Knowledge, attitude

and practices
towards STIs among
patients attending
STI friendly clinic
By Dr Raihan Abd Aziz
Supervisor: Dr Ezura Madiana Md Monoto

1
Introduction
• Sexually-transmitted infections (STIs) have remained an important global health
issue with a threat to public health.

• STI is a preventable disease and easy to cure. However, if it is not treated in

timely manner, it will lead to a various of complication such as spontaneous
abortion, still births, pelvic inflammatory disease, infertility, perinatal and
neonatal morbidities. (World Health Organization. Baseline Report on Global Sexually
Transmitted Infection Surveillance 2018)

• Patient who contracted STI has more risk for getting and transmitting HIV. One
of the mechanism is by increasing the patients susceptibility of getting HIV
through reduction of physical and mechanical barriers of the virus (eg ulcers in
the mucosa)(Cohen, 2004)
2
• In 2016, WHO has estimated that almost one million people acquiring
new infections every day, making up a total of about 379 million new
cases of 4 curable infections each year (chlamydia, gonorrhoea,
syphilis and Trichomoniasis). (World Health Organization. Baseline Report on
Global Sexually Transmitted Infection Surveillance 2018.)

• WHO has released its Global health sector strategy on sexually

transmitted infections 2016 - 2021. The strategy aims to reduce the
incidence of syphilis and gonorrhoea by 90% globally between 2018
and 2030.

3
• Ministry of Health has established a few “STI friendly clinic” in primary
care setting which are more accessible and acceptable to most-at-risk
populations (MARPs). This is to enhance the collaboration between
the primary care doctors and NGOs supporting the MARPS. (Malaysian
Guidelines in the treatment of STI, 2015)

• Despite all services provided by the government to curb STIs, having

good knowledge, attitude and preventative practice towards STI
among the patient will significantly reduce the high prevalence rate of
STI

4
Rationale of study
• Most of local studies emphasized on the study of knowledge, attitude and
practices of general population especially the youth. Eg (Awang et al., 2014)
(Folasayo et al., 2017)
• Only one local study assess the knowledge towards STI among patient attending
Venereal disease Clinic in Penang General Hospital and it was nearly a decade
ago (Anwar et al., 2010)
• No study has ever done to evaluate the knowledge, attitude and practices
towards STI among patients attending STI clinic in primary care
• Primary care is moving towards empowering STI friendly clinic. Hence the
importance of this study to evaluate the needs for up to date secondary
prevention of recurrent STI
• Serve as a platform for educational and behavioural interventions tailored to
patients attending STI clinic
5
Literature Review

6
 Author/year Title Study design Objectives Conclusion
(Anwar et al., 2010) A survey of knowledge Cross- sectional To assess patients’ This study
of sexually transmitted study using knowledge and demonstrates
infections among questionnaires and awareness of Sexually evidence of poor
patients at a public face to face Transmitted knowledges of STI
hospital in Pulau
interview among Infections. among patient
Pinang, Malaysia
107 patients attending STI services
attending Venereal in Penang General
OPD of HPP Hospital

7
 Author/year Title Study design
Awang et al., 2014 Knowledge of sexually Cross-sectional study
transmitted diseases involving 952 never-
and sexual behaviours married males aged
among Malaysian male 15–24 years from five
youths randomly selected
states in Malaysia
Objectives Conclusion
To examines the There are a large
knowledge of sexually proportion of the
transmitted diseases respondents who were
(STDs) among male not aware of STDs other
youths in Malaysia than syphilis and HIV/
AIDS and the means of
transmission,
such as multiple sex
partners, including
those who claimed to
be sexually
active
8
 Author/year Title Study design Objectives Conclusion
Literature review
Folasayo et al., 2017 Assessing the Cross- sectional study
Knowledge Level, using questionnaires
To assess the
knowledge ,
There is still lack of
knowledges on non
Attitudes, Risky involving 700 attitudes, risky HIV causes of STDs
Behaviors and participants. behaviours and and the risky
Preventive Practices preventative behaviour practised
on Sexually practices related to by sexually active
Transmitted Diseases sexually-transmitted student is worrying.
among University disease (STDs) among
Students as health and non
Future Healthcare health science
Providers in the university students
Central Zone of
Malaysia: A Cross-
Sectional Study

