Maternal perception of masking in children as a preventive strategy for COVID-19 in Nigeria: A multicentre study.

BACKGROUND: The use of face masks by children for the prevention of COVID 19 is still controversial, especially with regards to who should wear the face mask and at what age.
OBJECTIVES: The study aimed to ascertain the perception of mothers on masking in children as a preventive strategy for COVID-19.
METHODOLOGY: This was a cross-sectional study carried out in two health institutions among 387 mothers who presented with their children for the first time in the hospital during the COVID 19 pandemic. A pretested, semi-structured, interviewer-administered questionnaire which was designed by the researchers was used for data collection.
RESULTS: Minority (44.7%) of the mothers perceived masking in children as an appropriate measure for the prevention of COVID-19. The frequent reasons given by majority (55.3%) of the mothers for the inappropriateness of face mask in children included perceived difficulty in breathing (38.5%) and the child's readiness to pull it off (29.3%). A significantly higher proportion of the children whose mothers were 35 years and above, 64.2% would wear face masks when compared with 31.7% of those whose mothers were < 30 years of age (χ2 = 28.632, p<0.001). Similarly, a significantly higher proportion (51.0%) of the children who were more than one year of age would wear a face mask when compared with 20.5% of those aged eight days to one year (χ2 = 19.441, p<0.001). The children whose mothers were <30 years were about four times less likely to wear a face mask when compared with those whose mothers were aged 35 years and above. (AOR = 0.273; 95%CI: 0.155-0.478). The children whose fathers have attained tertiary education were about twice less likely to wear face masks when compared with those whose fathers have attained secondary education and less. (AOR = 0.554; 95%CI: 0.334-0.919). Mothers' perception of COVID-19 had no significant influence on children's use of face mask (χ2 = 2.337, p = 0.127).
CONCLUSION: Maternal perception of masking in children as an appropriate strategy for preventing COVID-19 is adjudged low in this study. Right perception is significantly enhanced by maternal educational status, employment and marital status.

Introduction

COVID -19 pandemic has affected about 215 countries in the world [1]. In Africa, South Africa ranks highest with 650,749 cases and 15,499 deaths while 56,388 cases and 1,083 deaths were recorded in Nigeria. Wearing face mask, social distancing and washing of hands are the only non-pharmaceutical means of prevention [1].

It has been documented that people who were asymptomatic can transmit the novel virus and this can only be reduced by wearing of face mask. Use of face masks are very vital tool for the prevention of COVID 19 even among children, especially when they go to school and get involved in social gatherings, like in churches [2].

Asymptomatic cases can also be seen in children, hence the urgent need for the use of face masks among them. A study among children with COVOD 19 revealed that 15.8% were asymptomatic [3]. There is thus evidence that asymptomatic children have the potential to transmit the infection.

It is pertinent to note that even though the viral load associated with COVID 19 is unknown, it is not known if viral shedding increases with severity [4].

The use of face masks in families and children is imperative and indispensable because of the rapid spread of this novel virus in homes. For instance, in China, it was reported that seven in ten human-to-human transmissions of COVID 19 occurred in homes [5, 6].

The World health organization has noted that household transmission of this virus is the harbinger of community spread [5, 6]. In developing countries where the health service is overwhelmed, people now self-isolate at home and this even increases the risk of spread. A study in China showed that the risk of transmission is high if no measure such as face mask was introduced [6-8]. They suggested home-made masks as being very effective during severe epidemics in preventing infections.

The World Health Organization (WHO) has stated that the use of face masks alone will not protect against COVID-19, but opined that the general public should wear face masks, especially a three-layer- fabric mask; which is essentially a non -medical mask [9, 10].

The World Health Organization also stated that children under five years of age should not wear masks. This stemmed from a “do no harm” point of view, which stated that at five years, children usually achieve significant developmental milestones, especially the fine motor, such as, pincer grasp. This fine motor milestone is needed to appropriately use a mask with minimal assistance [11]. However, some countries may contextualize the use of face masks for children to 2 or 3 years. Using the “do no harm approach”, if the age of two or three years of age is to be used for recommending mask use for children, a well-knitted and coordinated supervision by the mother is needed to ensure the correct use of the mask and to prevent any potential harm associated with mask wearing to the child. Recommendations involving different age groups have been made by WHO with respect to the use of face masks in children, as information on COVID-19 continues to evolve.

Most countries, utilize the global guidance from WHO but contextualize it. For instance, in Nigeria, the Presidential Task Force on COVID-19, Federal Ministry of Health, NCDC and partner organizations have intensified programs on the use of face mask. This includes awareness campaigns in communities to sensitize the people on the need to wear face masks. Various slogans and hashtags such as #MaskOnNaija, #MaskingForAFriend and #TakeResponsibility were used [10, 11].

A knowledge gap exists on this issue under study, as few studies on the use of face masks failed to highlight the impact of age and parental factors on the wearing of face masks in children.

The study aimed to ascertain the perception of mothers on masking in children as a preventive strategy for COVID-19.

Materials and methods

Study population

This study was carried out in two health institutions namely the Enugu State University Teaching Hospital, Enugu and Nnamdi Azikiwe University Teaching Hospital Nnewi, Nigeria. Both hospitals are tertiary health institutions and designated as isolation centres in the fight against COVID-19. Mothers of child bearing age who gave consent were recruited in the study while those who refused to give consent were excluded from the study.

Study area

This study was a prospective and cross-sectional study conducted among mothers who presented with their children to the children’s outpatient clinics, paediatric wards, as well as the children emergency room in the period of study.

Sampling technique

Systematic sampling technique using facility register was used to select clients as they present on each day of data collection. An average of 1186 clients presented in the three Paediatric clinics in the health facility including the Children out-patient department, Children Emergency and Immunization clinics monthly within this COVID-19 period. This number, 1186 served as sampling frame. The sampling interval was determined by dividing the sampling frame (1186) by sample size (384), hence a sampling interval of 3 was used. Every third client was recruited for the study based on the order of registration of clients in each of the clinics, on each day of data collection. The clients who attended the various clinics on the five working days of the week were included in the study.

The information given by the mother was supported by what was observed, as the mothers were present with the children during the study. We did not focus on mother-child dyad of wearing of face mask, though mothers were observed in the study, to be masked. However, the National COVID-19 protocol made it mandatory for adults to wear facemasks in public space, and this was strictly enforced by health facilities and financial institutions. Our observation of children wearing face masks necessitated this study. We did not focus on mother-child dyads while assessing maternal perception and the practice of wearing face masks. Even though adults were required to wear face masks, there was no such clear rule for the children.

Sample size estimation

The minimum sample size used in this study was calculated using the formula.

