Review 1: "Determinants of Timely Malaria Treatment among Under-Five Children Attending Public Health Facilities in Kisumu East Sub-County, Kenya: A Health Facility-Based Cross-Sectional Study"

RR:C19 Evidence Scale rating by reviewer:

• Reliable. The main study claims are generally justified by its methods and data. The results and conclusions are likely to be similar to the hypothetical ideal study. There are some minor caveats or limitations, but they would/do not change the major claims of the study. The study provides sufficient strength of evidence on its own that its main claims should be considered actionable, with some room for future revision.

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Review: This study uses results from a cross-sectional survey of 434 caregivers of children under-five with diagnosed malaria to assess the determinants of diagnosis and treatment using appropriate antimalarial within 24 hours of onset of symptoms. The authors focus on demand-side determinants and conclude that the ability to recognize malaria symptoms, positive perspective of approved malaria drug, use of over-the-counter medication, having health insurance and having previously sought timely malaria care were associated with timely malaria treatment, while visiting an herbalist, cost of malaria treatment and fear of malaria drug’s side effects were associated with delay of malaria treatment.

The conclusions of this study are generally justified by its methods and data. There are two major limitations related to generalizability of the findings, but they are not likely to change the primary claims of the study. The study provides sufficient strength of evidence that its main claims should be considered reliable.

The primary limitations of the study are related to selection of respondent and impact the generalizability of the findings. First, the study excluded caretakers who did not seek care. Because of this the interpretation of the results is regards to the timing of care, but not the equally important question of if a caretaker sought care at all. While this is an important limitation, I don’t believe the limitation impacts the conclusions or policy recommendations of the study, which remain valid even if they apply only to the set of those who sought care. Second, the study excludes caretakers who sought care elsewhere prior to coming to the public facility and who were less than 18 years old. Again, these limitations may lead to selection bias and limit generalizability, although are not likely to substantively change the policy conclusions associated with the key conclusions.