Association Between a History of Sexually Transmitted Diseases and Reproductive Health Knowledge Among Adolescents of Peru: A Cross-Sectional Study

Round 1

Reviewer 1 Report (Previous Reviewer 1)

Comments and Suggestions for Authors

This study addresses an important public health issue and contributes to the literature. However, my suggestions for the article are as follows:

- The title is appropriate and reflects the research question.
- The conclusion section of the abstract is not entirely consistent with the main finding. Although there was no statistically significant difference between the groups in terms of total knowledge scores, the statement "those with a history of STIs had higher knowledge" is included. The conclusion should be consistent with the statistical findings.
- The literature has been appropriately reviewed.
- The group with a history of STIs consisted of only 26 students.

Power analysis was not reported. The lack of significance in the main finding may be related to the small sample size.
- Since the difference in the main knowledge score was not significant, this difference should not be interpreted as "clinically significant" in the discussion section. Due to the cross-sectional design, conclusions such as "STI experience leads to increased knowledge" should not be drawn. - The conclusion section should be revised in line with the findings.

Author Response

Reviewer 1

This study addresses an important public health issue and contributes to the literature. However, my suggestions for the article are as follows:

COMMENT 1: - The title is appropriate and reflects the research question.

RESPONSE1: Thank you for your comments.

COMMENT 2: - The conclusion section of the abstract is not entirely consistent with the main finding. Although there was no statistically significant difference between the groups in terms of total knowledge scores, the statement "those with a history of STIs had higher knowledge" is included. The conclusion should be consistent with the statistical findings.

RESPONSE 2: The conclusions section has been revised and improved. Please review it.

COMMENT 3: - The literature has been appropriately reviewed.

RESPONSE3: Thank you for your comments.

COMMENT 4: - The group with a history of STIs consisted of only 26 students.

RESPONSE 4: Yes, this is the number of participants confirmed with STI. Since this was a single-center study, this is the number found, which coincides with reported STI frequency rates in schools.

 

COMMMENT 5: Power analysis was not reported. The lack of significance in the main finding may be related to the small sample size.

RESPONSE 5: The sampling method was non-probabilistic because the prevalence of STIs in high school students is low. Therefore, power calculations were not performed. This has been included as a limitation, and future studies should consider probabilistic analysis to improve the extrapolation of the results.

COMMENT 6: - Since the difference in the main knowledge score was not significant, this difference should not be interpreted as "clinically significant" in the discussion section. Due to the cross-sectional design, conclusions such as "STI experience leads to increased knowledge" should not be drawn.

RESPONSE 6: We have reviewed the text and adjusted it according to the suggestion.

 

COMMENT 7: - The conclusion section should be revised in line with the findings.

RESPONSE 7: The conclusions section has been revised and improved. Please review it.

Reviewer 2 Report (Previous Reviewer 2)

Comments and Suggestions for Authors

Dear Authors,

Thank you for your careful and thorough revision of the manuscript. I am pleased to see that the paper has been significantly improved in response to my previous comments and suggestions. 

I appreciate the effort invested in revising the manuscript and I have no further major objections.

Sincerely,

Reviewer

Author Response

Reviewer 2

Dear Authors,

Thank you for your careful and thorough revision of the manuscript. I am pleased to see that the paper has been significantly improved in response to my previous comments and suggestions. 

I appreciate the effort invested in revising the manuscript and I have no further major objections.

RESPONSE: Thank you for your comments.

Reviewer 3 Report (Previous Reviewer 4)

Comments and Suggestions for Authors

The manuscript shows clear improvements in structure, clarity of aim, contextualization within Peru, and moderation of claims. However, concerns remain unresolved, particularly regarding sample justification, analytical depth, psychometric transparency, and statistics.

The Intro now clearly show the Peruvian evidence gap. The rationale for comparing adolescents with and without STI history is well stated. The discussion integrates more Peru-literature.

The aim clarity fixed. Theoretical grounding still moderate.

The authors justified limited access to STI adolescents, however, no power calculation… remains an issue.

STI verification method is adequately addressed.

Improvements in clarifying AA-20, Cronbach alpha, cultural adaptation described. Psychometric transparency is improved but still limited.

Statistical analysis was partially addressed, lack of regression remains a limitation.

overstatement of non-significant finding was mostly addressed

figures & tables are almost addressed

sociocultural context is adequately addressed

policy implications is improved, but still not curriculum-level actionable detail.

response bias & missing data partially addressed. however no mention of missing data %. No statement confirming complete-case analysis.