Where Z = 1.96 i.e. the level of significance

P = proportion of mothers who have knowledge about children wearing face mask (taken as 50%; being a new study)

D = Tolerable error (0.05)

Using the above formula, the minimum sample size is 384

3.5% attrition rate was considered, this brought the final value to 398

Data collection

A pretested, semi-structured, interviewer-administered questionnaire which was designed by the researchers was used for data collection. The questionnaire was administered to the respondents by trained research assistants. The outcome variables were the proportions of mothers with varying perceptions/knowledge on masking in children as a pandemic antidote. We used the mother’s and child’s age, marital status, educational level of both mother and father, parity, and occupation of father and mother as independent variables.

Data analysis

Data entry and analysis were done using IBM Statistical Package for Social Sciences (SPSS) statistical software version 25. Frequency tables and cross-tabulation were generated. Chi- square test of statistical significance and multivariate analysis using binary logistic regression were used in the analysis and the level of statistical significance was determined by a p- value of <0.05. In determining the predictors of children wearing face masks, variables that had a p- value of <0.2 on bivariate analysis were entered into the logistic regression model. The results were reported using adjusted odds ratios (AOR) and 95% confidence interval and the level of statistical significance was determined by a p-value of <0.05. The outcome variable was the wearing of a facemask by children. This was determined by a Yes answer to the question of whether the child wears a face mask. This was confirmed by observation of the wearing of a face mask by the child during the period of data collection. Seven variables were used to assess the perception of COVID-19 among the respondents. Each correct answer by any of the respondents was given a score of one while an incorrect answer attracted a score of zero. Respondents who scored ≥60% of the total score were designated as having a good perception of COVID-19 while those that scored less than 60% of the total score were regarded as having a poor perception of COVID-19.

Ethical approval

The approval of the Enugu State University of Science and technology Health Research and Ethics Committee was obtained before commencing the study (Reference number: ESUTP/C-MAC/RA/034/Vol 1 /266).

Consent

Verbal informed consent was obtained from the respondents in order to participate in this study. Written informed consent was not obtained because some of the participants are not educated. The ethics committees/IRB approved this consent procedure.

Results

Table 1 shows mothers’ perception of masking in children. A minor proportion of the children, 43.5% wore face masks which were all home-made. The major reasons for the children not wearing face masks included perceived difficulty in breathing, 38.2% and child’s readiness to pull it off, 29.3%.

Table 1

Mothers’ perception of masking in children.

Variable	Frequency (n = 398)	Percent (%)
Age of child	(n = 398)
<8 days	227	57.0
8 days–1year	73	18.3
1–5 years	72	18.1
6–12 years	23	5.8
>12 years	3	0.8
Gender of the child
Male	220	55.3
Female	178	44.7
Do your child wear a face mask
Yes	173	43.5
No	225	56.5
Reason for not wearing mask	(n = 225)
Perceived difficulty in breathing	86	38.2
Pulls it off	66	29.3
Cries when wearing a mask	43	19.1
Sickly feeling	11	4.9
Feels child is too young	10	4.4
Corona not real/don’t see the need	9	4.0

Table 2 shows the factors influencing the use of face masks by the children. A significantly higher proportion of the children whose mothers were 35 years and above, 64.2% wear face masks when compared with those whose mothers were <30 years of age, 31.7%. (χ2 = 28.632, p<0.001). Similarly, a significantly higher proportion of the children who were more than one year of age, 51.0% wear a face mask when compared with those who were aged 8 days to one year, 20.5%. (χ2 = 19.441, p<0.001). A higher proportion of the children whose mothers who have attained secondary education and below, 48.7% wear a face mask when compared with those whose mothers attained tertiary education, 38.5% and the difference in proportions was found to be statistically significant, (χ2 = 4.183, p = 0.041). Also, a higher proportion of the children whose fathers attained secondary education and less,50% wear face mask when compared with those whose fathers have attained tertiary education, 35.2% and the difference in proportions was found to be statistically significant, (χ2 = 8.718, p = 0.003).

Table 2

Factors that influence the use of face masks by the children.

Variable	Child wears mask		χ2	p value
	(n = 398)
	Yes N (%)	No N (%)
Age of Mother
<30 years	51 (31.7)	110 (68.3)	28.632	<0.001
30–34 years	52 (40.6)	76 (59.4)
≥35 years	70 (64.2)	39 (35.8)
Age of child
<8 days	108 (47.6)	119 (52.4)	19.441	<0.001
8 days– 1 year	15 (20.5)	58 (79.5)
>1 year	50 (51.0)	48 (49.0)
Gender of baby
Male	94 (42.7)	126 (57.3)	0.110	0.741
Female	79 (44.4)	99 (55.6)
Marital status
Married	149 (42.3)	203 (57.7)	1.604	0.205
Single **	24 (52.2)	22 (47.8)
Educational attainment of Mother
Tertiary education	79 (38.5)	126 (61.5)	4.183	0.041
Secondary education and less	94 (48.7)	99 (51.3)
Employment status of Mother
Unemployed	16 (28.1)	41 (71.9)	6.431	0.040
Self-employed	105 (46.3)	122 (53.7)
Salaried employment	52 (45.6)	62 (54.4)
Educational attainment of Father
Tertiary education	62 (35.2)	114 (64.8)	8.718	0.003
Secondary education and less	111 (50.0)	111 (50.0)
Fathers’ employment status
Unemployed	7 (38.9)	11 (61.1)	0.163	0.922
Self-employed	126 (43.8)	162 (56.3)
Salaried employment	40 (43.5)	52 (56.5)
Mothers’ perception of COVID-19
Good	69 (39.2)	107 (60.8)	2.337	0.127
Poor	104 (46.8)	118 (53.2)

**Never married, widowed, separated/divorced

Mothers’ perception of COVID-19 has no significant influence on children wearing of face mask (χ2 = 2.337, p = 0.127)

Table 3 shows the predictors of a child’s use of a face mask. The children whose mothers were <30 years were about four times less likely to wear face mask when compared with those whose mothers were aged 35 years and above. (AOR = 0.273; 95%CI: 0.155–0.478). Similarly, the children whose mothers were between 30–34 years were 2.3 times less likely to wear a face mask when compared with those whose mothers were 35 years and above. (AOR = 0.436; 95%CI: 0.252–0.755. The children who were aged 8 days to one year were about four times less likely to wear a mask when compared with those who were > 1-year old. (AOR = 0.274; 95%CI: 0.132–0.567). The children whose fathers have attained tertiary education were about twice less likely to wear face masks when compared with those whose fathers have attained secondary education and less. (AOR = 0.554; 95%CI: 0.334–0.919).

