Determinants of knowledge on sexually transmitted infections among students in public higher education institutions in Melaka state, Malaysia.

INTRODUCTION: The increasing trend of sexually transmitted infections (STIs) among the young population is a significant public health problem. This study aimed to determine the level of knowledge on STIs among students in higher education institutions and its predicting factors, in Melaka.
METHODOLOGY: A cross-sectional study was conducted among 600 students from higher education institutions in Melaka aged between 18 to 30 years old. Multistage sampling of the institutions was performed. Valid and reliable self-administered questionnaire in the national language, Bahasa Malaysia, was used as to collect data on sociodemographic, personal background, knowledge on STIs and sources of information for STIs. Univariate, bivariate and multivariate analyses were conducted using IBM SPSS software version 25.
RESULTS: The response rate for this study was 88%. The mean knowledge score was 24.1 ±5.1 out of 38. HIV was the most known STIs while gonorrhoea, trichomoniasis and chlamydial infections were among the least known STIs. Oral intercourse was the least known sexual activity that could transmit STIs. Higher proportion of respondents had correct knowledge on control and preventive measures of STIs (between 78% and 95%) compared to correct knowledge on sign and symptoms of STIs (between 8.5% and 67.8%). More than 90% of the respondents were unaware that a person infected with STIs could be symptom free. Four variables were identified as the determinants of the knowledge on STIs, which were level of education, place of stay, history of sexual and reproductive health education and involvement in STIs awareness programs (F (4,445) = 11.405, p <0.001, R2 = 0.093).
CONCLUSIONS: The knowledge on STIs among students in higher education institutions was unsatisfactory. The existing sexual education programs can be strengthened by delivering more information on other STIs rather than focusing on HIV only. The future program should focus on students of diploma and/or skill certificate and staying off-campus.

Introduction

Increasing trend of sexually transmitted infections (STIs) among young adults is an alarming issue as they are among the major contributors for STIs cases worldwide [1,2]. The World Health Organization (WHO) has been performing global estimation for four curable STIs approximately every five years since 1995 [3]. The latest report published in June 2019 estimated about 380 million new cases of curable STIs in year 2016, with the WHO Region of the Americas having the highest incidence rate for syphilis and chlamydia among both men and women, while the WHO African region had the highest incidence rate for gonorrhoea and trichomoniasis in both men and women [3]. In Malaysia, the available surveillance systems for STIs reported an increasing trend of syphilis and gonorrhoea cases, with the incidence rate of syphilis being only 5.7 per 100,000 population in 2012 but had increased to 8.0 per 100,000 population in 2017 [4,5]. Similarly, the incidence rate of gonorrhea was 4.78 per 100,000 population in 2013 but had markedly increased to 10.39 in 2017 [5,6]. Nonetheless this marked increase in the incidence of syphilis and gonorrhea might have been contributed by the improvement in the surveillance systems for STIs in the country and the establishment of STI Friendly Clinics in selected government health clinics starting from the year 2015 [7].

Building social relationship, expanding the social network, and searching for romantic partner for stable relationship are part of the normal process in psychosexual development of young adult [8]. At the same time, most young adults are exposed to conducive environment that are favourable for them to engage in risky sexual behaviour based on peer and digital culture influences. The complex interactions between these biological, behavioural and sociocultural factors make them more vulnerable to get STIs compared to the older population [1]. The profound impacts of STIs are not merely the increased risk of HIV infection but also serious implications on the sexual and reproductive health, such as congenital syphilis, cervical cancer and infertility [9,10]. The provision of comprehensive health information, education and health promotion programs are important measures that should be prioritized by each country to end the epidemic of STIs [9]. As certain types of STIs do not present with obvious signs and symptoms, the public should have the knowledge on the different types of STIs and the spectrum of diseases caused by them. In addition, the information regarding the risk factors for STIs is also vital for the implementation of preventive measures [11].

Knowledge on STIs among young adults including undergraduate students in Malaysia is still lacking. For example, approximately 90% of the respondents in one higher education institution in the state of Selangor believed that STIs could be transmitted through handshakes [12]. Another study in several higher education institutions in Negeri Sembilan and Selangor conducted among students in the field of health, reported that only 63.9% of the respondents had knowledge that syphilis is a STI, 45.4% knew gonorrhoea is a STI and only 50% of the respondents knew STIs could be asymptomatic [13]. Additionally, a study conducted among male respondents aged 15 to 24 years in five states in Malaysia reported only 78.7% of the respondents knew that condom is one of the preventive measures of STIs [14].

In Malaysia, various platforms have been used to deliver sexual health information to young adults through school-based syllabus and community programs [15,16]. Under the National Policy in Reproductive Health and Social Education or also known as the PEKERTI policy, most of the programs target adolescents at school through sexual and reproductive health (SRH) topics which were embedded in other subjects such as biology and family health, Islamic education, moral physical and health education subjects.[15-17] Moreover, under the National Strategic Plan Ending AIDS (NSPEA) 2016–2030, all higher education institutions are required to have one compulsory session for education on sexual and reproductive health focusing on STIs, for newly registered students [15]. Furthermore, Malaysia is committed in making Melaka City the nation’s representative in the Association of South East Asian Nations (ASEAN) pilot project, known as ‘Getting to Zero City’ which began in the year 2013 [7,18,19]. “Getting to Zero City” is a regional project of the ASEAN leaders who commit to achieve zero new HIV infections, zero discrimination and zero AIDS-related deaths, in line with global response to end the HIV epidemic by 2030 [18,19]. The projects aim to intensify the efforts in eliminating HIV/AIDS by involving various government agencies and non-profit organizations in activities to key populations and young people. Examples of the activities include screening and harm reduction programs, health education, counselling and treatment services, [19]. Additionally, in response to the NSPEA, the project also has enhanced the existing STIs programs by offering more support and resources for preventive measures such as condom provision, health promotion and health education through STI-Friendly Clinics and various programs at community and organizational levels [7,18,19]. Despite these ambitious initiatives, the level of knowledge on STIs among the young adults, especially in Melaka, is not known.

Therefore, this study aimed to evaluate the knowledge on STIs among undergraduate students in higher education institutions in Melaka, and its predicting factors. The findings of this study can contribute to the efforts towards achieving the objectives of the “Getting to Zero City” project, by identifying the gaps in current educational programs on STIs.

Methodology

Study design and population

A cross -sectional study was conducted in the state of Melaka, Malaysia from September 2018 until July 2019. The study population was students from public higher education institutions in Melaka. The selected institutions offered different levels of education programs ranging from l certificate, diploma, and degree levels. The inclusion criteria of study participants were full-time students and aged between 18 and 30 years. The exclusion criteria were those on medical leave, absent during data collection, post-graduate students, and international students. The estimated sample size required to achieve a significance level of 0.05 at 95% confidence interval for the study was 600 based on the mean knowledge score from a previous study [20] after considering the design effect of 1.5 [21] and 20% non-response rate.

The sampling method was multistage sampling. During the first stage, 10 out of 21 public higher education institutions in Melaka were randomly selected using a random number generator. After being granted approval to conduct the study in these 10 institutions, the second stage of sampling was conducted by randomly selecting the study participants from the registration list using a computer-generated random sequence software. The sample size required was allocated proportionately to the number of students in each selected institution. The institutions with a larger number of students contributed to larger samples. The Student’s Welfare Department and lecturers of these institutions then informed the students regarding the research to avoid any mistrust among the students regarding the execution of the research. The participants were then contacted by the researcher via phone calls and invited to attend briefing sessions at the predetermined venue (classroom/hall). During the briefing sessions, the participants were informed about the research and were invited to voluntary participate in it. Only those who volunteered were given the consent form to be signed. Participants who returned the signed consent forms were then given the study questionnaire and were requested to complete the questionnaire before leaving the briefing venue. The researcher was always present to answer any queries.

