in the European Union, the annual financial impact is estimated to be approximately €7 billion, including direct costs only³. In low- and middle-income countries (LMICs), the burden is disproportionately higher due to limitations in infrastructure, overcrowding, inadequate sanitation, and scarce resources for infection prevention and control (IPC)⁴. The World Health Organization (WHO) highlights that the risk of acquiring an HAI in some LMICs can be up to 20 times higher than in high-income countries⁴.

Among all HAIs, urinary tract infections (UTIs) account for a significant proportion, and the vast majority of these are linked to indwelling urinary catheters⁵. A catheter-associated urinary tract infection (CAUTI) is defined as a UTI where an indwelling urinary catheter was in place for more than two days on the date of the event⁶. The pathogenesis of CAUTIs often involves bacteria forming biofilms on the inner and outer surfaces of the catheter. These biofilms protect the microorganisms from antibiotics and host defenses, making infections difficult to eradicate without catheter removal⁷.

The consequences of CAUTIs extend beyond localized discomfort. They are a primary source of secondary bloodstream infections (bacteremia), which have a mortality rate estimated to be between 10-30%⁸. Furthermore, CAUTIs contribute significantly to the development of antimicrobial resistance, a growing global crisis⁹.

The primary risk factor for CAUTI is prolonged catheter use ⁶. Despite guidelines recommending timely removal, catheters are often left in place due to convenience, forgetfulness, or lack of awareness of alternatives¹⁰. Additional risk factors unique to the patient are being older, female, or having diabetes or kidney disease¹¹. In many healthcare systems, particularly in resource-constrained settings like India, the responsibility of post-discharge catheter care falls almost entirely on family caregivers—a situation exacerbated by severe nursing staff shortages, as exemplified in Kerala, where the nurse-patient ratio in government hospitals can be as low as 1:50, a stark contrast to the Indian Nursing Council's recommended ratio of 1:4 for general wards and international standards¹². This deficit means nurses are often unable to provide adequate patient education or follow-up care, consequently placing non-medical family caregivers in charge of complex duties including maintaining catheter hygiene and a closed drainage system, ensuring securement of the catheter to prevent urethral traction, monitoring urine output and recognizing signs of infection (e.g., cloudiness, sediment, fever), and managing drainage bags and tubing correctly. The knowledge and practices of these caregivers are, therefore, a fundamental determinant in preventing CAUTIs, as inadequate knowledge can lead to errors in care, such as breaking the sterile closed system, improper perineal cleaning, or failing to recognize early warning signs, ultimately increasing the patient's risk of infection, rehospitalization, and associated complications¹³.

NEED AND SIGNIFICANCE OF THE STUDY:

Caregivers, encompassing both family members and paid helpers, constitute a cornerstone of the healthcare continuum, assuming a critical and often demanding role in managing the daily needs of patients, particularly those requiring invasive devices such as urinary catheters¹⁴. Urinary catheterization, a procedure involving the insertion of a sterile tube (composed of latex, polyurethane, or silicone) into the bladder to facilitate drainage, is a significant risk factor for infection if not managed with scrupulous care¹⁵. Evidence-based guidelines dictate that proper care is a complex process requiring strict adherence to protocols including meticulous hand hygiene, the use of aseptic techniques and gloves, regular emptying of drainage bags, secure catheter stabilization to prevent urethral traction, daily perineal cleansing, vigilant maintenance of a closed drainage system, and prevention of tubing kinks and obstructions^16,17. The adequacy of a caregiver's knowledge and practice in executing these procedures is not merely beneficial but is essential in preventing Catheter-Associated Urinary Tract Infections (CAUTIs), which represent a leading cause of healthcare-associated morbidity¹⁸.

The significance of this study is therefore multifaceted. Firstly, it addresses a crucial gap in patient safety by focusing on the frontline defenders against CAUTIs: the caregivers themselves. In resource-constrained settings with severe nurse shortages, their role transitions from supportive to primary, making their competency a direct determinant of patient outcomes¹⁷. Secondly, the findings will illuminate the specific areas of knowledge deficit and suboptimal practices among caregivers, providing a crucial evidence base for healthcare institutions and policymakers. This knowledge can be leveraged to develop targeted structured educational programs, training modules, and supportive resources tailored for caregivers. Ultimately, empowering caregivers with correct information and skills is paramount to reducing the incidence of preventable CAUTIs, decreasing associated complications and hospital readmissions, alleviating the financial burden on the healthcare system, and most importantly, improving the overall quality of life and well-being of patients dependent on long-term catheterization¹⁹.