Table 3

Predictors of the use of face mask by the children.

Variable	Adjusted odds ratio	Value	95% Confidence Interval
			Lower	Upper
Age of Mother
<30 years	0.273	<0.001	0.155	0.478
30–34 years	0.436	0.003	0.252	0.755
≥35 years	1
Age of child
<8 days	0.810	0.420	0.510	1.400
8 days– 1 year	0.274	<0.001	0.132	0.567
>1 year	1
Educational attainment of Mother
Tertiary education	0.715	0.257	0.401	1.276
Secondary education and less	1
Employment status of Mother
Unemployed	0.737	0.443	0.338	1.608
Self-employed	0.796	0.427	0.454	1.397
Salaried employment	1
Educational attainment of Father
Tertiary education	0.554	0.022	0.334	0.919
Secondary education and less	1
Mothers’ perception of COVID-19
Good	0.786	0.270	0.504	1.227
Poor	1

Mothers’ perception of COVID-19 has no significant correlation with prediction of children wearing face mask (χ2 = 0.504, p = 1.227)

Discussion

This study has shown varying maternal perceptions/knowledge of masking in children. It is very tasking for children who have no COVID to put on face masks, and they are likely to take them off since they make them uncomfortable. Children less than 2 years may not benefit from wearing a face mask but may rather be at risk of suffocation. This is because they have small airways, which can make them struggle when breathing and this can cause asphyxiation and even death [12]. The American Academy of Paediatrics has advised the washing of hands and social distancing for these groups of children [13]. Several studies have noted the efficacy and potency of face mask, especially surgical masks and N95 in warding off the transmission of Corona virus. These masks are noted to have the efficacy of protection against the pandemic at 68% and 91%, respectively [14]. Home-made masks were noted to be worn by children who were on masks during the study. Some studies have ascertained the efficacy of home-made masks [15]. They noted that some household materials, vacuum cleaner filters, and tea towels were very effective in the prevention of COVID 19 transmission but stated that they can cause a pressure drop, which makes breathing difficult. They recommended the use of 100% cotton t-shirts and pillowcases which have a filtration efficiency of 51% and 57%, respectively [15]. Linen was also reported to have an effectiveness of 61% [15]. Furthermore, they noted Quilting fabric as the best household fabric, followed by 600-count pillowcases and flannel. Cotton and bandanas were seen to have good tolerability and wearability and associated increased compliance, but with a decreased efficacy [15]. Esposito et al [3] noted that a home-made mask is important in curbing the possibility of transmission of the infection by asymptomatic carriers. They opined that homemade or purchased cloth masks are suitable for a child who is above the age of two to wear, but the right fit must be guaranteed.

It is gratifying to note that when a facemask is worn correctly, it alters and slows the propelling force of particles expelled from expectoration and prevents transmission [16, 17].

This study also showed that a good number of children did not wear face masks as a method of prevention of Corona virus infection. They hazarded reasons that these children have difficulty in breathing and readily pulled off the face masks.

The benefits of using face masks in children should be weighed against possible harm associated with it. This includes feasibility and discomfort, as well as the effect on interactions and social communication. Besides, the age of the child, socio-cultural correlates and the presence of adult supervision should be considered when masking a child [18].

There has been a lot of controversy surrounding the pattern and clinical profile of COVID 19. For instance, recently, the World Health Organization stated that the number of asymptomatic carriers was very small and that they could not transmit infection [19]. Recently, data showed that 50–75% of subjects with positive throat swab were totally asymptomatic [20]. It is important to note that asymptomatic cases are commonly seen among the paediatric population.

A study has shown that the use of a face mask is very effective in the prevention of COVID-19 in children. Though the effectiveness of homemade mask is not certain, it is documented that surgical masks prevent the inhalation of large droplets, but may not filter submicron-sized airborne particles [21]. It has been reported that asymptomatic people can transmit the new coronavirus 2019 and become important sources of COVID-19. The Universal use of face masks, hand hygiene and physical distancing is very useful in combating this novel virus. To reduce the role of asymptomatic people in COVID-19, it is expedient to prepare the child to use face masks. It is advisable to thoroughly educate the child on the need for compliance, without actually forcing it on him [3, 22–24].

Though a significant proportion of children who were more than one year of age would wear face masks when compared with those who were aged 8 days to one year, we noted that a good number of children less than two years still wore face masks.

This practice is not in keeping with WHO recommendations for wearing face masks in children. The WHO recommended the “do no harm” phenomenon on children wearing face mask. They stated that there is no need for a mask in children less than 5 years of age [25]. However, some countries may contextualize the use of face masks for children to 2 or 3 years [25]. If the age of two or three years of age is to be used for recommending mask use for children, a well-knitted and coordinated supervision is needed to ensure the correct use of the mask and to prevent any potential harm associated with mask use in the child [3]. It is important to note that for children between six and eleven years of age, a risk-based approach should be applied. This includes the intensity of transmission in the locale and availability of data on the risk of infection and transmission in that age group [3, 26]. Other factors such as beliefs, behaviour, customs or social norms and the child’s capacity to comply with the appropriate use of masks and availability of appropriate adult supervision should be considered [3, 24, 25]. For children and adolescents 12 years or older, WHO guidelines for mask use in adults should be used [26].

The misconception of children aged 8 days to 1 year would wear face masks as seen in this study, is an eye-opener that will help alert the government to strengthen the policy on the acceptable age of wearing a face mask as well as organize programs geared towards health education for all especially the mothers.

Besides, the majority of children whose mothers have attained at least secondary education wear face masks when compared with those whose mothers attained tertiary education. This study also showed that a higher proportion of the children whose fathers attained secondary education and less would wear face masks when compared with those whose fathers have attained tertiary education. Health education and promotion on the need for children to wear a face mask, at least for those above two years of age, should be intensified.

This study showed that mothers above 35 years of age, those who are married, whose husbands are employed and who had high educational status prefer that their children should wear a face mask as a preventive measure against Corona virus infection. Studies in Australia have shown that people aged 16–34 years are more reluctant to wear face masks [27], while 68% of subjects aged 50–59 years perceived wearing face masks as very commendable. In keeping with our study, Tang [28] et al, also noted a higher level of compliance among married people when compared with their unmarried counterparts. Taylor [29] et al, also noted that people who never married had very low compliance levels as regards wearing face mask [3]. Nevertheless, getting married increases with age, it could be that age/duration of the marriage is a better predictor of wearing of face mask. Some studies have opined that higher education was strongly associated with wearing face masks. They noted that participants with at least a senior high school education certificate were found to be more likely to wear face masks [29, 30].

