Knowledge and prevalence of common sexually transmitted infections among patients seeking care at selected health facilities in Southern Ghana

Araba Ata Hutton-Nyameaye; Morrison Asiamah; Karikari Asafo-Adjei; Charles Kwaku Benneh; Adwoa Oforiwaa Kwakye; Kofi Boamah Mensah; Kwabena Obeng Duedu; Kwame Ohene Buabeng

doi:10.1371/journal.pgph.0003422

. 2024 Jul 1;4(7):e0003422. doi: 10.1371/journal.pgph.0003422

Knowledge and prevalence of common sexually transmitted infections among patients seeking care at selected health facilities in Southern Ghana

Araba Ata Hutton-Nyameaye ^1,^2,^*, Morrison Asiamah ³, Karikari Asafo-Adjei ⁴, Charles Kwaku Benneh ⁵, Adwoa Oforiwaa Kwakye ⁶, Kofi Boamah Mensah ¹, Kwabena Obeng Duedu ^7,⁸, Kwame Ohene Buabeng ^1,²

Editor: Jana Jarolimova⁹

¹Faculty of Pharmacy and Pharmaceutical Sciences, Department of Pharmacy Practice, Kwame Nkrumah University of Science and Technology, Kumasi, Ashanti Region, Ghana

²Department of Pharmacy Practice, School of Pharmacy, University of Health and Allied Sciences, Ho, Volta Region, Ghana

³Department of Electron Microscopy and Histopathology, Noguchi Memorial Institute for Medical Research, Accra, University of Ghana, Greater Accra Region, Ghana

⁴Microbiology Unit, Ho Teaching Hospital, Ho, Volta Region, Ghana

⁵Department of Pharmacology and Toxicology, School of Pharmacy, University of Health and Allied Sciences, Ho, Volta Region, Ghana

⁶Department of Pharmacy Practice and Clinical Pharmacy, School of Pharmacy, University of Ghana, Legon, Greater Accra Region, Ghana

⁷Department of Biomedical Sciences, School of Basic and Biomedical Sciences, University of Health and Allied Sciences, Ho, Volta Region, Ghana

⁸College of Life Sciences, Birmingham City University, City South Campus, Birmingham, United Kingdom

⁹Massachusetts General Hospital, UNITED STATES

The authors have declared that no competing interests exist.

^✉

* E-mail: aharaba@uhas.edu.gh

Roles

Araba Ata Hutton-Nyameaye: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Validation, Visualization, Writing – original draft, Writing – review & editing

Morrison Asiamah: Conceptualization, Formal analysis, Methodology, Software, Validation, Visualization, Writing – original draft, Writing – review & editing

Karikari Asafo-Adjei: Data curation, Investigation, Methodology, Writing – original draft, Writing – review & editing

Charles Kwaku Benneh: Conceptualization, Validation, Visualization, Writing – original draft, Writing – review & editing

Adwoa Oforiwaa Kwakye: Methodology, Visualization, Writing – original draft, Writing – review & editing

Kofi Boamah Mensah: Conceptualization, Writing – original draft, Writing – review & editing

Kwabena Obeng Duedu: Conceptualization, Formal analysis, Supervision, Visualization, Writing – review & editing

Kwame Ohene Buabeng: Conceptualization, Methodology, Supervision, Writing – review & editing

Jana Jarolimova: Editor

PMCID: PMC11216559 PMID: 38950047

Abstract

The burden of Sexually transmitted infections (STIs) remains a public health problem that should be addressed considering its effect on society and close association with HIV. This study aimed to determine the knowledge and prevalence of common STIs and associated risk factors among adult patients seeking STI care in health facilities in Ho Municipality. This was an analytical cross-sectional study involving 178 adult clients seeking treatment for suspected STIs, from November 2020 to April 2021. Data on participants’ demographic characteristics, knowledge and health-seeking behaviour for STI therapy was obtained. Urine and blood samples were also taken from each participant for microbiological screening to identify the infecting pathogen and the specific STI. Multiple logistic regression and chi-square analyses were used to test the significance of associations. Of the 178 participants, 71.91% (n = 128) were women and 61.24% (n = 109) were unmarried. About 13% (n = 23) had poor knowledge of STIs. Prevalence of the STIs was 24.72% (n = 44) of which gonorrhoea was the highest 11.24% (n = 20), followed by chlamydia 10.11% (n = 18) and syphilis 7.30% (n = 13). Of all the participants, 3.37% (n = 6) had co-infections with at least 2 pathogens. Infection with all three pathogens was observed in a single participant. Participants who were married were associated with 61% reduced odds of sexually transmitted infection compared to participants who were unmarried (AOR = 0.39; Cl = 0.17–0.89). Participants who smoked had 6.5 times increased odds of the infection compared to nonsmoking participants (AOR = 6.51; Cl = 1.07–39.56). Although knowledge of STIs was high, it did not appear to contribute to lowering of the prevalence. This suggests there may be other factors other than awareness or knowledge driving STIs. There is an urgent need for further studies to ascertain the drivers of STIs beyond knowledge and awareness in the public.

Introduction

Sexually Transmitted Infections (STIs) are diseases contracted through sexual activity with a partner who has the infection [1]. Worldwide, over 1 million people are affected by STIs every day, with individuals experiencing one or more types of these infections [2]. In 2016, there was an estimated 367 million new cases of treatable STIs (chlamydia, gonorrhoea, syphilis, and trichomoniasis) globally [3]. Developing countries in regions such as South and Southeast Asia, Sub-Saharan Africa, Latin America, and the Caribbean recorded the highest proportion of STIs [4]. In underdeveloped countries, STIs are projected to be among the public health issues that impact the healthy life years of affected individuals [5]. An estimated 109.7 million individuals in Africa are currently affected by STIs, resulting in a significant 17% economic loss for the continent [6]. In Ghana, it has been approximated that 3.4% of the population is affected by STIs, and among individuals exhibiting symptoms, rates can be as elevated as 28% [7].

Sexually transmitted infections impose a significant burden of illness and death in numerous developing nations due to their impact on reproductive and infant health, as well as their contribution to the spread of Human Immunodeficiency Virus (HIV) infection. Understanding STIs and their potential repercussions is crucial for effective prevention and treatment. Individuals who lack knowledge about the symptoms may be unable to identify the urgency of seeking assistance, resulting in a failure to seek appropriate help [8]. For interventions and resources aimed at reducing the burden of STIs to be planned and implemented effectively, the prevalence and incidence have to be quantified [9].