 

 

Comments on the Quality of English Language

Writing quality improved overall, but minor grammatical inconsistencies, redundancy. Editing is recommended.

Author Response

Reviewer 3

The manuscript shows clear improvements in structure, clarity of aim, contextualization within Peru, and moderation of claims. However, concerns remain unresolved, particularly regarding sample justification, analytical depth, psychometric transparency, and statistics.

COMMENT 1: The Intro now clearly show the Peruvian evidence gap. The rationale for comparing adolescents with and without STI history is well stated. The discussion integrates more Peru-literature.

RESPONSE 1: Thank you for your comments.

 

COMMENT 2: The aim clarity fixed. Theoretical grounding still moderate.

RESPONSE 2: Thank you for your comments.

 

COMMENT 3: The authors justified limited access to STI adolescents, however, no power calculation… remains an issue.

RESPONSE 3: Yes, we agree with that, but non-probability sampling was more appropriate to compare both groups given the low prevalence of STI reported in high school students. This has also been included as a limitation.

 

COMMENT 4: STI verification method is adequately addressed.

RESPONSE 4: Thank you for your comments.

 

COMMENT 5: Improvements in clarifying AA-20, Cronbach alpha, cultural adaptation described. Psychometric transparency is improved but still limited.

RESPONSE 5: We have included details of the available validation and reliability data for the instrument in the manuscript. We believe this provides a better understanding of the measurements and results obtained. Thank you for your suggestions.

 

COMMENT 6: Statistical analysis was partially addressed, lack of regression remains a limitation.

RESPONSE 6: Yes, this preliminary study with a small population of students with STIs provides a snapshot of the situation in Peru. However, larger samples are needed to conduct other types of inferential or regression analyses to avoid bias. We believe that, based on these findings, future research should consider expanding the analysis and improving the interpretation of the results.

 

COMMENT 7: overstatement of non-significant finding was mostly addressed

RESPONSE 7: Thank you for your comments.

 

COMMENT 8: figures & tables are almost addressed

RESPONSE 8: Thank you for your comments.

 

COMMENT 9: sociocultural context is adequately addressed

RESPONSE 9: Thank you for your comments.

 

COMMENT 10: policy implications is improved, but still not curriculum-level actionable detail.

RESPONSE 10: We have included this information in the future directions section. We consider it important and it broadens the scope and implications of the article. Thank you for the suggestion.

 

COMMENT 11: response bias & missing data partially addressed. however no mention of missing data %. No statement confirming complete-case analysis.

RESPONSE 11: It has been mentioned that 100% of students responded to the questionnaires. We had no data loss in the sample included.

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

I would like to thank the authors for their effort in addressing a public health–relevant topic concerning adolescents’ health in Peru. Some of my suggestions are listed below.

Abstract: The phrase "had received talks on the subject" (92.3% vs. 72.5%, p = 0.004). p = 0.031) should be clarified.

The article should be revised overall for clarity of language. "Ty test were used" ? "T test"

The introduction is generally informative and supported by WHO data, but it is long and disjointed. The transition from global data to the research gap should be more fluid. Furthermore, the adolescent fertility rate should be double-checked for a possible typo (49/1000 instead of 4.9/100). The Peruvian context is introduced late; adding the country context at an earlier stage would strengthen the argument.

Method: The study was conducted with a cross-sectional design. Exclusion criteria are provided, but it would be better to show how many people were excluded and for what reason in the Participant selection flow diagram.

Results: The findings could be presented more fluently by dividing them into subheadings (descriptive data, knowledge level, behaviors). It is also recommended to reconsider the statistical interpretation of the findings. For example, the authors report a slightly higher mean knowledge score among students with prior STIs (15.4 ± 3.7 vs. 14.7 ± 3.9); however, the difference is not statistically significant (p = 0.417). Therefore, the statement "slightly higher knowledge" should be revised to reflect that no significant difference was found.

Discussion: The statement "adolescents with STIs have higher knowledge" is too strongly worded; at p > 0.05, this is misleading.

Conclusion: The statistically insignificant difference is presented as "marginally higher knowledge level"; this statement should be softened.

