PONE-D-22-02975Use of insecticide treated nets in children under five and children of school age in Nigeria: evidence from a secondary data analysis of demographic health surveyPLOS ONE

Dear Dr. Ujuju,

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.

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Clement Ameh Yaro, Ph.D

Academic Editor

PLOS ONE

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Additional Editor Comments:

EDITOR’S COMMENTS

Dear Authors,

The manuscript requires major revision. The authors should critically attend all the comments raised by the reviewers. The multivariate analysis needs to be re-examined. Also, the conclusion should be rewritten to capture the findings of the study.

FIRST REVIEWER

This paper examined the usage of insecticide-treated nets in children under five and school-going children in Nigeria using a secondary analysis of demographic and health survey data. Children are important aspect of malaria elimination program across the world and this paper presents some concerns that the authors need to addressed.

Major comments

1. As the world moves toward elimination, it would bring more valuable information to look into how stratification of malaria prevalence among children at sub-national level would look like under hypo, meso, and hyper endemic regions and how the usages of ITN net were distributed in such stratification.

2. What is the mechanism that could link the sex of the child being female and using ITN in a household? On the other hand, gender of the head of the household is not associated with the ITN use, While sex of the child is of little value for informing policy, I would suggest the authors to use a valid theoretical framework or literature to select variables for the model.

3. The multivariate model showed that malaria endemicity is a predictor for the ITN usage. NCMP usually puts much efforts to bring down the incidence and prevalence in malaria endemic regions, hence this finding suggested that interventions to increase the usage of ITN are working well. Please discuss this point in the paper.

4. The conclusion of “increase availability and access to ITN has resulted … “ is not supported by the findings in the paper. There is no results in the paper showing that the ITN availability or access to ITN increases.

Minor comments

1. The introduction section can be shortened by moving paragraphs between lines 83 and 110 to the methods section.

2. Table 3: put 1 or indicate as “reference” in the reference categories, rather than indicating with a symbol.(less...)

SECOND REVIEWER

Major comments:

1. Why it is called retrospective cross-sectional study?

2. Result session:

There were 32087 U5C in table 1, but slept under ITN (16,671) and not slept (5,769).

There were 54692 children of school age in table 1, but slept under ITN (21,690) and not slept (15,812).

Table 3 should be multivariable logistics regression and use AOR. Need to add reference group.

Please see the table for multivariable logistics regression from other international publication.

3. What is your implication of the study for Nigeria? What is the different information provided by your analysis compared to NDHS findings?

4. Conclusion should provide the specific input to program.

[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: No

Reviewer #2: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

**********

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: This paper examined the usage of insecticide-treated nets in children under five and school-going children in Nigeria using a secondary analysis of demographic and health survey data. Children are important aspect of malaria elimination program across the world and this paper presents some concerns that the authors need to addressed.

Major comments

1. As the world moves toward elimination, it would bring more valuable information to look into how stratification of malaria prevalence among children at sub-national level would look like under hypo, meso, and hyper endemic regions and how the usages of ITN net were distributed in such stratification.

2. What is the mechanism that could link the sex of the child being female and using ITN in a household? On the other hand, gender of the head of the household is not associated with the ITN use, While sex of the child is of little value for informing policy, I would suggest the authors to use a valid theoretical framework or literature to select variables for the model.

3. The multivariate model showed that malaria endemicity is a predictor for the ITN usage. NCMP usually puts much efforts to bring down the incidence and prevalence in malaria endemic regions, hence this finding suggested that interventions to increase the usage of ITN are working well. Please discuss this point in the paper.

4. The conclusion of “increase availability and access to ITN has resulted … “ is not supported by the findings in the paper. There is no results in the paper showing that the ITN availability or access to ITN increases.

