Title: Work experience was associated with the knowledge and practice of catheter-associated
urinary tract infection prevention among nurses at University of Gondar Comprehensive
Specialized Hospital, northwest Ethiopia, 2021
Version: 3 Date: 20 Oct 2022
Reviewer's report:
"PEER REVIEWER ASSESSMENTS:
OBJECTIVE - Full research articles: is there a clear objective that addresses a testable research
question(s) (brief or other article types: is there a clear objective)?
Yes - there is a clear objective
DESIGN - Is the current approach (including controls and analysis protocols) appropriate for
the objective?
No - there are major issues
EXECUTION - Are the experiments and analyses performed with technical rigor to allow
confidence in the results?
No - there are major issues
STATISTICS - Is the use of statistics in the manuscript appropriate?
No - there are issues with the statistics in the study
INTERPRETATION - Is the current interpretation/discussion of the results reasonable and not
overstated?
N/A - no results to interpret
OVERALL MANUSCRIPT POTENTIAL - Is the current version of this work technically
sound? If not, can revisions be made to make the work technically sound?
Maybe - with major revisions
PEER REVIEWER COMMENTS:
GENERAL COMMENTS: Overall impression: the paper is well-written but suffers from
methodological flaws. Also, some aspects of the methods are not clear to me.
Done well: the paper follows a logical structure that is easy to follow.
Not meeting best practice: important aspects of the methods are lacking; besides that, not the
most optimal methodological approach has been used.
REQUESTED REVISIONS:
MAJOR issues.
- The 'a priori' calculation of the number needed to be included in the survey is strange to me.
This number appeared to be 423 (while 495 nurses are working the institution). What if there
were only 350 nurses in the institution? Would the authors not execute the study? It looks also as
if the authors targeted this very specific number of nurses by means of a small team of research
nurses 'hunting' nurses in the hospital and asking to participate. At the same line, why do you
need a team for data collection when the survey is self-administered? It should be enough that
the survey is distributed among the nurses and that they choose to fill out the questionnaire.
All this triggers questions about voluntary and anonymized participation. These are essentials
in survey research but not mentioned. I need more transparency about the sampling technique.
- Definitions of poor & good knowledge are problematic. As I read the definition, it appears that
the mean (or median) score from the results are calculated and that all nurses scoring above this
mean/median are defined as having good knowledge. Thus, when the mean knowledge would
have been 20%, all nurses scoring higher would have been considered to have 'good' knowledge.
I assume this is just a badly phrased methodological aspect, but even if good knowledge is
defined as scoring correct on 50% of the questions, this would provide food for thought; don't we
may expect a higher level of knowledge from clinical nurses? Raising the bar to - for example
- 75%, would not be a bad idea.
- The above comment is also valid for ""good/poor practice"" and for ""favorable/unfavorable
attitude"".
- It is completely unclear to me how attitude was assessed.
- Regarding the questions to investigate the level of knowledge and practice: response
alternatives need to be reported. Also, for 'open questions' you need to report the response that
you consider a correct answer. How can you report 'yes' and 'no' rates for the question ""How
do you maintain the system?"" The full survey needs to be reported in the paper, as well as how
it was constructed (i.e., content validity process).
- The search for independent relationships with the outcome variables is suboptimal. The authors
choose to use multivariable logistic regression analysis which implies reducing variables such as
'knowledge' and 'practice' to binary variables (on the same problematic threshold as I explained
earlier). The investigators had better opted for a linear regression analysis in which the outcome
variables could be handled as a continuous variable. By reducing these to binary variables they
loose a lot of information.
MINOR comments
- Explain CAUTI abbreviation at its first use and use it consequently thereafter.
- Instead of reporting including variables in the multivariate analysis on basis of a relationship of
p<0.25 in ""binary"" logistic regression, the authors better use the terminology of ""univariate
analysis"". A logistic regression is always 'binary' even when adjusted for multiple covariates.
- Typo: ""In the US... "" instead of ""In United states..."" (line 60)
- Typo: ""UK"" instead of ""Britain"" (line 85)
- Typo: ""To the best of our knowledge..."" instead of ""As my best searching..."" (line 92-93)
- Table 6: explain in table legend what you mean by 'COR' (=?) and 'AOR' (=adjusted odds ratio).
ADDITIONAL REQUESTS/SUGGESTIONS:
As explained above, there are important aspects in the methodology (sampling technique,
definitions, statistics used) that need to be considered.
Yet, the data collected can be interesting; it is just a matter of using appropriate methods and
being transparent about the process that is (absolutely) necessary."