In many parts of Africa, STIs are one of the most common reasons for seeking medical attention. Despite their broad implications, individuals’ knowledge on STIs is limited [10]. Insufficient reporting regarding sexual behaviours can be caused by a lack of understanding about STIs as well as inappropriate sexual conduct [11]. In Ghana, like many other regions, the burden of STIs remains a critical concern, necessitating targeted efforts to enhance awareness, promote prevention, and improve access to quality healthcare services. This study therefore sought to identify health seeking behaviours and prevalent STIs as well as knowledge on STIs in adult patients seeking STI care in health facilities in Ho Municipality.

Methods

Ethical statement

Ethical approval was granted by Ghana Health Service Ethics Review Committee (GHS-ERC002/05/20), Committee for Human Research and Publication Ethics (CHRPE-KNUST) [CHRPE/AP/178/21] and Ho Teaching Hospital (HTH/RPPME/20/23) to begin data collection. Written consent was obtained from the study participants before the questionnaire was administered to them. The approved consent forms were kept securely under lock and key for review by the ethics committees. Participants were assured of privacy and confidentiality throughout the study.

Study setting and population

Facility-based cross-sectional study was employed using a validated and well-structured, pretested, open and close ended questionnaire for data collection from patients visiting three health facilities namely Ho Teaching Hospital, Ho Municipal Hospital and Ho Polyclinic in the Ho municipality. These three target facilities are the major health providers within the Ho Municipality.

The study population was patients visiting the Ho Teaching Hospital, Ho Municipal Hospital and Ho Polyclinic with suspected cases of STI. The average number of patients who visit these study sites were 60,000, 30,000 and 24,000 respectively annually. These health facilities offer both outpatient and inpatient department services and has functional units such as pharmacies and laboratory departments. Ho is the capital of the Volta region, which is one of the 16 regions in Ghana. It has a total area of 9,504 km² and found west to the Republic of Togo and faces the east side of Lake Volta with a population of 218,650 [12].

Patients between the ages of 18 years to 65 years who visited the three hospitals with STIs and willing to participate in the study were included. The participants’ symptoms included lower abdominal pain (females only), pain on urination, genital sores, and/or discharges from the penis or vagina. The exclusion criteria were persons who are unable to carry out self-care or receive medication by themselves.

The determination of the sample size was calculated using the Cochran formula, with prevalence assumed to be 7.7% based on a study conducted by Semwogerere et al., 2021 [13] with a confidence interval of 95%, a precision of 5% and non-response rate of 20%. The minimum number of 131 was required for the study, but the final sample size was 178.

Data collection process

Questionnaires were administered to patients with suspected cases of STI (study participants) seeking care and treatment at the study sites willing to participate in the study. Physicians at the various health facilities introduced the study to patients who had been diagnosed syndromically with STI after consultation. Syndromic care of STIs involves making a preliminary diagnosis by observing a specific collection of signs and symptoms in the patient [14]. The common clinical syndromes of STIs include urethral discharge in males, vaginal discharge, ano-genital ulcer disease, lower abdominal pain, skin rash–genital or generalized, scrotal swellings and genital warts [15,16]. The patients were briefed about the purpose of the study, the methods and ethical issues and those who consented to the study were included. Simple random sampling method was used to recruit the patients. The sampling method was employed to ensure every patient had an equal opportunity to take part in the study, minimize potential biases, and achieve a thorough representation of the study population. Participants were made to pick from an envelope containing folded shuffled papers with ‘Yes’ or ‘No’ written on them. Where a participant picked ‘Yes’ the participant was included and where the participant picked ‘No’ the participant was excluded.

A questionnaire was designed to collect quantitative data on participants’ knowledge on STI, patient’s history of STI, patient factors (smoking and alcohol intake status), sexual and health seeking behaviour. Some terms such as, “sexual partners” meant number of sexual partners the participant currently had, “past relationships” signified the number of relationships in the past year and all participants were questioned on the use of condoms and number of sexual intercourses/episodes per week. Furthermore, participants current use of alcohol was assessed while participants with/without knowledge on STI was asked if they had “heard of STI”. Also, orthodox treatment generally applied to the proven and widely acknowledged medical interventions that are practiced within the healthcare system. The questionnaire was developed from existing literature after careful review of literature.

Quality control

To assure the accuracy of the data, the validity and dependability of the study instrument were validated beforehand. A pilot test was also done with ten (10) patients in order to find and remove all errors as well as discrepancies within the questionnaire and authenticate it. Three (3) experienced research assistants in STIs were trained to aid with the gathering of data from the participants. Before the participants began answering, they were provided with a thorough explanation of the questions.

Laboratory analysis

Microbiological screening was done by collecting blood and urine samples from each participant to objectively assess the prevalence of the common STIs in the study area. Syphilis test kits (Wondfo One Step Syphilis- Sensitivity:100% and Specificity:98.8%)) and Cepheid Xpert CT/NG (Female urine- CT/NG Sensitivity:98.1% / 94.4%, Specificity:99.8% />99.9%, PPV [99.8%] / NPV [100%]; Male urine- CT/NG Sensitivity:98.5%/ 98.3%, Specificity:99.8% / 99.9%, PPV [99.8%]/ NPV [100%]) assay on the GeneXpert systems were used for detecting the presence of syphilis, chlamydia, and gonorrhoea respectively. As syphilis testing involved only treponemal antibodies, it is unable to differentiate between active verses past infection. All samples were collected and analysed according to the manufacturers’ protocols.

Statistical analysis

Descriptive statistics were used to summarize the socio-demographic characteristics of the study participants. Categorical predictor variables were summarized using frequencies and percentages, while continuous predictor variables were done using means and medians. The proportion diagnosed of STI was estimated as the number of participants who tested positive to any of the STI tests divided by the number of participants who were tested.

Also, the level of knowledge was assessed as a 24-item composite variable. Each item of the variable was assigned a score of “0” if the response to the item was wrong and a score of “1” if a response to an item was correct. The maximum score a participant could obtain was 24 points and the minimum score a participant could obtain was zero. Participants who scored a total of 0 to 8 points were considered as poor knowledge, 9 to 16 points as satisfactory knowledge and 17 to 24 points as good knowledge.

The associations between demographic characteristics, knowledge and risk of contracting an STI as well as behavioural factors were determined using inferential statistics. Factors that influenced the risk of STI were initially assessed by conducting a bivariate analysis using Pearson’s chi square test, then independent variable significant under this test were included in the multiple logistic regression to estimate the adjusted strength of association between the risk of STI and the predictors. STATA 15 was used for the analysis. The strength of association was reported as odd ratios. Associations with p-values of less than 0.05 were considered statistically significant.

Results

Demographic characteristics of the participants

The number of study participants was one hundred and seventy-eight (178). The mean age of the study participants was 28yrs ± 0.64 with the majority being between 24–40 years (n = 94, 52.81%). There were more females (n = 128, 71.91%) than males. About half of the participants reported to the Ho Municipal Hospital (n = 90, 50.56%). Almost all participants were handled at the outpatient department (OPD) (94.38%) with the exception of a few who were handled at the Obstetrics and Gynecology Unit. The detailed demographic characteristics of the study population is presented in Table 1 below.