Minor comments

1. The introduction section can be shortened by moving paragraphs between lines 83 and 110 to the methods section.

2. Table 3: put 1 or indicate as “reference” in the reference categories, rather than indicating with a symbol.

Reviewer #2: Reviewer’s Comments

Major comments:

1. Why it is called retrospective cross-sectional study?

2. Result session:

There were 32087 U5C in table 1, but slept under ITN (16,671) and not slept (5,769).

There were 54692 children of school age in table 1, but slept under ITN (21,690) and not slept (15,812).

Table 3 should be multivariable logistics regression and use AOR. Need to add reference group.

Please see the table for multivariable logistics regression from other international publication.

3. What is your implication of the study for Nigeria? What is the different information provided by your analysis compared to NDHS findings?

4. Conclusion should provide the specific input to program.

**********

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.

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: No

Reviewer #2: Yes: Thae Maung Maung

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

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PONE-D-22-02975R1Use of insecticide treated nets in children under five and children of school age in Nigeria: evidence from a secondary data analysis of demographic health surveyPLOS ONE

Dear Dr. Ujuju,

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 Aug 07 2022 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.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Clement Ameh Yaro, Ph.D

Academic Editor

PLOS ONE

Additional Editor Comments:

Manuscript Number: PONE-D-22-02975R1

Title: Use of insecticide treated nets in children under five and children of school age in Nigeria: evidence from a secondary data analysis of demographic health survey.

EDITOR’S COMMENTS

Dear Authors,

The manuscript requires major revision. The authors should attend to all the comments raised by the reviewers. The comments are very important and shouldn’t be neglected if the manuscript should be considered for publication.

REVIEWER 1

The authors have addressed my comments and concerns well and adequately. No further comments from my end.

REVIEWER 2

Major comments:

I would like to suggest to reconsider the analysis because your study objective is to determine the use of ITN in under five and children of school age in Nigeria.

In the result, you mentioned that “more than 80% of CU5 and school children used ITN”. This finding magnify your result of use of ITN because you used the denominator of those who had at least 1 ITN. It cannot be reflect the whole study population of CU5 and school children in Nigeria.

You need to discuss about the % of access to ITN, and use of ITN in total population, and use of ITN in those who had access. Need to compare 2 use of ITN and consider the implications of the study finding.

Therefore, your study objective should focus the access and use of ITN. You cannot omit “access” indicator to improve the ITN utilization implementation in Nigeria.

Minor comments:

1. Why it is called retrospective cross-sectional study?

Response: The demographic health survey was conducted in 2018 while secondary analysis for the manuscript was done in 2021. We adjudged the study to be retrospective. However, we have removed “retrospective” for clarity.

R1: Please remove “retrospective” for the clarity. Here is the sample that used in other manuscript.

“This study analysed the secondary data from MDHS 2015-16, which is a cross-sectional study.”

2. Result session:

There were 32087 U5C in table 1, but slept under ITN (16,671) and not slept (5,769).

Response: Table 2 was based on children in household who own at least 1 ITN. This variable has been added to Table 1 and also shows number of children in household without ITN for clarity Thank you.

R1: Thank you for clarification. Please add total N in the table 1 and 2. I would like to suggest to remove the “Never slept” column for clear vision and eyeballing of the table.

In the tables, Pvalue should be <0.001. No need to describe <0.0001.

3. There were 54692 children of school age in table 1, but slept under ITN (21,690) and not slept (15,812).

Response: Table 2 was based on children in households who own at least 1 ITN. This variable has been added to Table 1 and also show number of children in household without ITN.

R1: OK.

Table 3 should be multivariable logistics regression and use AOR. Need to add reference group.

Response: Reference group has been added.

Please see the table for multivariable logistics regression from other international publication.

Response: Table has been revised accordingly Thank you.

R1: Please mention multivariable logistic regression if you have adjusted the other factors. Please describe AOR instead of OR in the table 3 and in text.* is not the reference value. It is the reference group.

Generally, we describe “1” or Ref in the table. See in the below figure.

3. What is your implication of the study for Nigeria? What is the different information provided by your analysis compared to NDHS findings?