STATEMENT OF THE PROBLEM:

Assessment of Knowledge and Practice Regarding UTI Prevention among Caregivers of Patients on Continuous Bladder Drainage: A Study at a Tertiary Care Center in Thrissur.

OBJECTIVES:

1. To assess the level of knowledge regarding the prevention of urinary tract infections among caregivers of patients on continuous bladder drainage.

2. To assess the level of practice regarding the prevention of urinary tract infections among caregivers of patients on continuous bladder drainage.

3. To determine the association between the knowledge levels and practice levels of caregivers regarding the prevention of urinary tract infections.

4. To determine the association between the knowledge levels of caregivers and their selected socio-demographic variables.

5. To determine the association between the practice levels of caregivers and their selected socio-demographic variables.

OPERATIONAL DEFINITIONS:

· Knowledge regarding UTI prevention: Understanding of urinary system, continuous bladder drainage, UTI, and preventive measures measured by a structured questionnaire.

· Practice regarding UTI prevention: Reported actions by caregivers for urinary catheter care measured through a structured questionnaire.

· Caregivers: Individuals actively engaged in providing care to patients on continuous bladder drainage.

· Patients on continuous bladder drainage: Individuals catheterized for urine drainage for three days or more.

Assumptions:

The study is based on the following assumptions:

1. Caregivers of patients on continuous bladder drainage will have varying (heterogeneous) levels of knowledge and practice regarding UTI prevention.

2. The structured questionnaires used are valid and reliable tools capable of accurately measuring these levels of knowledge and practice.

3. Caregivers will provide honest and accurate responses to the questionnaire items.

Hypotheses:

The following hypotheses were tested in the study:

H₁: There is a significant association between the knowledge levels and practice levels among caregivers of patients on continuous bladder drainage regarding the prevention of UTIs.

H₂: There is a significant association between the knowledge levels among caregivers of patients on continuous bladder drainage and their selected socio-demographic variables.

H₃: There is a significant association between the practice levels of caregivers and their selected socio-demographic variables.

Theoretical Framework:

Peplau’s Theory of Interpersonal Relations served as the theoretical framework for this study²⁰. Hildegard Peplau defined nursing as a therapeutic, interpersonal relationship. She theorized that this relationship is an educational tool designed to foster personal growth and guide individuals toward constructive, creative, and productive lives within their communities^21,22. This framework was applied to the context of CAUTI prevention, where the caregiver assumes a role analogous to the nurse. In this model, the caregiver functions as a resource person and educator for the patient²³. The caregiver-patient interaction is an interpersonal process that requires the application of intellectual, interpersonal, and social skills to establish a therapeutic relationship based on trust. This trust is foundational for setting collaborative goals, such as preventing infection and promoting the patient's independence in managing their condition where possible.

The theory posits that for this relationship to be therapeutic and effective, the caregiver must possess the essential knowledge and competencies (practice) to educate and care for the patient. This includes technical skills such as maintaining a closed drainage system, preventing catheter obstruction, correctly positioning the drainage bag, and performing routine perineal care. It also encompasses fundamental health principles like practicing meticulous hand hygiene and encouraging adequate fluid intake⁶.

By providing structured education and training to caregivers, this study aligns with Peplau's view of nursing as an educative process. Empowering caregivers with knowledge enhances their role as a resource person, ultimately leading to improved patient outcomes—specifically, the prevention of CAUTIs—which reflects the theory's goal of achieving constructive and productive health outcomes²¹.

MATERIALS AND METHODS:

Research Approach:

A quantitative research approach was adopted for this study to objectively and systematically assess the knowledge and practice levels of caregivers regarding the prevention of urinary tract infections (UTIs) among patients on continuous bladder drainage (CBD)²³. This approach facilitates the collection of numerical data that can be statistically analyzed to identify patterns, relationships, and associations between variables.