Table 1. Demographic characteristics of participants.

Variable	Category	Frequency	Percentages
Age (years)	Less than 24	66	37.08
	24 to 40	94	52.81
	More than 40	18	10.11
Name of hospital	Ho Teaching Hospital	53	29.78
	Ho Polyclinic	35	19.66
	Ho Municipal Hospital	90	50.56
Occupation	Unemployed	38	21.59
	Employed	138	78.41
Unit	OPD	168	94.38
	Obstetrics and Gynae	10	5.61
Gender	Male	50	28.09
	Female	128	71.91
Education	No Education	4	2.25
	Primary Education	36	20.22
	Secondary Education	73	41.01
	Tertiary Education	65	36.52
Marital Status	Unmarried	109	62.64
	Married	65	37.36
Religion	Christian	175	98.31
	Muslim	3	1.69
Tested for STI	Negative	134	75.28
	Positive	44	24.72

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Symptoms exhibited by participants

The most common symptoms reported by men and women were discharge from penis (urethral discharge) [n = 38,76%] and vaginal discharge (n = 109,85.2%) respectively (Table 2).

Table 2. Symptoms reported by participants.

Symptoms	Category	Gender		Frequency (Percentages)
Symptoms	Category	Male	Female	Frequency (Percentages)
Discharge from Genitalia	Present	38 (76.0%)	109 (85.2%)	147 (82.6%)
Discharge from Genitalia	Absent	12 (24.0%)	19 (14.8%)	31 (17.42%)
Pain on Urination	Present	27 (54.0%)	29 (22.7%)	56 (31.5%)
Pain on Urination	Absent	23 (46.0%)	99 (77.3%)	122 (68.5%)
Lower abdominal pain	Present	2 (4.0%)	43 (33.6%)	45 (25.3%)
Lower abdominal pain	Absent	48 (96.0%)	85 (66.4%)	133 (74.7%)
Genital Sores	Present	4 (8.0%)	11 (8.6%)	15 (8.4%)
Genital Sores	Absent	46 (92.0%)	117 (91.4%)	163 (91.6%)

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Prevalence and knowledge of STIs among study participants

The overall prevalence of STIs was 24.72% (Table 1). Of these 8.43% (n = 15), 7.30% (n = 13) and 5.62% (n = 10) were gonorrhea only, chlamydial infections only, and syphilis only respectively (Table 3). Low levels of knowledge did not translate to a higher number of infections (Table 3). Among the participants, 3.37% (n = 6) had co-infections with two or three pathogens. Co-infections involving gonorrhoea and chlamydia were 1.69% (n = 3). Other dual co-infections as well as co-infections with all three pathogens were recorded in one participant each.

Table 3. Prevalence of STIs according to level of knowledge.

	Level of Knowledge
Infections	Poor	Satisfactory	Good	Missing	Total (%)
Chlamydia only	2 (4.55)	4 (9.09)	7 (15.91)	0 (0.00)	13 (29.55)
Gonorrhoea only	3 (6.82)	9 (20.45)	3 (6.82)	0 (0.00)	15 (34.09)
Syphilis only	2 (4.55)	4 (9.09)	4 (9.09)	0 (0.00)	10 (22.73)
Co-infections	1 (2.27)	3 (6.82)	1 (2.27)	1 (2.27)	6 (13.63)
Total	8 (18.18)	20 (45.45)	15 (34.09)	1 (2.27)	44 (100)

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Association between STI status, demographic and behavourial characteristics

Under the analysis, gender and marital status of the participants were statistically associated with the risk of sexually transmitted infection among the respondents. Additionally, females were 60% less likely to be at risk of STI infection compared to males (COR = 0.40; CI = 0.19–0.81). Married participants were 58% less likely to be at risk of STI compared to unmarried participants (COR = 0.42; CI = 0.19–0.93) (Table 4).

Table 4. Strength of association between STI status, demographic and behavourial characteristics.

Variable	Category	STI		COR	(95%CI)
Variable	Category	Negative	Positive	COR	(95%CI)
Age	Less than 24	45 (68.2%)	21 (31.8)	Ref
	24 to 40	74 (78.7)	20 (21.3)	0.58	0.28–1.18
	More than 40	15 (83.3)	3 (16.7)	0.43	0.11–1.64
Study Site	Ho Teaching Hospital	38 (71.7%)	15 (28.3%)	Ref
	Ho Polyclinic	29 (82.9%)	6 (17.1%)	0.52	0.18–1.52
	Ho Municipal Hospital	67 (74.4%)	23 (25.6%)	0.87	0.41–1.86
Occupation	Unemployed	26 (68.4%)	12 (31.6%)	Ref
	Employed	106 (76.8%)	32 (23.2%)	0.65	0.30–1.44
Gender	Male	31 (62.0%)	19 (38.0%)	Ref
	Female	103 (80.5%)	25 (19.5%)	0.40	0.19–0.81*
Education	No formal/ Primary educ.	31(77.5%)	9 (22.5%)	Ref
	Secondary Education	53 (72.6%)	20 (27.4%)	1.30	0.52–3.21
	Tertiary Education	50 (76.9%))	15 (23.1%)	1.03	0.40–2.65
Marital Status	Unmarried	79 (69.9%)	34 (30.1%)	Ref
	Married	55 (84.6%)	10 (15.4%)	0.42	0.19–0.93*
Heard of STI	No	12 (63.2%)	7 (36.8%)	Ref
	Yes	122 (76.7%)	37 (23.3%)	0.52	0.19–1.42
Level of Knowledge	Poor	15 (65.2%)	8 (34.8%)	Ref
Level of Knowledge	Satisfactory	77 (79.4%)	20 (20.6%)	0.49	0.18–1.31
	Good	42 (73.7%)	15 (26.3%)	0.67	0.24–1.90
Drink Alcohol	No	97 (79.5%)	25 (20.5%)	Ref
	Yes	37 (66.1%)	19 (33.9%)	1.99	0.99–4.04
Smoking Status	Non-Smoker	132 (77.2%)	39 (22.8%)	Ref
	Smoker	2 (28.6%)	5 (71.4%)	8.46	1.58–45.32*
Sexual Partners	No sexual partner	16 (69.6%)	7 (30.4%)	Ref
	One	102 (77.3%)	30 (22.7%)	0.67	0.25–1.79
	Two or more	13 (65.0%)	7 (35.0%)	1.23	0.34–4.42
Condom use	No	81 (76.4%)	25 (23.6%)	Ref
	Yes	53 (73.6%)	19 (26.4%)	1.16	0.58–2.32
Preferred treatment facility	Comm. pharmacy	19 (82.6%)	4 (17.4%)	Ref
Preferred treatment facility	Hospital	115 (74.2%)	40 (25.8%)	1.65	0.53–5.15
Sexual intercourse per week	Less than 3	66 (74.2%)	23 (25.8%)	Ref
Sexual intercourse per week	3–4	53 (80.3%)	13 (19.7%)	0.70	0.33–1.52
	Greater than 4	6 (66.7%)	3 (33.3%)	1.43	0.33–6.21
Past Relationships	one or less	103 (79.2%)	27 (20.8%)	Ref
	2 or more	28 (62.2%)	17 (37.8%)	2.32	1.11–4.84*

