Utilization of insecticide-treated bed nets among pregnant women in Myanmar-analysis of the 2015-2016 Demographic and Health Survey.

BACKGROUND: Due to the effectiveness of insecticide-treated nets (ITNs), most malaria-endemic countries resort to free distributions in the population with particular attention to pregnant women, a more vulnerable group. However, the mere issuance of ITNs does not usually translate to proper utilization. This study aimed to examine the utilization of ITNs and its associated factors among pregnant women in Myanmar.
METHODS: The data analyzed in this cross-sectional study were extracted from available survey datasets of the 2015-16 Myanmar Demographic Health Survey. The secondary data were presented using a chart, descriptive statistics and inferential statistics including simple and multiple logistic regression models. All analyses were performed using STATA, Version 15. A p-value <0.05 was considered statistically significant.
RESULTS: Of 466 currently pregnant women, the majority (96%) possessed bed nets for sleeping. Among them, 15.9% slept without a bed net the night before the survey, while 65.7% slept with untreated nets. Only about 1 in 5 (18.4%) slept under ITNs. In the multivariate logistic regression analysis, pregnant women residing in delta and lowland regions [adjusted odds ratio (aOR) = 7.70, 95% confidence interval (CI): 3.62, 16.38], plains (aOR = 7.09, 95%CI: 3.09, 16.25) or hilly areas (aOR = 4.26, 95%CI: 1.91, 9.52) were more likely to report non-utilization of ITNs than those residing in coastal regions.
CONCLUSION: Relatively poor ITN utilization was observed among pregnant women in Myanmar. Health promotion activities for ITN utilization should be implemented especially for pregnant women residing in the delta, lowland, plain and hilly regions. Other social-behavioral factors including perceived susceptibility to malaria, knowledge of ITNs, and attitude towards ITN that might favor the non-utilization of ITNs need to be further explored.

Introduction

In 2020, the World Health Organization (WHO) reported almost 241 million malaria cases and 0.6 million deaths in the world [1]. Furthermore, 24 to 40% of the pregnant women in each region were exposed to malaria infection during pregnancy [1]. Pregnant women are threefold more likely to contract severe malaria and possess twice the risk of mortality than nonpregnant women [2]. Malaria in pregnancy is defined as a medical emergency and ought to be treated in hospital settings to prevent further adverse consequences, including maternal deaths [3]. In 2019, a total of 56,640 malaria cases and 14 malaria-related deaths were reported in Myanmar, and 365 cases involved pregnant women [1]. The malaria vulnerability of pregnant women would be a major impediment to achieving the countrywide malaria elimination target by 2030. Therefore, all pregnant women should always use good malaria preventive practices. However, targeted malaria interventions towards pregnant women remain limited except for the prioritized distribution of insecticide-treated nets (ITNs). ITNs are a form of personal protection that has been proved to prevent malaria infection, and reduce the risk of severe sickness, and mortality due to malaria [4].

Many studies have shown the possible effects of important malaria preventive practices in reducing the number of newly confirmed malaria cases and interrupting localized malaria transmission [5, 6]. The utilization of ITNs is internationally recognized as one of the most efficient and effective malaria preventive tools [7]. Thus, the distribution of insecticidal nets should happen regularly in every malaria-endemic country. In Myanmar, impregnation of conventional bed nets is not usually used unless an abnormal number of malaria cases occur in an area [8]. Instead, all malaria projects conducted mass distribution of insecticidal nets, either ITNs or long-lasting insecticide-treated nets (LLINs) (hereafter included under ITNs), every other year according to the National Strategic Plan. The topping-up replenishments covering malaria vulnerable groups, including forest-related workers, pregnant women, and children, were followed each year until the next cycle of mass distribution [8]. Nevertheless, proper utilization of ITNs among the community remained poor despite growing evidence of net ownership status. Consequently, with the financial support from donors including the Global Fund in Myanmar, about 11 million ITNs were distributed in 2019 [2]. Overall, as per the 2014 nationwide population census [9], the numbers of distributed ITNs were estimated to represent 50% of the total country population or 75% of the rural population. The reported utilization rates fluctuated by different population groups– 19.5% in the nationwide general population [10], 46.6% among pregnant women living in artemisinin-resistant areas [11] and 52% in migrant populations [12], respectively.