9
 Author/year Title Study design Objectives Conclusion
Adegun, P. T. 2012 Knowledge of Cross sectional To assess the level of The prevalence of
sexually transmitted descriptive study was knowledge of knowledge of STIs is
Infections among carried out on 592 sexually transmitted high (81.2%)
patients attending patients attending infections and among patients
outpatient clinics at outpatient clinics. possible factors attending Outpatient
University Teaching associated with clinics of University
Hospital, Ado-Ekiti, All volunteered knowledge of Teaching Hospital,
Nigeria participants were patients attending Ado-Ekiti, Nigeria,
given a self- outpatient clinic especially among
administered the age group 25 to
structured 54
questionnaire

10
 Author/year Title Study design Objectives Conclusion
Shipitsyna et al., 2013 Sexual behaviours, Cross-sectional To ascertain sexual Male participants
knowledge and descriptive study behaviours, displayed riskier sexual
attitudes regarding involving total of 432 knowledge and behaviours and worse
safe sex, and participant whose attitudes about safe knowledge
prevalence of non- self-referred for STI sex and prevalence and attitudes about safe
and correlates sex than the women
viral sexually testing at youth
transmitted clinic. Study involved with STIs in attendees
infections among completing self- of youth clinics in St.
Petersburg, Russia
attendees of youth administered
clinics in questionnaires and
St. Petersburg, screening for 4
Russia curable bacterial STI

11
 Author/year Title Study design Objectives Conclusion
(Valdes et al., 2017) Knowledge, behaviors, Cross sectional study To assess the Knowledge of common
and attitudes of HIV- with self-administered knowledge and manifestations was poor
infected men about questionnaire done on attitudes about syphilis
syphilis 291 adult MLHIV and investigate the It is also reported that
attending care in one of sexual behaviors of men even though two thirds
the public hospital in living with HIV (MLHIV) of MLHIV knew about
Aquitaine region in oral transmission of
southwestern France syphilis, less than a third
used condoms for oral
intercourse.

This highlights a gap

between knowledge and
practice

12
Objectives
• General objectives
• To assess the knowledge, attitude and practice of patient attending STI friendly
clinic towards STIs
• Specific objectives
• To determine the demographic background of patients attending STI friendly
clinic in terms of age, gender, races, religion, education level, monthly
household income, marital status and sexual practices.
• To determine the association between different demographic background and
level of knowledge, attitude and practices towards STI among patients
attending STI clinic

13
Hypothesis
• Hypothesis Null: There is no association between demographic factors
and level of knowledge, attitude and practices towards STI among
patients attending STI clinic.

• Hypothesis Alternative: There is an association between demographic

factors and level of knowledge, attitude and practices towards STI
among patients attending STI clinic.

14
Research methodology
Inclusion criteria
Study design

• Cross- sectional study • • Age more than 18 years old

Research setting
• STI friendly clinic in KK Bandar Sungai Petani
• New patient with presentation suggestive of
STI
• Old patient registered to STI clinic
• High risk patients referred to STI clinic by
NGO
• Understand Bahasa Malaysia and English

Exclusion criteria
Study population

• Patient attending STI clinic • Does not present with STI symptoms and not
from high risk group

Sampling method

• Convenience sampling
15
Data from STI friendly clinic (STIFC) KK Bandar
Sungai Petani
2017 2018

Newly registered patient 78 92

Old cases ( follow up patient) 131 201

16
Definition of variables
• Independent variables:
• Age
• Gender
• Ethnicity
• Religion
• Education level
• Monthly income
• Marital status of patient
• Sexual orientation of patient