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Smokers were 8.5 times at risk of STI infection compared to non smokers (COR = 8.46; CI = 0.58–45.32) and having two or more past relationships increased risk of STI by two folds compared to having less than two past relationships (COR = 2.32; CI = 1.11–4.84). Other demographic and behavioral characteristics such as age, study site, occupation, educational level, information on STI, alcohol consumption, number of sexual partners, condom use, frequency of sexual intercourse and preferred treatment facility were not statistically associated with risk of sexually transmitted infection (Table 4).

From the multivariable analysis using the multiple logistic regression, the factors that were found to influence the risk of sexually transmitted infection were the marital and smoking statuses of the participants. It was observed that being married was associated with 61% reduced odds of sexually transmitted infection compared to being unmarried (AOR = 0.39; Cl 0.17–0.89). Participants who smoked were 6.5 times more likely to contract an STI (AOR = 6.51; Cl 1.07–39.56) (Table 5).

Table 5. Strength of association between Risk of STI infection, gender of participant, smoking status and history of relationships.

Variable	Category	COR	CI	AOR	CI
Gender	Male	Ref		Ref
	Female	0.40	0.19–0.81	0.54	0.24–1.22
Marital Status	Unmarried	Ref		Ref
	Married	0.42	0.19–0.93	0.39	0.17–0.89*
Smoking Status	Non-Smoker	Ref		Ref
	Smoker	8.46	1.58–45.32	6.51	1.07–39.56*
Past Relationships	one or less	Ref		Ref
Past Relationships	2 or more	2.32	1.11–4.84	6.51	0.76–3.78

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Health-seeking behaviour of participants

Self-medication was reported by 44.07% (n = 78) of the participants. Regarding where participants would normally prefer to seek care, if need be, 87.08% (n = 155) preferred to seek care in hospitals. Regarding the choice of treatment type, 79.21% (n = 141) preferred to orthodox treatment as opposed to herbal treatment. About 19.32% (n = 34), 24.43% (n = 43), 30.68% (n = 54) and 25.57% (n = 45) of participants reported having waited for less than 1 week, 1 to 2 weeks, 2 weeks to 1 month and more than a month respectively prior to seeking care.

Discussion

Discharges from the penis or vagina were the most common clinical symptoms reported by the study participants and this is consistent with studies done in Ghana [17,18] and South Africa [19]. The study revealed a concerning overall prevalence of STIs at 24.72%, highlighting a significant public health issue. Self-reported prevalence of symptomatic STI among female sex workers in Nigeria in a similar study by Sekoni et al [20] was 36.5%. In addition, similar studies in Ethiopia (Gondar) and Gambia by Geremew et al [21] and Butcher et al [22] reported prevalence of STI to be 74.1% and 9.8% respectively.

Further analysis of the cohort used in this study, indicated that gonorrhea, chlamydial, and syphilis infections account for 11.24%, 10.11% and 7.30% of the cases, respectively. Banong-le et al. [23] found the prevalence of syphilis infection among symptomatic patients in a study conducted in Ghana to be 3.2%. This is lower than this study findings (7.30%) [23]. Geremew et al. [21] also reported very high prevalence of syphilis (30%) and N. gonorrhoeae (20.8%) in a study conducted among symptomatic patients attending Gondar town Hospitals and Health Centers [21]. The prevalence of chlamydia among patients showing symptoms in a study carried out by Nyarko et al.[17] in Western Ghana was 20.4% and this is higher than chlamydia prevalence in this current study. These findings may due to difference in study population, study facilities and study location.

The study brings attention to the complexity of STI cases, with 3.37% of participants experiencing co-infections involving two or three pathogens. Co-infections of gonorrhea and chlamydia were observed in 1.69% of cases, while other dual co-infections and co-infections with all three pathogens were less common but still present. These findings emphasize the importance of comprehensive STI screening and management strategies to address the multifaceted nature of STI transmission. Generally, while laboratory diagnosis of STIs is more reliable, it is also time-consuming, expensive, and involves advanced technology and resources. This makes it challenging to utilise regularly in countries with limited resources. The majority of countries face a significant burden of STIs; nonetheless, they do not have the requisite technical expertise, specialised doctors, and laboratory infrastructure to effectively diagnose these STIs [24]. Considering the increased risk of antibiotic resistance and complications with untreated STI, clinicians should increase diagnostic testing of participants who visit their health facilities with STI syndromes. This would help identify the specific type of STI before treatment is started.

Interestingly, the results of this study suggests that low levels of knowledge about STIs did not necessarily correlate with a higher incidence of infections, as indicated in Table 3. Individuals encounter numerous obstacles in their efforts to prevent STIs, including discrimination, inadequate healthcare systems, insufficient money, and lack of legislative backing. The presence of social stigma related to STIs, especially within certain populations such as men who have sex with men (MSM), has a substantial influence on people’s inclination to seek medical assistance or reveal their sexual behaviour while seeking healthcare [25,26]. The findings in this study also underscores the need for targeted educational campaigns and interventions to bridge the gap between awareness and behaviours.

Married individuals were found to be 61% less likely to face STI risk in contrast to unmarried participants and this is in concordance with a study conducted by Taylor et al. [27] which signified that the occurrence of multiple partners and long-lasting relationships within a year was minimal among married individuals, moderate among cohabiting couples, and highest among individuals who were previously married or had never been married [27].

Additionally, smokers were identified as 6.5 times more susceptible to STI infection compared to nonsmokers. Even though there was a total of only seven (7) smokers in the whole cohort, the 95% confidence interval for the odds of STI for smokers versus non-smokers was very wide in multivariable analysis (1.07–39.56). This emphasized the association between smoking and its heightened susceptibility to STIs, highlighting the importance of targeted interventions for this population. Studies done by Berg et al.[28] and Bajaj et al.[29] in America and Canada respectively established that smoking is associated with a person’s tendency for dangerous sexual behaviour and raised the probability of developing an STI.