Entomologic surveys across the country have revealed the presence of abundant malaria vectors such as Anopheles minimus and A. dirus [13]. Thus, a need exists for immediate attention to strengthening the use of ITNs especially in rural areas where malaria is endemic and in other malaria vulnerable groups like pregnant women. Additionally, it remains critical to investigate the barriers to why people are not properly using the nets regardless of ownership status. Other studies in Thailand and Myanmar stated that types of occupation, sex, age, family wealth index, knowledge on malaria transmission, net ownership, household roofing, source of family income and geographical zones were associated factors for the use or nonuse of ITNs among the general population as well as migrant workers [12, 14–17]. However, none of the studies represented nationwide samples. By understanding the sociodemographic factors related to the utilization of ITNs, more specific interventions such as targeted health education sessions could be formulated and initiated.

In Myanmar, the one and only Demographic Health Survey to date [18] was carried out during 2015 and 2016. The final report included much demographic and socio-economic data describing the common health problems of the citizens across the country. The data, including bed net utilization among pregnant women, were mainly presented in descriptive styles of analysis. However, according to the survey [18], the ITNs utilization rate in each state or region was below average. The lowest utilization rates have been observed in peripheral areas including Chin State (38.5%) followed by Kayah State (39.7%). The highest utilization areas were one state along the Thailand-Myanmar border–Karen State (80.9%) and an urban area–Yangon Region (76.2%). One other published paper [10] addressed ITNs utilization among under-5 children and reported poor utilization of ITNs as well as underlying factors. Here we further analyzed the nationwide data to explore the ownership and utilization of insecticidal nets and the related variables towards non-utilization of insecticidal bed nets among pregnant women in Myanmar. The results will be useful for formulating targeted health education interventions to boost bet net utilization for preventing malaria transmission among pregnant women in Myanmar and potentially other Greater Mekong Subregion countries.

Methods

Study design and source of data

This study comprised an analytical cross-sectional study using secondary data from the Myanmar Demographic and Health Survey 2015–16 (MDHS 2015–16).

Myanmar Demographic and Health Survey 2015–16

To date, MDHS 2015–16 is the first and latest nationally representative survey to collect comprehensive data concerning basic demographic, socioeconomic, and health indicators of women and men aged 14 to 49 years residing in 15 states and regions. To obtain the representative samples for the whole country, the survey followed a stratified two-stage cluster sampling design yielding a response rate of 98%, ensuring the representativeness of the data. The first step was to estimate the numbers and points of clusters to be chosen either at the state or regional level and urban or rural areas. A total of 441 clusters have been included. This was followed by sampling a fixed number of 30 households from each cluster. All women aged 15 to 49 years in the selected households and all men aged 15 to 49 years in every second selected household were interviewed.

Three sets of questionnaires (households, men, and women) were used as a data collection tool. The contents were aligned with other worldwide DHS surveys except for some adjustments to the specific local context. The final questionnaire used for data collection was entirely in Burmese translated from English through various steps including a pretest. A training was organized for nine data collection masters recruited from the Ministry of Health. Those masters re-trained hundreds of field assistants from health departments, other non-governmental organizations, and ethnic groups. Data were collected from December 2015 to July 2016 using tablet computers. Data validation was also carried out at different levels. Field supervision together with technical monitoring visits were conducted by the DHS authority. A total of 466 currently pregnant women were included in the survey and were eligible to be involved in the present analysis.

Data variables

The outcome variable of interest used in this study was currently pregnant women not sleeping under insecticide-treated nets (ITNs) the night before the survey. An ITN is defined as a factory-treated net that does not need to be treated again (long-lasting insecticide-treated net–LLIN), a pretreated net received during the last 12 months or a net that had been impregnated with insecticide within the last 9 months.

The independent predictor variables included were as follows: firstly completed age, counted as the age in years each participant responded during the interview. The ranges were categorized into 15 to 24 years, 25 to 34 years, and 35 to 49 years. Second, the highest education attained comprising the educational attainments of the participants grouped as no education, primary, secondary, or higher levels. Third, place of residence and region consisted of regions categorized according to their characteristics: delta and lowland (Ayeyawady, Yangon and Bago Regions, Mon, and the Karen States), hilly (Kachin, Kayah, Chin and Shan States), coastal (Rakhine State and Tanintharyi Region) and plains (Magway, Mandalay, Sagaing Regions, and Nay Pyi Taw Union Territory). Fourth, wealth indexes, based on economic status, income, and property ownership, were differentiated into richer, richest, middle, poor and poorest quintiles. Fifth, number of household members included the total numbers of household members categorized as <3, 4 to 7, and >7. Sixth, number of under 5 children in the household in three groups, i.e., none, one, or more than one. The seventh variable constituted duration of current pregnancy: the reported duration of pregnancy was coded as <5 months or 6 to 10 months. Finally, access to mass media exposure was defined as ‘yes’ when access could be gained to either one of television, newspaper, or radio at least once weekly.

