Home | Volume 37 | Article number 68

Research

Knowledge of sexually transmitted infections and its associated factors among polytechnic college students in Southwest Ethiopia

Knowledge of sexually transmitted infections and its associated factors among polytechnic college students in Southwest Ethiopia

Tadesse Nigussie1, Tewodros Yosef1,&

 

1Department of Public Health, College of Medicine and Health Sciences, Mizan-Tepi University, Mizan Teferi, Ethiopia

 

 

&Corresponding author
Tewodros Yosef, Department of Public Health, College of Medicine and Health Sciences, Mizan-Tepi University, Mizan Teferi, Ethiopia

 

 

Abstract

Introduction: sexually transmitted infections (STIs) are infections that are transmitted from one person to another through sexual contact, and most of them are easily preventable and treatable. Global trends in STIs have increased. Sub-Saharan Africa carries a high burden of STIs, including HIV. Knowledge about STIs is very significant for preventing the adverse outcomes of young adult reproductive health. Therefore, this study aimed to assess the knowledge of sexually transmitted diseases and its associated factors among polytechnic college students in Southwest Ethiopia.

 

Methods: a cross-sectional study was conducted among 453 randomly selected students at Mizan-Aman polytechnic college in Southwest Ethiopia from April 1st to 30th, 2018. The data were collected through self-administered structured and pre-tested questionnaire. The collected data were entered using EPI-DATA version 4.2.0.0, and analyzed using SPSS version 20 statistical software.

 

Results: of the 453 participants, 177 (39.1%) had good knowledge about STIs. The study also found that being male (AOR = 1.72, 95% CI [1.12-2.86], P = 0.025), increased year of study (AOR = 3.65, 95% CI [1.69-8.43], P = 0.002), having one or no sexual partner (AOR = 1.53, 95% CI [1.35-3.56], P = 0.005), and source of information from mass media (Television/Radio) (AOR = 2.76, 95% CI [1.78-4.56], 0.013) were factors that associated with an increased level of knowledge about STIs.

 

Conclusion: the proportion of good knowledge about sexually transmitted infections was substantially low. Therefore, strengthening information, education, and communication (IEC) on the issue using health clubs and mass media (Television/Radio) is highly recommended. In addition, inculcating the sexual and reproductive health course in the educational curriculum plays a paramount importance.

 

 

Introduction    Down

Sexually transmitted infections (STIs) are infections that are transmitted from one person to another through sexual contact, and most of them are easily preventable and treatable [1, 2]. STIs represent a huge burden of disease worldwide with an annual incidence of about 333 million cases and have harmful effects on sexual health or reproduction [3-5]. Global trends in STIs have increased. Sub-Saharan Africa carries a high burden of STIs, contributing to more than 70% of the universal burden of infection [6]. Sexually transmitted infections are a major health problem that affects mostly young people in developing as well as developed countries [7] due to sexual experimentation occurring at this age [8]. Young adults are most vulnerable to infection because they engage in risky practices due to a lack of adequate knowledge of STIs [9, 10]. Knowledge of STIs is very significant for preventing adverse outcomes of young adult reproductive health [11, 12]. Insufficient knowledge about sexually transmitted infections is the major barrier to successfully prevent infection among young adult populations [13]. Since the lack of knowledge of STIs may lead to a delay in treatment [5], it may complicate the infection process. The health-seeking behavior of STIs may largely depend on knowledge about STIs [14]. Several studies have been conducted worldwide regarding knowledge about STIs and reported that 74.7% in India [15], 92.4% in Nigeria [16], 89.9% in Brazil [17], 98% in Tanzania [18], 88.5% in Jimma, Ethiopia [19], 79% in Dhaka, Bangladesh [20], 86.6% in Malaysia [21], 74% medical and 61.6% non-medical university students in Pakistan [22], 83.1% in Turkey [23], 68.3% in Klang Valley, Malaysia [24], 27% in Udupi Taluk, India [25], and 70.1% in northern Cape Province, South Africa [26] of the respondents had good knowledge of STIs. The factors that influence knowledge of STIs are diverse and include age, sex, residence, marital status, academic year, and acquiring information from friends/internet and mass media [5, 18, 27-34].