The findings on marital status and smoking status highlight the nuanced interplay of demographic and behavioral factors in shaping STI vulnerability, emphasizing the need for targeted interventions and public health initiatives to address specific risk factors identified in this study.

Considering the health-seeking behaviour of participants towards STI management in this study, this was very alarming because patients delayed in seeking healthcare for their genitourinary symptoms. It is recommended that patients with genitourinary symptoms must seek care immediately to prevent complications such as infertility. The possible reason for the delay maybe due to the cultural sensitiveness of discussing genitourinary issues in the Ghanaian setting [30]. Secondly, from the health belief model, the delay in seeking care questioned the confidence the patients had in the overall health system. Additionally, patients may have sought care outside the health system and also, the high cost of treatment. Delayed treatment is a bane to the effective management of STI as it may lead to Pelvic Inflammatory Diseases (PID), etc [31].

Some of the patients claimed that they had taken antimicrobials, antihistamines and herbal concoctions prior to seeking healthcare at the hospital. Self-medication poses a lot of challenges to the management of medical conditions even though STI patients are more likely to self-medicate on antibiotics [32]. This leads to an increase in antimicrobial resistance and its consequences.

The hospital is thus the recommended point of care as reported in this study. For community pharmacies and herbal centers, they may not be trained to adequately diagnose the aetiology of these symptoms. These syndromes of STIs could lead to a reduced quality of life of the individual [33] with inappropriate drug therapy. Patient’s preference is an integral factor that has been established to improving compliance to treatment [34] and this study finding showed that patients preferred both orthodox and herbal treatment although there is paucity of evidence on the efficacy and safety of herbal medicines on the management of STIs. This highlights the need for research on the safety and efficacy of herbal medicines on the Ghanaian market so that policies can focus on incorporating safe and efficacious herbal medicines into the national treatment guidelines.

One of the strengths of this study included the use of very sensitive and specific approved kits to detect the presence of multiple infectious organisms which overall improves the validity of the study findings.

The limitations of this study were that the study focused on only three common bacterial STIs even though all patients who presented with suspected cases of all types of STIs were included. Thus, there is an increased chance that the burden of STI would be higher than what we estimated considering other STIs such as chancroid, HIV/AIDs, herpes, etc. This study employed a cross-sectional design hence the conclusions are limited to associations not causality. This study is also subject to recall bias as participants were made to remember past events and hence there is a potential for inaccurate responses due to recall bias. To reduce the impact of recall bias, we reduced the number of items on the questionnaire that required recall. Additionally, the knowledge assessment of STI was not validated and cannot be generalized. It is difficult to make associations between STI knowledge and STI prevalence among those already symptomatic. Even those with low knowledge were at the health facilities because they were seeking care. There could still be an association between STI knowledge and STI prevalence among people with asymptomatic infections.

Conclusion

Almost thirty percent of the study participants had STI. The most vulnerable age group was 24–40 years. Gonorrhoea, chlamydia and syphilis and associated co-infections were prevalent in the participants seeking medical attention with suspected cases of STIs. Also, low STI knowledge was not associated with having an STI in this study. Demographic and behavioural characteristics such as marital status and smoking were found to be associated with the risk of contracting an STI. Continuous awareness and sensitization about STIs are essential to reducing the risk and spread of the problem. The prevalence of STI among patients with the suspected illness calls for more interventions to improve targeted treatment for better outcomes and minimize risks for antimicrobial resistance. The Government policy on STI education should therefore be reevaluated and more tangible and long-lasting strategies devised to strengthen knowledge and awareness about the mentioned STIs in this study and others reported in the Ghanaian health system to comprehensively combat these infections including HIV/AIDs.

Supporting information

S1 Questionnaire. QUESTIONNAIRE.

(DOCX)

pgph.0003422.s001.docx^{(20KB, docx)}

S1 Data

(DTA)

pgph.0003422.s002.dta^{(380KB, dta)}

Acknowledgments

We thank the management, staff and study participants of Ho Teaching Hospital, Ho Polyclinic and Ho Municipal Hospital for their support during the study.

Data Availability

The data has been uploaded as supporting information/supplementary file.

Funding Statement

The authors received no specific funding for this work.

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PLOS Glob Public Health. doi: 10.1371/journal.pgph.0003422.r001

Decision Letter 0

Hanna Landenmark

25 Sep 2023

PGPH-D-23-01356

Knowledge and prevalence of common sexually transmitted infections among patients seeking care at selected health facilities in Southern Ghana

PLOS Global Public Health

Dear Dr. Hutton-Nyameaye,

Thank you for submitting your manuscript to PLOS Global Public Health. After careful consideration, we feel that it has merit but does not fully meet PLOS Global Public Health’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please see the comments from three reviewers below. Reviewer 2 in particular has expressed significant concerns about several aspects of the manuscript and reporting, including interpretation of previous work. We now invite you to address these concerns.

Please submit your revised manuscript by Nov 06 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at globalpubhealth@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pgph/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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We look forward to receiving your revised manuscript.

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Staff Editor

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Reviewer's Responses to Questions

Comments to the Author

1. Does this manuscript meet PLOS Global Public Health’s publication criteria? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

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Reviewer #3: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #2: Yes

Reviewer #3: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the opportunity to review the manuscript on "Knowledge and prevalence of common sexually transmitted infections among patients seeking care at selected health facilities in Southern Ghana"

This is a valuable contribution to public health and to the body of knowledge on STIs control and management.

I am satisfied with other sections of the manuscript but there is a need for the authors to revisit data management, data analysis, interpretations and discussion of the results to improve the manuscript.

Data management - data needs to be prepare for reanalysis

-Some variables have many subcategories and it is not necessary.

Age categories: has five categories Less than 21, 21 - 30, 31-40; 41 - 50

Greater than 50. I advise the authors to collapse to at least 3 categories for the association to make sense. EG. 18-24, 25-40, 41 and above.

Level of Knowledge =Poor, Satisfactory, Good, Excellent. Authors can group excellent and good to remain with three categories

No sexual partners has FIVE categories. I suggest 3 categories no partner, one , two or more

Past relationships has SIX categories. I suggest 3 no relationship, one, two or more

Regrouping categories will improve the results when computing the association and strength of association, especially because some values for subcategories = 1, which dilutes the analysis.

Occupation is also a long list that need regrouping

Results

When presenting association and strength of association, the authors do not give clear interpretation of the results by subgroup? EG: LINE 171-184 please clarify which SUBCATEGORY is associated with to risk

Youth, average age or older age? male or female? smoker on nonsmoker, few or more sexual partners? few or more past relationships, low or high level of knowledge etc. This results will be improved once the subcategories are collapsed as suggested in the data management.