Response: Response has been included in the manuscript Thank you.

4. Conclusion should provide the specific input to program

Response: Conclusion revised.

R1: Please mention study strength and limitation instead of study limitation on line 301. It is mixed for strength and limitation.

REVIEWER 3

The study examined the use of insecticide treated nets and its correlates among children under five and children of school age in Nigeria using the 2018 Nigeria demographic and health survey data. They attempt to address very important public health challenge, especially in sub-Sahara African countries like Nigeria. Their decision to consider both the under 5s and those aged 5-14 is commendable. Studies of this nature are relevant to policymakers and other stakeholder for informed decision making. However, I have a reservation about ignoring the hierarchical structure of the DHS data used in their binary logistic regression models presented.

The background to the study looks good.

Like any other DHS data, the Nigeria DHS data is hierarchical in nature where we have children nested within households, and household nested within clusters (i.e., communities) but the authors did not explain how they account for the hierarchical structure of the data used in this study. Assuming this was not explored during their modelling stage using multilevel (i.e., mixed effect) regression analysis, it could lead to spurious statistical significance with its associated misleading interpretations. Fortunately, we have statistical software packages that allow easy implementation of the multilevel binary logistic regression analysis. Authors are encouraged to explore this and compare the results with the single level binary regression to improve the quality of their results in the manuscript.

Also, since the authors considered both children <5s and 5-14 years and analysed the data separately for these two (2) groups, it could be very useful to pool (i.e., combined) this data and conduct another analysis to assess the correlates for the pooled dataset. This result can then to compared to the separate analysis to inform policy decisions.

Furthermore, the reference categories, the adjusted odds ratios, and p-values in Table 3 are not properly presented, and they should present them in a standard format. The authors should see Table 4 in the publication

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0257944 for guidance. Also, is not acceptable to present a p-value=0.000 in a manuscript. This should be written as <0.01 or <0.001 in case of p-value=0.0000.

In the conclusion, I struggled to link the analysis done by the authors to their conclusion that “Based on the findings of this study, increased availability and access to ITN has resulted in an increased use by children in rural areas and poor households”. Clearly, this cannot be supported with the data available. I have noted that the previous Reviewer #1 raised same query in item 4 which the authors stated that they have revised in the conclusion and yet they actually did not revise this. I encourage the authors to pay attention to all queries raised and address them to the best of their ability.

The manuscript will also benefit from some few proofreading to improve the message.

REVIEWER 4

Comments:

1. How collinearity test was conducted?

2. How were the variables selected in the final model?

3. Did the authors adjust for the survey design and cluster effect? Please explain.

4. In table 3, both crude and adjusted odds ratio should be shown.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

Reviewer #3: (No Response)

Reviewer #4: (No Response)

**********

2. 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: Partly

Reviewer #3: Partly

Reviewer #4: No

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

Reviewer #4: No

**********

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

Reviewer #3: Yes

Reviewer #4: No

**********

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

Reviewer #3: Yes

Reviewer #4: 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 authors have addressed my comments and concerns well and adequately. No further comments from my end.

Reviewer #2: Major comments:

I would like to suggest to reconsider the analysis because your study objective is to determine the use of ITN in under five and children of school age in Nigeria.

In the result, you mentioned that “more than 80% of CU5 and school children used ITN”. This finding magnify your result of use of ITN because you used the denominator of those who had at least 1 ITN. It cannot be reflect the whole study population of CU5 and school children in Nigeria.

You need to discuss about the % of access to ITN, and use of ITN in total population, and use of ITN in those who had access. Need to compare 2 use of ITN and consider the implications of the study finding.

Therefore, your study objective should focus the access and use of ITN. You cannot omit “access” indicator to improve the ITN utilization implementation in Nigeria.