Data analysis

First, the utilization of insecticide-treated bed nets in the general population and among pregnant women was plotted using a bar chart. The percentages were calculated for pregnant women sleeping without nets, with untreated nets and with ITNs. To explore the true problem of ITN utilization status, utilization of ITN was estimated among total pregnant women and those with access to at least one ITN in their household. Second, general characteristics, demographic data, and socioeconomic status of pregnant women were analyzed using descriptive statistics including number, percentage, means and standard deviations. Last, the variables related to the non-utilization of insecticidal nets among pregnant women regardless of their ITN ownership status were explored using simple and multiple logistic regression models and presented using odds ratios with 95% confidence intervals. We included variables with a crude Chi-squared p-value of <0.2 in the multiple logistic regression model. All the analyses were performed using STATA (Version 15 STATA Corp., College Station, TX, USA). Weight factors and the ‘svyset’ command were applied to account for the two-stage stratified cluster sampling design. A p-value of <0.05 was considered statistically significant.

Ethics consideration

The DHS had been conducted in Myanmar in line with ethical standards after obtaining the required approval from the Ministry of Health. The identities of all the respondents were kept confidential. The present study has comprised a secondary data analysis of its data and ethics approval was not required. The study title was also registered at the DHS program website. The authorization letter to use the survey datasets has been granted by the DHS program officials.

Results

Background characteristics of currently pregnant women included in the Myanmar Demographic and Health Survey 2015–16

Of 466 currently pregnant women, more than half were aged 25 to 34 years. Most attained at least primary level education. About 44% resided in the delta and lowland region followed by 25.4% in plains areas. A total of 359 (77%) were from rural areas, and nearly half (49.8%) were categorized in the two poorest quintiles. Many respondents (59.3%) possessed 4 to 7 members in their households. The studied women bore a pregnancy either for 1 to 5 or 6 to 10 months. Only a few (12.8%) had more than one under-five child in their households. Nearly 60% of pregnant women had exposure to mass media (television, newspaper, or radio) at least once weekly ().

Bed net utilization among pregnant women involved in the Myanmar Demographic and Health Survey 2015–16

Most pregnant women, 96% (95% CI: 93.2, 97.7), possessed mosquito bed nets for sleeping while only 33% owned at least one insecticide-treated net (ITN) in their households (). However, 15.9% (95% CI: 12.4, 20.2) of pregnant women slept without a bed net the night before the survey. Many (65.7%) preferred to sleep under untreated nets. Only about one in five, 18.4% (95% CI: 14.7, 22.9) of total pregnant women slept under ITNs. Among pregnant women having access to at least one ITN in their households, almost 56% (86/154) slept under an ITN the night before the survey. Overall, about 84% of pregnant women slept in bed nets the night before the survey ().

Factors associated with non-utilization of insecticide-treated bed nets among currently pregnant women included in the Myanmar Demographic and Health Survey 2015–16

In the bivariate analysis, geographic location (p<0.001), place of residence (p = 0.019), wealth index (p = 0.034) and exposure to mass media (p = 0.014) were associated with non-utilization of ITNs. In the adjusted model analysis, the geographic location was significantly associated with the non-utilization of ITNs. Pregnant women who were residing in the delta and lowland region [adjusted Odd Ratio (aOR) = 7.70, 95% Confidence Interval (CI): 3.62, 16.38], plains (aOR = 7.09, 95%CI: 3.09, 16.25) and hills (aOR = 4.26, 95%CI: 1.91, 9.52) were more likely to practice non-utilization of ITNs than those living in coastal areas ().