Research Design:

A descriptive cross-sectional research design was employed to accurately explore, describe, and document the current state of knowledge and self-reported practices among the caregivers at a specific point in time ²⁴. This design is appropriate for determining the prevalence and nature of the variables of interest without manipulating them.

Setting of the Study:

The study was conducted in the medical and surgical wards of a selected 750-bed tertiary care center in Thrissur district, Kerala. This setting was chosen purposively due to its high patient inflow, which includes a significant number of patients requiring continuous bladder drainage, thereby ensuring adequate availability of participants²⁵. Furthermore, the setting provided ease of access for the researcher and a controlled clinical environment conducive to ethical data collection.

Population and Sample:

The target population for this study comprised all caregivers of patients on continuous bladder drainage admitted to the medical and surgical wards of the selected tertiary care center. A sample of 40 caregivers was selected using a non-probability purposive sampling technique to ensure the inclusion of participants who met the study's specific criteria and could provide the most relevant information for the research objectives²⁶.

Inclusion Criteria:

Caregivers were included in the study if they:

· Were providing care for a patient with an indwelling urinary catheter in situ for more than three days.

· Were able to read, write, and comprehend Malayalam to ensure informed consent and accurate completion of the data collection instruments.

Exclusion Criteria:

Caregivers were excluded from the study if they:

· Were caring for a patient with a suprapubic catheter, as the care protocols differ from those for urethral catheters.

· Were unwilling to provide consent to participate in the study.

Variables of the Study:

Independent variable: The socio-demographic characteristics of the caregivers (e.g., age, gender, education level, relation to patient, previous training)²⁷.

Dependent variables: The knowledge score and practice score of caregivers regarding the prevention of UTIs in patients with continuous bladder drainage ²³.

Study Tools: Three structured tools were used for data collection:

1. Socio-demographic Data Sheet (Tool I): This tool contained 7 items to gather information on age, gender, educational qualification, occupation, monthly income, and relationship with the patient.

2. Structured Knowledge Questionnaire (Tool II): This tool comprised 18 multiple-choice questions assessing knowledge about the urinary system, continuous bladder drainage (CBD), urinary tract infections (UTIs), and their prevention.

3. Structured Practice Checklist (Tool III): This tool consisted of 8 yes/no items evaluating self-reported practices regarding UTI prevention in patients on CBD.

Development and Validation of Tools:

These instruments were developed based on an exhaustive analysis of existing research and in-depth discussions with specialists across multiple nursing fields, such as medical, surgical, community, pediatric, and psychiatric care. The initial draft was reviewed by five subject experts for relevance and appropriateness. Following approval from the ethical committee, content validation was conducted by a panel of six experts. The tools were modified based on their suggestions to enhance clarity and comprehensiveness before finalization.

Pilot Study:

A pilot study was conducted with four caregivers of patients on continuous bladder drainage to assess the feasibility, clarity, and practicality of the data collection tools and procedures. Data from the pilot study were analyzed using descriptive statistics, which confirmed the suitability of the tools and the data collection process. No major changes were required, so the data were included in the main study.

Data Collection Procedure:

Data collection for the main study was conducted over a one-week period. All caregivers provided their written consent to participate only after being fully informed about the study's goals, what it would involve, and its potential risks and benefits. The structured knowledge questionnaire and practice checklist were then administered to the caregivers in the medical and surgical wards. Data collection was performed under the direct guidance of the investigators to ensure clarity of the questions, minimize errors, and achieve complete responses.

Plan for Data Analysis:

The data were analyzed using both descriptive and inferential statistics with SPSS software (version XX.0). Descriptive statistics, including frequency, percentage, mean, and standard deviation, were used to summarize the socio-demographic characteristics of the caregivers and their knowledge and practice scores. Inferential statistics were applied to test the study hypotheses. The Chi-square test was used to determine the association between knowledge levels and practice levels, as well as associations between knowledge/practice levels and selected socio-demographic variables. A p-value of < 0.05 was considered statistically significant.

