Household costs and health-related quality of life of childhood MDR-TB in Western Cape, South Africa
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Abstract
Background
Multidrug-resistant (MDR) tuberculosis (TB) in children remains a major public health challenge. Although treatment is provided free of direct charge in many countries, it can impose substantial indirect and non-medical costs on affected households. Evidence on the economic burden of childhood MDR-TB on families, remains limited.
Methods
A cross-sectional household survey was conducted in the Western Cape, South Africa, among 45 households with a child <15 years who initiated MDR-TB treatment between 2018 and 2021. Socioeconomic status, costs of accessing care, and health-related quality of life (HRQoL) were assessed and linked to health service utilisation data to estimate household-level costs.
Results
The median total cost per household was ZAR 7,443 (US$504) per episode of care (IQR: ZAR 4,119– 13,207), with indirect costs accounting for the largest share of household costs. Twenty-three (51.1%) of the households incurred catastrophic health expenditure, defined as >20% of annual household income. Costs increased with hospital-based care, longer treatment duration, and more frequent caregiver visits. The HRQoL of children was generally high, though not uniformly distributed.
Conclusions
Childhood MDR-TB places a substantial financial burden on already vulnerable households. Economic evaluations and care models should incorporate household costs and consider strategies to reduce the indirect burden of treatment on families.
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This Zenodo record is a permanently preserved version of a PREreview. You can view the complete PREreview at https://prereview.org/reviews/17517769.
Peer Review
Title:
Household costs and health-related quality of life of childhood MDR-TB in Western Cape, South Africa
Authors:
Wilkinson et al.
Reviewer:
Houser Chen
Summary and Overall Impression
This study examines the financial burden and health-related quality of life (HRQoL) of children with multidrug-resistant tuberculosis (MDR-TB) and their families in Western Cape, South Africa. Using a cross-sectional household survey of 45 households, the authors estimate direct and indirect costs of care and assess HRQoL using validated instruments. They find that despite free treatment, households experience substantial indirect costs—mainly transport and lost income—and that nearly half spend more …
This Zenodo record is a permanently preserved version of a PREreview. You can view the complete PREreview at https://prereview.org/reviews/17517769.
Peer Review
Title:
Household costs and health-related quality of life of childhood MDR-TB in Western Cape, South Africa
Authors:
Wilkinson et al.
Reviewer:
Houser Chen
Summary and Overall Impression
This study examines the financial burden and health-related quality of life (HRQoL) of children with multidrug-resistant tuberculosis (MDR-TB) and their families in Western Cape, South Africa. Using a cross-sectional household survey of 45 households, the authors estimate direct and indirect costs of care and assess HRQoL using validated instruments. They find that despite free treatment, households experience substantial indirect costs—mainly transport and lost income—and that nearly half spend more than 20% of annual income on TB-related care. Most children report good overall quality of life, although pain and emotional distress remain common. Overall, this paper addresses an important and underexplored area of pediatric MDR-TB research. The manuscript is clearly written, methodologically sound, and relevant to public health policy. However, several areas would benefit from further contextualization and discussion.
Major Comments
1. Sample Size and Representativeness The inclusion of only 45 households may limit statistical power and generalizability. The authors should acknowledge how potential selection bias (e.g., unreachable or non-consenting families) might affect cost and HRQoL estimates. Comparing respondent demographics to known regional data could help readers assess representativeness. 2. Measurement of Indirect Costs Indirect costs were estimated using South Africa's national minimum wage. Since many caregivers likely work informally or are unemployed, this assumption could over- or underestimate the true economic burden. Please justify this decision, and, if possible, include sensitivity analyses or note how alternative valuation methods (e.g., opportunity cost or median reported wage) might change the results. 3. Interpretation of HRQoL Scores The mean VAS and EQ-5D-Y scores are presented without comparison to normative data. Providing reference values for healthy children in South Africa or similar settings would contextualize whether the observed scores indicate near-normal functioning or persistent impairment. 4. Impact of COVID-19 The study period overlapped with the COVID-19 pandemic, but the paper gives little detail on how this affected access to care, household income, or costs. Even a brief discussion—such as acknowledging service disruptions or transportation restrictions—would enhance the relevance of the findings.
Minor Comments
- The introduction could more clearly identify the specific research gap in pediatric MDR-TB cost and HRQoL data. - Some tables (e.g., cost breakdowns) could be simplified to improve readability. - Clarify the currency conversion rate and reference year in the Methods section. - The policy discussion would be stronger if it proposed concrete interventions (e.g., cash transfers, transport subsidies, or nutritional support).