Measures

A validated and reliable self-administered questionnaire used in the study was adapted from several studies [12,13,22,23]. The questionnaire consisted of three parts. Part 1 comprised of 13 items related to sociodemographic characteristics and personal background of the respondents. Part 2 was on knowledge of STIs which consisted of five constructs. The first construct consisted of 10 items on type of STIs, the second construct consisted of seven items on the mode of transmission of STIs, the third construct consisted of seven items on the risk factors of STIs, the fourth construct consisted of eight items on the sign and symptoms of STIs, and the fifth construct consisted of six items on the control and preventive measures of STIs. Each item had three-answer options which were ‘yes’, ‘no’, or ‘don’t know’. One score was given to a correct answer and zero score was given to an incorrect answer. The maximum score was 38 and the minimum score was 0. Part 3 comprised of one question on the source of information for STIs. The entire questionnaire was developed in English. Forward and backward translation was performed by an English teacher who holds a master’s degree in Art (English Language). Face validity was tested among students from one of the public higher education institutions in Melaka aged 18 to 30 years old who were not included as participants in this study. Amendments were made based on the feedback given by the students. Content validity was performed by three public health physicians. The modifications on the questionnaire were made based on the recommendations given by them.

The questionnaire was tested for its reliability on 60 students, which was 10% of the total sample size. The students have been selected from one of the public higher institutions in Melaka, and they were not included as study participants. The internal consistency of the questionnaires was estimated by using Cronbach’s alpha where the value of more than 0.7 was considered acceptable [24]. The value of Cronbach’s alpha for each construct was summarized in “Table 1”. All items in each construct were retained and all constructs were retained to give the overall Cronbach’s alpha of 0.83 for knowledge of STIs.

Table 1

Summary of the Cronbach’s alpha index value.

Construct	Number of items	Mean (SD)	Cronbach’s alpha index value
Knowledge of type of STIs	10	4.13 (2.07)	0.69
Knowledge on mode of transmission of STIs	7	3.90(2.21)	0.79
Knowledge on risk factors of STIs	7	4.57(2.05)	0.77
Knowledge on sign and symptom of STIs	8	3.70(2.43)	0.79
Knowledge on control and prevention of STIs	6	4.53(2.19)	0.92

Note: SD: Standard deviation.

Variables

The dependent variable in this study was knowledge scores on STIs while independent variables were sociodemographic factors (age, sex, marital status, ethnicity, religion and level of education), personal background (type of academic course, place of stay, history of sexual and reproductive health education at school, involvement in STIs program and parent’s education level). The “level of education” refers to the education levels of respondents at the point of data collection whether the respondents currently taking Malaysian Skill Certificate, diploma, or a bachelor’s degree. Those who were studying for a degree, they will be classified as “degree” and those who were studying for a diploma and/or skill certificate were classified as “non-degree” respondents. For the “type of academic course”, courses in fashion, art and design, photography, creative imaging, hospitality management, finance management, business administration, and education were considered as “art courses”, while “science courses” refer to courses related to engineering namely technology communication engineering, computer engineering, industrial and manufacturing engineering, mechanical engineering, automotive, electrical engineering. “Involvement in STIs program” refers to the involvement of respondents in any programs or health talks on STIs organized in their schools, college, or in the community. The type of program referred to the latest STIs program the respondents participated in, be it programs organized in the schools, college, or community settings. History of sexual and reproductive health education at school was asked to ensure the participants were aware regarding SRH education delivered in the schools since there were no specific curriculum or subject named as SRH in school because SRH topics were embedded in other subjects such as biology and family health, Islamic education, moral physical and, health education subjects [17].

Statistical analysis

The data were described and analyzed using the International Business Machines Statistical Package for Social Sciences (SPSS) version 25.0. Normality testing was performed on continuous variables which included the total knowledge scores and the age of the respondents.

Descriptive statistic or univariate analysis was used to assess the frequency distribution, the mean and standard deviation for knowledge score of STIs by sociodemographic and personal backgrounds. The bivariate analysis used in this study was independent t-test except for three variables that did not fulfil the assumptions for independent t-test which were ethnicity, religion, and marital status. The data for the knowledge score for each group in these three variables were not normally distributed. Therefore, Mann-Whitney U test was used in bivariate analysis for ethnicity, religion, and marital status. Multiple linear regression (MLR) was used to identify the determinants for the knowledge score of STIs. Covariates (level of education, place of stay, history of SRH, and involvement in STIs program) were also adjusted using MLR. Variables with a significance level of 0.25 were chosen to be imputed into the model [25]. Dummy variables were created and coded as 0 and 1, where 0 was labelled as the reference group. Stepwise selection approach was used, as it provided the most parsimonious model. Assumptions of normally distributed residuals were fulfilled for total knowledge scores using graphical methods. Significance was predetermined at a probability value of 0.05 and less.

Ethical approval

This research project was approved by the Ethics Committee for Research Involving Human Subjects Universiti Putra Malaysia (UPM/TNCPI/RMC/1.4.18.2 (JKEUPM)). This study was also granted permission by the directors and Vice Chancellors of each institution. Written consent was obtained from all participants. Participants were informed that their involvement in this research was voluntary and that all information they provided remain confidential. All the data and documents from this study will be kept in locked storage and will be disposed of according to the standard operating procedure, five years after the completion of the study.

Results

The total number of respondents approached by the researcher was 700. Of this, 680 students were found to be eligible. Another 20 students were not eligible due to various reasons such as being on the semester break and doing practical training outside the campus. A total of 680 self- administered questionnaires were disseminated to these eligible respondents and all of the questionnaires were returned to the researcher within the allocated time. However, 80 questionnaires were incomplete (more than 5%) hence were excluded during the final analysis. Therefore, the response rate was 88.23%.

Majority of the respondents were of Malay ethnicity (95.8%), single (99.3%) and aged between 19 and 21 years (61%). The mean age of the respondents was 21 ± 1.59 years. The distribution of male and female respondents was almost equal. “Table 2” shows the respondents’ sociodemographic characteristics.

Table 2

Sociodemographic characteristics and personal background of respondents.

Characteristics	n	(%)
Age (Years)
<23	482	80.3
≥23	118	19.7
Sex
Male	304	50.7
Female	296	49.3
Ethnicity
Malay	575	95.8
Chinese	8	1.3
Indian	4	0.7
Others	13	2.2
Marital status
Single	596	99.3
Married	4	0.7
Religion
Muslim	581	96.8
Buddha	7	1.2
Hindu	4	0.7
Christian	8	1.3
Education level
Skill Certificate	167	27.8
Diploma	178	29.7
Bachelor	255	42.5
Type of course
Art	323	53.8
Sciences	277	46.2
Place of stay
In campus/hostel	377	62.8
Out campus	223	37.2
History of sexual and reproductive health education at school
Yes	307	51.2
No	143	23.8
Unable to recall	150	25.0
Involvement in STIs program
Yes	328	54.7
School program	106	32.3
Not school program	222	67.7
No	272	45.3
Father’s education
No formal education	10	1.7
Primary school	43	7.2
Secondary school	285	47.5
College/university	262	43.7
Mother’s education
No formal education	14	2.3
Primary school	35	5.8
Secondary school	330	55.0
College/university	221	36.8

Note: STI: Sexually transmitted infection.

The overall mean knowledge score was 24.09 ±5.06 out of 38. “Table 3” shows respondents’ replies on the knowledge of STIs. The most known STI was HIV while the least known STIs were trichomoniasis (12.5%), chlamydia (14.3%), and gonorrhoea (19.0%). Majority of the respondents were aware of the mode of transmission of STIs, which was through vaginal intercourse (90%) and anal intercourse (80%). However, on average, about one-third of respondents provided incorrect answe14rs especially on vertical transmission (39%), blood transfusion (37%), and oral intercourse (36%). In terms of risk factors of STIs, the top three risk factors that were misunderstood by the respondents were uncircumcised male (76%), smoking (33%), and early sexual debut (26%). About 90% of the participants did not know that those who are infected with STIs may not have any signs and symptoms. The top three control and preventive measures of STIs that the respondents were unaware of are: being faithful in an intimate relationship (23%), using condoms during sexual activity (15%), and vaccination against certain types of STIs (14%).

Table 3

Knowledge of STIs.