Minor comments:

1. Why it is called retrospective cross-sectional study?

Response: The demographic health survey was conducted in 2018 while secondary analysis for the manuscript was done in 2021. We adjudged the study to be retrospective. However, we have removed “retrospective” for clarity.

R1: Please remove “retrospective” for the clarity. Here is the sample that used in other manuscript.

“This study analysed the secondary data from MDHS 2015-16, which is a cross-sectional study.”

2. Result session:

There were 32087 U5C in table 1, but slept under ITN (16,671) and not slept (5,769).

Response: Table 2 was based on children in household who own at least 1 ITN. This variable has been added to Table 1 and also shows number of children in household without ITN for clarity Thank you.

R1: Thank you for clarification. Please add total N in the table 1 and 2. I would like to suggest to remove the “Never slept” column for clear vision and eyeballing of the table.

In the tables, Pvalue should be <0.001. No need to describe <0.0001.

3. There were 54692 children of school age in table 1, but slept under ITN (21,690) and not slept (15,812).

Response: Table 2 was based on children in households who own at least 1 ITN. This variable has been added to Table 1 and also show number of children in household without ITN.

R1: OK.

Table 3 should be multivariable logistics regression and use AOR. Need to add reference group.

Response: Reference group has been added.

Please see the table for multivariable logistics regression from other international publication.

Response: Table has been revised accordingly Thank you.

R1: Please mention multivariable logistic regression if you have adjusted the other factors. Please describe AOR instead of OR in the table 3 and in text.* is not the reference value. It is the reference group.

Generally, we describe “1” or Ref in the table. See in the below figure.

3. What is your implication of the study for Nigeria? What is the different information provided by your analysis compared to NDHS findings?

Response: Response has been included in the manuscript Thank you.

4. Conclusion should provide the specific input to program

Response: Conclusion revised.

R1: Please mention study strength and limitation instead of study limitation on line 301. It is mixed for strength and limitation.

Reviewer #3: The study examined the use of insecticide treated nets and its correlates among children under five and children of school age in Nigeria using the 2018 Nigeria demographic and health survey data. They attempt to address very important public health challenge, especially in sub-Sahara African countries like Nigeria. Their decision to consider both the under 5s and those aged 5-14 is commendable. Studies of this nature are relevant to policymakers and other stakeholder for informed decision making. However, I have a reservation about ignoring the hierarchical structure of the DHS data used in their binary logistic regression models presented.

The background to the study looks good.

Like any other DHS data, the Nigeria DHS data is hierarchical in nature where we have children nested within households, and household nested within clusters (i.e., communities) but the authors did not explain how they account for the hierarchical structure of the data used in this study. Assuming this was not explored during their modelling stage using multilevel (i.e., mixed effect) regression analysis, it could lead to spurious statistical significance with its associated misleading interpretations. Fortunately, we have statistical software packages that allow easy implementation of the multilevel binary logistic regression analysis. Authors are encouraged to explore this and compare the results with the single level binary regression to improve the quality of their results in the manuscript.

Also, since the authors considered both children <5s and 5-14 years and analysed the data separately for these two (2) groups, it could be very useful to pool (i.e., combined) this data and conduct another analysis to assess the correlates for the pooled dataset. This result can then to compared to the separate analysis to inform policy decisions.

Furthermore, the reference categories, the adjusted odds ratios, and p-values in Table 3 are not properly presented, and they should present them in a standard format. The authors should see Table 4 in the publication https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0257944 for guidance. Also, is not acceptable to present a p-value=0.000 in a manuscript. This should be written as <0.01 or <0.001 in case of p-value=0.0000.

In the conclusion, I struggled to link the analysis done by the authors to their conclusion that “Based on the findings of this study, increased availability and access to ITN has resulted in an increased use by children in rural areas and poor households”. Clearly, this cannot be supported with the data available. I have noted that the previous Reviewer #1 raised same query in item 4 which the authors stated that they have revised in the conclusion and yet they actually did not revise this. I encourage the authors to pay attention to all queries raised and address them to the best of their ability.