We noted a higher proportion of children whose fathers attained secondary education and less, wear a face mask when compared with those whose fathers have attained tertiary education. A study showed that men, in general, don’t wear face mask especially when wearing a face covering is not mandatory [24], but they tend to wear a mask when wearing a face covering is mandatory. In Nigeria, there is no penalty or any punitive measures for not wearing a face mask. These highly educated men and those in tertiary institutions know that there is no law and will not bother to wear face masks and they could extend the same apathy to their children. However, their counterparts with secondary education may be ignorant of the non-punitive measures and will prefer to wear a mask out of fear of breaking the law [31].

This study showed that mothers’ perception of COVID-19 has does not influence children’s use of face masks. This simply means that mothers’ perception or knowledge of COVID 19 did not really affect their practice on their children wearing face masks. This gap in perception of COVID 19 and practice of prevention by use of masks in children could be closed by improving behaviour change through campaigns, to reach everyone with appropriate information and guidance. Communication and information dissemination should be intensified.

Conclusion

Maternal perception of masking in children as an appropriate strategy for preventing COVID-19 is adjudged low in this study. Right perception is significantly enhanced by maternal educational status, employment status and marital status. Furthermore, there is a misconception with regards to mothers putting on face masks on children less than 1 year. Mothers’ perception of COVID-19 had no influence on children’s use of face masks.

Recommendation

Children’s use of face masks below the age of two years should be discouraged. There should be a clarion call on the government to intensify efforts geared towards making policies on public health promotion, as well as on non- governmental agencies to provide accurate information on the use of facemasks in children.

Limitation

We did not ascertain the practice of masking on mother-child pair.

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19 Aug 2020

PONE-D-20-19085

Maternal factors and predictors of wearing face mask on children, in the prevention of COVID 19. A multicentre study

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Reviewer #1: Thank you for raising the important issue of children wearing a face mask and the maternal predictive factors. This is an important and very timely issues.

Authors have done a good analysis of literature but what is lacking is the policy guidelines in Nigeria. based on WHO or other recommendations- what has the government mandated and disseminated. this is not described. Most countries utilize the global guidance from WHO but contextualize it.

Authors claim that this study will establish the need to wear a mask. While the authors have quoted from the literature about the need to wear a mask, i don't think the analysis lends itself to convincing people on the need t wear a mask.

The question that authors are seeking to answer should be further clarified. Is it the proportion of women who have the knowledge that face mask is essential for children? You write- proportion of mothers who have knowledge of child wearing of face mask. Please describe in detail how you assess the knowledge and the perception.

In the statistical analysis - did you look for variation in young mothers by educational status and also for those above 35 by educational status? could be highly correlated. The age and education status Do you see the same predictive factors? It would have been interesting to see f the wearing of the masks by the mothers themselves also had the similar pattern.. Interesting to see that tertiary education of the father has the opposite effect on wearing a mask by the child. Could the authors explain why?

There is no study limitations mentioned. Please add. in addition- please strengthen the conclusion and what the authors would like to see change as a result of this study. Please add some recommendations for policy and programs

Reviewer #2: General comments.

The authors of this manuscript essentially conducted a KAP study on mothers regarding the wearing of facemask in their children. It was a timely multi-centre, cross-sectional descriptive study in a sub-Saharan African setting which is not spared by the global COVID-19 pandemic. Thus, establishing the KAP on this important preventive strategy of the pandemic is relevant. However, there are some major and minor concerns about this manuscript.

Major concerns

1. Under the Abstract and title, the authors need to note these flaws: The title requires modification for clarity. It is not reflective of the content of the manuscript. The background did not provide the research gap to be filled. The study aim was not explicit enough (it was like a repetition of the study title). For methodology, pertinent elements like sample size, study instrument and how it was administered were missing. Reportage of the results should be improved. The conclusion is not in sync with the results

2. Introduction- The first sentence which reads- ‘Corona Virus infection (COVID 19) has now attained community infection and is now very common in families’- appears rather ambiguous. I think corona virus infection is not synonymous with COVID-19 (the latter is the disease caused by the former). Do the authors mean that the pandemic is now at the level of community transmission? Although the authors tried to highlight what is already known about the topic and the research question, the aim of the study as stated here (‘ascertaining the perception of mothers on the use of face mask in children in this COVID era’) is different from the aim as stated under the Abstract.

3. Methods- The authors revealed the study instrument here as structured self-administered questionnaires. A concise detail of the questionnaire items would have enlightened the reader. Would all the respondents have understood the items? An interviewer-administered questionnaire could have been a better approach.

4. Results- The ‘practice’ aspect of this study namely ‘the wearing of face mask in children’ was based on proxy-report and not observational. Thus, the information provided by these mothers on the proportion of their children who did wear face mask may not be reliable. This underscores the fact that an observational study of mother-child dyads would have been better. For instance, the authors reported that children aged 8 days to 1 year wore face masks. The practice is even contradictory to the reported WHO recommendation in children. The authors reported some socio-demographic variables as predictors of the practice of wearing face mask in children. Curiously, they were silent on the role of knowledge and perception. Maternal knowledge and perception ought to influence their practice of using face mask on their children

5. Discussion- The content and flow of this section should be improved. The authors did not highlight any limitations of the current study. The conclusion was not precise enough but was too concise to have conveyed the message of the study.

**********

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: 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.

Submitted filename: REVIEW for PLOS ONE MS.docx

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21 Aug 2020

Department of pediatrics,

College of Medicine,

University of Nigeria Enugu Campus (UNEC),

University of Nigeria Teaching Hospital,

PMB 01129,

Postal Code 400001, ENUGU, NIGERIA.

20th August, 2020

Editor-in-Chief,

Plos One

Dear Sir,

MANUSCRIPT CORRECTION: RESPONSES TO EDITOR’S COMMENTS

The authors are grateful to you, all the members of the Editorial Board and the

reviewers for giving us the opportunity to make corrections on our manuscript titled”

Maternal factors and predictors of wearing face mask on children, in the prevention of COVID 19. A multicentre study.”

Please find below point-by-point corrections made, based on the editor’s comments:

Editors comment

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

Authors Response

We have done this.

Editors comment

2. Please amend your current ethics statement to address the following concerns:

a) Did participants provide their written or verbal informed consent to participate in this study?

Authors Response

We have added consent to participate section. See page 8 line 168-171

Editors comment

b) If consent was verbal, please explain i) why written consent was not obtained, ii) how you documented participant consent, and iii) whether the ethics committees/IRB approved this consent procedure.

Authors Response

We have explained why we obtained verbal consent. See page 8 line 172-175

Editors comment

3. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses.

