Self-reported sexually transmitted infections and related symptoms among women in Ghana

Florence Gyembuzie Wongnaah; Khadijat Adeleye; Augustus Osborne; Richard Gyan Aboagye; Bright Opoku Ahinkorah

doi:10.1371/journal.pone.0348770

Peer Review History

Original SubmissionDecember 17, 2025
2 Feb 2026 Decision Letter - Kahsu Gebrekidan, Editor -->PONE-D-25-67170-->-->Self-reported sexually transmitted infections and their symptoms among women in Ghana: Findings from a nationwide analysis-->-->PLOS One Dear Dr. Wongnaah, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Mar 19 2026 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. 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If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions -->Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. --> Reviewer #1: Yes Reviewer #2: Yes ******** -->2. Has the statistical analysis been performed appropriately and rigorously? --> Reviewer #1: Yes Reviewer #2: Yes ****** -->3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.--> Reviewer #1: Yes Reviewer #2: Yes ****** -->4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.--> Reviewer #1: Yes Reviewer #2: 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: Thankyou for this wonderful well thought out manuscript. Its results will go a long way in informing the body of public health and STI medicine. appropriate methods were employed to adduce sound deductions. However, some of the suggestions to address are as follows: 1. Line 159-169 Results narrative. The narrative captured only percentages, would it be better if the absolute figures were also included alongside the percentages? 2. Line 170-178 Prevalence. would it make it better to state the prevalence starting with the highest to the lowest? 3. Line 179-220 Analysis. The final model at multivariate analysis has many variables which will affect the statistical output of the model. At bivariate analysis e.g. religion didn't have a statistically significant P value, what would be the justification of having it in our final model at multivariate analysis? There is visible overlapping of strata confidence intervals. it would be prudent to keenly analyze for effect modification and confounding which will eventually give as a better predictive model. conclusively its a privilege to have read and critiqued this manuscript. Great work team!! Reviewer #2: This manuscript addresses an important public health issue using nationally representative DHS data and applies appropriate statistical methods. The topic is relevant to PLOS ONE readership and aligns well with global STI research priorities. However, the manuscript would benefit from stronger methodological transparency, clearer justification of variable construction, deeper interpretation of findings, and language/structural polishing. ****** -->6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. 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NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications. --> Attachments Attachment Submitted filename: Review comments _PONE-D-25-67170.docx https://doi.org/10.1371/journal.pone.0348770.r001
Revision 1
5 Apr 2026 Author Response RESPONSE TO REVIEWERS’ COMMENTS REVIEWER #1: Thank you for this wonderful well thought out manuscript. Its results will go a long way in informing the body of public health and STI medicine. appropriate methods were employed to adduce sound deductions. However, some of the suggestions to address are as follows: Response: Thank you. 1. Line 159-169 Results narrative. The narrative captured only percentages, would it be better if the absolute figures were also included alongside the percentages? Response: Thank you. We have added the figures to the percentages. 2. Line 170-178 Prevalence. would it make it better to state the prevalence starting with the highest to the lowest? Response: Thank you. We have revised the results description to list them from highest to lowest. 3. Line 179-220 Analysis. The final model at multivariate analysis has many variables which will affect the statistical output of the model. At bivariate analysis e.g. religion didn't have a statistically significant P value, what would be the justification of having it in our final model at multivariate analysis? There is visible overlapping of strata confidence intervals. it would be prudent to keenly analyze for effect modification and confounding which will eventually give as a better predictive model. Response: Thank you. We included religion in the multivariate regression because one of its categories was statistically significant. Also, we checked for evidence of collinearity among the variables and found no evidence of high collinearity. Conclusively its a privilege to have read and critiqued this manuscript. Great work team!! Response: Thank you. REVIEWER 2 Review summary This manuscript addresses an important public health issue using nationally representative DHS data and applies appropriate statistical methods. The topic is relevant to PLOS ONE readership and aligns well with global STI research priorities. However, the manuscript would benefit from stronger methodological transparency, clearer justification of variable construction, deeper interpretation of findings, and language/structural polishing. The manuscript could be suitable for publication with the following revisions. 