Author Response

Please see the attached.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Dear authors,

Thank you for the opportunity to review your manuscript, "Association between a history of sexually transmitted diseases and reproductive health knowledge among adolescents of Peru: an observational study." Your research addresses a critical public health issue, particularly relevant for Peru, where adolescent sexual health remains understudied. The manuscript is well-written and presents important findings for sexual health education programs.

Abstract

The abstract successfully communicates the study's cross-sectional design, sample characteristics, key findings regarding similar knowledge levels between groups, and significant differences in contraceptive use and educational exposure.

Suggestions for improvement:

• Define "STI" on first use in the abstract
• Specify the maximum possible score for the AA-20 questionnaire to contextualize the mean scores of 15.4 and 14.7 points
• Line 23-24: Correct the p-value error. The text states "received talks (92.3% vs. 72.5%, p = 0.004). p = 0.031" but Table 2 shows p = 0.031 for this comparison. Remove the p = 0.004 or clarify which comparison it refers to
• Clarify whether "used some form of contraception" means lifetime use, current use, or use at last intercourse
• Include specific correlation coefficients or effect sizes for the key relationships found

Introduction

The introduction provides a comprehensive overview of adolescent sexual and reproductive health globally and in Latin America, with strong epidemiological data from the WHO, a well-structured literature review that progresses logically from global burden to Latin American context to the specific gap in Peruvian research, and a clear justification for comparing adolescents with and without STI history.

Suggestions for improvement:

• While the research gap is stated, consider adding a sentence explaining why this comparison matters theoretically (e.g., whether experiencing an STI serves as a "teachable moment" that enhances knowledge acquisition)
• The age range for adolescence (13-19 years, line 32) differs from WHO's standard definition (10-19 years). Clarify whether this was intentional based on your school-based sampling
• Consider briefly mentioning the most prevalent STIs among Peruvian adolescents to contextualize your 15.9% STI prevalence finding
• Strengthen the transition between discussing the problem (lines 49-55) and stating the research gap (lines 56-62)

Materials and Methods

The methodology section presents a clear cross-sectional observational design following CROSS guidelines, well-defined inclusion criteria with justified exclusions, appropriate sampling from a characterized high-poverty population in San Juan de Lurigancho, a validated instrument (AA-20) with excellent internal consistency (Cronbach's α = 0.930), and a sound statistical analysis plan with appropriate parametric and non-parametric tests.

Suggestions for improvement:

• Line 18 in Abstract: "Ty test" appears to be a typographical error. Based on your Methods section (line 113), you used an independent samples t-test. Correct "Ty test" to "t-test" in the abstract
• Lines 129-130: Demographic information is ambiguous. The statement "14 (8.5%) was male" is unclear. While 14/164 = 8.5% mathematically, it's not clear what this refers to. Consider revising to: "Among the 26 participants with STI history, 14 (53.8%) were male" if that's what is meant, or clarify which group the 8.5% represents
• Figure 2 caption (line 137): Confusing notation. The notation "**p > 0.05" is counterintuitive because ** conventionally indicates high significance (p < 0.01), not non-significance. Remove the asterisks or use a different symbol for non-significant findings
• Provide critical details about the AA-20 questionnaire: What is the maximum possible score? How is the total score calculated from the four questions? The cut-off of "above 15 points" (lines 95-96) for higher knowledge needs justification—was this established by instrument developers or determined for this study?
• Clarify the operational definition of "previous STI" (lines 85-87). Was this self-reported diagnosis, clinically confirmed from medical records, or based on symptomatic history? The reliability and interpretation of findings depend heavily on how the STI history was ascertained
• Relocate ethical considerations (lines 118-123) to the beginning of section 2 for better methodological flow
• Consider adding sample size justification or power analysis, particularly given the relatively small number of students with STI history (n=26)
• Data collection during "national anniversary activities" (line 103) may introduce selection bias. Briefly address whether certain students were more or less likely to attend during this period

Results

The results section presents findings clearly and systematically with appropriate descriptive statistics, including means and standard deviations, well-organized demographic characteristics in Table 1, useful violin plot visualization showing knowledge score distributions, comprehensive reporting of reproductive and sexual behavior factors with statistical significance testing, and clear presentation of prevention methods identified by both groups.