• Dependent variables
• Description of knowledge; in percentage of right or
wrong answer
• Description of attitude; using Likert scale ( Strongly
disagree, disagree, agree, strongly disagree)
• Description of practice, in percentage of yes or no
answer
17
Definition of variables
• Low educational level : SPM and lower
• High educational level: Diploma, Matriculation and above

18
Conceptual framework
Demographic factor
• Race
• Gender
• Age
• Religion
• Marital status
• Education level
• Level of income
• Sexual orientation
Knowledge on STI Preventative
practice on STI

Attitudes towards
STI

19
Sample size
Sample size estimation was calculated using the population
mean formulae(S. Lemeshow et al, 1990). Prior data indicate that
the mean of knowledge level on STIs was 12.21 (standard
deviation = 9.14)(Anwar et al., 2010). If the Type I error
probability and precision are 0.05 and 0.15, we will need to study
96 samples. With an additional of 20% dropout rate, the sample
size is 120 samples.

20
Sample size

21
Data collection form
• Developed from Folasayo et al., 2017, STDQuestionnaires1.pdf
• Consist of 4 sections with total of 46 questions on demographic,
knowledge on STI, attitudes on STI, and practices on STI.
• Each question will have responses either multiple choices or Likert
scale.

22
Sections Details

Section A Consist of 9 questions on the demographic backgrounds and

• Demographics sexual orientation

Section B Consist of 13 multiple choice questions on participants’

• Knowledge on knowledge on STI
STI • Symptoms
• Routes of transmission
• Diagnosis
• Preventative practices
• Complication

23
Sections Details
Section C Consist of 18 questions on attitude of participants towards :
• Attitude on STI •
• Prevention against STI
• Screening of STI
• Risky sexual behaviour
• Symptoms of STI

Section E Consist of 8 questions on safe and risky sexual practice

• Practices • Barrier methods
towards STI • Sexual partners
• STI screening ( participants and partner)
• High risk practices ( IVDU, Alcohol, pornographic)
24
Questionnaire
• Adapted from Folasayo et al., 2017 with minimal changes to the
demographic contents (STDQuestionnaires1.pdf )
• Will be using bi language, questionnaires validated in both English and
Malay.

Pilot testing to ensure the Adjustment to the

Approval from copyright
content and phrasing of the questionnaire according the
holder
item is appropriate pilot testing

25
Flow chart of study
Patient attending STI clinic
in between data collection
period will be selected
Participants will be
excluded if
• Questionnaire were not returned
• More than 20% question not
answered
Completed questionnaire
will be included and
analysed

Patient will be selected Questionnaire will be

through convenient collected at the end of the Data analysis using SPSS
sampling clinic follow up

The purpose of the study The selected patient will

will be given to the be given consent form and Report write up
selected patient. questionnaire
26
Ethical consideration
Permission from author to use questionnaire

Approval from Research & Ethics committee UKM

Approval from National Health Institute(MREC)&

registration with NMRR

Permission obtained from the PKD and FMS in

charge of the STI clinic

Consent from the patients to participate in the study

and confidentiality of patients will be protected
27
Gantt chart
Oct 18 - March Apr 2019 Aug – Dec Jan 2020 June- Aug- Sept-Dec Jan- feb
Feb 2019 - July 2019 – May Sept 2020 October 2020 2021
2019 2019 2020 2020
Literature
review
Proposal
presentation
Proposal
write up
Ethics
submission &
approval
Questionnair
e
preparation
Data
collection
Data analysis
& write up
First draft