Discussion

The present study constitutes the first report documenting the utilization of insecticide-treated nets (ITNs) among the country’s representative samples of pregnant women in Myanmar. The results estimated a relatively poor ITNs utilization among pregnant women who mostly preferred to use conventional or untreated nets. The result aligned with other research conducted in Myanmar and Cameroon, in which only 46.6% and 21.8% of pregnant women slept under ITNs [11, 19]. While Myanmar is struggling to attain its malaria elimination target within the given time frame amid limited resources availability [20], prevention becomes fundamental, and should be prioritized at least among malaria vulnerable groups like pregnant women. Every pregnant woman in Myanmar should seek antenatal care at the nearest or most convenient health center starting from the early first trimester followed by regular visits until delivery [21]. Healthcare officers could spread malaria-related health messages during each visit especially for pregnant women residing in ongoing malaria-endemic areas so that unnecessary adverse consequences from the transmission of malaria could be eliminated. Whenever possible, observing proper ITNs utilization among pregnant women should also be accompanied by a home visit.

Given the higher malaria vulnerability among pregnant women, the prioritized distribution of insecticidal nets and expansion of their utilization should also be in place. In this study, although most pregnant women possessed either treated or untreated nets, some did not sleep under bed nets while only a few slept under ITNs. Related studies in Myanmar [11, 22] concluded the uniform results of poor utilization of ITNs despite an increase in distribution. The ITNs utilization rate might be influenced by socio-demographic factors such as age, sex, numbers of family members and type of net, including color and opacity [11, 16, 23, 24]. Some women preferred to use the kinds of nets that uphold utmost privacy rather than a transparent one [11]. Misbeliefs that insecticidal nets could be somehow harmful to their skin and give discomfort or hot feelings were reported among pregnant women [14, 19, 24]. Therefore, the national program should consider putting tremendous effort into distributing ITNs and continue expanding their use by reinforcing directions towards proper use.

Myanmar is composed of 14 states/ regions and one union territory. More than 70% of the total population lives in rural areas [18]. Presently, the country is focusing on flattening malaria caseloads in all states and regions. Particular attention and resource allocations are provided to these areas based on reported cases. Therefore, disparities might exist among each area in terms of strategy and malaria control activities including ITN distribution. Recent national data showed that Chin State presented the highest malaria burden area followed by Karen State. Generally, a greater disease control effort delivered a larger outcome or improvement. However, this study observed the highest non-utilization status among pregnant women residing in delta and lowland regions (Ayeyawady, Yangon, and Bago Regions, Mon, and Karen States) than those living in coastal areas. All the areas except Karen State are in central Myanmar where malaria cases are steeply decreasing, and malaria elimination-specific activities have been implemented since 2017 [8]. Once the malaria burden is reduced, people’s perception of disease severity decreases [25]. The presence of ongoing political instabilities, conflicts, and the influx of population migration inside Karen State might hinder the proper ITNs utilization among pregnant women. Our overall results have been given weight by other studies [10, 17] in Myanmar in which people living in delta and lowland areas presented the poorest utilization status of ITNs.

Generally, malaria is more prevalent in rural areas where high vector density is located. Thus, rural communities might be more aware of the disease, and keep practicing preventive measures, than those living in urban areas. Consequently, pregnant women from the urban areas showed lesser ITN utilization status in this study. Other studies [4, 10] in Myanmar and Ghana also reported that people living in rural areas possessed a higher bed net utilization rate. Thus, malaria awareness-raising campaigns should be implemented primarily in urban areas of the delta, lowland, plain and hilly regions. Given that preventing re-establishment by interrupting onward transmission from the imported malaria cases is essential, pregnant women residing in urban areas should always follow good preventive practices.

Many studies concluded that the individual’s economic status was associated with levels of malaria preventive practice in the community [10, 26–28]. Mostly, ITNs are distributed free of charge directly to the hands of pregnant women. Meanwhile, the country’s GDP is at the lowest level. Universal Health Coverage is still in the skilling up phase [29]. Rural families with financial hardship are trying hard to earn a decent income for their daily survival and healthcare seeking. Therefore, most are usually remote from routine malaria control interventions including awareness-raising campaigns. As per local culture, additionally, women always give priority to their children or other family members. When ITN ownership status is not high, pregnant women cannot utilize the ITN although they possess good malaria preventive knowledge. Need-based targeted interventions are recommended to take place among underprivileged individuals with low economic status in need of support. All families should possess at least one ITN per two persons in their households.