In sub-Saharan Africa, comprehensive accurate knowledge about STIs remains low in most countries [35], especially in Ethiopia, knowledge of STIs is very low. According to EDHS 2016, 20% of women and 38% of men have comprehensive knowledge about STIs transmission and prevention [36]. In Ethiopia, young adults are frequently involved in risky sexual behavior [37, 38], which predispose them to a multiplicity of sexual and reproductive health problems. Improving STIs awareness through inculcating sexual and reproductive health into the educational curriculum to prevent and control STIs plays paramount importance [26]. Despite the fact that the prevalence of STIs is high in Ethiopia [39], there is no sufficient shreds of evidence that showed knowledge about STIs among adolescents and youths in the study area. To design appropriate intervention for improving the knowledge of STIs among young adults, the availability of sufficient data on the issue is of paramount importance. Therefore, this study aimed to assess the knowledge of sexually transmitted diseases and its associated factors among polytechnic college students in Southwest Ethiopia.

 

 

Methods Up    Down

Study design, setting, and period: a cross-sectional study was conducted at Mizan-Aman polytechnic college (MAPtC) students from April 1st to 30th, 2018. MAPtC is found at 585 km Southwest of Addis Ababa, the capital city of Ethiopia. The college teaches students in ten departments, with five/four levels for each department. The departments were Garment and Textile, Automotive, Road construction, Water and Sanitation, Information communication technology, Building electrical installation, Electrotechnology, Masonry construction, General metal fabrication, and Surveying technology.

Populations: the source of the population was all regular students at the polytechnic college, who were attending their class during the study period. The study population was randomly selected students who studied at the polytechnic college during the study period.

Sample size determination and sampling method: the sample size was determined using a single population proportion formula. With an input of expected proportion of knowledge about STIs in Chercher, Ethiopia (17.5%) [13], 5% margin of error, 95% confidence interval, 10% for non-response compensation, and a design effect of 2. The final computed sample size was 489. A two-stage stratified random sampling technique was used to select 489 regular students. In polytechnic college, there were ten departments with five/four levels for each department. The departments were stratified based on levels (level I-V). For each level, the sample size is proportionally allocated. The potential participants were selected using systematic random sampling.

Data collection instrument and procedures: data were collected through self-administered structured and pre-tested questionnaire. The questionnaire was composed of three sections (socio-demographic factors, knowledge regarding STIs including HIV (including 4 questions on type, symptoms, mode of transmission, and prevention of STIs with a total of 18 items) and behavioral factors). The questionnaire was developed by reviewing relevant literature in English, then translated it into the local language, and retranslated back it into English to check the consistency by an independent translator. The training was given to data collectors and supervisors concerning the objective and process of data collection and to discuss the presence of an ambiguous question in the questionnaire.

Study variables: the dependent variable was knowledge of sexually transmitted infections. The independent variables were age, sex, residence, marital status, religion, academic year, drinking alcohol, smoking cigarette, condom use, watching pornography, number of sexual partners, and source of acquiring information.

Operational definitions: good knowledge was defined as those who scored the mean and above value of knowledge-related questions [14]. Poor knowledge was defined as those who scored below the mean value of knowledge-related questions [14]. Multiple sexual partners are defined as the behavior of a person with two or more sexual partners [37].

Data processing and analysis: the collected data were entered into EPI-Data version 4.2.0.0, and analyzed using SPSS version 20 software for windows. The results are presented in tables and numerical summery measures (mean and standard deviation). A binary logistic regression analysis was used to look for the association between outcome and independent variables and dependent variables. The independent variables with a p-value of less than 0.25 in the bivariate logistic regression were included in the multivariable logistic regression. Finally, variables in the multivariable logistic regression with a p-value < 0.05 were considered as significantly associated with the outcome variable. The Hosmer-Lemeshow goodness-of-fit test indicated (P = 0.756) that the model was good enough to fit the data well.

Ethical consideration: before the actual data collection, a permission letter was obtained from Mizan-Tepi University to Mizan Aman Polytechnic College. All study participants were informed about the purpose of the study, their right to deny participation, anonymity, and confidentiality of the information. Written informed consent was also obtained before participation in the study.

 

 

Results Up    Down

Socio-demographic characteristics: of the 489, 453 students filled the questionnaires making a response rate of 92.6%. The majority of the respondents were male (53.6%), single (88.1%), and orthodox religious followers (54.7%). More than half (57.6%) of the respondents were from urban. The mean age of the respondents was 20 (±2.02 SD) years, ranging from 18 to 30 years (Table 1).