Final
manuscript
28
Budget
Items Price

Photocopy of questionnaire
▪ (11 pages x RM 0.10) x 120 RM 132.00

Total RM 132.00

29
Statistical Analysis Plan

• The data analyses will be performed using the IBM SPSS Statistics for
Windows Version 21.0. First, the data will be manually entered into
the software. The data cleaning will be subsequently conducted to
detect any errors that could affect the accuracy of the results. After
that, the actual analysis will be carried out.
• In this study, descriptive statistics will be employed for selected
variables. The findings will be presented based on the types and
distribution of the data. Categorical data will be presented as
frequencies and percentages, while numerical data will be presented
as means and standard deviations (if normally distributed), or as
medians and interquartile ranges (if not normally distributed).
30
• Comparison of the differences in normally distributed numerical data between
two independent groups will be analysed using the independent t-test, while
the Mann-Whitney test will be used if the data are not normally distributed.
• Comparison of the differences in normally distributed numerical data between
three or more groups will be analysed using the one-way analysis of variance
(ANOVA) test, while the Kruskal-Wallis test will be used if the data are not
normally distributed.
• To study the correlation between two sets of numerical data, the Pearson's
product-moment correlation will be used if the homoscedasticity is assumed,
while Spearman's rank-order correlation will be used if the heteroscedasticity
is assumed. All probability values are two-sided, and a level of significance of
less than 0.05 (p-value < 0.05) will be considered as statistically significant

31
References
• ANWAR, M., SULAIMAN, S. A. & KHAN, T. M. 2010. A survey of knowledge of
sexually transmitted infections among patients at a public hospital in Pulau
Pinang, Malaysia. Med Princ Pract, 19, 312-8
• AWANG, H., WONG, L. P., JANI, R. & LOW, W. Y. 2014. Knowledge of sexually
transmitted diseases and sexual behaviours among Malaysian male youths.
J Biosoc Sci, 46, 214-24
• FOLASAYO, A. T., OLUWASEGUN, A. J., SAMSUDIN, S., SAUDI, S. N., OSMAN,
M. & HAMAT, R. A. 2017. 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 Health, 14
• COHEN, M. S. 2004. HIV and sexually transmitted diseases: lethal synergy.
Top HIV Med, 12, 104-7.
32
• SHIPITSYNA, E., KRASNOSELSKIKH, T., ZOLOTOVERKHAYA, E., SAVICHEVA, A.,
KROTIN, P., DOMEIKA, M. & UNEMO, M. 2013. Sexual behaviours, knowledge
and attitudes regarding safe sex, and prevalence of non-viral sexually
transmitted infections among attendees of youth clinics in St. Petersburg,
Russia. J Eur Acad Dermatol Venereol, 27, e75-84.
• World Health Organization. Baseline Report on Global Sexually Transmitted
Infection Surveillance 2018
• VALDES, A., CAZANAVE, C., DABIS, F., NEAU, D., LACOSTE, D., GABORIEAU, V.,
FARBOS, S. & DWORKIN, M. S. 2017. Knowledge, behaviors, and attitudes of
HIV-infected men about syphilis. Med Mal Infect, 47, 470-476

33
Thank you

THANK YOU
34
Appendix

35
Data Analysis Dummy Table
Sociodemographic data
Variables Categories n/(%)
Gender Male
Female
Transgender Female*
Transgender Male*
Age 19 -24
25 – 34
35 – 44
45 – 54
55 - 64
> 64

*self-declared 36
Variables Categories n/ ( %)
Race Malay
Chinese
Indian
Others
Religion Islam
Buddha
Christian
Hindusim
Others
Level of education Primary school
Secondary school
SPM
Sijil/Diploma/Degree/Master/PHD
37
Variables Categories n/ ( %)
Marital status Single
Divorced/ Widowed
Married
Sexual orientation Heterosexual
Bisexual
Homosexual
Employment Self-employed
Private/government employee
Unemployed(includes homemaker)
Student
Monthly income <RM 2500
RM 2500-RM5000
RM 5000-RM10000
RM10000-RM15000
>RM 15000
38
Data on knowledge of STI
Knowledge on STI categories n/(%)
1) Possibility for an individual to have STIs other than HIV without Yes
having symptoms No
2) Which of the following are sexually transmitted infections? Yes
a) Gonorrhea No
b) Syphilis Yes
No
b) Genital herpes Yes
No
c) Trichomoniasis Yes
No
d) Tuberculosis Yes
No
e) Asthma Yes
No