Disseminating health messages using mass media proved effective in many areas, including improving malaria preventive practice [23, 30]. Yet, the approach is likely to be more beneficial for remote areas with transportation difficulties and when in-person mass gathering activities are not allowed for the sake of controlling disease transmission, e.g., COVID-19 [31]. In Myanmar, malaria-related health messages have been broadcast by the government’s ministries and projects [32]. Therefore, no doubt pregnant women residing in areas with access to mass media should have noticed those health messages and know how to practice excellent bed nets utilization.

The study encountered a few limitations. First, it involved secondary data analysis of available data from countrywide demographic and health surveys. Therefore, the number of variables was limited. Other social-behavioral factors including misbeliefs, knowledge of ITN, attitude towards ITN and perceived susceptibility to malaria of pregnant women that might favor the non-utilization of ITNs need to be further explored. Second, the data obtained only by the questionnaire might under- or overestimate the actual situation. Respondents might also wrongly report between conventional bed nets and ITNs. However, these might have been escalated by data collection visits conducted during the DHS by observing ITN utilization. Third, the DHS survey was conducted from 2015 to 2016. Therefore, ITN ownership status might differ since then due to rigorous distributions made after the country’s endorsement towards nationwide malaria elimination in 2015. Despite these limitations, this study provides essential information which could be relied upon to improve the effective utilization of ITNs especially among pregnant women and perhaps children under five; since they are vulnerable to malaria.

Conclusions

Although the bed net ownership status was high, a relatively poor ITN utilization rate was observed among pregnant women in Myanmar. It may jeopardize the attainment of countrywide malaria elimination by 2030. Eliminating unwarranted maternal mortality due to malaria transmission and enhancing the utilization of ITNs among pregnant women is essential. Targeted health education activities among pregnant women should be implemented throughout the country. Next, healthcare professionals should implement routine health education sessions or awareness-raising campaigns for pregnant women during antenatal care visits to foster malaria preventive practices. The priority group includes vulnerable pregnant women residing in urban areas of the delta, lowland, plain and hilly regions.

31 Jan 2022

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Reviewer #1: Thank you very much for this opportunity to revise the manuscript titled "Utilization of insecticide-treated bed nets to prevent malaria transmission among pregnant women in Myanmar – A secondary data analysis of the 2015-2016 nationwide Demographic Health Survey" that was submitted to PLOS ONE. The study is original research that utilized secondary data from 2015-2016 nationwide Demographic Health Survey-Myanmar. The study revealed very low rate of insecticide-treated bed nets usage among pregnant women. Insecticide-treated bed nets are the simplest way of preventing mosquito bites. Mosquito bites causes malaria. Malaria infection affects all persons in malaria endemic areas, however pregnant women and children under five are more vulnerable. In pregnancy, Malaria can cause anaemia, which lead to stillbirths and in some instance maternal morbidity and mortality. Due to the effectiveness of ITNs, most malaria endemic countries resort to free distributions to the population with special attention to the expectant mothers and postnatal mothers. However, in most countries the mere distribution of ITNs do not translate to utilisation. From above therefore, this study therefore is considered very important for policy directions. However, for this work to be published in Plos One, these are some comments for the authors in order to improve the manuscript:

Abstract

Methods under Abstract ought to be improved.

• Indicate the version of STATA used for the analysis.

• The study design in missing in this section.

• At what point, is a variable said to be significant in the inferential statistics?

Introduction

-The authors begin talking about Insecticides Treated bed Nets. However, in many European countries, the use of this method of malaria prevention is little known, so it could be interesting to add a sentence explaining what it consists of and what health benefits it has. This will help readers form countries in which malaria is not endemic to appreciate the importance of this study.

The authors may refer to a study in Ghana for the definition and benefits of ITNs … Utilization of Insecticides Treated Mosquito Nets (ITNs) Among Pregnant Women in Kassena-Nankana Municipality… Kindly refer to the introduction and cite appropriately.

-Kindly read the following published work in Myanmar and update line 78 to 81…. Other studies in Thailand and Myanmar stated that types of occupation, gender, age, socioeconomic status, net ownership, and residing places ….

Liu, H., Xu, J. W., Guo, X. R., Havumaki, J., Lin, Y. X., Yu, G. C., & Zhou, D. L. (2015). Coverage, use and maintenance of bed nets and related influence factors in Kachin Special Region II, northeastern Myanmar. Malaria journal, 14(1), 1-12.