Knowledge of STIs and source of information for STIs: of the 453 respondents, 216 (47.7%) were mentioned sexual intercourse as modes of STIs transmission. One-hundred fifty (33.1%) responded condoms used to prevent STIs and 10 (2.2%) had misconceptions (contraceptive pills) about STIs prevention (Table 2). Of the 453, 177 (39.1%) had good knowledge of sexually transmitted infections. Of the 177 respondents with good knowledge about sexually transmitted infections, 103 (58.2%) were male and 74 (41.8%) were female students. One hundred fifty-four (34%) had a source of information from health professionals followed by 136 (30%), 95 (21%), 40 (8.8%) and 28 (6.2%) had a source of information from mass media (Television/Radio), friends, parents, and newspapers/books respectively.

Behavioral profiles: forty-seven (10.4%) respondents were cigarette smokers. Nearly one-fourth (23.6%) and 172 (38%) of the respondents were alcohol drinkers and watching pornography at least once a time in lifetime respectively. Of the 180 sexually active, 119 (66.1%) and 82 (45.6%) used condoms in their last sexual intercourse and had multiple sexual partners, respectively, (Table 3).

Factors associated with knowledge of STIs: bivariate analysis was done for potentially expected associated factors. Independent variables found statistically significant at P < 0.25 in the bivariate analysis were included in the multivariable binary logistic regression model. Finally, sex, academic year, number of sexual partners, and acquiring information from mass media (Television/Radio) were found to be significantly associated with good knowledge of STIs (Table 4).

 

 

Discussion Up    Down

Several studies have revealed that sexually transmitted infections are the cause of the multiplicity of complications and result in poor sexual and reproductive health due to delays in treatment as a result of a lack of knowledge about STIs [5, 40]. Health-seeking behavior may largely depend on knowledge about STIs [14]. Based on the above scenario, we aimed to assess the knowledge of sexually transmitted diseases and its associated factors among polytechnic college students in Southwest Ethiopia. The proportion of good knowledge about sexually transmitted infections was 39.1% (34.6% - 43.6%). This finding was higher than 27% in Udupi Taluk, India [25]. However, lower than 45.4% in Gondar, Ethiopia [35], 68.3% in the Klang Valley, Malaysia [24], 70.1% in northern Cape Province, South Africa [26], 74.7% in urban slums of Jorhat District, India [15], 79% in Dhaka, Bangladesh [20], 86.6% in Malaysia [21], 89.9% in Brazil [17], 92.4% in Nigeria [16], and 98% in Dar es Salaam, Tanzania [18]. The variation observed compared to other studies could be due to the differences in methodology, sample size, and operational definition used. Besides the sociocultural, socioeconomic, and behavioral characteristics of the study participants may play a great role in the variation observed.

In this study, being male was associated with good knowledge about STIs. This finding was supported by a study conducted in Addis Ababa, Ethiopia [10]. However, a study conducted in Portugal revealed that women had greater knowledge than men [32]. Another study revealed no variation was found between gender and the level of knowledge about sexually transmitted infections [29]. Respondents with increased academic years were associated with having good knowledge about STIs. This study was consistent with a study conducted in Nepal [21, 34]. This could be because of the higher level of education related to more knowledge about STIs. Among sexually active, 98 (54.4%) of the respondents had fewer than two sexual partners (means one or no). Respondents with fewer than two sexual partners were significantly associated with good knowledge about STIs. Those with one and no sexual partners due to the fear of the diseases resulted from their knowledge of the symptoms and health consequences of STIs than those with having multiple sexual partners. However, the result was inconsistent with a study conducted in Sweden, which revealed that the experience of many sexual partners and having a history of STIs were associated with a higher level of knowledge [41] and in southern Gondar Ethiopia, the seroprevalence of syphilis was significantly associated with women who have multiple sexual partners [42]. This variation could be explained by the differences in sociocultural and behavioral characteristics.

Mass media (Television/Radio) is an important method, that is used to create awareness for a large audience on a certain issue. Thus, mass media (Television/Radio) exposure was positively associated with good knowledge about a specific issue. Of the 177 respondents with good knowledge about STIs, 100 (56.5%) of the respondents had exposure to mass media (Television/Radio). Getting information from mass media (Television/Radio) was significantly associated with having good knowledge about STIs. This finding is consistent with previous studies done in Tanzania, Nepal, and Vietnam [5, 18, 34]. The authors acknowledge some limitation of the study, the nature of the study design may not show a cause-and-effect relationship. It was also difficult to ascertain which comes first between the association of attitude toward condom use and knowledge about sexually transmitted infections.