39
Knowledge on STI categories n/(%)
2) Which of the following are sexually transmitted infections? Yes
g) HIV/ AIDS No
h) Chlamydia Yes
No
i) Hepatitis B Yes
No
j) Hepatitis C Yes
No
3) What sre the causative organism of STI? Yes
a) Bacteria No
b) Virus Yes
No
c) Parasites Yes
No
e) Mosquitoes Yes
No

40
Knowledge on STI categories n/(%)
4) What are the routes of sexually transmitted infections? Yes
a) Sexual intercourse No
b) Blood transfusion Yes
No
c) Sharing needles Yes
No
d) Infected mother to an unborn child Yes
No
e) Kissing Yes
No

41
Knowledge on STI categories n/(%)
5) A female who does not want to become infected with STIs should Yes
use contraceptive pills No
6) Use of condoms will decrease the risk of being infected with STIs Yes
No
7) Avoiding sex beyond marriage can also reduce chances of Yes
infection No
8) Alcohol intake can increase an individual’s susceptibility to STIs Yes
No
9) Intake of some drugs can increase an individual’s susceptibility to Yes
STIs No
10) Having multiple sexual partners can increase chances of being Yes
infected No
11) Sexual abstinence is the most effective means of avoiding STIs Yes
No

42
Knowledge on STI categories n/(%)
12) What are the symptoms of STIs Yes
a) Ulcers in the genitals No
b) Pain while passing out urine Yes
No
c) Swollen glands, fever and body ache Yes
No
d) Discharge from penis Yes
No
e) Discharge from vagina Yes
No
f) Itching around vagina Yes
No
g) Sore throat Yes
No
h) Painless sores on the mouth and genital area Yes
No

43
Knowledge on STI categories n/(%)
13) What are the possible complications of untreated/poorly treated STIs Yes
a) Infertility No
b) Cervical Cancer Yes
No
c) Body weakness Yes
No
d) Ectopic pregnancy Yes
No
e) Still birth Yes
No

44
Attitude towards STI
Attitude towards STI Categories n/(%)
STI problem is something which I have not given much thought Strongly agree
to Agree
Disagree
Strongly disagree
STIs are not dangerous because they can be cured Strongly agree
Agree
Disagree
Strongly disagree
Homosexual men are solely to be blamed for the spread of STIs Strongly agree
Agree
Disagree
Strongly disagree
I feel condoms protect against STIs Strongly agree
Agree
Disagree
45
Strongly disagree
Attitude towards STI Categories n/(%)
I feel it’s not necessary to use condom during anal sex Strongly agree
Agree
Disagree
Strongly disagree
If both partners are infected with STIs, I feel there’s no need of Strongly agree
using condom Agree
Disagree
Strongly disagree
I feel numerous sexual partners play no role in STIs transmission Strongly agree
Agree
Disagree
Strongly disagree
I feel condoms are the best tools for the prevention of STIs Strongly agree
Agree
Disagree
Strongly disagree
46
Attitude towards STI Categories n/(%)
In my opinion, I feel STIs can cause death if left untreated Strongly agree
Agree
Disagree
Strongly disagree
I feel it’s not necessary for academic instituitions to discuss Strongly agree
issues regarding prevention of STIs Agree
Disagree
Strongly disagree
I feel banning of prostitution can control the spread of STIs Strongly agree
Agree
Disagree
Strongly disagree
I feel screening test for STIs is good Strongly agree
Agree
Disagree
Strongly disagree 47
Attitude towards STI Categories n/(%)
I feel screening test for STIs is good Strongly agree
Agree
Disagree
Strongly disagree
I feel screening test for STIs before marriage is important Strongly agree
Agree
Disagree
Strongly disagree
I think watching/ reading pornographic materials ca contribute Strongly agree
to risky sexual behaviours Agree
Disagree
Strongly disagree
If I notice symptoms of STIs, I think I should seek treatment Strongly agree
immediately Agree
Disagree
Strongly disagree
48
Attitude towards STI Categories n/(%)
If I have unprotected sexual intercourse, I am most concerned Strongly agree
about Agree
A) Getting HIV
Disagree
Strongly disagree
B) Getting STIs aside from HIV Strongly agree
Agree
Disagree
Strongly disagree
C) Unwanted pregnancy Strongly agree
Agree
Disagree
Strongly disagree