1. Title and Scope Lines 1–2: Self-reported sexually transmitted infections and their symptoms among women in Ghana: Findings from a nationwide analysis Issues • The title does not specify that data are from the 2022 GDHS. • “Their symptoms” is vague. Suggested Revision Self-reported sexually transmitted infections and related symptoms among women in Ghana: Evidence from the 2022 Ghana Demographic and Health Survey Response: The authors have revised the title to read “Self-reported sexually transmitted infections and related symptoms among women in Ghana: Evidence from the 2022 Ghana Demographic and Health Survey”. 2. Abstract – Methods and Results Need Precision a) Methods Lines 31–37 • Sampling design, weighting, and handling of complex survey design are not mentioned. • The composite outcome needs justification. Suggested Addition The analysis accounted for sampling weights, clustering, and stratification using DHS survey commands. Response: The authors have added the sentence that reads “The analysis accounted for sampling weights, clustering, and stratification using DHS survey commands” to the methods section. b) Results Lines 42–51 • Results mix multiple outcomes but emphasize only the composite in regression. • Regions are grouped (Ahafo, Northern, Savannah) without explanation. Suggested Revision Clarify that regression results mainly refer to the composite outcome, and specify that Savannah was significant only in bivariate or multivariable (whichever is correct). Response: Thank you for this comment. We have improved the description of the results section in the abstract to enhance clarity. c) Conclusion Lines 52–57 • The phrase “women with more children and those initiating sex later” is ambiguous. Suggested Revision Self-reported STIs were lower among older women, those currently working, women with children, and those initiating sexual activity at later ages. Response: The authors have revised the sentence to read “Self-reported STIs were lower among older women, those currently working, women with children, and those initiating sexual activity at later ages”. 3. Introduction – Improve Flow and Accuracy a) Global Burden Statistics Lines 64–68 “…374 million new infections… resulting in 2.5 million deaths annually” This statement is inaccurate. WHO does not attribute 2.5 million deaths annually to curable STIs. Suggested Action Verify and correct mortality statistics or remove death estimate. Response: We have corrected the statistics. b) Redundancy Lines 27–30 and 77–83 Both describe global burden and surveillance limitations. Consider merging to avoid repetition. Response: Thank you. We have revised the paragraphs. c) Research Gap Lines 96–104 The gap is mentioned but not strongly articulated. Suggested Addition To our knowledge, no recent nationally representative study has examined self-reported STIs and related symptoms among women using the 2022 GDHS, particularly incorporating regional disaggregation and behavioural factors. Response: Thank you. We have added this suggestion to the study. 4. Methods – Clarify Key Analytical Decisions a) Inclusion Criteria Lines 122–124 “women with data on all variables of interest” Concern This implies listwise deletion, which may bias estimates. Suggested Revision • Specify percentage excluded. • Consider multiple imputation or justify complete-case analysis. Response: The authors have indicated that 13.4% of the 15,014 women of reproductive age were excluded from the study due to missing observations for one or more variables of interest. b) Outcome Variable Coding Lines 131–134 “don’t know” recoded as “no” Concern This may underestimate prevalence. Suggested Revision Justify this choice or conduct sensitivity analysis excluding “don’t know”. Response: The don’t know category was less than 5%. Additionally, this category ‘don’t know’ had no variation in the prevalence estimate from the initial sensitivity test. c) Composite Outcome Lines 126–127 Explain why combining STI, discharge, and sores is epidemiologically meaningful. Suggested Addition A composite outcome was created to capture women experiencing any indication of STI or related symptoms, improving sensitivity in identifying potential infections in settings where laboratory confirmation is unavailable. Response: Thank you for the suggestion. The authors have incorporated it into the study. d) Multicollinearity No mention of checking multicollinearity. Suggested Addition (Methods) Variance inflation factors (VIF) were assessed to examine multicollinearity. Response: We have added that the variance inflation factor was used to examine evidence of multicollinearity among the variables. 5. Results – Presentation Issues a) Table 1 Line 166 “61.% of the women…” Typographical error. Correction 61.0% Response: We have corrected this to read ’61.0%’. b) Figure 1 Lines 171–177 • No confidence intervals shown. • Figure not described sufficiently. Suggested Improvement Include error bars or state in caption: Bars represent weighted prevalence; error bars indicate 95% CI. Response: We have revised Figure 1 to include the error bars. c) Bivariate Tables Tables 2 (Lines 197–203) • Two tables both labeled “Table 2”. • Rename second as Table 3 and shift subsequent tables. Response: We have renamed the tables. 