Strengths
- Integrates household survey data with clinical records, reducing recall bias. - Addresses an intersection of economic, social, and health outcomes rarely studied in children with MDR-TB. - Employs validated HRQoL instruments with clear methodological transparency. - The writing is structured and accessible for multidisciplinary readers.
Overall Recommendation
This is a valuable and timely contribution to the understanding of the socioeconomic impact of childhood MDR-TB. The revisions suggested above would clarify methodological assumptions, improve interpretability, and strengthen policy relevance. Recommendation: Minor Revision.
Competing interests
The authors declare that they have no competing interests.
Use of Artificial Intelligence (AI)
The authors declare that they used generative AI to come up with new ideas for their review.
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This Zenodo record is a permanently preserved version of a PREreview. You can view the complete PREreview at https://prereview.org/reviews/17517794.
Peer Review
Title:
Household costs and health-related quality of life of childhood MDR-TB in Western Cape, South Africa
Authors:
Wilkinson et al.
Reviewer:
Houser Chen
Summary and Overall Impression
This study examines the financial burden and health-related quality of life (HRQoL) of children with multidrug-resistant tuberculosis (MDR-TB) and their families in Western Cape, South Africa. Using a cross-sectional household survey of 45 households, the authors estimate direct and indirect costs of care and assess HRQoL using validated instruments. They find that despite free treatment, households experience substantial indirect costs—mainly transport and lost income—and that nearly half spend more …
This Zenodo record is a permanently preserved version of a PREreview. You can view the complete PREreview at https://prereview.org/reviews/17517794.
Peer Review
Title:
Household costs and health-related quality of life of childhood MDR-TB in Western Cape, South Africa
Authors:
Wilkinson et al.
Reviewer:
Houser Chen
Summary and Overall Impression
This study examines the financial burden and health-related quality of life (HRQoL) of children with multidrug-resistant tuberculosis (MDR-TB) and their families in Western Cape, South Africa. Using a cross-sectional household survey of 45 households, the authors estimate direct and indirect costs of care and assess HRQoL using validated instruments. They find that despite free treatment, households experience substantial indirect costs—mainly transport and lost income—and that nearly half spend more than 20% of annual income on TB-related care. Most children report good overall quality of life, although pain and emotional distress remain common. Overall, this paper addresses an important and underexplored area of pediatric MDR-TB research. The manuscript is clearly written, methodologically sound, and relevant to public health policy. However, several areas would benefit from further contextualization and discussion.
Major Comments
1. Sample Size and Representativeness The inclusion of only 45 households may limit statistical power and generalizability. The authors should acknowledge how potential selection bias (e.g., unreachable or non-consenting families) might affect cost and HRQoL estimates. Comparing respondent demographics to known regional data could help readers assess representativeness. 2. Measurement of Indirect Costs Indirect costs were estimated using South Africa's national minimum wage. Since many caregivers likely work informally or are unemployed, this assumption could over- or underestimate the true economic burden. Please justify this decision, and, if possible, include sensitivity analyses or note how alternative valuation methods (e.g., opportunity cost or median reported wage) might change the results. 3. Interpretation of HRQoL Scores The mean VAS and EQ-5D-Y scores are presented without comparison to normative data. Providing reference values for healthy children in South Africa or similar settings would contextualize whether the observed scores indicate near-normal functioning or persistent impairment. 4. Impact of COVID-19 The study period overlapped with the COVID-19 pandemic, but the paper gives little detail on how this affected access to care, household income, or costs. Even a brief discussion—such as acknowledging service disruptions or transportation restrictions—would enhance the relevance of the findings.
Minor Comments
- The introduction could more clearly identify the specific research gap in pediatric MDR-TB cost and HRQoL data. - Some tables (e.g., cost breakdowns) could be simplified to improve readability. - Clarify the currency conversion rate and reference year in the Methods section. - The policy discussion would be stronger if it proposed concrete interventions (e.g., cash transfers, transport subsidies, or nutritional support).
Strengths
- Integrates household survey data with clinical records, reducing recall bias. - Addresses an intersection of economic, social, and health outcomes rarely studied in children with MDR-TB. - Employs validated HRQoL instruments with clear methodological transparency. - The writing is structured and accessible for multidisciplinary readers.
Overall Recommendation
This is a valuable and timely contribution to the understanding of the socioeconomic impact of childhood MDR-TB. The revisions suggested above would clarify methodological assumptions, improve interpretability, and strengthen policy relevance. Recommendation: Minor Revision.
Competing interests
The authors declare that they have no competing interests.
Use of Artificial Intelligence (AI)
The authors declare that they did not use generative AI to come up with new ideas for their review.
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