49
Attitude towards STI Categories n/(%)
If I notice symptoms of STIs in my partner, I will advise him/her Strongly agree
to seek treatment immediately Agree
Disagree
Strongly disagree
I am worried about contracting STIs Strongly agree
Agree
Disagree
Strongly disagree

50
Practices regarding sexual behaviours and STIs
Preventative practice on STIs Categories n/(%)
Have you ever had sex? Yes
No
Did you use a condom the last time you had sex? Yes
No
Do you have sex with only one partner Yes
No
If you ever received blood transfusion, was the blood screened? Yes
No
Do you get tested for STIs annually? Yes
No
Does your partner get tested for STIs annually? Yes
No

51
Risky behaviour Categories n/(%)
Do you inject drugs before having sex? Yes
No
Do you take drugs before having sex? Yes
No
Do you drink alcohol before having sex? Yes
No
Do you share injection needle with others? Yes
No
Do you read pornographic materials? Yes
No
Have you had sex with multiple partners within past twelve months? Yes
No
Do you have sex with commercial sex workers? Yes
No

52
 Associations between patients knowledge level and
their sociodemographic characteristics.
Variables Knowledge level N ( %) x² p Prevalance
Good ( %) Poor(%) Ration (CI)#
Gender
Male
Female
Transgender female
Transgender male
Age group
19 -24
25 – 34
35 – 44
45 – 54
55 - 64
> 64 53
Variables Knowledge level N ( %) x² p Prevalance
Good ( %) Poor(%) Ration (CI)#
Race
Malay
Chinese
Indian
Others
Religion
Islam
Buddha
Christian
Hindusim
Others

54
Variables Knowledge level N ( %) x² p Prevalance Ration (CI)#
Good ( %) Poor(%)
Education level
Low education
High education
Employment
Private/government
employee
Unemployed(includes
homemaker)
Student
Monthly salary
<RM 2500
RM 2500-RM5000
RM 5000-RM10000
RM10000-RM15000
>RM 15000 55
Variables Knowledge level N ( %) x² p Prevalance
Good ( %) Poor(%) Ration (CI)#
Marital status
Single
Married
Divored/widowed

Sexual orientation
Heterosexual
Bisexual
Homosexual

56
 Associations between patients’ practices and their
sociodemographic characteristics and knowledge
Variables Practices level N ( %) x² p Prevalance
Acceptable ( %) Non Acceptable(%) Ration (CI)#
Gender
Male
Female
Transgender female
Transgender male
Age group
19 -24
25 – 34
35 – 44
45 – 54
55 - 64
> 64 57
Variables Practices level N ( %) x² p Prevalance
Acceptable ( %) Non Acceptable(%) Ration (CI)#
Race
Malay
Chinese
Indian
Others
Religion
Islam
Buddha
Christian
Hindusim
Others

58
Variables Practices level N ( %) x² p Prevalance Ration (CI)#
Acceptable ( %) Non Acceptable(%)
Education level
Low education
High education
Employment
Private/government
employee
Unemployed(includes
homemaker)
Student
Monthly salary
<RM 2500
RM 2500-RM5000
RM 5000-RM10000
RM10000-RM15000
>RM 15000
59
Variables Practices level N ( %) x² p Prevalance
Acceptable ( %) Non Acceptable(%) Ration (CI)#
Marital status
Single
Married
Divored/widowed

Sexual orientation
Heterosexual
Bisexual
Homosexual
Knowledge
Good
Poor

60