The manuscript will also benefit from some few proofreading to improve the message.

Reviewer #4: Comments:

1. How collinearity test was conducted?

2. How were the variables selected in the final model?

3. Did the authors adjust for the survey design and cluster effect? Please explain.

4. In table 3, both crude and adjusted odds ratio should be shown.

**********

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: No

Reviewer #2: Yes: Thae Maung Maung

Reviewer #3: Yes: Justice Moses Aheto

Reviewer #4: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Use of insecticide treated nets in children under five and children of school age in Nigeria: evidence from a secondary data analysis of demographic health survey

PONE-D-22-02975R2

Dear Dr. Ujuju,

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.

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Kind regards,

Clement Ameh Yaro, Ph.D

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

The manuscript requires minor revision before consideration for publication, the authors should kindly respond to all the comments raised by the reviewers.

REVIEWER 1

The authors did a great job and provided satisfactory revisions to the paper which significantly improved the message in the manuscript.

However, the authors did not discuss the policy relevance of the significant unobserved household and community level residual (random) effects observed in their results. This should be presented briefly at the discussion section. The authors can benefit from the discussion of the publications below to address this issue and support their findings with same papers. I am happy to provide a quick review within a day after the authors address this.

References

1) https://journals.plos.org/plosone/article/authors?id=10.1371/journal.pone.0269066

2) https://onlinelibrary.wiley.com/doi/full/10.1002/hsr2.453

REVIEWER 2

Thanks for addressing my comments. I would still suggest to show the crude odds ratio. If the authors do not want to show them in the main manuscript, please add a supplementary table showing the crude odds ratio. This will help the readers and future audiences specailly who want to conduct a systematic review and meta-analyses.

REVIEWER 3

Welldone on your research. Please see below my comment to improve the quality of your paper.

1) The independent variables are not robust enough. If your aim is to include variables that would likely influence the utilization of ITNs then some very important variables captured in 2018 NDHS should not be left out bearing in mind that promoting ITN use in Nigeria was a mass national campaign which was publicized through various media channels. It would have been expected that more individual, socio-demographic and media variables (found in the NDHS) such as child birth order, preceding birth interval, mother's educational level, father's educational level, listening to radio, watching TV, reading newspaper are included in the analysis.

The chosen independent variables does not offer a good understanding of the factors contributing to ITN in Nigeria. For instance, child sex - does it really matter if the child is male or female to use the provided ITN? Head of household's sex - most households (99%) in Nigeria are headed by men, when ITN was obtained - how does this contribute to their usage?

In addition, wealth index as used in NDHS serves as an indicator of wealth that is consistent with expenditure and income measures. It was represented as a score of household assets via the principle components analysis method (PCA), this means that household ownership of radio and television is included in the wealth index estimation and so should not be a standalone variable. Therefore, given the set of variables used, it does not come as a surprise that rural residence and wealth index were significantly associated with ITN use.

2) Why include school age children (5 - 14)? The ITN campaign was targeted at children under-5 in Nigeria to whom free ITN was given. School age children (5 - 14) were not given free ITN, they would have to purchase the ITN and this can influence their usage especially if the household is poor. Having both groups of children in the same analysis given the difference in access to the ITN would bias the study findings. I recommend using only children under-5 years for this study if reference is to be made to the ITN campaign in Nigeria OR clearly include this disparity in access to ITN between children under-5 and school age children as a study limitation which readers should approach with caution.

3) It is worth stating that the ITN mass campaign in Nigeria might have influenced the result of this study given that this has been largely focused on poor households in rural areas.

4) The cross-sectional nature of the study design is a limitation on the study's ability to establish a causal relationship between the observed predisposing factors and ITN use in Nigeria.

5) As part of the study limitation, it is worth mentioning the effect of residual confounding as a result of unmeasured co-variates such as climatic factors, season of the year, topography, biomes, etc. These factors influence the prevalence of malaria in a region and thus the use of ITNs.