Discussion

For all the statement made in the discussion, the authors cite only one study. This show lack of synthesis and balanced comparison with other studies. I encourage the authors to include more studies because STIs is a global topic and there are a lot of studies even in the region of Africa to compare with.

Abstract

After collapse subcategories and running the statistics, the authors have to realign the assignment.

Reviewer #2: Overall

This manuscript presents data from a cross-sectional study among 178 individuals seeking STI care in Ho Municipality in Ghana. Prevalence of chlamydia, gonorrhoea, and syphilis, in this population was 35.3%, 39.2%, and 25.5%, respectively. This is likely to be expected given they are reported to be symptomatic. Multivariate logistic regression is used to assess factors associated with STI diagnosis.

The introduction is very broad, and doesn’t provide enough background information to justify the study. If data on current prevalence of STIs in Ghana is available, please provide it. If no such data is available, state this. Furthermore, a large sub-section of the study is based around a single study by Seidu et al., which demonstrated self-reporting of STIs in the previous 12 months from demographic health and surveillance data. The results of the study appear to be misrepresented, and so this section needs to be re-formulated.

The methods are relatively clear, and I have just suggested a few minor changes for clarity. However, a significant issue is the lack of symptoms data as it makes it more difficult to determine who the sample is and who they are meant to represent.

Some aspects of the results section are unclear, particularly surrounding presentation of data.

The discussion needs a significant re-writing. There are several errors related to presenting this study’s own results. Furthermore, some of the comparisons with other studies and data are inappropriate due to differences in study design and populations. There needs to a unifying focus or thread through the discussion – at present, it is quite long but very disjointed, jumping from one topic to the next.

Overall, there are several major issues that need to be addressed before being suitable for publication.

Abstract

Page 2, line 25: “STIs”

1. Please provide full term before first use of abbreviations.

Page 2, lines 26-28: “This study aimed to determine the knowledge and prevalence of common STIs and associated risk factors among adult patients seeking care in health facilities in Ho Municipality.”

2. To ensure the study aim is as accurate as possible, I suggest making it explicit that the sample is adult patients seeking “STI” care.

3. Please provide numbers alongside the percentages for demographic factors and STI prevalence data.

Introduction

Page 3, lines 50-51: “Sexually Transmitted infections (STIs) are infections acquired through sexual intercourse with an infected partner (1).”

4. Please consider re-phrasing or removing the term “infected partner”, as the term “infected” is potentially stigmatising.

Page 3, lines 51-52: “Globally, STIs affect more than 1 million people worldwide, with one or more infection types occurring per day.”

5. I think this sentence is trying to convey that recent data suggests that there are around 1 million new infections of chlamydia, gonorrhoea, trichomoniasis or syphilis per day. This sentence needs to be re-phrased to make this more clear, as currently the meaning is quite confusing. Additionally, specifying the STIs that are being referred to is important. A reference is also required (current reference number 5 would be sufficient). Given that mention of 367 million new cases per year is subsequently discussed in this paragraph, consider removing this sentence altogether.

Page 3, lines 52-53: “Almost 30 different STIs have been established; some of which are easily managed while others are not treatable (2).

6. The reference for this statement is a 2013 therapeutics textbook. I suggest providing a more recent and relevant reference. Consider removing the specific number of STIs that have been “established” as this is likely to change and is open to debate.

Page 3, lined 58-60: “For interventions and resources aimed at reducing the burden of STIs to be planned and implemented effectively, the prevalence and incidence have to be quantified (6).”

7. The introduction needs to address why this specific study is required. For example, what data is already available on STIs in Ghana? What could then be done with the data? At present, the introduction is very broad.

Page 3, lines 61-62: “In many parts of Africa, STIs are one of the most common reasons for seeking medical attention.”

8. Please provide a reference to support this statement

Page 3, lines 65-67: “The prevalence of STI self-reporting was 6% in a study conducted by Seidu et al.(9) in Ghana (9). This means that a small number of patients self-report as compared to the number of patients who are clinically diagnosed with STIs.”

9. The comparison drawn is not reflective of the findings of the study by Seidu et al, which looks at the prevalence of STI self-reporting in Ghana demographic and health surveillance data. Men were asked during the survey “if they had contracted a disease through sexual intercourse in the previous 12 months”, to which they answered yes or no. No mention appears to be made in the study, comparing their findings of self-reporting with “patients who are clinically diagnosed with STIs”. Either provide an additional reference to support this comparison or change above. Additionally, the reference number “9” is in two places in the above sentence.

Page 3, lines 68-71: “Therefore, self-reporting must be encouraged to facilitate the prompt of these infections. Effective public health interventions such as self-reporting are however hinged on understanding the health seeking triggers in persons who may have STIs.”

10. Although seeking healthcare when symptomatic should be encouraged, the use of “self-reporting” here is confusing. It appears to be building on the above reference to Seidu et al. But in that study “self-reporting” did not refer to healthcare seeking – it solely referred to whether a participant reported having an STI in the previous 12 months” during a DHS survey. I think this section needs to be re-written with a better representation of what the data in Seidu et al. is presenting. Additionally, I think a word is missing after “prompt”.

Page 3, lines 73-75: “This study therefore sought to identify health seeking behaviours and prevalent STIs as well as knowledge on STIs in persons who were reporting in various health facilities in southern Ghana.”

11. As with comment above, please ensure the study aim is as accurate as possible, by making it explicit that the sample is adult patients seeking STI care.

Methods

Page 6, lines 101-103: “The deter

PLOS Glob Public Health. 2024 Jul 1;4(7):e0003422. doi: 10.1371/journal.pgph.0003422.r002

Author response to Decision Letter 0

4 Jan 2024

Attachment

Submitted filename: Response to Reviewers.docx

pgph.0003422.s003.docx^{(40.5KB, docx)}

PLOS Glob Public Health. doi: 10.1371/journal.pgph.0003422.r003

Decision Letter 1

Jennifer Tucker

19 Feb 2024

PGPH-D-23-01356R1

Knowledge and prevalence of common sexually transmitted infections among patients seeking care at selected health facilities in Southern Ghana

PLOS Global Public Health

Dear Dr. Hutton-Nyameaye,

Please pay particular attention to the comments from Reviewer 4, who requests revision of the results section for clarity regarding the total individuals included in the study, as well as clarification regarding methodological reporting and whether STI diagnosis followed routine standard of care procedures.

Please submit your revised manuscript by Apr 01 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at globalpubhealth@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pgph/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

We look forward to receiving your revised manuscript.

Kind regards,

Jennifer Tucker, PhD

Associate Editor

PLOS Global Public Health

Journal Requirements:

Additional Editor Comments (if provided):

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #4: (No Response)

Reviewer #5: All comments have been addressed

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2. Does this manuscript meet PLOS Global Public Health’s publication criteria? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.

