Factors associated with awareness about syphilis and gonorrhoea among women in Bangladesh

Currently, syphilis and gonorrhoea among women is a topic Background: great concernin Bangladesh. To date, little is known in the existing literature regarding its prevalence, and the current level of syphilis and gonorrhoea awareness among women with regard to prevention is inadequate. This research aims to identify factors associated with awareness of syphilis and gonorrhoea among women in Bangladesh. Data were collected from Methods: women by the Bangladesh Demographic and Health Survey (BDHS) 2011 as a cross-sectional study. The seven divisions surveyed were Dhaka, Rajshahi, Rangpur, Chittagong, Barisal, Khulna and Sylhet. The number of women in the seven divisions totalled 17,842. The chi-squared test and a logistic regression model were used to determine the social-demographic factors associated with awareness about syphilis and gonorrhoea among women in Bangladesh. The rate of awareness about syphilis and gonorrhoea among women Results: in Bangladesh was 13.3% and 15.7%, respectively. The chi-squared test and logistic analysis demonstrated that there is a significant association between the awareness of syphilis and gonorrhoea with the respondents’ age, location of the respondents’ house, educational level of the respondent, socioeconomic status, geographic region, and respondents that listened to the radio and watched TV. There is an essential need to expand the learning Conclusions: and teaching program in Bangladesh regarding syphilis and gonorrhoea, mainly among younger women (<25 years) in all topographical and rural areas. Advertising drives and mass broadcasting programs can be used to increase knowledge within societies, particularly among women. In addition, the low awareness of syphilis and gonorrhoea indicates that prevention interventions are required among women.


Introduction
Generally, women are in greater danger of contracting sexually transmitted infections compared with men 1 .Treponema pallidum is a microaerophilic spirochete that causes syphilis, a chronic systemic venereal illness with various characteristics, which is also characterised by latent periods and flare-ups or incidents of energetic virus 1 .Gonorrhoea is a general venereal illness caused by the bacterium Neisseria gonorrhoea.Symptoms include painful urination and pain around the urethra.Virtually any mucous membrane can be infected 2,3 .Previous research has shown that the rate of awareness of gonorrhoea was 4%, while that for syphilis was 5% among 1,550 women in Bangladesh 4 , while further research showed that rate of awareness for syphilis and gonorrhoea was 0.9% and 0.5%, respectively 4 .The World Health Organization reported an incidence of 340 million individuals with gonorrhoea and syphilis among 15-49 year olds, the majority of whom resided in Asia 5 .In developed and developing countries, such as Bangladesh, gonorrhoea and syphilis area major health and economic problem 5 .Per day more than 1 million individuals obtain a sexually transmitted infection, and per year, a projected 500 million individuals contract one of four sexually transmitted infections, including gonorrhoea and syphilis 6 .Geographic region, place of residence, respondent's age, education, listening to the radio and watching television have a sufficient association with knowledge concerning sexually transmitted diseases, in general, among women in Bangladesh 7 .Syphilis and gonorrhoea are harmful to the health of women and infants [8][9][10] .Gonorrhoea is caused by pelvic inflammatory diseases, which can lead to sterility, ectopic gravidity, and long-lasting pelvic pain [11][12][13][14][15]16 . Addtional, investigation specified that syphilis and gonorrhoea combined can be co-factors for HIV infection [16][17][18][19] .In Bangladesh, previous studies have identified the sero-prevalence of sexually transmitted infections and reproductive tract infections in the general population 20 .However, a nationwide study concerning the rate of awareness of syphilis and gonorrhoea, specifically, among women in Bangladesh is lacking.Consequently, the goal of this study is to identify the associated factors concerning knowledge about these diseases among women in Bangladesh.

Sample design
This cross-sectional study used data collected in the Bangladesh Demographic and Health Survey (BDHS) 2011, which includes data collected from women.Dhaka, Rajshahi, Rangpur, Chittagong, Khulna, Barisal and Sylhet are seven administrative divisions in Bangladesh.Each division is subdivided into zilas (administrative areas), and each zila into upazilas (sub-administrative areas).Each urban area in an upazila is divided into wards, and into mohallas (villages) within a ward.Each rural area in an upazila is divided into union parishads (UP; local administrative areas) and mouzas (villages) within a UP.These divisions allow the country as a whole to be easily separated into rural and urban areas 21 .