Knowledge of STIs	Correct Answer		Incorrect answer
	n	%	n	%
Type of STIs
Syphilis	327	54.5	273	45.5
Pneumonia	460	76.7	140	23.3
HIV	554	92.3	46	7.7
Tuberculosis	426	71.0	174	29.0
Trichomoniasis	75	12.5	525	87.5
Genital herpes	209	34.9	391	65.1
Hepatitis B	149	24.8	451	75.2
Gonorrhoea	114	19.0	486	81.0
Chlamydia	86	14.3	514	85.7
Measles	345	57.5	255	42.5
Mode of transmission
Vaginal intercourse	537	89.5	63	10.5
Anal intercourse	479	79.8	121	20.2
Oral intercourse	384	64.0	216	36.0
Using public toilet	414	69.0	186	31.0
Blood transfusion	377	62.8	223	37.2
Vertical transmission	365	60.8	235	39.2
Hand shaking	438	73.0	162	27.0
Risk factors
Sexual activity without condom	518	86.3	82	13.7
Multiple sexual partner	572	95.3	28	4.7
Same sex relationship	487	81.2	113	18.8
Having sex with sexual worker	552	92.0	48	8.0
Early sexual debut	444	74.0	156	26.0
Uncircumcised male	147	24.5	453	75.5
Smoking	401	66.8	199	33.2
Sign and symptoms
Itchiness at genitalia	386	64.4	214	35.6
Abnormal vaginal or urethral discharges	407	67.8	193	32.2
Vomiting	286	47.7	314	52.3
Pain during sexual intercourse	393	65.5	207	34.5
Ulcer at genitalia	335	55.8	265	44.2
Headache	312	52.0	288	48.0
Prolonged cough more than 2 weeks	297	49.5	303	50.5
Showing no sign and symptom	51	8.5	549	91.5
Control and prevention
Using condom during sexual activity	513	85.5	87	14.5
Avoid premarital sexual intercourse	553	92.2	47	7.8
Be faithful in the intimate relationship	465	77.5	135	22.5
Do screening test	556	92.7	44	7.3
Get early treatment	570	95.0	30	5.0
Get vaccinated to protect against certain type of STIs	514	85.7	86	14.3

Note: STI: Sexually transmitted infection.

Most of the respondents obtained information on STIs from three major sources which were the internet (41.3%), lessons at school or college (27.8%) and health personnel (16.7%). Parents and friends contributed to only 1% and 2% as source of information on STIs respectively. Other sources of information regarding STIs are as tabulated in “Table 4”.

Table 4

Distribution of sources of information for STIs among respondent (N = 600).

Source of information	n	%
Lesson at school/college	167	27.8
Internet	248	41.3
Television	13	2.2
Radio	4	0.7
Reading materials	40	6.7
Parent	8	1.3
Friends	13	2.2
Partner	5	0.8
Health personnel	100	16.7
Others	2	0.3

Note: STI: Sexually transmitted infection.

From both independent t-test and Mann-Whitney U test, six variables were found to be significantly associated with the level of knowledge on STI, with p-value 0.05 and less. These variables were age, education level, type of course, history of SRH lesson, involvement in STIs program, and place of stay, as shown in “Table 5”.

Table 5

Association between sociodemographic and personal factors and knowledge score of STIs.

Variables	N	Knowledge score of STIs	Test statistic t/Z	p- value
Age (years)
<23	482	23.82 (5.198) c	-1.365a	0.003*
≥23	118	25.19 (4.291) c
Sex
Male	304	23.97 (5.293) c	-0.587a	0.557
Female	296		24.21 (4.809) c
Ethnicity
Malay	578	24.00 (7.000) d	-0.914b	0.361
Non- Malay	22		24.00 (5.000) d
Religion
Muslim	582	24.00 (7.000) d	-0.100b	0.921
Non-Muslim	18		26.00 (5.000) d
Marital status
Not married	596	24.00 (7.000) d	-1.522b	0.128
Married	4		28.50 (9.000) d
Education level
Not degree	345	23.52 (5.379) c	-3.296a	0.001*
Degree	255		24.85 (4.488) c
Type of course
Art	323	24.52 (4.669)	2.230	0.026*
Science	277	23.59 (5.444)
History of SRH lesson
Yes	307	24.84 (4.746)	3.454	0.001*
No	143	23.01 (5.459)
Involvement in STIs program
Yes	328	24.57 (5.007)	2.581	0.010*
No	272	23.51 (5.069)
Type of program
School program	106	25.08 (4.663)	-1.318	0.189
Not school program	222	24.32 (5.157)
Place of stay
In campus	377	24.63 (5.014)	3.439	0.001*
Out campus	223	23.17 (5.013)
Father’s education
Not going to college	338	24.09 (5.036)	0.009	0.992
Going to college	262	24.09 (5.098)
Mother’s education
Not going to college	379	24.25 (4.958)	1.036	0.301
Going to college	221	23.81 (5.226)

Note:

*Significant at p ≤ 0.05,

a Independent t-test,

b Mann-Whitney U test,

c Mean (Standard Deviation),

d Median (Interquartile Range).

STI: Sexually transmitted infection; SRH: Sexual and reproductive health.

The variables with p-value of 0.25 and less were chosen to be imputed into the preliminary model in the multiple regression analysis. These variables were age, marital status, level of education, type of course, history of SRH lesson, involvement in STIs program, type of undergraduate program, and place of stay. In the final model, four variables were identified to be statistically significant in predicting the level of knowledge [F (4,445) = 11.405, p <0.001, R2 = 0.093]. The significant variables were level of education, history of SRH education, involvement in STIs program, and place of stay as shown in “Table 6". Respondents’ predicted knowledge scores were equal to 25.06 + 1.89 (level of education)– 2.03 (place of stay)– 1.18 (history of SRH education)– 1.08 (involvement in STI program). Respondents who were studying in the degree program scored 1.89 more than those who were not, those staying out of campus scored 2.03 less than those staying in campus, those without a history of SRH education scored 1.18 less than those with history of SRH education, and those who were not involved in STIs program scored 1.08 less than those who were. These four variables explained 9.3% of the variation in the knowledge score of STIs, and each variable explained 8.5% variation in the knowledge score of STIs while another 91.5% variance in the knowledge score of STIs was explained by other factors which were not studied.

Table 6

Determinants of knowledge score on STIs.

Variable	Unstandardized coefficient		Standard coefficient	t	p-value	95% CI
	B	Std error	Beta			Lower bound	Upper bound
Constant	25.060	0.387		64.752	<0.0001	24.300	25.821
Level of education	1.889	0.485	0.185	3.898	<0.0001*	0.937	2.841
0 = Not degree**
1 = Degree
Place of stay	-2.028	0.478	-0.194	-4.241	<0.0001*	-2.968	-0.170
0 = In campus**
1 = Out campus
History of SRH education	-1.178	0.513	-0.109	-2.297	0.0220*	-2.187	-0.489
0 = Yes**
1 = No
Involvement in STIs program	-1.078	0.491	-0.106	-2.194	0.029*	-2.044	-1.088
0 = Yes**
1 = No

** Reference group,

*Significant at p < 0.05, R2 = 0.093, Adjusted R2 = 0.085.

STI: Sexually transmitted infection; SRH: Sexual and reproductive health.

Discussion

Sexually transmitted infections among young adults are increasing worldwide including Malaysia [1,3,5,9]. Policy and programs have been put in place [11,16] in order to manage these trends. This cross-sectional study aimed to determine the level of knowledge on STIs and its determinants among undergraduate students of higher education institutions in Melaka. This study was conducted 5 years after the implementation of the “Getting to Zero City” pilot project. The present study yielded a good response rate that was contributed by the commitment and cooperation of the institutions’ management including lecturers and students’ affairs departments. Majority of the respondents were Malay, and this could be due to the Malay ethnicity being the largest ethnic group in Melaka and majority of the public higher education institutions in Melaka is accommodated by Malay ethnics [26].

The knowledge of STIs among the respondents in this study was slightly higher than other studies conducted among students in higher institutions and the general population. In the present study, the mean knowledge score was 24 out of 38 scores (63%) compared to another study conducted among university students in the central zone of Malaysia (53%) [13] and university students in Thailand (49%) [27]. While a study conducted among patients who attended a venereal clinic in Malaysia had reported the mean knowledge score of 12 out of 33 (36%) [23]. The higher knowledge scores observed in our study might be contributed by the recent information received by the participants since all higher education institutions must organize an awareness program on HIV/STI once a year in response to the NSPEA 2016–2030 [11]. As expected, HIV was the most well-known STIs among the respondents. This finding was consistent with findings from previous studies among the young population [12-14,22,27-31]. Lesser awareness on other STIs was also observed among young people in previous studies conducted locally [12-14]. This could be due to lesser attention given to the other STIs during health talks or programs.