Reviewer #4: Partly

Reviewer #5: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #4: Yes

Reviewer #5: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)?

Reviewer #4: Yes

Reviewer #5: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #4: Yes

Reviewer #5: Yes

**********

6. Review Comments to the Author

Reviewer #4: This is a cross-sectional study conducted in three outpatient clinics in Ghana enrolling adults with STI symptoms to evaluate STI knowledge and the prevalence of gonorrhea, chlamydia, and syphilis. The authors found a high prevalence of curable STIs and several demographic and behavioral factors associated with having an STI.

While the previous reviewers’ comments have been addressed, I have still identified a number of items that I believe need to be rectified prior to publication, in particular a discrepancy in the total number of individuals with an STI accounting for co-infections vs the total numbers of individual STIs added together (see comment in results section with asterisks below).

Introduction

The sentence in lines 53-54 needs clarification to states that 1 million people worldwide acquire a new infection every day, not that 1 million people worldwide are affected by STIs.

In line 71, I presume that it is ‘symptoms of STIs’ that are one fo the most common reasons for seeking medical attention. If so, please clarify here.

Does the statement ‘knowledge on STIs is limited’ in line 72 refer to individuals’ knowledge of STIs and their symptoms, or knowledge about the epidemiology of STIs in Ghana? Or both? It would be helpful to clarify here, and if it is the latter (epidemiology), to expand on why. E.g. inadequate epidemiologic surveillance, lack of access to etiologic testing, etc.

Methods

Line 112 “physician at the various health facilities introduced the study to patients. Who had been diagnosed with STI after consultation” – can you please clarify how STIs are diagnosed normally at the clinical sites. Presumably this is syndromic management but it would be helpful to clarify for readers who may not be familiar with the local standard of care.

Line 121 – was any of the data collected using the questionnaire qualitative? I believe this should be "quantitative"

Laboratory analysis: the statement in lines 148-150 regarding syphilis testing only involving treponemal antibodies would be more logical to include in the laboratory analysis, rather than the statistical analysis section; recommend moving this up.

It would be very helpful to include the list of questions used to assess STI knowledge as part of this manuscript, potentially as a supplementary file, as this would be informative to readers in interpreting the results of the knowledge assesmsnet. Were these questions part of a validated STI knowledge tool used previously in other settings? What do the questions ask about - STI symptoms? transmission? sequelae? How were the score categories of 0-6, 7-12, and 13-24 points to represent low, satisfactory, and good knowledge levels chosen? Is this based on prior literature? Why not divide the participants into tertiles of STI knowledge scores, for example?

Please provide additional details regarding the measures collected in the questionnaire (and presented later in Table 4). For example, does “sexual partners” mean number of sexual partners in a specific time frame (eg, past 1 month?). What does “past relationships” mean – is this number of prior lifetime sexual partners or something else? Is condom use and sexual intercourse per week only asked of/reported for participants who report a current/recent sexual partner, or everyone? How is “heard of STI” asked or assessed? Is alcohol use any alcohol use at all, or over a certain amount, and in what time frame? Consider including a copy of the questionnaire as a supplementary file.

Line 160 – was a p-value threshold of <0.05 from the bivariate analyses used to determine if a variable would be included in the multivariable logistic regression, or a different threshold?

Results

Line 170 – Please define the acronym OPD for readers who may not be familiar with this.

Table 2 – Consider simplifying the table by removing or combining the cells for symptoms that are not applicable to one of the genders (eg, discharge from penis for female participants)

Lines 180-181 – The statement “low levels of knowledge did not translate to higher number of infections” seems like a conclusion to be made from a statistical analysis demonstrating that there was no association between level of knowledge and STI prevalence; it would thus be clearer to make this statement later in the results section where the univariate analyses are presented.

**Table 3 and lines 179-184 - Since there were 7 participants with co-infections, the total number of individuals with any STI (one or more) cannot be the same as the sum of the individual STIs. In looking at the number and type of coinfections described in lines 181-184, I have calculated out the total number of individuals with any STI to be 42 rather than 51, giving a different overall prevalence of any STI in the sample (42/178 = 23.6%). Please confirm if this is correct and amend the results accordingly. Additionally, note should be made in table 3 that individuals with co-infections are being counted multiple times in the table.

Line 188 – Age does not show a statistically significant association with having an STI based on table 4, instead, smoking status and number of past relationships do and should be included in this sentence instead of age.

Line 211 – please define ‘orthodox treatment’

Discussion

Line 219-220: It is unclear why the authors have compared the STI prevalence found in this study with STI prevalence among a different population (pregnant women) in a different part of the world (Nepal). This is not a relevant comparison, as there is no reason to suspect that these two prevalence rates should be similar. There are many studies reporting STI prevalence in more similar populations (symptomatic adults of both genders in West Africa) that would be a more appropriate comparison to the present study.

Lines 222 – 223: these percentages represent percent of the total cohort, not percent of the total infections.

Lines 223 – 229: were the Banong-le et al and Nyarko et al studies conducted among symptomatic patients or those attending STI services? Would be helpful to mention this if the prevalence rates are being compared.

Lines 236-238: is diagnostic testing available in Ghana? While increasing diagnostic testing would help avoid both over- and under-treatment of STIs, this is not available in many parts of the world. An acknowledgement and/or discussion of this challenge would strengthen the discussion section overall.

LInes 240-243: There is an important opportunity here to discuss the challenges faced by individuals in preventing STIs despite high levels of knowledge. Many factors have been identified, including social norms that discourage condom use, gender power imbalance, inability for women to negotiate condom use/safe sex, etc.

Lines 249-250: It would be helpful to mention that there were only 7 smokers total in the whole cohort and that the 95% confidence interval for the odds of STI for smokers vs non-smokers was very wide in multivariable analysis (1.07-39.56), therefore, these results have to be interpreted with caution, and it is possible that the risk of STI is only slightly higher for smokers vs non-smokers.

Lines 250-254: As above, I would be cautious with interpretation of this finding and with the results of the literature. In the Berg et al study, smoking was “associated with” higher risk sexual behaviors, it cannot be concluded that smoking itself “enhanced” a person’s tendency for higher risk sexual behavior.

Lines 261-262: have any studies (behavioral science, qualitative studies) reported on the cultural sensitiveness of discussing genitourinary issues in the Ghanaian setting? It would be helpful to cite literature from Ghana or a similar setting to support this statement.

Lines 263-264: did the study participants actually report that they had low confidence in the overall health system? If not, I would be clear here that this is only a possible explanation for the observed delays in seeking care.

Lines 278-279: the statement regarding incorporation of herbal medicines into the national treatment guidelines, while important, seems contradictory to the point made in the previous sentence regarding lack of evidence on efficacy and safety of herbal medicines. Perhaps the need is for greater research on the safety and efficacy of herbal medicines so that those that are safe and efficacious could be incorporated into treatment guidelines.