Authors Response

We have included additional details with respect to questionnaire used in the study. See page 7 line 148-150

Editors comment

For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.

Authors Response

We have added a copy of the questionnaire as Supporting Information.

Editors comment

4. Please state whether you validated the questionnaire prior to testing on study participants. Please provide details regarding the validation group within the methods section.

Authors Response

A pretested, semi-structured, interviewer-administered questionnaire was used. See page 7 line 148-150

Editors comment

5. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability.

Editors comment

7. Please include your tables as part of your main manuscript and

Authors Response

We have included tables in the manuscripts and we have also removed the individual files. See page 9-13

Editors comment

Please note that supplementary tables should be uploaded as separate "supporting information" files

Authors Response

We have taken note of that

Reviewer’s comments

Reviewer #1: Thank you for raising the important issue of children wearing a face mask and the maternal predictive factors. This is an important and very timely issues.

Authors response

Thanks for the commendation

Reviewer’s comments

Authors have done a good analysis of literature but what is lacking is the policy guidelines in Nigeria. based on WHO or other recommendations- what has the government mandated and disseminated. this is not described. Most countries utilize the global guidance from WHO but contextualize it.

Authors response

We have added the WHO recommendations of wearing face mask in introduction and discussion. See page 5 line 95-102. We have also added the WHO recommendations in the Nigerian context. See page 5 line 97-102

Reviewer’s comments

Authors claim that this study will establish the need to wear a mask. While the authors have quoted from the literature about the need to wear a mask, i don't think the analysis lends itself to convincing people on the need t wear a mask.

Authors response

This statement has been expunged

Reviewer’s comments

The question that authors are seeking to answer should be further clarified. Is it the proportion of women who have the knowledge that face mask is essential for children? You write- proportion of mothers who have knowledge of child wearing of face mask. Please describe in detail how you assess the knowledge and the perception.

Authors response

The focus is use of facemask by the child. The mothers’ perception of COVID-19 has been included. See table 2 and 3

Reviewer’s comments

In the statistical analysis - did you look for variation in young mothers by educational status and also for those above 35 by educational status? could be highly correlated. The age and education status Do you see the same predictive factors? It would have been interesting to see f the wearing of the masks by the mothers themselves also had the similar pattern.. Interesting to see that tertiary education of the father has the opposite effect on wearing a mask by the child. Could the authors explain why?

There is no study limitations mentioned. Please add. in addition- please strengthen the conclusion and what the authors would like to see change as a result of this study. Please add some recommendations for policy and programs

Authors response

Information on wearing of facemask by mothers was not obtained. (This is now regarded as a limitation of the study). The perception of COVID-19 by the mothers was the focus for the mothers. In determining the factors affecting child use of facemask, the age of the mothers was categorized into three, <30 years, 30-34 years and 35 years and above. The educational attainment of the mothers and fathers of the children was categorized into tertiary education and secondary education and less.

We have explained why tertiary education of the father has the opposite effect on wearing a mask by the child. We have added limitation to the study, broadened the conclusion and we have mentioned recommendation for policies and program. See page 16 line 313-322

Reviewer’s 2 comments

Reviewer #2: General comments.

The authors of this manuscript essentially conducted a KAP study on mothers regarding the wearing of facemask in their children. It was a timely multi-centre, cross-sectional descriptive study in a sub-Saharan African setting which is not spared by the global COVID-19 pandemic. Thus, establishing the KAP on this important preventive strategy of the pandemic is relevant. However, there are some major and minor concerns about this manuscript.

Authors response

Thanks for the commendation

Reviewer’s 2 comments

Major concerns

1. Under the Abstract and title, the authors need to note these flaws: The title requires modification for clarity. It is not reflective of the content of the manuscript. The background did not provide the research gap to be filled. The study aim was not explicit enough (it was like a repetition of the study title). For methodology, pertinent elements like sample size, study instrument and how it was administered were missing. Reportage of the results should be improved. The conclusion is not in sync with the results

Authors response

We have snagged the title and provided the research gap in the background and the study aim has been expanded. We also added sample size, sample technique, study instrument to the study. The conclusion has been expanded. We have rewritten the reportage of the results. However, these modifications blew the abstract to more than the accepted 250 words format. See title and abstract

Reviewer’s 2 comments

2. Introduction- The first sentence which reads- ‘Corona Virus infection (COVID 19) has now attained community infection and is now very common in families’- appears rather ambiguous. I think corona virus infection is not synonymous with COVID-19 (the latter is the disease caused by the former). Do the authors mean that the pandemic is now at the level of community transmission? Although the authors tried to highlight what is already known about the topic and the research question, the aim of the study as stated here (‘ascertaining the perception of mothers on the use of face mask in children in this COVID era’) is different from the aim as stated under the Abstract.

Authors response

We have deleted COVID 19 from the statement. We have replaced with pandemic.

We have corrected the aim in the abstract to be same with that in the introduction. See page 5 line 103-108

Reviewer’s comments

3. Methods- The authors revealed the study instrument here as structured self-administered questionnaires. A concise detail of the questionnaire items would have enlightened the reader. Would all the respondents have understood the items? An interviewer-administered questionnaire could have been a better approach.

Authors response

We used interviewer-administered questionnaire. We have added this in methodology. See page 7 line 148-150

Reviewer’s comments

4. Results- The ‘practice’ aspect of this study namely ‘the wearing of face mask in children’ was based on proxy-report and not observational. Thus, the information provided by these mothers on the proportion of their children who did wear face mask may not be reliable.

Authors response

The information given by the mother was supported with what was observed as the mothers were present with the children during the study. See page 6 line 130-131

Reviewer’s comments

This underscores the fact that an observational study of mother-child dyads would have been better. For instance, the authors reported that children aged 8 days to 1 year wore face masks. The practice is even contradictory to the reported WHO recommendation in children.

Authors response

This was what was observed and reported. Another aspect of the study was providing information to the mothers on the correct use of facemasks. In fact, the finding of children aged 8 days to 1 year wearing face mask is an eye opener and will help alert the government to strengthen policy on acceptable age of wearing face mask and organize program geared on health education. See page 15 line 284-292

Reviewer’s comments

The authors reported some socio-demographic variables as predictors of the practice of wearing face mask in children. Curiously, they were silent on the role of knowledge and perception. Maternal knowledge and perception ought to influence their practice of using face mask on their children

Authors response

This has been included. Thanks for the observation. How the perception of COVID-19 by the mothers was assessed has also been included. See table 2 and 3

Reviewer’s comments

5. Discussion- The content and flow of this section should be improved. The authors did not highlight any limitations of the current study. The conclusion was not precise enough but was too concise to have conveyed the message of the study.