Generally, the respondents knew that STIs were not only transmitted through sexual activities but also through other routes such as vertical transmission, blood transfusion, and oral intercourse. Similar findings were reported by previous studies conducted among higher institution students in Malaysia and Saudi Arabia [12,13,28]. Amongst the three common sexual activities asked in the present study, oral intercourse was the least known sexual activity that can act as a mode of transmission for STIs. Oral sex is being practiced by both heterosexual and homosexual groups and usually perceived as low risk or safer activity [32]. However, our finding was not consistent with a study conducted among the first-year undergraduate in one of the universities in Turkey, where more respondents knew about oral intercourse as a mode of transmission of STIs as compared to vaginal intercourse [22]. Our study showed that less than one-third of the respondents knew that being uncircumcised (for males) is one of the risk factors for STIs. This finding is inconsistent with a study conducted among males who attended the clinic for HIV testing in Namibia where 66% of the respondents knew male circumcision could reduce STIs transmission [33]. Furthermore, one-third of our respondents thought smoking is one of the risk factors for STIs. They might be confused with the indirect health effects of smoking that could lead to an immunocompromised state and could lead the individual to contract infectious diseases [34].

Among all the components of knowledge on STI, our respondents had the poorest level of knowledge on the signs and symptoms of STIs Our findings are consistent with previous studies [12-14,22,27-29]. More than 90% of the respondents were unaware that a person infected with STIs could be showing no sign or symptoms. These findings could explain the late detection of STIs cases among both males and females [1-3,9]. In addition, half of the respondents thought that a prolonged cough of more than two weeks is a sign and symptom for STIs. Since tuberculosis is one of the commonest co-infections among HIV patients [35,36] the sign and symptoms of tuberculosis may be thought to be associated with STIs.

In general, our findings show that the respondents had adequate knowledge on the control and preventive measures of STIs compared with several previous studies conducted locally among the young population in Malaysia [12-14,23]. This could be contributed by the HIV/STI education program that has been carried out. In addition, the mandatory requirement of HIV screening tests before marriage for Muslim couples in Malaysia might have resulted in increased awareness on the importance of avoiding pre-marital sexual activity and getting screening tests done [37]. However, we expected the proportion of the respondents who were aware of the role of the condom as a preventive measure for STIs would be higher than that found in this study which was 85%. Furthermore, about 85% of our respondents were aware of the role of vaccination in protecting against STIs, which was higher than the findings in one of the studies conducted among university students at Taif, Saudi Arabia. Their findings showed that only 38% of their respondents knew the existence of vaccination as one of the protective methods against STIs [28]. Our findings could be contributed by the free vaccination services for two viral STIs namely Hepatitis B and Human Papillomavirus (HPV) for Malaysians. The existence of this free vaccination could contribute to the increase in the awareness on the availability of vaccines to protect against certain STIs.

The present study found that the internet is the main source of information for STIs followed by the syllabus at school or college and health personnel. This could be attributed by the high percentage of the young population who are smartphone users in Malaysia. The Malaysian Communications and Multimedia Commission (MCMC) reported that 88% of young people aged between 20 and 30 years are smartphone users with 30% of them are internet users in year 2018 [38,39]. Furthermore, a study showed that about half of polytechnic students in Malaysia spend their leisure time surfing on the internet [40]. These data could explain why the internet was the most preferred channel to gain information for STIs in our study. Our findings are inconsistent with previous studies conducted in other countries. For example, the main source of information among university students in Turkey was reading materials such as books and magazines [22] and in Thailand was lesson at school/college [27]. In Nigeria, radio and television were the main sources for STIs information among secondary schools’ students [29], while in another study conducted among youth in Italy, parents and teachers were the main sources of information for STIs [30].

About one third of our respondents claimed to have received information on STIs through lessons given in schools or colleges. Even though sexual and reproductive health was taught in school, a study showed that the information delivered was perceived as inadequate [41]. A study conducted among 1706 university students on what they had received during school-based sexual education found that information on STIs was lacking [42]. In addition, a study concluded that cooperation between schools, young people, families, and communities is vital to amplify the success of sexuality education [43]. However, our findings showed that parents and friends were the least relied on as source of information on STIs. Although parents are expected to provide sexual education to their offspring, usually they are reluctant to do so as they assume that will indirectly provide permission for their children to explore on sexual behaviors [44]. Our findings were in contrast with a study conducted among male university students in Saudi Arabia where friends were the main source of information for STIs and were reported to be a significant factor in determining the knowledge of STIs [28]. A meta-analysis showed that peer education approaches have significantly contributed to increase knowledge on HIV (OR: 0.37; 95% CI: 1.88, 2.75) [45].

From regression analysis, four determinants were found to be significantly associated with knowledge of STIs in this study. These factors were level of education, place of stay, history of SRH education and involvement in STIs programs. In the present study, the respondents with higher education level were found to have better knowledge of STIs. Similar result was reported by previous studies [21,46]. A study conducted in Iran among women aged 15 to 49 years showed that women whose education level was lesser than the degree level had nearly 5 times lower knowledge score than those who have a degree [21]. A study conducted among high school students in the United States showed that the students in higher grade had better knowledge score than those in the lower grade [46]. History of receiving SRH education at school was found to be a significant factor influencing the knowledge of STIs in our study. Therefore, Malaysia should continue and improve the implementation of SRH education in schools [42] as well as at tertiary levels organized by government and non-governmental organizations [15,16].

Another significant factor for knowledge of STIs found in our study was place of stay. The respondents who lived on campus had significantly better knowledge of STIs as opposed to those who lived out of campus. Under the National Strategic Plan Ending AIDS 2016–2030, all higher educational institution must organize an educational program on HIV/STIs once a year [15]. In addition, on campus students need to adhere to their institution’s regulation of compulsory attendance of organized programs in order to obtain merit for continuity of stay on campus. Therefore, students who lived on campus might have recently exposed to the information on HIV/STIs and these influenced their knowledge on STIs.

The strength of this study includes the random sampling method used during the selection of study’s participants. Additionally, students from half of the public higher education institutions available in Melaka were included in this study, which can justify the generalizability of this study’s findings among the study population. Melaka state which was chosen to represent Malaysia in the “Getting to Zero City” was a suitable location to assess the knowledge on HIV and other STIs infections. Moreover, a validated and reliable questionnaire used in this study was tailored and modified to suit our local context, thus the information bias can be further minimized. In terms of study limitation, the findings from this study could not represent students in higher education institutions in Malaysia because the study populations were restricted to one state only which was Melaka state. Besides, several other factors which could influence the knowledge of STIs were not examined in this study such as sexual practices and history of STIs. Selection bias might have occurred during the selection of the study’s participants since they might feel obliged to join the study because they were instructed by the college administrators. However, the researchers have attempted to reduce the selection bias by randomly selecting the participants from the list of registered students and personally approach them by phone calls and offered voluntarily participation. Another possible bias that could have occurred in this study is information bias. Some respondents may be hesitant in answering the questions truthfully due to the sensitive and personal nature of the topic being asked in our local setting. Besides, recall bias could occur on events such as exposure to SRH education and involvement in STIs programs. However, the researcher has attempted to reduce the bias by ensuring the validity and reliability of the questionnaires.

Conclusion

The current findings show that the knowledge level on STIs has slightly increased compared to those in previous local studies, but it was still unsatisfactory. Knowledge on STIs was mainly obtained from the internet and the main STI known was HIV.

As previous exposure to SRH education and involvement in STIs programs are the determinants for knowledge on STIs, the existing education programs in the country should be continued and enhanced, by conveying more information on other types of STIs rather than focused solely on HIV. Besides, the target group of future programs should focus on students of diploma and/or skill certificates and staying off-campus. Future research also should focus on studying other factors that can contribute to the low level of knowledge on STIs.

Questionnaires.

(XLSX)

Click here for additional data file.

28 Jun 2020

PONE-D-20-11879

Knowledge on sexually transmitted infections among undergraduate students in “Getting to Zero City”, Malaysia: A cross-sectional study

PLOS ONE

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1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

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2. Please address the following:

- Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.