Cheng, B., Htoo, S. N., Mhote, N. P. P., & Davison, C. M. (2021). Association between biological sex and insecticide-treated net use among household members in ethnic minority and internally displaced populations in eastern Myanmar. Plos one, 16(6), e0252896.

Methods

-Kindly specify if the study design is descriptive or analytical cross-sectional study

-Line 126 to 138 including the figure 1 should be moved to introduction.

- Kindly make a sub heading for dependent (outcome) and independent (explanatory) variables and provide vivid description to each.

- The criteria for inclusion into the logistics was not stated. This has the tendency affect the goodness of fit of the model.

See the following (concentrate on the data analysis only);

Mekonnen, B. D., & Wubneh, C. A. (2020). Prevalence and associated factors of contraceptive discontinuation among reproductive-age women in Ethiopia: using 2016 Nationwide Survey Data. Reproductive Health, 17(1), 1-10.

Abubakari, A., Taabia, F. Z., & Ali, Z. (2019). Maternal determinants of low birth weight and neonatal asphyxia in the Upper West region of Ghana. Midwifery, 73, 1-7.

Mutaru, A. M., Asumah, M. N., Ibrahim, M., Sumaila, I., Hallidu, M., Mbemah, J. M., ... & Zakaria, D. Y. (2021). Knowledge on Sexually Transmitted Infections (STIs) and sexual practices among Nursing Trainees in Yendi Municipality, Northern Region of Ghana. European Journal of Health Sciences, 6(4), 33-47.

Results

-Table 1; kindly check the percentages of Wealth index, it is more than 100.0%. Kindly check the values at 1 decimal place again and make necessary changes.

-Line 194, the authors discovered that 96% of the pregnant women possessed bed nets. However, in figure 2 no such information is captured. kindly reconcile the descriptions and figure 2.

-For consistency in reporting of findings …I suggest the authors reports findings as … 96% (95% CI: 93.2, 97.7)

-line 195-198, it is indicated that… “However, 16% (95% CI: 12.4, 20.2) of pregnant women slept without a bed net last night prior to the survey which was a bit higher than the general population (12%). Many of both groups preferred to sleep under the untreated nets. Only about one in five (18.4%, 95% CI: 14.7, 22.9) pregnant women slept under insecticide-treated bed nets”.

-From above, my understanding is that about 84% and 88% of pregnant women and general population respectively slept in bed nets a night to the survey. Is that correct?

-If above question is correct, how then did we get only 18.4% of pregnant women reported to be using insecticide-treated bed nets?

_How do we know that the other nets were not treated? In the introduction, I came across free distribution of bed nets aimed at meeting the 2030 targets by the country. It is the case that, majority of the 96% ownership of bed nets are not treated? Kindly explain and make it clear to the reader.

-The authors further indicated that, only 18.4% slept in ITNs. this is problematic. Because the dependent (outcome) variable was not clearly defined, it is becoming very difficult to understand these findings.

-I would suggest that the methods be clarified to give true meaning to these findings.

-Bed nets and insecticide-treated bed nets should not be used interchangeably. Insecticide-treated bed nets are bed nets, but not all bed nets are insecticide-treated bed nets.

-I also suggest definition of terms at the methods to give true meaning to the findings.

_Line 207 -215 is not very necessary. I suggest to the authors to expunged expunge it.

-Only one variable is significant at the adjusted model because the authors did not control confounding variables. I would suggest that, only significant variables or variables with a p value less than 0.2 at bivariate analysis level be considered in the adjusted model analysis. This should be clearly stated at the methods. You may refer to the materials provided at the methods sections.

Discussions

-The discussion is okay and up to date, However, if authors would not mind, I would suggest they add some studies from Africa to support the work. I am suggesting very recent studies for your perusal and update. Africa is another malaria endemic area and almost all the interventions outline in the study are being done in most Africa countries.

Ngouakam, H., Fru-Cho, J., & Tientche, B. (2021). Awareness, Use, Care of Insecticide-treated Bed Nets among Pregnant Women in Buea (Buea) and Bonassama (Douala). Health Science Journal, 15(2), 1-8.

Asumah, M. N., Akugri, F. A., Akanlu, P., Taapena, A., & Boateng, F. (2021). Utilization of insecticides treated mosquito bed nets among pregnant women in Kassena-Nankana East municipality in the upper east region of Ghana. Public Health Toxicology, 1(2), 1-11. (Read to see why rural folks tend to use ITNs more than the urban folks, and the wealth index too at the discussion section)

Tassembedo, M., Coulibaly, S., & Ouedraogo, B. (2021). Factors associated with the use of insecticide-treated nets: analysis of the 2018 Burkina Faso Malaria Indicator Survey. Malaria Journal, 20(1), 1-9.