Authors response

We have added limitation to the study, broadened the conclusion and we have mentioned recommendation for policies and program. See page17 line 329-342

Once again, the authors thank you, the editorial team and the reviewers most sincerely for your critical review and suggestions which have improved the write up of this manuscript.

We hope this revised version of the manuscript will now be suitable for publication in your Journal.

Thank you Sir,

Dr. Chinawa Josephat

Corresponding Author

Submitted filename: PONIT BY POINT FACE MASK.docx

Click here for additional data file.

15 Sep 2020

PONE-D-20-19085R1

Wearing of face mask by children and associated maternal factors; in the prevention of COVID 19: A multicentre study

PLOS ONE

Dear Dr. Chinawa,

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 10 October. 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: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Francesco Di Gennaro

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

Dear authors,

follow reviewer suggestion you can improve your manuscript

[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: (No Response)

Reviewer #2: (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

**********

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

Reviewer #1: (No Response)

Reviewer #2: 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

**********

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: No

Reviewer #2: No

**********

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: Thank you for addressing previously raised concerns. The authors have done a great job of addressing most of the issues. few suggestions are listed below.

1. There needs to be a thorough copy edit because there are several typographical errors. For instance, warding off is written as wading off

2. Please add the word Nigeria in the title.

Wearing of face mask by children and associated maternal factors; in the prevention of 2 COVID 19: A multicentre study in Nigeria

3. There is a lot of controversy on the use of face masks by children, especially in a situation where decisions bothering on who should wear the mask and at what age, still remain unknown. This statement does not convey the full guidance issues by WHO and Unicef of “doing no harm” and they are recommending that there is no need for mask for children < 5 years of age. However, some countries may contextualize it to 2 or 3 years. The authors need to highlight the correct wearing of masks at the outset

https://www.who.int/publications/i/item/WHO-2019-nCoV-IPC_Masks-Children-2020.1

Reviewer #2: (No Response)

**********

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: 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.

Submitted filename: REVIEWERS COMMENTS FOR REVISED MS (PLoS ONE).docx

Click here for additional data file.

16 Sep 2020

REVIEWER #1:

Thank you for addressing previously raised concerns. The authors have done a great job of addressing most of the issues. few suggestions are listed below.

1. There needs to be a thorough copy edit because there are several typographical errors. For instance, warding off is written as wading off

This has been corrected. See Page 13 line 239

2. Please add the word Nigeria in the title.

Wearing of face mask by children and associated maternal factors; in the prevention of 2 COVID 19: A multicentre study in Nigeria

The second reviewer changed the title entirely but we have added the phrase “in Nigeria” to the title. See page 1 line 1-2

3. There is a lot of controversy on the use of face masks by children, especially in a situation where decisions bothering on who should wear the mask and at what age, still remain unknown. This statement does not convey the full guidance issues by WHO and Unicef of “doing no harm” and they are recommending that there is no need for mask for children < 5 years of age. However, some countries may contextualize it to 2 or 3 years. The authors need to highlight the correct wearing of masks at the outset

https://www.who.int/publications/i/item/WHO-2019-nCoV-IPC_Masks-Children-2020.1

The statement is now rewritten. See page 5 line 98-109

REVIEWER 2

REVIEWER’S COMMENTS ON REVISED MANUSCRIPT (PONE-D-20-19085R)

TITLE- Wearing of face mask by children and associated maternal factors; in the prevention of

COVID 19: A multicentre study

General comments

Although the authors tried to address some of the issues pointed out in my previous review, the answers are not yet satisfactory. The revised manuscript still requires some modifications to improve its quality as there are obvious inconsistencies. The casuistry adopted by the authors in some of their responses has not been able to convince me on a number of specific issues which I have highlighted below

Specific issues and comments

1. Title: The current version of the title appears tenuous and does not reflect the message of the paper. Undoubtedly, the study was a KAP study on maternal perception of a preventive strategy for COVID-19 and not an observational study. I therefore suggest the authors modify the title thus- ‘Maternal perception of masking in children as a preventive strategy for COVID-19: a multicentre study’

We have changed the title to read “‘Maternal perception of masking in children as a preventive strategy for COVID-19: a multicentre study’”. The first reviewer wanted us to add……. in Nigeria. So the tile now reads “‘Maternal perception of masking in children as a preventive strategy for COVID-19 in Nigeria: a multicentre study” See page 1 line 1and 2

2. Abstract: The objective (or aim) as currently stated can be modified to read- ‘The study aimed to ascertain the perception of mothers on masking in children as a preventive strategy for COVID-19.’

This has been rewritten. Page 2 line 30-31

3. The summary of the Results here should be re-written for clarity. For instance, the statement- ‘A minor proportion of the children, 44.7% do wear face mask’- appears untenable in the context of this study. I presume the authors meant- ‘Minority (44.7%) of the mothers perceive masking in children as an appropriate measure for the prevention of COVID-19’.

This has been corrected to read “Minority (44.7%) of the mothers perceive masking in children as an appropriate measure for the prevention of COVID-19’.” See page 2 line 36-39

The succeeding sentence- ‘The major reasons for the children not wearing face mask include perceived difficulty in breathing, 38.2% and that the child pulls it off, 29.3%.’- is suggested to read- ‘The major reasons given by the mothers for the inappropriateness of face mask in children include perceived difficulty in breathing (38.5%) and the child’s readiness to pull it off (29.3%).’

The statement now reads “The major reasons given by the mothers for the inappropriateness of face mask in children include perceived difficulty in breathing (38.5%) and the child’s readiness to pull it off (29.3%)” See page 2 line 36-39

Again, one wonders how the authors arrived at the inferential statistics about the effect of maternal age, children’s age paternal educational status and maternal perception of COVID-19 on masking in children. The impression created here is that the authors actually observed masking in the children of these mothers. On the contrary, I suspect the authors merely evaluated the perception of selected mothers on the subject of masking in children as a preventive strategy for COVID-19. The conclusion that ‘The perception of mothers on the children wearing face mask is low’ should rather read-‘Maternal perception of masking in children as an appropriate strategy for preventing COVID-19 is adjudged low in this study. Right perception is significantly enhanced by maternal educational status etc.….’

We have now rewritten the conclusion to read “Maternal perception of masking in children as an appropriate strategy for preventing COVID-19 is adjudged low in this study. Right perception is significantly enhanced by maternal educational status” See page 3 line 53-55

4. Introduction: The opening sentence as corrected by the authors- ‘Corona Virus pandemic has now attained community infection and is now very common in families’- still appears ambiguous. What do they mean by the pandemic now attaining community infection?