6. Multivariable Analysis – Interpretation a) Health Facility Visit Lines 225–227 Interpretation is brief. Suggested Expansion This may reflect reverse causality, where women seek care due to symptoms, or increased detection among facility users rather than increased risk. Response: Thank you. We have included this interpretation in the discussion section. b) Condom Use Associated with Higher STI Reporting (Table 3) This counterintuitive result requires discussion. Suggested Explanation Women with symptoms may initiate condom use after infection, or socially desirable reporting may bias responses. Response: Thank you. However, the authors did not find any significant association between condom use and reporting any STIs and related symptoms. c) Age Not Significant for “Any STI” Outcome (Table 3) Yet emphasized in text. Suggested Action Differentiate which outcomes show age effects. Response: We have revised the results description for age to read “Women aged 40–44 years (aOR = 0.70; 95% CI: 0.52–0.93) and 45–49 years (aOR = 0.55; 95% CI: 0.40–0.76) were less likely to report any STIs and related symptoms compared with those aged 15-19. Similarly, lower likelihood of reporting genital discharge was found among women aged 40-44 (aOR = 0.69; 95% CI: 0.51, 0.95) and 45-49 (aOR = 0.52; 95% CI: 0.37, 0.74). 7. Discussion – Needs Strengthening Currently limited interpretation is provided. Add: • Comparison with Ghana DHS 2014/2017. • Comparison with Ethiopia, Mali, Nigeria studies. • Policy implications (screening, youth-focused services, region-targeted interventions). Response: Thank you. We have revised the policy implications section. Also, the current discussion section compared studies that used the DHS dataset and other studies from sub-Saharan African countries. 8. Limitations Section Missing Add a dedicated subsection. Suggested Content • Self-reported data → recall/social desirability bias • Cross-sectional design → no causality • Symptoms not laboratory-confirmed • Exclusion due to missing data Response: Thank you. The authors have revised the limitations of the study to include the self-reported data, cross-sectional design, symptoms not laboratory-confirmed and exclusion of respondents with missing data. 9. Ethics Statement Lines 155–158 Should mention specific ethics committees and approval numbers if available. Response: We have added the institutional review board that granted ethics approval, with the approval number. • Minor Comments • Standardize terminology: use STIs consistently (avoid alternating with STDs). • Italicize statistical symbols (p, OR). • Replace “Genital sore or ulcer” with “genital sores/ulcers” throughout. • Check references formatting consistency. • Capitalization: “Islamic” → “Islam”. Response: We have corrected these minor errors throughout the manuscript. ✅ Recommendation Minor Revision The manuscript is methodologically sound but requires: ✔ Clearer justification of analytic choices ✔ Stronger interpretation ✔ Correction of technical and typographical issues ✔ Addition of limitations and expanded discussion Response: Thank you. The authors have extensively revised the manuscript. Attachments Attachment Submitted filename: Response to Reviewers Comments on STIs_R1 (1).docx https://doi.org/10.1371/journal.pone.0348770.r002
22 Apr 2026 Decision Letter - Kahsu Gebrekidan, Editor Self-reported sexually transmitted infections and related symptoms among women in Ghana: Evidence from the 2022 Ghana Demographic and Health Survey PONE-D-25-67170R1 Dear Dr. Florence, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. 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Has the statistical analysis been performed appropriately and rigorously? --> Reviewer #1: Yes Reviewer #2: Yes ****** -->4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.--> Reviewer #1: Yes Reviewer #2: Yes ****** -->5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.--> Reviewer #1: Yes Reviewer #2: Yes ****** -->6. 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: The shared compliance report of the authors is in line with the issues raised during review. This enriches the manuscript and makes it better readable and informative. Thankyou Reviewer #2: The manuscript is now suitable for publication. The authors have responded comprehensively to all reviewer concerns, strengthened the methodological rigor, improved interpretation of findings, and addressed all technical and typographical issues. The study makes a valuable contribution to understanding STI burden among women in Ghana using nationally representative data. ****** -->7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.--> Reviewer #1: Yes: Aeku Job Michael Reviewer #2: Yes: Kibir Temesgen Assefa ******** Attachments Attachment Submitted filename: Review report.odt https://doi.org/10.1371/journal.pone.0348770.r003
Formally Accepted
Acceptance Letter - Kahsu Gebrekidan, Editor PONE-D-25-67170R1 PLOS One Dear Dr. Wongnaah, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS One. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, 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. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Kahsu Gebrekidan Academic Editor PLOS One https://doi.org/10.1371/journal.pone.0348770.r004

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