-Limitation of this study should be mentioned at the end of the discussions.

Reviewer #2: General comments

The overall structure of the manuscript is good and written based on the commonly agreed structure. The discussion and conclusion section needs major revision based on the objective and the result of the study.

Specific comments

1. Title: it can be modified “utilization of insecticide treated bed nets among pregnant women in Myanmar: analysis of 2015-2016 demographic and health survey”. Because no need of mentioning ---to prevent malaria transmission… as it is known.

2. Abstract

2.1 Background- it lacks information why the authors did the analysis.

2.2 Result- The description of the use of bed net is not clear. It stated that 16% slept without bed net and 18.4 slept under ITN. What about others…16% +18.4%=34.4%, 65.6% are they users or not. Make it clear for the reader. In the main document, it is clear.

Mentioning the result of bivariate analysis in the abstract is not important.

2.3 Conclusion- the recommendation sentence is not based on the significant variable. Mass media exposure do not show a significant association with utilization.

Keywords: it is good if arranged alphabetically

3. Introduction

• Reference number one is outdated you can update and use the 2021 malaria report which indicates 241 million cases of malaria. (https://www.who.int/news-room/fact-sheets/detail/malaria)

• Based on line 51 and 52 sentence, malaria is not a problem of pregnant women. How do the authors explain the public health importance of this research for Myanmar?

• It is good if the authors indicate the interventions by different stakeholders to increase ownership and utilization of ITN among pregnant women.

4. Method

• It is good if line number 126 to 138 presented under the introduction section, which shows the intervention by different stakeholders.

5. Result

• Table 1- the bracket under percentage column for all percent is not necessary as it is written in a separate column. In the table the frequency added to 99.9% not 100%, check it.

• Line 196 seems discussion, not description of the result. It can be stated in the discussion section.

• Line 207-215 should be under bed net utilization, not the factors associated with bed net utilization.

6. Discussion

• The discussion should be guided by the objective of the study. However, most of the parts of the discussion is based on the general understanding not based on the result of the study. Only paragraph 2 and 3 focused discussion based on the objective.

• It lacks the limitation of the study. Many variables may be missed because it is a secondary data such as knowledge, attitude, risk perception etc.

7. Conclusion

• The recommendation part (line 310-318) is a general recommendation not based on the result of the study. Mass media and other intervention suggested is not the significant variables, which is associated with utilization of ITN in this study.

Reviewer #3: The authors focused on the ownership and utilisation insecticide treated nets among pregnant women in Myanmar. Women constitute with children, a major risk group and known to be vulnerable to the disease. Despite great achievement in malaria control during the past decade, due to various interventions, the disease remains a huge public concern in developing countries. This is due partly to low utilisation of ITNs and poor attitude to preventive measures. Therefore, this paper presented aimed at to understand factors associated with the non-utilization of ITNs among pregnant women in Myanmar. The manuscript revealed a relatively poor ITNs utilization rate pregnant woman in Myanmar which could jeopardise the attainment of the malaria elimination goal by 2030. Residing in plains and hilly areas were preditors of non-utilisation of ITNs among pregnant women in Myanmar. With regards to weakness, minor English revision may be useful. The manuscript was well written following PLOS ONE recommended outline. The manuscript represents a high level of scientific work and appear to be an interested topic for scientists works in the areas of ITNs universal coverage.

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Reviewer #1: No

Reviewer #2: Yes: Teklemariam Gultie

Reviewer #3: Yes: bonaventure tientche

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3 Feb 2022

Dear Editors and Reviewers.

Thank you for the constructive comments, critiques, and valuable suggestions. We have now attempted to address each point and provide a point-by-point response in bold blue text in the Response to Reviewers file. Page and Line numbers are referred to clean manuscript file. Figure 1 that is similar to a copyright figure has now been excluded.

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21 Feb 2022

24 Feb 2022

Dear Editors and Reviewers.

Thank you for the constructive comments, critiques, and suggestions. We have now attempted to address each point and provide a point-by-point response in bold blue text below. Page and Line numbers are referred to clean manuscript file.