Sampling procedure
The BDHS survey was conducted by a two-stage stratified sample of households.Initially, a total of 600 areas were selected, with 207 clusters in urban areas and 393 in rural areas.A complete household listing operation was then carried out in all of the selected areas to provide a sampling frame for the second-stage selection of households.In the second stage of sampling, a systematic sample of 30 households on average was selected per area to provide statistically reliable estimates of key demographic and health variables for the country as a whole, for urban and rural areas separately, and for each of the seven divisions.A total of 18,222 ever-married women aged 12-49 were identified in these households, and 17,842 were interviewed, yielding a response rate of 98% 21 .

Data analysis
SPSS v21 was used to conduct statistical analysis.χ 2 tests were used to calculated the association between awareness about syphilis and gonorrhoea and the respondent's age, place of residence, education, socioeconomic grade, geographic region, and if the respondents listen to radio and watch TV.A p-value of 0.05 was considered significant at the 95% confidence intervals (CI) level.To identify the predictive factors with awareness about syphilis and gonorrhoea, and the socio-demographic variables (Table 1), a logistic regression analysis was conducted.The dependent variable used in the model was a dichotomous binary variable: Y=1 if the women have awareness about syphilis and gonorrhoea, and Y=0 otherwise.Respondent's age, place of residence, education, socio-economic grade, geographic region, and if the respondent listen to radio and watch TV were measured as predictive variables (Table 1).

Results
Table 2 presents the association between awareness about syphilis and gonorrhoea and the designated social-demographic variables of women in Bangladesh.The rate of awareness about syphilis From Table 3, women aged 25-35 years and 36-49 years were, respectively, 1.91 and 3.01, and 1.77 and 2.63 times more aware of syphilis and gonorrhoea, respectively, compared to women aged <25 years.Women that lived in rural areas had 0.72 and 0.82 times less awareness about syphilis and gonorrhoea, respectively, than women living in urban areas in Bangladesh.Education was shown to be an important factor for awareness about syphilis and gonorrhoea among women: Women who had finished primary, secondary and higher teaching were, respectively, 1.56, 3.41, and 1.59, and 3.72 times more aware of syphilis and gonorrhoea than women who had no education.The level of awareness about syphilis and gon-orrhoea increased with the level of women's education.The middle class and rich women were, respectively, 1.17 and 1.23, and 1.06 and 1.22 times more aware of syphilis and gonorrhoea than poor women.In addition, women living in Dhaka, Khulna, Chittagong, Rajshahi, Rangpur and Sylhet divisions had less awareness about syphilis and gonorrhoea than women living in the Barisal division.Women who listen to radio and watch TV were, respectively, 1.17 and 1.01, and 1.13 and 1.11 times more aware of syphilis and gonorrhoea, respectively, compared to women who did not listen to radio or watch TV in Bangladesh.

Discussion
Awareness about syphilis and gonorrhoea leads to the promotion of health care among women in Bangladesh.The present study was designed to identify the awareness about syphilis and gonorrhoea among women.In this study, the rate of awareness about syphilis and gonorrhoea among women in Bangladesh is 13.3% and 15.7%, respectively.Bangladesh in previous studies shows that, the rate of awareness about syphilis and gonorrhoea is between 4-5.7% and 5-6.3% respectively, 4,16 .The Bangladesh government should give urgent attention to increase awareness about the rate of syphilis and gonorrhoea in Bangladesh, since syphilis and gonorrhoea can lead to ectopic pregnancy, low birth weight, pelvic inflammatory diseases and infertility, which are increasing day-by-day 16 .Older women have a higher level of awareness about syphilis and gonorrhoea, since they have acquired knowledge related to sexuality and reproduction 22 .In this study, middle-aged and older women have better awareness about syphilis and gonorrhoea compared to younger women (<25 years).The old-style society system and health service overlook younger women in Bangladesh.The level of women's education is significantly associated with awareness about syphilis and gonorrhoea.Education makes an important contribution to awareness, and it showed a statistically significant association with awareness in the current study (p<0.001).A higher level education provides women with various opportunities, such as practice of health scare and knowledge on reproductive health.This is supported by the encouraging effect of teaching for the development of awareness about syphilis and gonorrhoea seen in previous studies 23,24 .In this study, women that live in urban areas have more awareness about syphilis and gonorrhoea, as do women in the Barisal (urban) area.Urban areas are exposed more to mass media and education programs compared with rural areas.Mass media is an important channel, as music, newspapers, songs and advertising can communicate awareness about syphilis and gonorrhoea.The major sources of information about syphilis and gonorrhoea for women are the radio and TV, and in the present study women that listened to the radio and watched TV were more likely to know about the two STIs.This is similar to the suggestion established by Khan and Goel in their research: The level of awareness increased with age and literacy, which shows policymakers that educational intervention programs may be effective 23,25 .One of the limitations of this research is that the material was self-reported and few studies have studied syphilis and gonorrhoea in Bangladesh.Therefore, Bangladesh needs more research about these diseases.