Suggestions for improvement:

• Clarify the demographic information in lines 129-130 as noted above to avoid reader confusion
• The finding about abortion in Table 2 (7.7% vs 18.8%, p=0.003) is statistically significant but receives minimal attention in the text (only mentioned in line 138). Students with STI history were significantly LESS likely to consider abortion a solution—this interesting and significant finding deserves more emphasis in the Results and discussion in Discussion sections
• Add effect sizes (Cohen's d) for the significant group comparisons in Table 2, not just p-values, to help readers interpret the magnitude of differences
• Consider adding median lines or boxes to Figure 2 violin plot to more clearly show the central tendency alongside the distributions
• Consider reporting which specific AA-20 questions showed the largest differences between groups to provide more granular insight into knowledge patterns

Discussion

The discussion effectively interprets findings within the context of international and Latin American literature, introduces the concept of "teachable moments" appropriately to explain higher knowledge in those with STI history, identifies the critical confusion between contraceptive and barrier methods as a fundamental educational gap, reviews the Peruvian historical context comprehensively across three decades of research, and proposes appropriate directions for enhanced educational interventions.

Suggestions for improvement:

• Expand the discussion of your primary finding. The non-significant difference (p=0.417) in overall knowledge scores is your main research question, but receives limited discussion. While the 0.7-point difference (15.4 vs 14.7) is statistically non-significant, discuss whether this difference is clinically meaningful, why personal experience with an STI doesn't translate to substantially better knowledge, and what this suggests about information-seeking or retention after STI diagnosis
• The significant abortion finding is completely absent from the Discussion despite being statistically significant (p=0.003) in Table 2. Students with STI history were less likely to view abortion as a solution for young pregnant women. Why might STI experience change attitudes toward pregnancy or abortion? Does experiencing one reproductive health event shift perspectives on another? This deserves thoughtful analysis
• Address limitations of self-reported STI history more thoroughly. Since STI history is your primary grouping variable, potential misclassification deserves more than a brief mention (line 229). Discuss how social desirability bias might affect self-reporting, whether adolescents accurately know their STI diagnosis, and how misclassification might bias results toward or away from the null
• Explain why the "teachable moment" effect appears modest in your sample (lines 175-185). What barriers might prevent adolescents from seeking or retaining information even after an STI diagnosis? Consider factors like stigma, healthcare access, or quality of post-diagnosis counseling
• Compare your 15.9% STI prevalence with other Peruvian adolescent studies for context. Is this consistent with expected rates, or might selection bias explain this prevalence?
• Discuss the implications of finding that 92.3% of those with STI history had received educational talks versus 72.5% without (p=0.031). Does this suggest STI diagnosis prompts educational outreach, or that education alone is insufficient for primary prevention?

Conclusion

The conclusion effectively summarizes the marginally higher knowledge among students with STI history, appropriately emphasizes the persistent and critical confusion between contraceptive efficacy and STI prevention, and acknowledges a higher likelihood of protective behaviors in those with STI history.

Suggestions for improvement:

• Add specific, actionable recommendations for educational programs based on your findings. For example: "Sexual health education programs should explicitly differentiate between pregnancy prevention and infection prevention, using distinct visual materials, terminology, and teaching modules for each, rather than conflating all methods under general 'protection"
• Include a statement about the importance of reaching adolescents with comprehensive education before they experience an STI, given that your findings suggest only a modest knowledge advantage after STI occurrence
• Conclude with specific future research directions: longitudinal studies tracking knowledge acquisition over time following STI diagnosis, qualitative research exploring how adolescents with STI history seek, process, and retain sexual health information, and intervention studies testing whether education that explicitly separates pregnancy from infection prevention improves both knowledge and behavior

References

The reference list is comprehensive, current, and includes appropriate international and Latin American literature. The mix of WHO sources, peer-reviewed articles, and Peruvian-specific studies (including thesis work) appropriately contextualizes the research within both global and local frameworks.

Sincerely,

Reviewer

Author Response

Please see the attached.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

Title and introduction are clear and inform well on this public health concern. Some comments to improve:

Please have a new look at the recent litterature

Cite more precise STD other than Chlamydia which is a particular bacteria in this age group. For instance, could  alert on HIV recent infections in some countries (Eastern Europe)

Material and Method: if the case, describe the specificity of this selected school and its  social or cultural bias such as religion, : what is socio-critical humanist theory?

We are curious to know the demographic characteristics on all 216 eligible students (same than the included ?) and why did you excluded drug use and mental health conditions as they add to the STI risk and loss of knowledge. because of no individual consent? parents/family consent?