RESULTS:

Table 1: Socio-Demographic Characteristics of Caregivers (n = 40)

Variable	Category	Frequency	Percentage (%)
Age (years)	20–30	5	12.5
	30–40	5	12.5
	40–50	15	37.5
	50–60	8	20
	60–70	7	17.5
Gender	Male	9	22.5
Gender	Female	31	77.5
Education	Primary	17	42.5
	High School	12	30
	Higher Secondary	6	15
	Degree	5	12.5
Employment	Employed	18	45
Employment	Unemployed	22	55
Socio-Economic Status	APL	20	50
Socio-Economic Status	BPL	20	50

Table 2: Relationship with Patient and Previous Exposure to UTI Awareness Programmes (n = 40)

Variable	Category	Frequency	Percentage (%)
Relationship with Patient	Spouse	19	47.5
	Son/Daughter	9	22.5
	Parent	6	15
	Sister/Brother	5	12.5
	Others	5	12.5
Previous Exposure to Awareness Programme	Yes	1	2.5
Previous Exposure to Awareness Programme	No	39	97.5

The socio-demographic profile of the 40 caregivers is presented in Tables 1 and 2. Analysis of the data revealed that the majority of caregivers (37.5%) were between 40 and 50 years of age. Most caregivers were female (77.5%). In terms of educational attainment, the largest group had completed primary education (42.5%), followed by high school education (30%). Slightly more than half of the caregivers were unemployed (55%), and an equal distribution was observed in socio-economic status, with half (50%) belonging to the Above Poverty Line (APL) category and half to the Below Poverty Line (BPL) category.

Regarding their relationship to the patient, nearly half (47.5%) of the caregivers were spouses, followed by sons or daughters (22.5%). A critical finding was that an overwhelming majority (97.5%) of caregivers reported no previous exposure to any awareness programme on the prevention of urinary tract infections. The fact that most of this group has never received training reveals a major gap, indicating an urgent need for organized educational programs designed for them.

Table 3: Distribution of Caregivers According to Knowledge and Practice Regarding Prevention of Urinary Tract Infection (n=40)

Variable	Category / Score	Frequency (n)	Percentage (%)
Knowledge	Good (>80%)	5	12.5
	Average (50–80%)	32	80
	Poor (<50%)	3	7.5
Practice	Good (>60%)	28	70
Practice	Poor (<60%)	12	30

The distribution of caregivers according to their knowledge and practice scores is presented in Table 3. The data indicate that the majority of caregivers (80%) possessed an average level of knowledge regarding UTI prevention, scoring between 50–80%. A smaller proportion (12.5%) demonstrated good knowledge (scoring above 80%), while only 7.5% had poor knowledge (scoring below 50%). In contrast, the assessment of practice revealed a more favorable outcome. A significant majority of caregivers (70%) reported good preventive practices (scoring above 60%), while 30% were categorized as having poor practices (scoring below 60%). This disparity between knowledge and practice scores suggests that while caregivers' theoretical understanding may be moderate, their applied, practical competence in performing preventive care is notably stronger.

Table 3: Relationship between knowledge and practice regarding the prevention of UTI among caregivers of patients on CBD.

Knowledge	Practice: Good	Practice: Poor	df	χ² value
Good	15	6	1	10.3
Poor	6	19

A Chi-square test of independence was performed to examine the relationship between knowledge and practice. The analysis revealed a statistically significant association, χ²(1, n=40) = 10.3, p < .05. Thus, the null hypothesis was rejected, and the research hypothesis (H₁) was accepted. The data show that more knowledgeable caregivers are more likely to correctly manage continuous bladder drainage.

The analysis of the association between socio-demographic variables and practice scores revealed that none of the factors examined—including age, gender, education, occupation, and socio-economic status—demonstrated a statistically significant association with caregivers' practices regarding UTI prevention (*p* > .05). This finding indicates that the quality of preventive practices remained consistent across diverse demographic subgroups. This consistency suggests that adherence to preventive measures is likely influenced more by external, modifiable factors—such as the awareness programs and structured care instructions provided during hospitalization—than by inherent personal or background characteristics of the caregivers.