Conclusions
Knowledge about infectious diseases, especially syphilis and gonorrhoea, in Bangladesh has been an important theme in population based studies.Educating women is an important step in increasing knowledge consciousness about syphilis and gonorrhoea.Highly effective sexual health education should be included in textbooks and infectious diseases prevention programmes, which will achieve positive health outcomes among rural poor women of Bangladesh.At present, awareness about syphilis and gonorrhoea shows there is more risk to women in different regions (Rajshahi, Rangpur, Sylhet and Chittagong divisions).Rural school based educational programmes are needed to increase the awareness about syphilis and gonorrhoea.However, mass media (broadcasting and television) play a large role in increasing awareness about infectious diseases, such as syphilis and gonorrhoea.Therefore, Bangladeshi government policy should focus on increasing educational programmes at the public level about syphilis and gonorrhoea through the use of radio, television, the Internet, newspapers and textbooks.

Ethical approval
Ethical approval for this study was not applicable, since ethical approval for the collection of data was previously approved for BDHS.

5.
World Health Organization: Global prevalence and incidence of selected curable sexually transmitted infections: overviews and estimates.Geneva, Switzerland, 2001.

Reference Source
I have read this submission.I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Introduction
1st paragraph.One of the most common symptoms of gonorrhea in males, urethral discharge, was not mentioned.
2nd paragraph.The following statement is incorrect: "Gonorrhea is caused by pelvic inflammatory diseases,…" I think the authors meant to say "Gonorrhea causes pelvic inflammatory disease which can lead to sterility…" This is a typographical error which significantly changed the meaning of a sentence.There are other less significant such errors throughout the paper and, as recommend by the other reviewer, the paper would benefit from proofreading to detect and correct these.
Background information on the national prevalence rates of syphilis and gonorrhea would be helpful in understanding the results of the study.Are such data available?If so they should be provided in the introduction.

Results
It is striking that all the independent variables tested where independently associated with level of knowledge about syphilis and gonorrhea despite the fact there must be significant confounding of the analysis i.e., for example, socioeconomic status is always strongly correlated with educational level.This correlation is so strong it is somewhat surprising that that both variables were independently associated knowledge levels.The large sample size probably accounts for this and this the major strength of the paper.

Discussion
It was striking that the Barisal region had significantly higher knowledge levels than the other districts.
From what I could learn on the internet, this is a relatively rural area which, based on the results of the comparison of rural vs. urban area knowledge levels, should have had lower knowledge levels.Dhaka is the largest city in Bangladesh yet knowledge levels in the Dhaka region were significantly lower than in the Barisal region.It would be important for the authors to help the reader understand this unexpected finding in the Discussion Section of the paper.If there are better sexual health education programs in Barisal, perhaps these could be adapted in other parts of the country.
The statement concerning the importance of mass media that songs can communicate awareness of syphilis and gonorrhea struck me.Is this really true in Bangladesh?If so, it would be novel and it would be The statement concerning the importance of mass media that songs can communicate awareness of syphilis and gonorrhea struck me.Is this really true in Bangladesh?If so, it would be novel and it would be interesting to know more songs used for sexually transmitted infection (STI) education.