The statement “the pandemic now attaining community infection” has been expunged

The statement after the study aim which reads- ‘It will also form the first data base on this topic in this region’- is considered a redundant statement and should be deleted.

This has been deleted

5. Materials and Methods: What do the authors mean by ‘The outcome variables in this study are the level of knowledge and perception of mothers on children wearing face mask’? (Lines 152-153). Nevertheless, this statement gives away the crux of the study as maternal knowledge/perception on masking in children as a preventive strategy for COVID-19. Thus, the authors should not be reporting about proportions of children who do wear face mask but rather on proportions of mothers with varying perceptions/knowledge on masking in children as a pandemic antidote.

We have now rewritten the outcome variables to read “proportions of mothers with varying perceptions/knowledge on masking in children as a pandemic antidote” See page 8 line 164-167

Again, this statement in lines 154 to 155 – ‘We used age, marital status, educational level, parity, husband’s educational level and occupation as independent variables’- is unclear. Do these variables-age, marital status and educational level-refer to the mothers?

This has been rewritten to read ‘We used mother’s and child’s age, marital status, educational level of both mother and father, parity, and occupation of father and mother as independent variables.” See page 8 line 15-167

Results: The authors in trying to justify the fact that they observed the children of the mothers wearing face mask stated ‘The information given by the mother was supported with what was observed as the mothers were present with the children during the study. See page 6 line 130-131’. Did the authors study mother-child dyads? It was not stated in this study. What form of face masks were worn by the children that were neonates and infants? Do the authors have customized face masks for such age groups in their region? The WHO dissuades the use of face masks in children less than 2 years. Recently, the age bar has been raised to 12 years.

We did not focus on mother child dyad of wearing of face mask, though mothers were observed in the study, masked. However, the National COVID-19 protocol made it mandatory for adults to wear facemasks in public space, but this was strictly enforced by health facilities and financial institutions. Our observation of child wearing face mask necessitated this study. However, there was no such clear rule for children. See page 7 line 142-150. The home-made face mask was used by neonates and infants’ children in this study.

6. Discussion: The revised discussion is not yet robust enough. Several syntax errors and redundant sentences precluded its clarity. For instance, the opening sentence-‘This study has gone a long way to show the importance of prevention of COVID 19 in children by wearing of face mask’ is ambiguous.

We have rewritten the statement to now read “This study has shown varying maternal perceptions/knowledge on masking in children as a pandemic antidote.” See page 13 line 232.We have added some items in discussion. See Discussion section

Several of such statements are littered through this section.

We have tried our best to correct all syntax errors

Even the study limitation is unrealistic. How could the authors not have observed if the mothers wore face masks since they claimed they observed masking in their children? If it was an oversight, it further confirms my belief that the study was fundamentally conducted on evaluating maternal perception/knowledge on masking in children.

We have deleted the study limitation since the study was fundamentally conducted on evaluating maternal perception/knowledge on masking in children. See page 17 line 350-351

Submitted filename: THE PLOS ONE ULTIMATE POINT BY POINT.docx

Click here for additional data file.

29 Sep 2020

PONE-D-20-19085R2

Maternal perception of masking in children as a preventive strategy for COVID-19 in Nigeria: a multicentre study.

PLOS ONE

Dear Dr. Chinawa,

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 20 October 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: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Francesco Di Gennaro

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

Dear authors follow minor comments of reviewers to improve your article

[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: (No Response)

Reviewer #2: All comments have been addressed

**********

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

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

**********

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: A minor proportion of the children, 44.7% wore face 194 masks which were all home-made.

According to Table 1 this should be 43.5% 44.7% are females

230. Children less than 2 years may not 231 benefit from wearing face mask but may rather be in danger. –Please clarify this statement. I am assuming that you are suggesting that wearing a mask maybe more high-risk for them

Reviewer #2: (No Response)

**********

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: 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.

Submitted filename: SECOND REVIEW OF MANUSCRIPT- FOR PLoS.docx

Click here for additional data file.

29 Sep 2020

Re- Maternal perception of masking in children as a preventive strategy for COVID-19 in

Nigeria: a multicentre study.

REVIEWER’S COMMENTS

Review Comments to the Author

Reviewer #1: A minor proportion of the children, 44.7% wore face 194 masks which were all home-made.

According to Table 1 this should be 43.5% 44.7% are females

This is now corrected. See Page 9,line 197-198

230. Children less than 2 years may not 231 benefit from wearing face mask but may rather be in danger. –Please clarify this statement. I am assuming that you are suggesting that wearing a mask maybe more high-risk for them

We have modified the statement. See Page 13 line 238

The authors have done pretty well in addressing the concerns raised in the previous review. However, there are still some specific issues that need their attention to further improve this manuscript

1. Under the ABSTRACT, some statements need correction. I suggest these lines should read- ‘The frequent reasons given by majority (55.3%) of the mothers for the inappropriateness of face mask in children…….’ ‘A significantly higher proportion (64.2%) of the children…..would wear face masks when compared with 31.7% of those whose mothers were < 30 years of age (x2 =28.632, p<0.001).’ Similarly, a significantly higher proportion (51.0%) of the children who were more than one year of age would wear face mask when compared with 20.5% of those aged eight days to one year (x2=19.441, p<0.001).’

This has been corrected. See Page 2 line 37-45

2. Lines 118-119 (Under INTRODUCTION), the study aim should be written as it appears in the ABSTRACT.

We have written the study aim as it appeared in the abstract. See Page 6 line 119-120

3. Under RESULTS, lines 191-194 should reflect what is in the Abstract. As currently written, the message is inconsistent with that in the Abstract.

We have reflected statements in results to be in keeping with that in abstract.

See page 9 line 193-198

Under DISCUSSION, lines 230-231 read ‘Children less than 2 years may not benefit….may rather be in danger.’ The authors should add ‘….may rather be in danger of suffocation’.

We have added the phrase may rather be at risk of suffocation’. See Page 13 line 238

4. Line 252 should be re-written thus- ‘Few mothers in this study…’

This has been added. See Page 14 line 260

5. Lines 274-276- In line with my previous suggestions, ‘wear face masks’ should rather read ‘would wear face masks’ to be in keeping with the study title of maternal perception of masking in children.

This has been effected. See Page 15 Line 282-283

6. Similarly, lines 295-298 should be corrected accordingly.

This has been corrected. See Page 15 Line 299

7. For line 313- delete this redundant statement-‘These assertion is also upheld in our study.’

This has been deleted

8. The study limitation as currently stated is ambiguous. The authors should rather state that they did not evaluate the concordance of maternal perception of masking with actual wearing of face mask in their children.