 

 

Conclusion Up    Down

The proportion of good knowledge about sexually transmitted infections was substantially low. Therefore, strengthening information, education, and communication (IEC) on the issue using health clubs and mass media (Television/Radio) is highly recommended. In addition, inculcating the sexual and reproductive health course in the educational curriculum plays a paramount importance.

What is known about this topic

  • Sexually transmitted infections are a major health problem that affects mostly young people in developing as well as developed countries;
  • Young adults are most vulnerable to infection because they engage in risky practices due to a lack of adequate knowledge of STIs; knowledge of STIs is very significant for preventing adverse outcomes of young adult reproductive health;
  • In sub-Saharan Africa, comprehensive accurate knowledge of STIs remains low in most countries, especially in Ethiopia, knowledge of STIs is very low.

What this study adds

  • The proportion of good knowledge of sexually transmitted infections was substantially low;
  • The study found that sex, academic year, number of sexual partners, and acquiring information from mass media (Television/Radio) were found to be significantly associated with good knowledge of sexually transmitted infections;
  • Therefore, it is very important to inculcate the sexual and reproductive health course in the educational curriculum to increase students´ knowledge level of sexually transmitted infections.

 

 

Competing interests Up    Down

The authors declare no competing interests.

 

 

Authors' contributions Up    Down

TN and TY were involved in the conception, design, acquisition of data, analysis, and interpretation of the results. TY drafted the manuscript, and then all authors approved it for publication. All authors read and approved the final version of this manuscript and equally contributed to its content.

 

 

Acknowledgments Up    Down

First, we would like to thank all study participants for their participation in the study. Second, our gratitude goes to Mizan-Aman polytechnic college academic and administrative staffs who gave us full collaboration during the study.

 

 

Tables Up    Down

Table 1: socio-demographic characteristics of the respondents at MAPtC in Southwest Ethiopia

Table 2: knowledge regarding STIs among respondents at MAPtC in Southwest Ethiopia

Table 3: behavioral profiles of the respondents at MAPtC in Southwest Ethiopia

Table 4: factors associated with good knowledge of sexually transmitted infections of the respondents at MAPtC in Southwest Ethiopia

 

 

References Up    Down

  1. CDC. Information for Teens: Staying Healthy and Preventing STDs. 2017.

  2. Ketting E, Ivanova O. Sexuality Education in Europe and Central Asia. 2018.

  3. Yohannes B, Gelibo T, Tarekegn M. Prevalence and Associated Factors of Sexually Transmitted Infections among Students of Wolaita. Int J Sci Technol Res. 2013;2(2):86-94. Google Scholar

  4. Ribeiro dos Santos Carvalho MP, Guimarães AR, Moraes PA, Teles AS, Andre de Matos M. Prevalence of signs and symptoms and knowledge about sexually transmitted diseases. Acta Paul Enferm. 2015;28(1):95-100. Google Scholar

  5. Sau HN, Anh KD, Giang TV, Cuong TN, Thu HTL, Truong TN et al. Lack of Knowledge about Sexually Transmitted Diseases (STDs): Implications for STDs Prevention and Care among Dermatology Patients in an Urban City in Vietnam. Int J Environ Res Public Heal. 2019;16(6):1080. PubMed | Google Scholar

  6. Kharsany ABM, Karim QA. HIV Infection and AIDS in Sub-Saharan Africa: Current Status. Open AIDS J. 2016;10:34-48. PubMed | Google Scholar

  7. Visalli G, Picerno I, Vita G, Spataro P, Bertuccio MP, Images F. Knowledge of sexually transmitted infections among younger subjects of the city of Messina (Sicily). J prev med hyg. 2014;55(1):17-22. PubMed | Google Scholar

  8. Weaver RD. An Assessment of Sexually Transmitted Disease Knowledge Among 7th Grade Students. Walden Diss Dr Stud Collect. 2015. Google Scholar

  9. Nubed KC, Jane-Francis TKA. Knowledge, attitudes and practices regarding HIV/AIDS among senior secondary school students in Fako Division, South West Region, Cameroon. BMC Public Health. 2016;16:847. PubMed | Google Scholar

