TB commonly affects people of lower socioeconomic status and exacerbates poverty and social deprivation through catastrophic costs25 and reduced household income. Most children with TB develop TB after contact with an adult family member with infectious PTB. A high number of TB notifications in children indicates an ongoing adult epidemic (170). TB in the family unit does not only result in transmission to children: it also poses a threat to household income and financial security. Some examples of the impact of TB on children include dropping out of school following parental bereavement from TB or to work to maintain household income (171). TB in childhood or adolescence may disrupt or delay schooling and impair growth (172).
As part of the process of developing the consolidated guidelines on the management of TB in children and adolescents, a conceptual framework was developed that outlined the pathways and mechanisms that most plausibly explain the socioeconomic impact of TB on children and adolescents (Atkins S, Heimo L, Carter D et al., unpublished data, 2022).
In this framework material, educational and psychosocial impacts contributed to in child impoverishment; missed educational opportunities; reduced physical, intellectual and emotional growth; and poor mental health.
An associated scoping review reported that time spent caring for a child with TB impacted on family spending, nutrition and education, and overall reduced household income, all of which were associated with lowered family well-being. TB impacted on children’s education, particularly when the affected family member was male and the primary breadwinner, sometimes with inter-generational consequences. Hospitalization and other aspects of TB treatment, including directly observed treatment, impacted on school attendance. In addition, perceived and enacted stigma had practical implications for TB diagnosis, clinic attendance and treatment, and other psychosocial impacts beyond stigma, including breakdown of parental relationships were reported.
In addition to the scoping review, an analysis of data from 10 national TB patient cost surveys was undertaken, including almost 1500 children and adolescents. National patient cost surveys are not usually designed or powered to detect the proportion of children and adolescents with catastrophic costs, but the findings from these analyses provided useful additional insights into the consequences of a TB diagnosis for children and adolescents. Overall, if the person with TB was a child or adolescent, the proportion of households that experienced catastrophic costs was lower (41.8%, 95% CI 22.9–60.8%) than if the person was an adult (56.2%, 95% CI 44.4–68.1%).
School disruption was one of the major consequences among children (8.4%, 95% CI 3.4–13.4%) and adolescents (18.7%, 95% CI 8.8–28.7%) with TB. Food insecurity was experienced by 19.8% (95% CI 3.7–35.8%) of children with TB and 20.5% (95% CI 11.5–29.8%) of adolescents with TB. Households had little access to social protection during TB treatment. In households where the person with TB was a child, a pooled average of 7.9% (95% CI 1.9–14.0%) had access to social protection; for adolescents, this figure was 12.0% (95% CI 2.2–21.9%).
These findings emphasize the need for social protection for children and adolescents with TB. In addition, based on identified needs, a family-centred approach to social protection may be used. Education, food insecurity and social protection are multisectoral issues that require strong linkages with programmes in other sectors as they strive for comprehensive TB care.
Based on the findings of the scoping review, the following steps may help mitigate and better understand the socioeconomic impact of TB on children and adolescents, including:
- models of care and treatment adherence strategies that are family- and child-friendly and that have fewer socioeconomic consequences, while still facilitating treatment completion and maintaining a supportive environment for treatment overall;
- family-centred models of care for the design of strategies and policies to mitigate the direct and indirect effects of TB on children and adolescents;
- additional complementary research to evaluate the socioeconomic impact of TB care for children and adolescents and the effect of social protection and other mitigation strategies.
25The operational definition of “catastrophic costs as a result of TB” refers to medical and non-medical out-of-pocket payments and indirect costs exceeding a given threshold (e.g. 20%) of the household’s income. Medical costs refer to the sum of out-of-pocket payments for TB diagnosis and treatment made by people with TB in a given household. Non-medical out-of-pocket costs are payments related to the use of TB health services, such as payments for transportation, accommodation or food. Both costs are net of any reimbursements to the individual who made the payments. Indirect costs refer to patient or guardian lost time, lost wages (net of welfare payments) and lost income due to TB health-care seeking and hospitalization during the TB episode.