We have added this in limitation. See Page 18 line 350-351

Submitted filename: THE FINALLY POINT BY POINT ORIGINAL- FOR PLoS.docx

Click here for additional data file.

13 Oct 2020

PONE-D-20-19085R3

Maternal perception of masking in children as a preventive strategy for COVID-19 in Nigeria: a multicentre study.

PLOS ONE

Dear Dr. Chinawa,

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 10 November. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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We look forward to receiving your revised manuscript.

Kind regards,

Francesco Di Gennaro

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

Dear Authors follow reviewer suggest (minor suggestions) to improve your manuscript

[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: (No Response)

Reviewer #2: (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: (No Response)

Reviewer #2: Partly

**********

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

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: (No Response)

Reviewer #2: No

**********

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: Thank you for addressing the comments. Please clarify the following

Table 1 shows the wearing of face mask by the children. Minority (44.7%) of the mothers

193 perceived masking in children as an appropriate measure for the prevention of COVID-19. The

194 frequent reasons given by majority (55.3%) of the mothers for the inappropriateness of face

195 mask in children included perceived difficulty in breathing (38.5%) and the child’s readiness

196 to pull it off (29.3%)

In table1- 44.7 and 55.3 refers to gender - male and female. Please clarify if it is for mothers? the table is titles Child wearing a mask so its very confusing.

Reviewer #2: General comments:

Although the authors have progressively improved the quality of this manuscript by their revisions, I would urge them to be more painstaking in responding to the specific issues of concern previously raised. This will not only eliminate inconsistencies within the manuscript but also improve the lexicon of their written English.

Specific comments:

1. Abstract- In line 41, the repeated figure (64.2%) should be deleted.

2. In my previous reviews, I pointed out that the manuscript has grammar and syntax errors. I suggested an English editing to be done. However, it appears the authors have disregarded this suggestion. This is evident in some errors noted as follows: ‘was’ used instead of ‘were’ (Line 77), ‘is’ used instead of ‘are’ (Line 78), ‘In China’ instead of ‘in China’ (Line 90) and ‘intensified program’ used instead of ‘intensified programs’, etc. Furthermore, I guess the statement in line 145 should read ‘we did not focus on mother-child dyads while assessing maternal perception and the practice of wearing face masks, though…..’ In fact, this assertion throws up an inconsistency with lines 178-179 where the authors stated that a ‘Yes’ answer on wearing face mask was confirmed by their observation of masking in children during data collection. How could the authors not have focused on mother-child pairs in the study when they reported masking in both the mothers and their children? This again negates the study limitation in lines 350-351 which states ‘We did not evaluate the concordance of maternal perception of masking with actual wearing of face mask in their children.’ Let the authors correct this inconsistency

3. Finally, I urge the authors to subject the manuscript to English editing. I suggest they could use the ‘grammarly’ software if they cannot utilize the available English editing services

**********

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: 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.

15 Oct 2020

Reviewer #1: Thank you for addressing the comments. Please clarify the following

Table 1 shows the wearing of face mask by the children. Minority (44.7%) of the mothers 193 perceived masking in children as an appropriate measure for the prevention of COVID-19. The194 frequent reasons given by majority (55.3%) of the mothers for the inappropriateness of face

195 mask in children included perceived difficulty in breathing (38.5%) and the child’s readiness 196 to pull it off (29.3%)

This statement has been expunged and the section rewritten. See page 9 line 192-195

In table1- 44.7 and 55.3 refers to gender - male and female. Please clarify if it is for mothers? the table is titles Child wearing a mask so its very confusing.

This has been corrected. See page 9 line 192. See also Table one

Reviewer #2: General comments:

Although the authors have progressively improved the quality of this manuscript by their revisions, I would urge them to be more painstaking in responding to the specific issues of concern previously raised. This will not only eliminate inconsistencies within the manuscript but also improve the lexicon of their written English.

Specific comments:

1. Abstract- In line 41, the repeated figure (64.2%) should be deleted.

This has been deleted.

2. In my previous reviews, I pointed out that the manuscript has grammar and syntax errors. I suggested an English editing to be done. However, it appears the authors have disregarded this suggestion. This is evident in some errors noted as follows: ‘was’ used instead of ‘were’ (Line 77), ‘is’ used instead of ‘are’ (Line 78), ‘In China’ instead of ‘in China’ (Line 90) and ‘intensified program’ used instead of ‘intensified programs’, etc.

We have sent the paper to Grammarly for English editing. We believe that the paper looks better than the previous one. The corrected syntax is as highlighted. See page 4 and 5

Furthermore, I guess the statement in line 145 should read ‘we did not focus on mother-child dyads while assessing maternal perception and the practice of wearing face masks, though.’

This has been corrected. See page 7 line 146-148

In fact, this assertion throws up an inconsistency with lines 178-179 where the authors stated that a ‘Yes’ answer on wearing face mask was confirmed by their observation of masking in children during data collection. How could the authors not have focused on mother-child pairs in the study when they reported masking in both the mothers and their children

Though we reported masking in both mothers and their children, but unfortunately, we did not ascertain the practice of masking on mother-child pair as this was not factored in the questionnaire. We are sorry for this.

This again negates the study limitation in lines 350-351 which states ‘We did not evaluate the concordance of maternal perception of masking with actual wearing of face mask in their children.

The study limitation now reads “We did not ascertain actual practice of masking on mother-child pair”. See page 17 line 343

’ Let the authors correct this inconsistency

We have tried to correct these inconsistencies

3. Finally, I urge the authors to subject the manuscript to English editing. I suggest they could use the ‘grammarly’ software if they cannot utilize the available English editing services

We have subjected the article to English editing using Grammarly.

Submitted filename: MOST ZENNIT FACE MASK POINT BY POINT.docx

Click here for additional data file.

9 Nov 2020

Maternal perception of masking in children as a preventive strategy for COVID-19 in Nigeria: a multicentre study.

PONE-D-20-19085R4

Dear Dr. Chinawa,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Francesco Di Gennaro

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Dear Authors congratulations

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: All comments have been addressed

**********

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: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: (No Response)

**********

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: Please correct the following sentence.

Do your child wear a face mask

It should read - Does your child wear a mask

Reviewer #2: Thank you for addressing the concerns I raised about your manuscript. During the galley proof, you can further improve the lexicon

**********

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: Samuel Uwaezuoke

12 Nov 2020

PONE-D-20-19085R4

Maternal perception of masking in children as a preventive strategy for COVID-19 in Nigeria: a multicentre study.

Dear Dr. Chinawa:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Francesco Di Gennaro

Academic Editor

PLOS ONE