- Please ensure you have thoroughly discussed any potential limitations of this study within the Discussion section.

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Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Partly

Reviewer #5: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

**********

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: No

Reviewer #5: Yes

**********

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Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: No

Reviewer #5: Yes

**********

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: There are various issues that authors need to rectify in this paper.

1- Was this study representative of the Malaysian population? In my NO, because your study mainly comprised of the Sample from the Melaka state and on top of that the Majority of the respondents are Muslims, so its really challenging to make it compatible with the diverse Malaysian population. However, if the title and methods and other parts where authors have tried to justify this study as a representative of Malaysian population are restricted to Melaka only then it will be more suitable for this study.

Title must have "Melaka" and "Malay Muslims" because your data is more representative to this population instead of the whole Malaysia.

2- Abstract: Results section, add some more results that give an idea to the readers who were your main study population. Change "Marks" to score.

3- Introduction: some facts from this report should be in the introduction to give a better idea about the current STI situation in Malaysia https://www.moh.gov.my/moh/resources/Penerbitan/Laporan/Umum/Report_GAM_2019_(Final).pdf

it will be ideal if the following papers are cited as well and the results are compared and contract with them

"Analysis on sex education in schools across Malaysia. Johari Talib , Maharam Mamat, Maznah Ibrahim & Zulkifli Mohamad"

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5334713/

4- Methods, Need more explanation about study respondents? also provide details how multistage sampling was performed and how many institutes were approached for consent to this study. For reliability analysis how many subjects were invited for the pilot testing? were these included in the final analysis or excluded. Share the reliability analysis tables with Scale items if deleted options so that readers can see what was the reliability of each item.

Standardize throughout MARKS to SCORE

Analysis: in the abstract author claim " Univariate, bivariate and multivariate analyses

were conducted using IBM SPSS software version 25" was performed but in the methods information is missing about this part. need to provide details which variables was included for which analysis what were the co-varaites etc

5- RESULTS

- Reliability and validity additional data need to be provided

- Chi-sq was applied which give association among the variables, I suggest to see the difference among the group not the association. go for t-test and ANOVA to achieve this objective

- Results from the regression model need to be explained in detail and its interpretation need to improved in the results and discussion section

6- Limitation section is missing

7- Conclusion need revision after re-analysis of the results

Reviewer #2: Re:

Manuscript #: PONE-D-20-11879

Title: Knowledge on sexually transmitted infections among undergraduate students in “Getting to Zero City”, Malaysia: A cross-sectional study

Authors: norain binti mansor; Norliza Ahmad; Hejar Abdul Rahman

Mansor et al. have presented data on the lack of knowledge on sexually transmitted infections among undergraduate students in Malaysia. Although this is an important theme, the methods are incomplete.

Some of my concerns, questions and suggestions regarding this manuscript are outlined below:

1. Some of the abbreviations were not identified in the context, e.g. AOR.

2. Line 117; Reference linked with the sample size estimation; it is not clear how the reference supports the statement.

3. Line; 150; Is it True that calculated total knowledge score can be considered as continuous variables? Please define how the total knowledge score was calculated.

4. Line 155; Was the constructed logistic regression model adjusted to all variables observed in the study? Please define as appropriate within the context.

5. Table 1; different religions seem not to be represented equally in utilised sample, especially "Buddha"? Any explanation?

6. Table 5; What is the value and role used to dichotomise the total knowledge score into two groups, namely; Adequate and Inadequate? And what is the rationale behind that?

7. Table 2; Revise percentage for " Do screening test", 92.7+7.8=100.5!.

8. Line 339; please state limitation to this study.

BW

Reviewer #3: Given the current increase in the incidence rates for a variety of sexually transmitted infections in the Asia-Pacific region this paper is timely and relevant. The study design is fairly basic but adequate to address the research questions. THere are some issue with how the paper was presented which must be addressed before the paper can be considered for publication.

Introduction

- In Malaysia, the available surveillance systems for STIs reported

an increasing trend of syphilis and gonorrhoea cases, with the incidence rate of syphilis being

only 5.7 per 100,000 population in 2012 but had increased to 8.0 per 100,000 population in

2017 [4, 5]. Similarly, the incidence rate of gonorrhoea was 4.78 per 100,000 population in

2013 but had markedly increased to 10.39 in 2017

These seem to be quite large increases in incidence in malaysia. Is it possible this could also be connected to changes in the surveillance system itself? Is an increase in reporting possible?

- The second sentence of the second paragraph starting ' The interactions between their internal conflicts..." does not make sense. I don't know what this sentence is trying to say

- In the introduction overall, the reader is left a little confused as to what STIs we are interested in. The title and its reference to "Zero city" implies that we will focus on HIV. In the introduction though we mainly hear about syphilis and gonorrhoea. Need to be clear up front what you are interested in analysing.

Methods

- There is a missing step in the methods section between describing the study population and how they were sampled and then the measures section. We need to know how the students were actually recruited and by who. Was the contact through their education institution? Or did the researchers approach them directly? How were the questionnaires actually administered? Online? This research is on quite a sensitive subject. The details of what i have asked for here are important for assessing the results of the research. For example, people may answer an online survey more openly than a face to face interview.

- To interpret Table 2 we need more specifics about what the actual questions asked were, and what the correct answers were. Don't assume your audience know these things already. For example in Table 2 I assume that there was a question like: " which of the following are STIs" but that is never explicitly said in the methods to this paper. Continuing on i assume that there is a question like: "Which of the following are modes of transmission for STIs" but i don't know for sure.

Results

- You are missing a table 4. You go straight from 3 to 5.

- In Table 5 you have categories of knowledge as 'Adequate' or 'in adequate'. I may have missed it but i can't find definitions for these categories. This should be in the Methods somewhere. Even if it is in the Methods you should include it again as a footnote to the table.

Discussion

- You observe that your study sample had a higher knowledge score than was found in other studies. I know this could be for a variety of reasons but in the discussion you should think about what these reasons may be. For example was the Thai study in second para of Discussion also amongst university students?

Reviewer #4: Why getting to zero city included in the title? Overall title needs to be revised.

Rationale needs to be included. What we already know about this title is missing.

How knowledge was measured? What was the overall Knowledge level? Why three options; Yes, No and DN were included. To see the Knowledge, Yes OR NO can be sufficient. Did you validated / pretested the tool in local context?

Objectives and title both should be revised as per the results. Author has analyzed the association and predictors of Knowledge as well.

Conclusion also needs to be revised.

Overall this needs lot of work to be revised.

Reviewer #5: Knowledge on sexually transmitted infections among undergraduate students in

“Getting to Zero City”, Malaysia: A cross-sectional study

Journal: Plos One

Reviewer’s comments

The manuscript by Mansor et al. presents the results of an original study. They collected data about STI knowledge from undergrad students in a large city in Malaysia using questionnaires.

The study conduct, statistic methods use, and other analyses are appropriate.

The reasonable conclusions are presented. To me the language use is understandable.

I have several comments as follows;

Title

-The full title should include the city name “Mekala”

-The short title on the title page

“Predictors of knowledge of sexually transmitted infections among undergraduate students.”

is different from the one in the submission system

“Knowledge on sexually transmitted infections among undergraduate students in Malaysia.”

Please reconcile.

Abstract

-Introduction: the first sentence “….is an alarming issue”, please specify that it is an alarming issue of what.

-Results: The response rate for this study was 88%. Please specify whether the authors mean response rate participate in the study (other 12% denied to join) or questionnaire completion rate (12% of questionnaires were not returned, or 12% of questions in the questionnaires were not answered).

-Conclusion: what did the authors mean by the term “lower level of education” (all were undergrad student; did they mean the first year student? It should be clarified)

Introduction

In the 4th paragraph, please provide background information about the “Getting to zero” project. Was it implemented in the city or in the university campus. Who were the target population that joined the activities? What kind of thing can people learn from the project?

Methodology

-Ethic approval: typo error in the last sentence, it should be “…will be disposed five years after the completion of the study”

Results

-Firstly, the same question as in the abstract: The response rate for this study was 88%. Please specify whether the authors mean response rate participate in the study (other 12% denied to join) or questionnaire completion rate (12% of questionnaires were not returned, or 12% of questions in the questionnaires were not answered).