DISCUSSION:

This study provides critical insights into the dynamics of knowledge and practice among caregivers of patients on continuous bladder drainage, a group bearing significant responsibility for preventing hospital-acquired infections. The key findings reveal a disparity between theoretical knowledge and practical application, a significant association between the two, and a notable influence of specific demographic factors.

The observation that the majority of caregivers (80%) possessed only average knowledge, while a high proportion (70%) demonstrated good practice, presents a compelling paradox (Table 3). This suggests that practical, hands-on learning and the urgency of the care situation may drive competency more effectively than theoretical understanding alone. This finding aligns with the principles of Bandura's Social Learning Theory, which posits that behaviour is learned through observation and imitation²⁸. Caregivers often learn by watching healthcare professionals, thus adopting practices without fully internalizing the underlying scientific rationale. Furthermore, the high percentage (97.5%) of caregivers with no prior formal training (Table 2) underscores that their learning is predominantly incidental, occurring during patient care rather than through structured education⁶.

The analysis confirmed a statistically significant association between knowledge and practice (χ²(1) = 10.3, p<.05; Table 5). This is a crucial finding, as it empirically supports the theoretical framework of this study, Peplau’s Theory of Interpersonal Relations, which posits that the caregiver's role as an educator is contingent upon their own knowledge base¹⁵. This result corroborates findings from a study by Jain et al. (2015), which also identified a knowledge-practice gap but a positive relationship among healthcare staff, emphasizing that knowledge is a necessary, though not always sufficient, foundation for good practice¹⁹.

A particularly significant demographic finding was that caregivers above 45 years of age were associated with poorer knowledge scores. This generational gap may be attributed to lower formal education levels or less familiarity with digital sources of health information, which are increasingly a primary means of disseminating health knowledge¹⁹. This highlights a vulnerable subgroup that requires targeted, perhaps more accessible, educational interventions. Conversely, the fact that practice levels were consistent across all demographic variables is an encouraging finding. It implies that when proper training and instructions are provided during hospitalization, individuals from all backgrounds are equally capable of adhering to effective preventive measures²⁷. This reinforces the notion that behavior in a clinical context can be effectively shaped by institutional protocols and training, potentially outweighing the influence of personal socio-demographic determinants²⁹.

CONCLUSION AND IMPLICATION FOR NURSING PRACTICE:

In conclusion, while knowledge gaps exist, the strong practical performance and its association with knowledge are positive indicators. The identified deficiency in formal awareness programs (97.5% had no prior exposure) represents a critical opportunity for intervention. Nursing practice must move beyond ad-hoc instruction towards implementing standardized, structured, hands-on, and repetitive training programs for caregivers before patient discharge ¹⁵. These programs should be particularly tailored to overcome the knowledge barriers observed in older caregivers. By doing so, nurses can fully actualize their role as educators per Peplau's theory, empowering caregivers effectively and ultimately reducing the incidence of CAUTIs¹⁸.

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Received on 22.09.2025 Revised on 03.12.2025

Accepted on 25.01.2026 Published on 30.07.2026

Available online from August 05, 2026

Int. J. Nursing Education and Research. 2026;14(3):204-210.

DOI: 10.52711/2454-2660.2026.00041

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Creative Commons License.

Socio-demographic Variable	Category	Good (n)	Poor (n)	df	χ² value	Significance
Gender	Male / Female	5 / 12	5 / 18	1	0.306	NS
Age	<45 yrs / >45 yrs	9 / 6	6 / 19	1	5.409	S
Education	Primary / Higher	4 / 11	13 / 12	1	2.46	NS
Occupation	Employed / Unemployed	5 / 10	11 / 14	1	0.40	NS
Socio-economic Status	APL / BPL	13 / 3	10 / 14	1	0.153	NS

Socio-demographic Variable	Category	Good (n)	Poor (n)	df	χ² value	Significance
Age	<45 yrs / >45 yrs	13 / 8	11 / 8	1	0.16	NS
Gender	Male / Female	5 / 16	5 / 14	1	0.83	NS
Occupation	Employed / Unemployed	7 / 14	9 / 10	1	0.81	NS
Education	Primary / Higher	8 / 13	9 / 10	1	0.351	NS
Socio-economic Status	APL / BPL	12 / 9	12 / 7	1	0.15	NS