  10. Cherie A, Berhane Y. Knowledge of Sexually Transmitted Infections and Barriers to Seeking Health Services among High School Adolescents in Addis Ababa, Ethiopia. J AIDS Clin Res. 2012;3(5). Google Scholar

  11. Exavery A, Lutambi AM, Mubyazi GM, Kweka K, Mbaruku G. Multiple sexual partners and condom use among 10-19-year-olds in four districts in Tanzania: What do we learn? BMC Public Health. 2011 Jun 22;11:490. PubMed | Google Scholar

  12. Silassie AG, Giorgis MW, Kahsay N, Fisaha Y, Zerihun Z, Tadesse K et al. Knowledge, Attitude and Practice of Condom Utilization among Axum Preparatory School Students. J AIDS Clin Res. 2016;7(4). Google Scholar

  13. Dula J, Oljira L, Geda B, Kinati T. Knowledge of Sexually Transmitted Disease and Barriers to Seeking Sexual and Reproductive Health Care among Chercher High School Students. Advances in Pharmacoepidemiology and Drug Safety. 2017; 6(1):216. PubMed | Google Scholar

  14. Tsadik M, Lul Lam ZH. Delayed health care seeking is high among patients presenting with sexually transmitted infections in HIV hotspot areas, Gambella town, Ethiopia. HIV AIDS (Auckl). 2019 Aug 30;11:201-209. PubMed | Google Scholar

  15. Baruah A, Das BR, Sarkar AH. Awareness about sexually transmitted diseases among adolescents in urban slums of Jorhat district. Int J Med Sci Public Heal. 2016;5(11):2373-7. Google Scholar

  16. Amu EO, Adegun PT. Awareness and Knowledge of Sexually Transmitted Infections among Secondary School Adolescents in Ado Ekiti, South Western Nigeria. J Sex Transm Dis. 2015;2015:260126. PubMed | Google Scholar

  17. Genz N, Maria S, Meincke K, Laura M, Carret V, Cândida A et al. Sexually Transmitted Diseases: Knowledge and Sexual Behavior of Adolescents. Texto Context Enferm. 26(2):1-12. Google Scholar

  18. Mwambete KD, Mtaturu Z. Knowledge of sexually transmitted diseases among secondary school students in Knowledge of sexually transmitted diseases among secondary school students in Dar es Salaam, Tanzania. Afr Health Sci. 2014;6(3):165-169. PubMed | Google Scholar

  19. Demis A, Adera A, Workeneh D. Determination of knowledge, attitudes and practices on prevention of sexually transmitted infections among seto semero high school students. MOJ Public Health. 2017;5(5):142-153 Google Scholar

  20. Mou SZ, Bhuiya FA, Mohammed S, Islam S. Knowledge and perceptions of sexually transmitted diseases, HIV / AIDS, and reproductive health among female students in Dhaka, Bangladesh. Int J Adv Med Heal Res. 2015;2(1): 9-15. Google Scholar

  21. Folasayo AT, Oluwasegun AJ, Samsudin S, Saudi SS, 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. Int J Environ Res Public Heal. 2017;14(2):159. PubMed | Google Scholar

  22. Kalar N, Kalar MU, Zehra SS, Dharamshi HA, Patel S, Faraz A et al. To assess the level of awareness of pre-marital sexually transmitted diseases (STDs) screening between medical and non-medical students in Karachi, Pakistan. Int J Collab Res Intern Med Public Heal. 2012;4(12):1959-1970. Google Scholar

  23. Ekşį Z, Kömürcü N. Knowledge Level of University Students about sexually transmitted diseses. Procedia - Soc Behav Sci. 2014;122:465-472. Google Scholar

  24. Zin NM, Ishak I, Manoharan K. Knowledge, attitude and practice towards sexually transmitted diseases amongst the inmates of women shelters homes at Klang. BMC Public Health. 2019;19(Suppl 4):639. PubMed | Google Scholar

  25. Rana M, Kamath R, Ashok L, Shetty B, Guddattu V, Chandrasekaran V. Knowledge and attitude regarding STIs including HIV and RTIs among college adolescent girls in urban Udupi Taluk. Glob J Med PUBLIC Heal. 2015;4(1).