-Table 1: Does educational level mean the current or the highest level ever finished?

-involvement in STIs program: please clarify in the footnote or somewhere to be referred to what STIs program means.

-Sociodemographic: Did the authors collect data on sexual behaviors of study participants i.e. gender role, sexual experience, age at sexual debut, sexual partners? Those are interesting and useful information among this population.

-The 2nd paragraph: line 8, “the top three risk factors that were answer wrongly”. The term should be modified to “the top three risk factors that were misunderstanding”

-Table 5 why the authors used the cut-off age at 23 years?

Some categories are not understandable to general reader, i.e. school vs. not school program.

In “History of SRH education” there are 2 groups, yes and no.

If it was the standard SRH education in school, why not everyone has ever attended them prior to continue their higher education?

Were there any differences in characteristics of student who stay in and out of campus? Was it more expensive to stay outside? Were there any specific inclusion criteria for students who get accommodation in the campus i.e. come from far away town, study in some faculties, or final year student who need to work late at night? Those might be confounders which create difference between those who live in and out of campus.

Discussion

In the first paragraph, the author mentioned including lecturers and students’ affair department in the study. This would make the study more vulnerable for coercion. Please explain how they involved in the study recruitment or other activities.

What were the interventions in the “Getting to zero city” pilot project? Please provide more details for the readers to imagine.

Please add the strength and limitation to the discussion.

**********

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Reviewer #1: Yes: Tahir Khan

Reviewer #2: No

Reviewer #3: No

Reviewer #4: Yes: Ramesh Kumar

Reviewer #5: No

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11 Aug 2020

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

Thank you for your comments. We have revised the format according to PLOS ONE style template.

2. Please address the following:

- Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.

- Please ensure you have thoroughly discussed any potential limitations of this study within the Discussion section.

Thank you for your comments. We have uploaded our questionnaires as supplementary information and the limitations of the study have been added under Discussion section. (please refer to line 548 – 561 in revised manuscript with track changes)

3.Reviewer comments

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: There are various issues that authors need to rectify in this paper.

1- Was this study representative of the Malaysian population? In my NO, because your study mainly comprised of the Sample from the Melaka state and on top of that the Majority of the respondents are Muslims, so its really challenging to make it compatible with the diverse Malaysian population. However, if the title and methods and other parts where authors have tried to justify this study as a representative of Malaysian population are restricted to Melaka only then it will be more suitable for this study.

Title must have "Melaka" and "Malay Muslims" because your data is more representative to this population instead of the whole Malaysia.

Thank you for your comments. We do agree that this study is not representative of Malaysian students. The study populations were students from public higher educational institutions in Melaka, a state in Malaysia. We have addressed the issue of generalisability of our study as one of our study’s limitation. We also have revised the title of the study. However, we would not specify the title to Malay Muslims because the selection of the study participants was random selection and on voluntary basis. There is a small proportion of non-Malays who volunteered to participate in this study. Furthermore, the students of public of higher educations in Melaka were mainly Malay as Malays are the majority ethnic in Melaka. (please refer to line 411-413 in revised manuscript with track changes)

2- Abstract: Results section, add some more results that give an idea to the readers who were your main study population. Change "Marks" to score.

Thank you for your comments. Additional information has been added under result section in abstract and marks already changed to score (refer to line 56-66 in revised manuscript with track changes).

3- Introduction: some facts from this report should be in the introduction to give a better idea about the current STI situation in Malaysia https://www.moh.gov.my/moh/resources/Penerbitan/Laporan/Umum/Report_GAM_2019_(Final).pdf

it will be ideal if the following papers are cited as well and the results are compared and contract with them

"Analysis on sex education in schools across Malaysia. Johari Talib, Maharam Mamat, Maznah Ibrahim & Zulkifli Mohamad"

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5334713/

We appreciate the suggestion given and the references suggested have been included as our references (reference number 7,13,41). (refer line 94, 122, 146, 419, 428, 434, 451, 461 and 494 in revised manuscript with track changes)

4- Methods, Need more explanation about study respondents? also provide details how multistage sampling was performed and how many institutes were approached for consent to this study. For reliability analysis how many subjects were invited for the pilot testing? were these included in the final analysis or excluded. Share the reliability analysis tables with Scale items if deleted options so that readers can see what was the reliability of each item.

Thank you for your comments. We have included more details on study respondents, multistage sampling, and the reliability test under methodology (refer line 161-232 in revised manuscript with track changes)

Standardize throughout MARKS to SCORE

Analysis: in the abstract author claim " Univariate, bivariate and multivariate analyses

were conducted using IBM SPSS software version 25" was performed but in the methods information is missing about this part. need to provide details which variables was included for which analysis what were the co-varaites etc

Thank you for your comments. The details on variable used for each analysis have been provided under “Statistical analysis” section, refer line 264-279 in revised manuscript with track changes)

5- RESULTS

- Reliability and validity additional data need to be provided

- Chi-sq was applied which give association among the variables, I suggest to see the difference among the group not the association. go for t-test and ANOVA to achieve this objective

- Results from the regression model need to be explained in detail and its interpretation need to improve in the results and discussion section

Thank you for your comments. We have provided additional information for reliability and validity of the questionnaires under methodology section. (please refer to line 215- 232). We also have rerun the analysis and applied independent t-test and Mann-Whitney test since the dependent variable used was continuous variable. Multiple linear regression was used in multivariate analysis (please refer to line 264- 279, 369-396 in revised manuscript with track changes).

6- Limitation section is missing

Thank you for your comments. Limitations have been added under discussion) (please refer to line 548-561 in revised manuscript with track changes)

7- Conclusion need revision after re-analysis of the results

Thank you for your comments. Conclusion have been revised accordingly (please refer to line 566-576 in revised manuscript with track changes).

Reviewer 2:

1. Some of the abbreviations were not identified in the context, e.g. AOR.

Thank you for your comments. We have revised all the abbreviations used in the manuscript and provide the full word.

2. Line 117; Reference linked with the sample size estimation; it is not clear how the reference supports the statement.

Thank you for your comments. Since this study involved multistage sampling, the design effect used for sample size calculation was based on the reference linked and sample size was calculated based on previous study (please refer line 169-172 in revised manuscript with track changes)

3. Line; 150; Is it True that calculated total knowledge score can be considered as continuous variables? Please define how the total knowledge score was calculated.

Thank you for your comments. We have revised the analysis for the study. Knowledge score has been calculated as continuous variable (please refer to line 237 in revised manuscript with track changes)

4. Line 155; Was the constructed logistic regression model adjusted to all variables observed in the study? Please define as appropriate within the context.

Thank you for your comments. We have revised the analysis and conducted the multiple linear regression analyses (please refer to line 264- 279, 369-396 in revised manuscript with track changes).

5. Table 1; different religions seem not to be represented equally in utilised sample, especially "Buddha"? Any explanation?

Thank you for your comments. Majority of the public higher educational institutions in Melaka were reserved for Bumiputera which is Malay ethnicity. Thus, the proportion of other ethnicity and religion were unequally distributed. We already performed Mann Whitney’s U test to accommodate for not normally distributed data in our analysis (please refer to line 269 & 411-413 in revised manuscript with track changes).

6. Table 5; What is the value and role used to dichotomise the total knowledge score into two groups, namely; Adequate and Inadequate? And what is the rationale behind that?

Thank you for your comments. We have revised the analysis and making the dependent variable as continuous data. (Please refer to line 237 in revised manuscript with track changes).

7. Table 2; Revise percentage for " Do screening test", 92.7+7.8=100.5!.

Thank you for your comments. We have revised the calculation and it supposed to be 92.7 + 7.3=100% (please refer to Table 3, line 343 in revised manuscript with track changes)

8. Line 339; please state limitation to this study.

Thank you for your comments. Limitations of the study have been added under the discussion section (please refer to line 548-561 in revised manuscript with track changes).

Reviewer 3

BW

Reviewer #3: Given the current increase in the incidence rates for a variety of sexually transmitted infections in the Asia-Pacific region this paper is timely and relevant. The study design is fairly basic but adequate to address the research questions. There are some issues with how the paper was presented which must be addressed before the paper can be considered for publication.

