PONE-D-23-33162Willingness and ability to pay for breast cancer treatment among patients from Addis Ababa, Ethiopia: a cross-sectional studyPLOS ONE

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Academic Editor

PLOS ONE

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[We thank all collaborators including the employees of the public and private health facilities where data were collected, BC patients who were willing to be interviewed and DAAD PAGEL project No. 57513614, Else-Kroener-Foundation, German Ministry of Research and Education that provided support in various ways for successful accomplishment of this study. Special thanks go to the School of Public Health, College of Health Science Addis Ababa University and Martin-Luther-University, Halle-Wittenberg, Germany for their major contribution to this study by providing the necessary technical and logistic support during the study as required. We acknowledge the proofreading assistance of Dawn M. Bielawski, PhD.]

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 [This work was supported by DAAD PAGEL project No. 57513614. It was also supported by Else-Kroener-Foundation through Martin-Luther-University, Halle-Wittenberg, Germany, Grant No. 2018_HA31SP. The work was also supported through the German Ministry of Research and Education, Grant 01KA2220B. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript]

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. 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

Reviewer #3: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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3. 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

Reviewer #3: Yes

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4. 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: Yes

Reviewer #3: Yes

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5. 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: Manuscript “Willingness and ability to pay for breast cancer treatment among patients from Addis Ababa, Ethiopia: a cross-sectional study” has described the reality of Breast Cancer treatment in Ethiopia. The manuscript is well written and data provided support the author’s conclusion.

Reviewer #2: Comments to the Author

Congratulations on the submitted manuscript. The topic is timely and will be of interest to the readers of the journal. However, a few changes are suggested to improve the clarity of this manuscript. I have several recommendations and questions about the manuscript.

1.Abstract

Methods: We collected data from 204 randomly selected BC patients who received

treatment at one of four different health facilities (one public and three private) between

April 2020 and January 2021.

Recommend replacing the word “we” with “researchers”

What are the inclusion and exclusion criteria?

2. Introduction

Very good explanation

3. Methodology

Please state the sample design used in this study.

4. Recommendation

Recommend adding the subheading for recommendations for this study.

5.Conclusion

How do the findings add to the body of scientific knowledge on the particular issue?

Should highlight the implication of the results to health policy.

6. References

Most of the citations are less than 5 years. 39/61

Recommendation: 5 years above is more updated.

Please add doi in the article’s references.

Reviewer #3: Overall, the article is well-structured with distinct sections for abstract, introduction, methods, results, and conclusions. This makes it easy to follow.

1. Line 59; consider rephrasing "According to the Addis Ababa Population Based Cancer Registry database" to "According to data from the Addis Ababa Population Based Cancer Registry."

2. Line 63, instead of "Many BC patients come to Tikur Anbessa Specialized Hospital-Radiation Centre," you could write "Many breast cancer (BC) patients seek treatment at the Tikur Anbessa Specialized Hospital-Radiation Centre."

3. Line 74; consider rephrasing "This holds true for BC patients" to "This is also applicable to BC patients."

4. Line 89, it would be clearer to replace "To determine whether the treatment is affordable or not" with "To determine the affordability of treatment."

5. Line 90, "Willingness to pay (WTP) is defined as a person's willingness to pay for the good or services he/she wants to buy while ability to pay (ATP) is defined as the person's ability to pay for the chosen good or services" could be simplified to "Willingness to pay (WTP) refers to a person's willingness to pay for desired goods or services, while ability to pay (ATP) refers to their financial capacity to do so.

6. Line 102; consider rephrasing "Examining WATP is central to a meaningful analysis of demand for health care services" to "Analyzing WATP is crucial for understanding the demand for health care services."

7. While you've mentioned that the sample size was distributed among the four health facilities based on the number of BC patients they treated before data collection, it would be beneficial to provide more details on how this distribution was carried out. Was it a simple proportional allocation, or were there other considerations involved?

8. It's good that you accounted for a non-response rate of 15%. However, providing a brief justification or citing literature for choosing this specific rate would enhance the transparency of your methodology.

9. The assumed standard deviation of direct medical costs ($355 USD per BC treatment) seems crucial for sample size calculation. Providing a justification or reference for this assumption would strengthen the validity of your calculations.

10. It's mentioned that imputations were not performed for missing data. While this is acceptable, it would be useful to mention the extent of missing data and any sensitivity analyses conducted to assess the impact of missing data on the results.

11. Line 114 "For this study, we included all BC patients who were permanently residing in Addis Ababa and who were receiving BC treatment in PCC and the three privately owned health facilities at the time of data collection." - To improve clarity, consider rephrasing: "For this study, we included all breast cancer (BC) patients permanently residing in Addis Ababa and receiving treatment at PCC and the three privately owned health facilities at the time of data collection."

12. Line 149 "Informed patient consent was obtained orally at the beginning of each interview and documented on the questionnaire by the data collectors." - Consider revising for clarity: "Informed consent was obtained orally from each patient at the beginning of the interview and documented on the questionnaire by the data collectors."

13. In Table 1 Explanation of Income Categories: Provide a brief explanation of the income categories (e.g., low-income, middle-income, high-income) to give context to readers who may not be familiar with the currency or income distribution in the study setting

14. In Table 4, the sample sizes for some categories (e.g., unemployed) are very small, which could affect the reliability of estimates.

15. It might be beneficial to compare the costs reported in this study with national or regional averages for breast cancer treatment. This comparison could help contextualize whether the observed costs are consistent with broader trends in healthcare pricing.

16. Line 271; there is number 3 between ( ); it stands for what?

17. Line 245; the numbers order is not corrected, Please fix it?

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Reviewer #1: No

Reviewer #2: Yes: DR RUSNANI AB LATIF

Reviewer #3: No

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Attachments

Attachment

Submitted filename: Reviewer MA comments.docx

Willingness and ability to pay for breast cancer treatment among patients from Addis Ababa, Ethiopia: a cross-sectional study

PONE-D-23-33162R1

Dear Dr. Unverzagt,

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.

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Kind regards,

Ahmed Mancy Mosa, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

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 #2: All comments have been addressed

Reviewer #3: All comments have been addressed

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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 #2: Yes

Reviewer #3: Yes

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

Reviewer #2: Yes

Reviewer #3: 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 #2: (No Response)

Reviewer #3: Yes

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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 #2: Yes

Reviewer #3: Yes

**********

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 #2: Dear Authors

Congratulations on your manuscript, I have checked the reviewer’s comment, and all the amendments were implemented in response to the reviewers' recommendations and commendations.

Reviewer #3: the authors have addressed all comments provided previously in the first round of revision. I am in favor of accepting the manuscript for publishing.

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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 #2: Yes: DR RUSNANI AB LATIF

Reviewer #3: No

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