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28 Feb 2022

Utilization of insecticide-treated bed nets among pregnant women in Myanmar – analysis of the 2015-2016 Demographic and Health Survey

PONE-D-22-00065R2

Dear Dr. Aung,

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.

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Additional Editor Comments (optional):

Reviewers' comments:

2 Mar 2022

PONE-D-22-00065R2

Utilization of insecticide-treated bed nets among pregnant women in Myanmar – analysis of the 2015-2016 Demographic and Health Survey

Dear Dr. Aung:

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.

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PLOS ONE

Table 1

Background characteristics of currently pregnant women included in the Myanmar Demographic and Health Survey 2015–16 (n = 466).

Characteristics		Number	Percentage
Age
	15–24 years	131	28.2
	25–34 years	249	53.3
	35–49 years	86	18.5
Education
	No education	63	13.6
	Primary	203	43.6
	Secondary or higher	200	42.8
Region
	Delta and lowland	206	44.2
	Hills	92	19.8
	Coastal	50	10.6
	Plains	118	25.4
Residence
	Urban	107	22.9
	Rural	359	77.1
Wealth index
	Poorest	139	29.8
	Poorer	93	20.0
	Middle	76	16.4
	Richer	75	16.2
	Richest	82	17.6
Number of household members
	1–3	123	26.4
	4–7	276	59.3
	More than 7	67	14.3
Duration of current pregnancy
	1–5 months	240	51.4
	6–10 months	226	48.6
Number of under 5 children in the household
	None	219	47.0
	One	187	40.2
	More than one	60	12.8
Mass media exposure
	At least once a week	279	59.8
	Less than once a week	187	40.2
Have mosquito net(s) for sleeping
	Yes	447	(96.0)
	No	19	(4.0)
Have at least one insecticide treated net in household
	Yes	154	(33.0)
	No	312	(67.0)

Table 2

Factors associated with non-utilization of insecticide-treated bed nets among currently pregnant women included in the Myanmar Demographic and Health Survey 2015–16 (n = 466).

Characteristics		Total	ITN non-utilization		cOR	p-value	aOR	95%CI
			n	(%)
Total		446	380	81.6
Age						0.075
	15–24 years	131	99	75.4	Ref:		Ref:
	25–34 years	249	206	83.0	1.60		1.63	0.91, 2.89
	35–49 years	86	75	86.8	2.15		2.02	0.91, 4.48
Education						0.389
	No education	63	49	76.8	Ref:		-	-
	Primary	203	164	80.6	1.25		-	-
	Secondary or higher	200	168	84.1	1.59		-	-
Region						<0.001*
	Delta and lowland	206	183	89.0	10.03		7.70	3.62, 16.38
	Hills	92	73	78.8	4.62		4.26	1.91, 9.52
	Coastal	50	22	44.6	Ref:		Ref:
	Plains	118	102	86.3	7.84		7.09	3.09, 16.25
Residence						0.019*
	Urban	107	96	89.5	2.23		1.20	0.53, 2.70
	Rural	359	284	79.2	Ref:		Ref:
Wealth index						0.034*
	Poorest	139	110	79.2	Ref:		Ref:
	Poorer	93	70	75.3	0.80		0.62	0.31, 1.27
	Middle	76	59	77.0	0.88		0.60	0.27. 1.33
	Richer	75	66	87.8	1.89		1.27	0.51, 3.18
	Richest	82	75	91.2	2.72		1.41	0.48, 4.13
Number of household members						0.588
	1–3	123	100	81.3	Ref:		-	-
	4–7	276	229	82.7	1.10		-	-
	more than 7	67	51	77.3	0.78		-	-
Duration of current pregnancy						0.474
	1–5 months	240	198	82.8	Ref:		-	-
	6–10 months	226	182	80.3	0.84		-	-
Number of under 5 children in the household						0.084
	None	219	186	84.9	Ref:		Ref:
	One	187	151	80.6	0.74		0.86	0.48, 1.53
	More than one	60	43	72.5	0.47		0.59	0.27, 1.26
Mass media exposure						0.014*
	At least once a week	279	238	85.2	Ref:		Ref:
	Less than once a week	187	142	76.1	1.55		0.91	0.51, 1.61

ITN: Insecticide-treated Net; cOR: Crude Odd Ratio; aOR: Adjusted Odd Ratio; CI: Confidence Interval; *Significance at p<0.05.