Results: show the AA questionnaire. your reference is not the questionnaire. we will better understand the figure 2. In table 2 they are 8 item  : same or different than the AA questionnaire?

No need of figure 3. just results.

Discussion: paragraph 3,you have a large and various bibliography in different countries, as well as exemples of some youth public health action, why not explain the public health concern in Peru at the time of study and evolution in 2025?

Paragraphs 4.1, 4.2 etc right numbers? start at 4.0 at the beginning of discussion  

 

Author Response

Please see the attached.

Author Response File: Author Response.pdf

Reviewer 4 Report

Comments and Suggestions for Authors

While the topic is important, the paper lacks adequate novelty, methodological soundness, and clarity in structure and language. The observed associations are weak and insufficiently contextualized. The topic remains socially relevant in Peru given STI and pregnancy issues.

However, single-school sampling limits generalizability. The gap (lines 56–62) claims no prior Peru comparison, but fails to show why such comparison matters for intervention or policy. A stronger synthesis is needed to establish originality.

The research question is clear and measurable, but the rationale for its formulation is weakly justified. The authors assume prior STI experience might improve knowledge but do not provide a strong theoretical or empirical foundation.

Novelty is moderate. While there are limited Peruvian studies directly comparing adolescents with vs. without STI, the general relationship between experience and knowledge has been extensively studied worldwide. The study does not present innovative variables, instruments, or analytical frameworks. It adds local data but does not advance conceptual understanding of adolescent sexual health determinants.
Lines 15-17. Aim is vague. rephrase objective clearly (to compare knowledge of reproductive health between adolescents with and without STI history).

Line 24: double p?

Line 33. “Following fetal development” redundant phrase; remove.

Line 40. Replace “early marriage is also prevalent” with “early marriage remains prevalent”.

To enhance contribution, authors should integrate behavioral or educational theory (TPB,  Health Belief Model…), include multivariate analysis, discuss implications for education curriculum reforms.

Line 91. Clarify if “four closed-ended questions” or “20 items”—the title “AA-20” suggests 20, not 4. Possible inconsistency.Sample size is weak. No sample size calculation provided. Sampling method not randomized may have high selection bias. Report sample size justification.

Clarify how STI history was confirmed: self-report or verified?

AA-20: only 4 closed questions too short to measure knowledge reliably. Needs more psychometric transparency.

Line 130. Typo “was male” =  “were male”.

Variables are limited. Socioeconomic, family communication, and sexual activity frequency omitted.

Lines 118-123. Delete as it is dublicated with lines 263-267.

Figure 2 legend mislabels “p > 0.05” as significance symbol (**). It is misleading to assign (**) to p>0.05. Write (ns) = not significant, or just report the p value. Figure 2 lacks legend for axis units.

Figures are acceptable but lack confidence intervals or error bars.

Tables 2 clear but need to mark p-values with significance (use p < 0.05).  Consider chi-square test rather than t-test for categorical data.

Figure 3. It needs to specify legends for sub-figures A and B.

Only t-tests and descriptive stats. No adjustment for confounders. Results lack effect sizes or CIs in the tables. Include confidence intervals for key comparisons.

It needs to perform logistic regression (predictors of good knowledge).

The key finding (slightly higher knowledge among STI group) is statistically nonsignificant, yet overstated in the Abstract and Discussion. (“slightly greater understanding…” appears multiple times). Line 248. Clarify what “marginally higher” means. report effect size (Cohen’s d).

No mention of missing data handling or potential response bias.

Supplementary material needs to be supplied in English.

Discussion: Good international comparison. Well-written contextual discussion about misconceptions.

However, there is overgeneralization: claims of “slightly better knowledge” are not statistically supported.

Excessive repetition of global literature with little integration or critical synthesis.

No discussion on socio-cultural context in Peru (Catholic influence, limited sexual education policy….).

Citations to WHO, CDC are appropriate but overused; rely more on peer-reviewed Peru sources.

Conclusions modestly align with data but overstate impact.

Policy implications are generic. Authors should specify actionable recommendations (curriculum design, parental engagement…).

Future directions are reasonable but speculative.

Writing is fair but needs language editing for academic tone and grammatical consistency.

Author Response

Please see the attached.

Author Response File: Author Response.pdf

Reviewer 5 Report

Comments and Suggestions for Authors

Please see the attached comments.

Comments for author File: Comments.pdf

Author Response

Please see the attached.

Author Response File: Author Response.pdf