Introduction

- In Malaysia, the available surveillance systems for STIs reported

an increasing trend of syphilis and gonorrhoea cases, with the incidence rate of syphilis being

only 5.7 per 100,000 population in 2012 but had increased to 8.0 per 100,000 population in

2017 [4, 5]. Similarly, the incidence rate of gonorrhoea was 4.78 per 100,000 population in

2013 but had markedly increased to 10.39 in 2017

These seem to be quite large increases in incidence in malaysia. Is it possible this could also be connected to changes in the surveillance system itself? Is an increase in reporting possible?

Thank you for your comments. A marked increase in the incidence of syphilis and gonorrhoea might be contributed by the improvement in the surveillance systems and the establishment of STI Friendly Clinics in selected government health clinics starting from year 2015 [7]. (please refer to line 91-94 in revised manuscript with track changes).

- The second sentence of the second paragraph starting ' The interactions between their internal conflicts..." does not make sense. I don't know what this sentence is trying to say

Thank you for your comments. We have provided a clearer statement in the paragraph. The sentences were trying to explain the reason for young adults to be more vulnerable to acquire STIs, which we try to relate their psychosexual development and the exposure to favorable situation for risky sexual behaviors such as peer influence and digital media culture (please refer to line 96-101 in revised manuscript with track changes).

- In the introduction overall, the reader is left a little confused as to what STIs we are interested in. The title and its reference to "Zero city" implies that we will focus on HIV. In the introduction though we mainly hear about syphilis and gonorrhoea. Need to be clear up front what you are interested in analysing.

Thank you for your comments. The study mainly focused on knowledge of STIs and we have revised the title (please refer to line 6-7 in revised manuscript with track changes).

Methods

- There is a missing step in the methods section between describing the study population and how they were sampled and then the measures section. We need to know how the students were actually recruited and by who. Was the contact through their education institution? Or did the researchers approach them directly? How were the questionnaires actually administered? Online? This research is on quite a sensitive subject. The details of what i have asked for here are important for assessing the results of the research. For example, people may answer an online survey more openly than a face to face interview.

Thank you for your comments. We have provided more information on study population, sampling method and data collection procedure (please refer to line 160-193 in revised manuscript with track changes).

- To interpret Table 2 we need more specifics about what the actual questions asked were, and what the correct answers were. Don't assume your audience know these things already. For example in Table 2 I assume that there was a question like: " which of the following are STIs" but that is never explicitly said in the methods to this paper. Continuing on i assume that there is a question like: "Which of the following are modes of transmission for STIs" but i don't know for sure.

Thank you for your comments. We have provided the questionnaires form which the reader can refer for further information (S1-Appendix)

Results

- You are missing a table 4. You go straight from 3 to 5.

Thank you for your comments. We have revised the analysis and new table have been provided (please refer to line 350 in revised manuscript with track changes).

- In Table 5 you have categories of knowledge as 'Adequate' or 'in adequate'. I may have missed it but i can't find definitions for these categories. This should be in the Methods somewhere. Even if it is in the Methods you should include it again as a footnote to the table.

Thank you for your comments. We have revised the analysis and the knowledge score has been measured as continuous variable (please refer to line 237, 336 in revised manuscript with track changes).

Discussion

- You observe that your study sample had a higher knowledge score than was found in other studies. I know this could be for a variety of reasons but in the discussion you should think about what these reasons may be. For example was the Thai study in second para of Discussion also amongst university students?

Thank you for your comments. We have provided reason for higher score observed in our study in the discussion. Yes, the study in Thailand was conducted among university students (please refer line 427 in the revised manuscript with track changes).

Reviewer 4

Reviewer #4: Why getting to zero city included in the title? Overall title needs to be revised.

Rationale needs to be included. What we already know about this title is missing.

Thank you for your comment. We have revised the title (please refer to line 6 in revised manuscript with track changes).

How knowledge was measured? What was the overall Knowledge level? Why three options; Yes, No and DN were included. To see the Knowledge, Yes OR NO can be sufficient. Did you validated / pretested the tool in local context?

Thank you for your comments. We reanalyzed the knowledge as continuous variable. The questionnaires have been validated and tested for its reliability on 60 students from one of the public higher educational institutions in Melaka. Further information on validity and reliability test were provided under methodology section (please refer to line 215-229 in revised manuscript with track changes).

Objectives and title both should be revised as per the results. Author has analyzed the association and predictors of Knowledge as well.

Thank you for your comments. We have revised the title and objectives We have revised the title (please refer to line 6 &152-153 in revised manuscript with track changes).

Conclusion also needs to be revised.

Thank you for your comments. We have revised the conclusion based on the results of the new analysis (please refer to line 572 in revised manuscript with track changes).

Overall this needs lot of work to be revised.

Thank you for your comments. We have improved the title, methodology section, analysis part, result, and discussion part.

Reviewer #5: Knowledge on sexually transmitted infections among undergraduate students in

“Getting to Zero City”, Malaysia: A cross-sectional study

Journal: Plos One

Reviewer’s comments

The manuscript by Mansor et al. presents the results of an original study. They collected data about STI knowledge from undergrad students in a large city in Malaysia using questionnaires.

The study conduct, statistic methods use, and other analyses are appropriate.

The reasonable conclusions are presented. To me the language use is understandable.

I have several comments as follows;

Title

-The full title should include the city name “Mekala”

Thank you for your comments. We have changed the title into “Determinants of knowledge on sexually transmitted infections among students in public higher education institutions in Melaka state, Malaysia”. (please refer to line 6 in the manuscript with track changes).

-The short title on the title page

“Predictors of knowledge of sexually transmitted infections among undergraduate students.”

is different from the one in the submission system

“Knowledge on sexually transmitted infections among undergraduate students in Malaysia.”

Please reconcile.

Thank you for your comments. We have removed the short title in the front page after following the manuscript body formatting guidelines and change the short title in the system as “Determinants of knowledge of sexually transmitted infections among undergraduate students”.

Abstract

-Introduction: the first sentence “….is an alarming issue”, please specify that it is an alarming issue of what.

Thank you for your comments. We have rephrased the sentence (please refer to line 42 in revised manuscript with track changes).

-Results: The response rate for this study was 88%. Please specify whether the authors mean response rate participate in the study (other 12% denied to join) or questionnaire completion rate (12% of questionnaires were not returned, or 12% of questions in the questionnaires were not answered).

12 % refer to those who did not complete the questionnaires (more than 5% of the questionnaires were not complete) and they were excluded in the final analysis. (please refer to line 297-303 in revised manuscript with track changes).

-Conclusion: what did the authors mean by the term “lower level of education” (all were undergrad student; did they mean the first-year student? It should be clarified)

Thank you for your comments. We have provided more information on the study participants under methodology part. The selected institutions in our study have offered a range of post-secondary courses that range from Malaysia Skill Certificate, diploma, and degree level. Lower level of education refers to those who are not taking degree courses which are Malaysia Skill Certificate and diploma (please refer to line 240-244 in revised manuscript with track changes).

Introduction

In the 4th paragraph, please provide background information about the “Getting to zero” project. Was it implemented in the city or in the university campus. Who were the target population that joined the activities? What kind of thing can people learn from the project?

Thank you for your comments. The project is implemented at city level and main aim of the project is to intensify the efforts towards elimination of HIV/AIDS. The project emphasizes on collaborative effort between different agencies within Melaka including higher educational institutions. Among the objectives of ‘Getting to Zero’ project is to increase the general knowledge and the awareness on HIV and to reduce the high-risk behaviour practices especially among young population. The activities included in the project are surveillance program, screening program, counselling and treatment services, health education and etc. The project primarily aims the key population for HIV (please refer to line 133-145 in revised manuscript with track changes).

Methodology

-Ethic approval: typo error in the last sentence, it should be “…will be disposed five years after the completion of the study”

Thank you for your comment. We have improved the sentence (please refer to line 293 in revised manuscript with track changes).

Results

-Firstly, the same question as in the abstract: The response rate for this study was 88%. Please specify whether the authors mean response rate participate in the study (other 12% denied to join) or questionnaire completion rate (12% of questionnaires were not returned, or 12% of questions in the questionnaires were not answered).

Thank you for your comments. We have provided additional information on response rate under result section (please refer to line 297-303 in revised manuscript with track changes).

-Table 1: Does educational level mean the current or the highest level ever finished?