6) Your study revealed an increase in use of ITN among under-5 children living in poor households, rural areas and meso/hyper endemic areas of Nigeria. Please provide a well-balanced discussion around the contribution of these THREE identified factors to ITN use in Nigeria not only on meso/hyper endemic areas.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: (No Response)

Reviewer #4: (No Response)

Reviewer #5: (No Response)

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2. 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 #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

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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 #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

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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 #3: The authors did a great job and provided satisfactory revisions to the paper which significantly improved the message in the manuscript.

However, the authors did not discuss the policy relevance of the significant unobserved household and community level residual (random) effects observed in their results. This should be presented briefly at the discussion section. The authors can benefit from the discussion of the publications below to address this issue and support their findings with same papers. I am happy to provide a quick review within a day after the authors address this.

References

1)https://journals.plos.org/plosone/article/authors?id=10.1371/journal.pone.0269066

2)https://onlinelibrary.wiley.com/doi/full/10.1002/hsr2.453

Reviewer #4: Thanks for addressing my comments. I would still suggest to show the crude odds ratio. If the authors do not want to show them in the main manuscript, please add a supplementary table showing the crude odds ratio. This will help the readers and future audiences specailly who want to conduct a systematic review and meta-analyses.

Reviewer #5: Welldone on your research. Please see below my comment to improve the quality of your paper.

1) The independent variables are not robust enough. If your aim is to include variables that would likely influence the utilization of ITNs then some very important variables captured in 2018 NDHS should not be left out bearing in mind that promoting ITN use in Nigeria was a mass national campaign which was publicized through various media channels. It would have been expected that more individual, socio-demographic and media variables (found in the NDHS) such as child birth order, preceding birth interval, mother's educational level, father's educational level, listening to radio, watching TV, reading newspaper are included in the analysis.

The chosen independent variables does not offer a good understanding of the factors contributing to ITN in Nigeria. For instance, child sex - does it really matter if the child is male or female to use the provided ITN? Head of household's sex - most households (99%) in Nigeria are headed by men, when ITN was obtained - how does this contribute to their usage?

In addition, wealth index as used in NDHS serves as an indicator of wealth that is consistent with expenditure and income measures. It was represented as a score of household assets via the principle components analysis method (PCA), this means that household ownership of radio and television is included in the wealth index estimation and so should not be a standalone variable.

Therefore, given the set of variables used, it does not come as a surprise that rural residence and wealth index were significantly associated with ITN use.

2) Why include school age children (5 - 14)? The ITN campaign was targeted at children under-5 in Nigeria to whom free ITN was given. School age children (5 - 14) were not given free ITN, they would have to purchase the ITN and this can influence their usage especially if the household is poor. Having both groups of children in the same analysis given the difference in access to the ITN would bias the study findings. I recommend using only children under-5 years for this study if reference is to be made to the ITN campaign in Nigeria OR clearly include this disparity in access to ITN between children under-5 and school age children as a study limitation which readers should approach with caution.

3) It is worth stating that the ITN mass campaign in Nigeria might have influenced the result of this study given that this has been largely focused on poor households in rural areas.

4) The cross-sectional nature of the study design is a limitation on the study's ability to establish a causal relationship between the observed predisposing factors and ITN use in Nigeria.

5) As part of the study limitation, it is worth mentioning the effect of residual confounding as a result of unmeasured co-variates such as climatic factors, season of the year, topography, biomes, etc. These factors influence the prevalence of malaria in a region and thus the use of ITNs.

6) Your study revealed an increase in use of ITN among under-5 children living in poor households, rural areas and meso/hyper endemic areas of Nigeria. Please provide a well-balanced discussion around the contribution of these THREE identified factors to ITN use in Nigeria not only on meso/hyper endemic areas.

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Reviewer #3: Yes: Justice Moses Aheto

Reviewer #4: No

Reviewer #5: No

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