Conclusions
Four geographic regions were singled out as parts of Bangladesh with the lowest knowledge of syphilis and gonorrhea.However, it does not appear that there is much difference between these four regions and the Dhaka and Khulna regions.Only the Barisol region seems to have be better knowledge of these two STIs than any of the other regions.
The main message of the paper is clear as stated in the concluding sentence.Much greater knowledge of STIs in needed throughout all of Bangladesh regardless of socioeconomic status and educational level.This will be a daunting task given the relatively low levels of access to mass media in the country.-Place of residence: It has been interpreted as "Women that lived in rural areas had 0.72 and 0.82 times less awareness about syphilis and gonorrhoea, respectively, than women living in urban areas in Bangladesh (Column: Right, Paragraph:2, Line:4)"-I would suggest to check this interpretation by a statistician.

Is
-Geographic region: The author should include a justification in the Method's data analysis paragraph why they used Barisal as a reference category.In my opinion, Dhaka can be a reference category as it is capital city of Bangladesh.

Discussion:
The authors justified with possible reasons about their findings.
In first paragraph, the authors described the level of awareness separately at now and in the past.I would suggest to show this information in one sentence as, "Over one and a half decades (from 1997-2001 to 2011), the awareness on syphilis and gonorrhoea has been slightly/poorly/unsatisfactory increased from 4-5.7% to 13.3% and 5-6.3% to 15.7% respectively (ref)."

Grammatical or Typo-errors:
The whole manuscripts should be checked by an English editor as a few typo-errors have been observed.Such as: Abstract: "Currently, syphilis and gonorrhoea among women is a topic great concern in Bangladesh.To date, little is known in the existing literature regarding its prevalence, and the current level of syphilis and gonorrhea awareness among women with regard to prevention is inadequate (Page 1)."The authors may want to write: Currently, syphilis and gonorrhoea among women is a topic great concern in Bangladesh. of Methods: "This cross-sectional study used data collected in the Bangladesh Demographic and Health Survey (BDHS) 2011, which includes data collected from women (Page-3)."The use of word 'collected' twice makes the sentence unclear.
Discussion: "A higher level education provides women with various opportunities, such as practice of health scare and knowledge on reproductive health (Page-6)."The author may write care instead of scare.The benefits of publishing with F1000Research: Your article is published within days, with no editorial bias You can publish traditional articles, null/negative results, case reports, data notes and more The peer review process is transparent and collaborative Your article is indexed in PubMed after passing peer review Dedicated customer support at every stage For pre-submission enquiries, contact research@f1000.com the work clearly and accurately presented and does it cite the current literature?Partly Is the study design appropriate and is the work technically sound?Yes Are sufficient details of methods and analysis provided to allow replication by others?Yes If applicable, is the statistical analysis and its interpretation appropriate?I cannot comment.A qualified statistician is required.Are all the source data underlying the results available to ensure full reproducibility?Yes Are the conclusions drawn adequately supported by the results?Partly No competing interests were disclosed.Competing Interests: Referee Expertise: Sexually transmitted infections I have read this submission.I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.Director, Research to Policy Limited (R2PL), Dhaka, Bangladesh This article provides updated information on awareness level of Bangladeshi women on two important sexually transmitted diseases, syphilis and gonorrhea including associated factors with the awareness level.It has been prepared based on national survey called Bangladesh Demographic and Health Survey (BDHS) 2011.Therefore, data used in this article is valid and widely acceptable.However, I have few

Is the work clearly
and accurately presented and does it cite the current literature?PartlyIs the study design appropriate and is the work technically sound?PartlyAre sufficient details of methods and analysis provided to allow replication by others?PartlyIf applicable, is the statistical analysis and its interpretation appropriate?PartlyAre all the source data underlying the results available to ensure full reproducibility?YesAre the conclusions drawn adequately supported by the results?YesNo competing interests were disclosed.Competing Interests:Referee Expertise: Sexual and Reproductive Health, Cholera and Oral Cholera Vaccine I have read this submission.I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Table 3 . Predictive factors concerning awareness about syphilis and gonorrhoea among women stratified by socio-economic and demographic variables, using data from the BDHS 2011.
* p<0.05 level of significance

Table 2 :
It should indicate total 'n' for Syphilis and total 'n' for Gonorrhoea in the Heading as it is not cited in the Method section.