Thank you for your comments. The current level. (please refer to line 240-244 in revised manuscript with track changes).

-involvement in STIs program: please clarify in the footnote or somewhere to be referred to what STIs program means.

Thank you for your comments. STIs program refers to any involvement of respondents in any programs or health talk about STIs organized in their college or university or in the community. (please refer to line 249-253 in revised manuscript with track changes).

-Sociodemographic: Did the authors collect data on sexual behaviours of study participants i.e. gender role, sexual experience, age at sexual debut, sexual partners? Those are interesting and useful information among this population.

Thank you for your comments. No information on sexual behaviour collected for this study

-The 2nd paragraph: line 8, “the top three risk factors that were answer wrongly”. The term should be modified to “the top three risk factors that were misunderstanding”

Thank you for your comments. We have changed the word as suggested (please refer to line 342 in revised manuscript with track changes).

-Table 5 why the authors used the cut-off age at 23 years?

Thank you for your comments. We rationalized the cut-off 23 years old based on a local study conducted among local university students that have reported those who aged more than 23 years old were reported to have higher knowledge on STIs from the reference below:

Folasayo AT, Oluwasegun AJ, Samsudin S, Saudi SN, Osman M, Hamat RA. Assessing the knowledge level, attitudes, risky behaviors and preventive practices on sexually transmitted diseases among university students as future healthcare providers in the central zone of Malaysia: a cross-sectional study. International journal of environmental research and public health. 2017 Feb;14(2):159.

Some categories are not understandable to general reader, i.e. school vs. not school program.

Thank you for your comments. These categories referring to the type of program involved by the participants. School programs refer to involvement in STIs program in school. Not a school program refers to involvement of STIs in the college and community. We have provided information regarding variables in this study under variable section (please refer to line 251-253 in revised manuscript with track changes).

In “History of SRH education” there are 2 groups, yes and no.

If it was the standard SRH education in school, why not everyone has ever attended them prior to continue their higher education?

Thank you for your comments. There was no specific curriculum or subject were named as SRH in the school’s curriculum. SRH topics were embedded in other subjects such as biology and family health, Islamic education, moral physical and health education subjects. The question was asked to ensure the participants were aware regarding SRH education delivered in the schools. (please refer to line 253-257 in revised manuscript with track changes).

Were there any differences in characteristics of student who stay in and out of campus? Was it more expensive to stay outside? Were there any specific inclusion criteria for students who get accommodation in the campus i.e. come from far away town, study in some faculties, or final year student who need to work late at night? Those might be confounders which create difference between those who live in and out of campus.

Thank you for your comments. Unfortunately, no further information collected on the characteristics of the students who live out campus. Basically, we specifically asked the place of stay because those who live out campus usually did not compulsory to join any educational programs held in the campus. While those who lived in the campus are compulsory to join the program. Under the National Strategic Plan Ending AIDS 2016-2030, each of higher educational institution is compulsory to organize an educational program on HIV/STIs once a year. Thus, if the students stay in campus, they might have recently exposed to the information on HIV/STIs and it will influence their knowledge on STIs. (please refer to line 533-540 in revised manuscript with track changes).

Discussion

In the first paragraph, the author mentioned including lecturers and students’ affair department in the study. This would make the study more vulnerable for coercion. Please explain how they involved in the study recruitment or other activities.

Thank you for your comments. We have provided further explanation on data collection procedure under methodology section (please refer to line 173-192 in revised manuscript with track changes).

What were the interventions in the “Getting to zero city” pilot project? Please provide more details for the readers to imagine.

Thank you for your comments. We have provided additional information on the project. (please refer to line 134-145 in revised manuscript with track changes).

Please add the strength and limitation to the discussion.

Thank you for your comments. We have provided the strength and limitation of the study under discussion section (please refer to line 547-567 in revised manuscript with track changes).

23 Sep 2020

PONE-D-20-11879R1

Determinants of knowledge on sexually transmitted infections among students in public higher education institutions in Melaka state, Malaysia

PLOS ONE

Dear Dr. Ahmad,

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Academic Editor

PLOS ONE

Additional Editor Comments:

Thank you for your revisions, addressing all the major concerns raised by the reviewers. As you could find below, reviewer #3 still has some minor comments. Please address these comments carefully. Also, please take this opportunity to improve the writing quality, cleaning the grammatical errors and typos, minimizing passive voice use, and avoiding long and complex sentences. You may not have a chance to proofread your article should the journal accept it for publication.

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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 #1: All comments have been addressed

Reviewer #3: All comments have been addressed

Reviewer #5: All comments have been addressed

**********

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Reviewer #1: Yes

Reviewer #3: Yes

Reviewer #5: Yes

**********

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Reviewer #1: Yes

Reviewer #3: Yes

Reviewer #5: Yes

**********

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Reviewer #1: Yes

Reviewer #3: Yes

Reviewer #5: Yes

**********

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Reviewer #3: Yes

Reviewer #5: Yes

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Reviewer #1: All comments are addressed and no further corrections are required. However, paper may get more clarity upon getting English editing.

Reviewer #3: (No Response)

Reviewer #5: Review manuscript PONE-D-20-11879R1

“Determinants of knowledge on sexually transmitted infections among students in public higher education institutions in Melaka state, Malaysia".

The authors have successfully addressed all reviewers’ comment.

I now have only few minor comments/editing points as follows;

-Page 7 line 166, there should be a period after the close parenthesis.

-Page 7 line 169, the letter “s” should be removed.

-Page 8, the Table 1 should have a bottom line.

-Page 13 There are several unclear terms in the Table 3 that might require clarification.

“having sex man with man” should be either “homosexual relationship” or “same sex relationship”

“Abnormal discharges” should be accompanying with the organ where it came from i.e. vagina, nasal, or urethral.

“Be faithful” should be written in a full term as “Be faithful in the intimate relationship”

-Please specify the full term of abbreviations used in the Tables in each footnote, to make them easier for readers to read and understand at a glance.

**********

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Reviewer #1: Yes: Tahir M Khan

Reviewer #3: Yes: Matthew Kelly

Reviewer #5: Yes: Linda Aurpibul MD. MPH.

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29 Sep 2020

Response to Reviewers.

Reviewer #1: All comments are addressed, and no further corrections are required. However, paper may get more clarity upon getting English editing.

Thank you for your comment: We have sent for English proofread. The amendments are highlighted by the track changes.

Reviewer #5: Review manuscript PONE-D-20-11879R1

“Determinants of knowledge on sexually transmitted infections among students in public higher education institutions in Melaka state, Malaysia".

The authors have successfully addressed all reviewers’ comment.

I now have only few minor comments/editing points as follows;

-Page 7 line 166, there should be a period after the close parenthesis.

Thank you for your comment. We have addressed it. See Page 7, line 172.

-Page 7 line 169, the letter “s” should be removed.

Thank you for your comment. We have addressed it. See Page 8, line 175.

-Page 8, the Table 1 should have a bottom line.

Thank you for your comment. We have addressed it. See Page 8, Table, 1.

-Page 13 There are several unclear terms in the Table 3 that might require clarification.

“having sex man with man” should be either “homosexual relationship” or “same sex relationship”

“Abnormal discharges” should be accompanying with the organ where it came from i.e. vagina, nasal, or urethral.

“Be faithful” should be written in a full term as “Be faithful in the intimate relationship”

Thank you for your comment. We have addressed these. See Page 13, Table 3.

-Please specify the full term of abbreviations used in the Tables in each footnote, to make them easier for readers to read and understand at a glance.

Thank you for your comment. We have addressed these. See Page 8, Table 1. Page 12, Table 2. Page 14, Table 3. Page 14, Table 4. Page 15, Table 5. Page 16, Table 6.

Submitted filename: Response to reviewer-29September2020.docx

Click here for additional data file.

5 Oct 2020

Determinants of knowledge on sexually transmitted infections among students in public higher education institutions in Melaka state, Malaysia

PONE-D-20-11879R2

Dear Dr. Ahmad,

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Siyan Yi, MD, MHSc, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

13 Oct 2020

PONE-D-20-11879R2

Determinants of knowledge on sexually transmitted infections among students in public higher education institutions in Melaka state, Malaysia

Dear Dr. Ahmad:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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on behalf of

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Academic Editor

PLOS ONE