Conclusion

Line 295 – as only associations can be drawn, I would state that marital status and smoking “were associated with” (rather than “influenced”) STI risk

As STI knowledge was a major focus of the study, I would consider stating the finding that low STI knowledge was not associated with having an STI in the conclusions section.

Reviewer #5: The Authors have sufficiently addressed the concerns raised by the previous reviewers

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PLOS Glob Public Health. 2024 Jul 1;4(7):e0003422. doi: 10.1371/journal.pgph.0003422.r004

Author response to Decision Letter 1

6 Apr 2024

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pgph.0003422.s004.docx^{(28.3KB, docx)}

PLOS Glob Public Health. doi: 10.1371/journal.pgph.0003422.r005

Decision Letter 2

Jana Jarolimova

3 May 2024

PGPH-D-23-01356R2

Knowledge and prevalence of common sexually transmitted infections among patients seeking care at selected health facilities in Southern Ghana

PLOS Global Public Health

Dear Dr. Hutton-Nyameaye,

In particular, please address the comments below regarding the accurate reporting of STI prevalence rates. We encourage consultation with a biostatistician as needed. Additionally, please note the recommended limitations to address.

Please submit your revised manuscript by Jun 02 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at globalpubhealth@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pgph/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

We look forward to receiving your revised manuscript.

Kind regards,

Jana Jarolimova, M.D.

Guest Editor

PLOS Global Public Health

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments (if provided):

1) The prevalence rates reported in the results do not reflect the true prevalence of each STI, as those STIs that were part of co-infections are not counted. Unless there is a reason to treat STIs that are detected as monoinfections vs co-infections differently (this would be unlikely), recommend that the prevelance rate for each STI is reported as the total number of people with each STI (including those with mono-infections and those with co-infections) dividided by the total sample size. of note, the sum of these prevalence rates will not be the same as the prevalence rate for any STI, as people with coinfections will only be counted once for the overall STI rate.

2) Methods - clarify in lines 128-129 whether past relationships were lifetime relationships or relationships in past year.

3) Specify which answers on the STI knowledge survey were considered 'correct' (in the supplemental data)

4) Add to limitations:

-Non-validated STI knowledge assessment used, may not be generalizable

-Difficult to make associations between STI knowledge and STI prevalence among those already symptomatic - even those with low knowledge are arriving bc they’re seeking care. There could still be an association between STI knowledge and STI prevalence among people with asymptomatic infections.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLOS Glob Public Health. 2024 Jul 1;4(7):e0003422. doi: 10.1371/journal.pgph.0003422.r006

Author response to Decision Letter 2

4 Jun 2024

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PLOS Glob Public Health. doi: 10.1371/journal.pgph.0003422.r007

Decision Letter 3

Jana Jarolimova

10 Jun 2024

Knowledge and prevalence of common sexually transmitted infections among patients seeking care at selected health facilities in Southern Ghana

PGPH-D-23-01356R3

Dear Dr Hutton-Nyameaye,

We are pleased to inform you that your manuscript 'Knowledge and prevalence of common sexually transmitted infections among patients seeking care at selected health facilities in Southern Ghana' has been provisionally accepted for publication in PLOS Global Public Health.

Before your manuscript can be formally accepted you will need to complete some formatting changes, which you will receive in a follow up email. A member of our team will be in touch with a set of requests.

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IMPORTANT: The editorial review process is now complete. PLOS will only permit corrections to spelling, formatting or significant scientific errors from this point onwards. Requests for major changes, or any which affect the scientific understanding of your work, will cause delays to the publication date of your manuscript.

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Thank you again for supporting Open Access publishing; we are looking forward to publishing your work in PLOS Global Public Health.

Best regards,

Jana Jarolimova, M.D.

Guest Editor

PLOS Global Public Health

***********************************************************

Reviewer Comments (if any, and for reference):

Please edit the last sentence in Results paragraph titled, "Prevalence and Knowledge of STIs among study participants" (lines 191-192), as the way that the text is currently worded, the total number of participants with coinfections would be 7 rather than 6. Specifically, the text states "Among the participants, 3.37% (n=6) had co-infections with two or three pathogens. Co-infections involving gonorrhoea and chlamydia were 2.25% (n=4). Other dual co-infections as well as coinfections with all three pathogens were recorded in one participant each." This would add up to: 4 patients with gonorrhea-chlamydia coinfection + 1 patient with gonorrhea-syphilis coinfection + 1 patient with chlamydia-syphilis coinfection + 1 patient with all three infections = 7 patients. however the true number should be 6.

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Questionnaire. QUESTIONNAIRE.

(DOCX)

pgph.0003422.s001.docx^{(20KB, docx)}

S1 Data

(DTA)

pgph.0003422.s002.dta^{(380KB, dta)}

Attachment

Submitted filename: Response to Reviewers.docx

pgph.0003422.s003.docx^{(40.5KB, docx)}

Attachment

Submitted filename: Response to Reviewers.docx

pgph.0003422.s004.docx^{(28.3KB, docx)}

Attachment

Submitted filename: Response to Reviewers.docx

pgph.0003422.s005.docx^{(21.2KB, docx)}

Data Availability Statement

The data has been uploaded as supporting information/supplementary file.

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Knowledge and prevalence of common sexually transmitted infections among patients seeking care at selected health facilities in Southern Ghana

Araba Ata Hutton-Nyameaye

Morrison Asiamah

Karikari Asafo-Adjei

Charles Kwaku Benneh

Adwoa Oforiwaa Kwakye

Kofi Boamah Mensah

Kwabena Obeng Duedu

Kwame Ohene Buabeng

Roles

Abstract

Introduction

Methods

Ethical statement

Study setting and population

Data collection process

Quality control

Laboratory analysis

Statistical analysis

Results

Demographic characteristics of the participants

Table 1. Demographic characteristics of participants.

Symptoms exhibited by participants

Table 2. Symptoms reported by participants.

Prevalence and knowledge of STIs among study participants

Table 3. Prevalence of STIs according to level of knowledge.

Association between STI status, demographic and behavourial characteristics

Table 4. Strength of association between STI status, demographic and behavourial characteristics.

Table 5. Strength of association between Risk of STI infection, gender of participant, smoking status and history of relationships.

Health-seeking behaviour of participants

Discussion

Conclusion

Supporting information

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Hanna Landenmark

Roles

Author response to Decision Letter 0

Decision Letter 1

Jennifer Tucker

Roles

Author response to Decision Letter 1

Decision Letter 2

Jana Jarolimova

Roles

Author response to Decision Letter 2

Decision Letter 3

Jana Jarolimova

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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