Estimate the burden of sexual dysfunction due to non-communicable diseases in Ethiopia: Systematic review and meta-analysis

Background Untreated sexual dysfunction is a serious sexual problem that adversely affects the quality of life. Body of evidence indicates non-communicable diseases are common comorbid conditions associated with sexual dysfunction. Therefore, this review was aimed to synthesize and estimate the burden of sexual dysfunction and its determinant factors among patients with non-communicable diseases in Ethiopia. Methods Cross-sectional studies were systematically searched using PubMed, Google Scholar, African Journals Online, Cochran Library, Scopus database, and gray literature. Data were extracted using a standardized Joanna Briggs Institute form. The I2 statistic was used to check heterogeneity across the included studies. A funnel plot and Egger’s regression test were used to check the presence of publication bias. Sensitivity analysis was deployed to check the effect of a single study on the overall estimation. All statistical analyses were done using STATA version 11.0 software. Result A total of six studies with 2,434 study participants was included. The estimated pooled sexual dysfunction was 68.04% (95% CI: 56.41–79.67). Based on the subgroup analysis, the highest prevalence of sexual dysfunction was reported among patients with mental related illness, 73.02% (95% CI: 54.00–92.03). Conclusion In this review, nearly seven out of ten patients with chronic illness have sexual dysfunction, which implies sexual dysfunction was highly prevalent among non-communicable patients. Therefore, health care providers should screen and manage sexual dysfunction during follow-up for improving patient quality of life and sexual reproductive health satisfaction.

1. The title of the manuscript is not fully appropriate and consistent with the study aim.
The last sentence of the background part of the abstract "estimate the burden of sexual dysfunction due to non-communicable disease in Ethiopia" is more appropriate for such investigation.
Response: We thank you very much for this important recommendation. We edited the title accordingly. 2. "Non-communicable disease" is better to be replaced by "Non-communicable diseases" in the last sentence of the background part of the abstract. Response: thank you, for your important comment. Based on your recommendations, we have made revision of the manuscript accordingly 3. "Noncommunicable Diseases" is correct for keywords according to the MeSH database of PubMed. Response: We would like to say thank you once again for your fruitful comments. This has been addressed as your recommendation. 4. The first two sentences of the introduction, exploring the statistics, need to be explained which year the belong to, provided in the reference. Response: Based on your recommendations, we have addressed the issue. In line 44-48. 5. A grammatical and linguistic edit is essential for this manuscript, as the numerous issues are apparent in it and make understanding the provided draft difficult.
Response: thank you very much for your important comment. We acknowledge that English is not our first language and we have edited the manuscript by an English language instructor. Based on your recommendations, we have made revision of the manuscript accordingly. 6. 2 nd paragraph of introduction: are NCDs comorbidities of sexual dysfunction or sexual dysfunction is a comorbidity of NCDs? Response: Based on your recommendations, we have addressed the issue. In line 55-56. 7. 4 th paragraph of introduction: references for the first sentence should be merged in a citation manager. Response: Based on your recommendations, we have addressed the issue. In line 67-69.
8. The knowledge gap is not well addressed in the introduction of the manuscript and needs to be explained more.
Response: Based on your recommendations, we have addressed the issue. In line 49-54. 9. The "Objective" and "Research question" after the introduction, could be merged into the introduction part and is a repeat of the mentioned notions in the introduction. Response: Based on your recommendations, we have addressed the issue. In line 73-77. 10. In methods and materials: in inclusion criteria, types of included NCDs should be provided specifically.
Response: Based on your recommendations, we have addressed the issue. 11. In methods and materials: in inclusion criteria, what is the reference for the standardized tool for sexual dysfunction measurement? Is it validated before for the Ethiopian population? Response: Based on your recommendations, we have addressed the issue. In line 95-102.
12. In methods and materials: in exclusion criteria, are there any criteria of exclusion for any of NCDs, participants, or sexual dysfunction disorders? The exclusion criteria could be more detailed based on the aims of this study. Response: Based on your recommendations, we have addressed the issue. 13. In methods and materials: why didn't authors search the Scopus database?
Response: We thank you very much for this important recommendation and comment. It was writing problems, so it is corrected accordingly 14. In methods and materials: the search period is stated to be from inception to 2020 and also a period of 2000-2020? Please clarify which one is the searched period exactly. Response: We thank you very much. Included study published from 2000-2020 Searching time was from May 1-31/ 2020 and updated June 5/2020 15. In methods and materials: there is not so much information about the screening process of the articles and about how did the screening was done by one or two authors.  "Fig" and "Figure" terms should be unified as " Figure" in the manuscript.
Response: we did based on the comments 20. Why there is no Figure 4 in or at the end of the manuscript?
Response: we did based on the comments 21. The terms "non-communicable patients" and "non-communicable clients" are not proper provided in many parts of the manuscript. Response: Based on your recommendations, we have addressed the issue.

22.
In discussion: did authors find any explanation for the higher prevalence of sexual dysfunction in patients with mental disorders? Please include some information about this important finding in the discussion section.

Response: Based on your recommendations, we have addressed the issue.
In line 219-223 23. In discussion: findings are not discussed well enough, and it seems authors could use literature to highlight the importance of the investigated notion and compare results with other similar studies.
Response: Based on your recommendations, we have addressed the issue.
In line 219-223 24. Also, authors could replace the paragraph "Implications of the study findings" into the discussion as a part for policymakers and public health authorities, besides the provided implications for the clinicians. Response: Based on your recommendations, we have addressed the issue. 25. Figure 5 legend, "log" should be corrected in the legend and "LogitSD" on the figure.
Response: Based on your recommendations, we have addressed the issue. Table 1