  26. Nyasulu P, Fredericks M, Basera TJ, Broomhead S. Knowledge and risk perception of sexually transmitted infections and relevant health care services among high school students in the Platfontein San community, Northern Cape Province, South Africa. Adolesc Health Med Ther. 2018;9:189-197. PubMed | Google Scholar

  27. Nayak S, Toppo NA, Tomar SP, Kasar PK, Tiwari R. A study on knowledge about sexually transmitted infections (STIs) and AIDS among adolescents of rural areas of Jabalpur district. Int J Med Sci Public Heal. 2016;5(08):1592-1595. Google Scholar

  28. Mansour P, Hospital C, Hospitals AF, Region T, Arabia S. Knowledge And Awareness Of Sexually Transmitted Diseases among Male University Students in Taif, Saudi Arabia. Int J Med Sci Public Heal. 2014;3(3):342-348. Google Scholar

  29. Cogen O, Mizrak B, Unsal A, Celik N, Ture A. Determining the Married Couples´ Levels of Knowledge about Sexually Transmitted Diseases. Int J Caring Sci. 2018;11(2):672-676. Google Scholar

  30. Masavkar SP, Naikwadi AM. Awareness of Sexually Transmitted Diseases [STDs] in College Students. J Cont Med A Dent. 2016;4(2):15-18. Google Scholar

  31. Trajman A, Belo MT, Teixeira EG, Dantas VCS, Salomão FM, Cunha AJLA. Knowledge about STD / AIDS and sexual behavior among high school students in Rio de Janeiro, Brazil. Cad Saúde Pública, Rio Janeiro. 2003;19(1):127-133. PubMed | Google Scholar

  32. Eysenck MW, Reis M, Ramiro L, Matos MG, Diniz JA. Nationwide survey of contraceptive and sexually transmitted infection knowledge, attitudes and skills of university students in Portugal. Int J Clin Heal Psychol. 2013;13(2):127-137. Google Scholar

  33. Oluyemi JA, Yinusa MA. Knowledge of Sexually Transmitted Diseases among Secondary School Adolescents in Asa Local Government Area of Kwara State Nigeria. African Sociological Review. 2015;19(1):63-76. Google Scholar

  34. KC VK, Karki SB, Niraula BR. Correlates of Knowledge about Sexually Transmitted Diseases (STDs) among Youths in Nepal. Janapriya J Interdiscip Stud. 2017;2(1):101-109. Google Scholar

  35. Shiferaw Y, Alemu A, Girma A, Getahun A, Kassa A, Gashaw A et al. Assessment of knowledge, attitude and risk behaviors towards HIV / AIDS and other sexual transmitted infection among preparatory students of Gondar town, north west Ethiopia. BMC Res Notes. 2011 Nov 21;4:505. PubMed | Google Scholar

  36. Central Statistical Agency. Ethiopia Demographic and Health Survey. 2016.

  37. Yosef T, Daniel A, Nigussie T, Girma Y. Sexual Behaviour among Technical Vocational and Educational Training (TVET) College Students at Mizan-Aman Town, South West Ethiopia, 2018. J AIDS Clin Res. 2019;10(10):803. Google Scholar

  38. Belay SA, Worku Y, Tsion Addisu AA. Assessment of magnitude of risk sexual behavior among Mizan high school and preparatory school students, South West, Ethiopia, 2016: descriptive cross-sectional study. Int J Sci Reports. 2018;4(3):68-74. Google Scholar

  39. Schönfeld A, Feldt T, Tufa BT, Orth MH, Andre' F, Million GM et al. Prevalence and impact of sexually transmitted infections in pregnant women in central Ethiopia. Int J STD AIDS. 2018 Mar;29(3):251-258. PubMed | Google Scholar

  40. Anwar M, Sulaiman AS, Khan M. A Survey of Knowledge of Sexually Transmitted Infections among Patients at a Public Hospital in Pulau Pinang, Malaysia. Med Princ Pract. 2010;19(4):312-318. PubMed | Google Scholar

  41. Andersson-Ellström A, Milsom I. Knowledge about the prevention of sexually transmitted diseases: a longitudinal study of young women from 16-23 years of age. Sex Transm Infect. 2002 Oct;78(5):339-341. PubMed | Google Scholar

  42. Yitbarek YG, Ayele AB. Prevalence of Syphilis among Pregnant Women Attending Antenatal Care Clinic, Sede Muja District, South Gondar, Northwest Ethiopia. J Pregnancy. 2019 Jul 14;2019:1584527. PubMed | Google Scholar