Knowledge, Attitude, and Practice Toward Antitubercular Agents Among Pulmonary Tuberculosis Patients in Southwestern China: A Cross-Sectional Study

Introduction

Tuberculosis (TB) is the leading cause of death from a single infectious disease agent worldwide. A global total of 10.8 million people were reported as newly diagnosed with TB in 2023, with China accounting for 74,000 new cases, ranking third globally.¹ Despite the World Health Organization’s (WHO) emphasis on directly observed treatment, short-course (DOTS) strategy and fixed-dose combination (FDC) to improve adherence,² patient-level barriers persist, particularly in low-resource settings. Knowledge, Attitudes, and Practices (KAP) research methodology is commonly used in public health and health behavior areas, WHO recommends KAP surveys to identify knowledge gaps, cultural beliefs, and behavioral barriers in tuberculosis (TB) control, enabling targeted interventions and effective communication strategies.³ However, most existing KAP studies focus on general tuberculosis (TB) awareness rather than knowledge of first-line antitubercular agents.^4–6 Evidence from Chongqing, China—a region with high TB incidence (51.73/100,000, ranking 8th in mainland China) and mortality (0.36/100,000, ranking 4th in mainland China) rates,⁷ coupled with significant socioeconomic disparities—remains limited.⁸ This study aimed to evaluate KAP toward first-line antitubercular drugs among active pulmonary TB patients in Chongqing, China and identify modifiable sociodemographic factors driving KAP disparities. Findings will guide the development of context-specific strategies to optimize TB care in similar settings.

Materials and Methods

Patients

A simple sampling survey was conducted among 190 patients with active pulmonary TB who visited the TB clinic of Chongqing Ninth People’s Hospital from June 1, 2021 to December 31, 2021. Each patient was limited to one answer. Inclusion criteria: 1) patients aged 15–75 years old; 2) those diagnosed with active secondary TB; 3) HRZE/HR anti-TB treatment <6 months for treatment-naive patients; 4) informed consent was obtained and case information was complete. Exclusion criteria: 1) patients who could not take the medicine independently due to their age and physical dysfunction; 2) those who could not complete the questionnaire due to mental and psychological abnormalities, difficulties in expression and understanding, etc.

Questionnaire Design

The questionnaire was designed through discussion among physicians and researchers with extensive experience in the diagnosis and treatment of pulmonary TB. A pre-survey was conducted to validate the rationality and readability of the questionnaire. Researchers underwent unified training before participating in the research. The questionnaire includes four parts: demographics (6 questions), knowledge (5 questions, scored 0–9), attitude (4 questions, scored 4–20), and practice (4 questions). Demographics included age, gender, education, occupation, income, and drug dosage form. For the knowledge section, researchers verified patients’ actual medication regimens. For the medication plan (drug name, dosage, frequency), 0 points indicated that all drugs were wrong, 1 point indicated that some were right, and 2 points indicated that all were right. For the medication time, 0 points indicated that the time was wrong and 1 point indicated that the time was right. For adverse drug reactions (ADRs), 0 points were used for 0 correct answers, 1 point for 1–2 correct answers, and 2 points for ≥3 correct answers. The attitudes section included attitudes about voluntarily stopping taking drugs or missing drugs, the relationship between drug resistance and taking drugs, and the impact of taking drugs on life, which were scored using the 5-point Likert scale, where 1 = “strongly disagree”, 2 = “disagree”, 3 = “neutral”, 4 = “agree”, and 5 = “strongly agree”. The practice section included the use of anti-TB drugs, managing ADRs, post-treatment after a missed dose, and whether to actively acquire drug knowledge. To ensure accuracy, practice data were cross-validated through patient self-reports and researchers’ reviews of prescriptions and clinical visit records in the medical system. This study was approved by the Ethics Committee of Chongqing Ninth People’s Hospital (No. 2021–011).

Sample Size Calculation

The sample size was calculated using the following formula:⁹

where z is the z score; ε is the margin of error; N is the population size; and p is the population portion. According to the 2015–2020 Chongqing Ninth People’s Hospital data, an estimated 300 new cases of TB were reported each year. With a population proportion of 50%, a margin of error of 5%, and a confidence interval of 95%, the sample size was set at 169, conservatively estimating the invalid rate of the questionnaires being 10%.

Data Analysis

Data were analyzed using SPSS 25.0. Statistical tests indicated that all continuous variables in this study were non-normally distributed. Therefore, continuous data were expressed as the median and interquartile range [M (P25,P75)]. Categorical variables were expressed as frequency and percentage. Data were compared using the rank sum test. The χ2 test or Fisher’s test was used to compare categorical variables. Subgroup analyses included gender (male, female), age (< 60 years, ≥ 60 years), income level (<1000 yuan, ≥ 1000 yuan), educational level (secondary school or below, junior college or above), occupation type (farmer, other), and pharmaceutical dosage forms taken (only compound preparations, including single preparations). P < 0.05 was considered statistically significant.

Results

Demographic Characteristics

Among 190 respondents, 188 were included in the final analysis (98.9% response rate), excluding 2 cases with incomplete basic information. Of the 188 eligible patients, 129 were males (68.6%) and 59 were females (31.4%). The average age was 49.2 ± 17.8 years old, ranging from 16 to 75 years. Low educational attainment (secondary school or below: 76.6%) and low-income status (<1000 yuan/month: 44.1%) were prevalent. Occupations were predominantly farmers (28.7%) and workers (25.0%). Most patients (70.7%) received single-drug formulations. Full demographic details are provided in Table 1.

Table 1 Respondent Demographics Information

Knowledge

The median knowledge score was 7 (4, 8), with 44.7% of participants scoring below the median. 64.9% correctly identified their prescribed drugs, and 61.2% knew the correct administration time, but only 50.3% accurately reported dosage, frequency, or adverse drug reactions (ADRs) (Table S1).

Subgroup analyses revealed significant disparities. Age: Patients aged ≥60 years scored lower than those <60 years (P = 0.001). Education: Junior college-educated participants outperformed those with ≤secondary education (P < 0.001). Income: Participants earning <1000 yuan/month had lower scores than higher-income groups (P = 0.049). Occupation: Farmers scored lower than non-farmers (P = 0.015). Treatment: Fixed-dose combination (FDC) users scored higher than single-drug users (P < 0.001). No gender-based differences were observed (P = 0.261). Full statistical results are presented in Table 2 and Figure 1A.

Table 2 Knowledge Score in Subgroups

Figure 1 Knowledge, Attitude, and Practice (KAP) Toward First-Line Antitubercular Drugs Among Pulmonary Tuberculosis Patients (A) Knowledge Scores: Distribution of medication literacy scores (0–9 points) across demographic subgroups. Higher scores indicate better understanding of drug names, dosages, frequencies, and adverse reactions. (B) Attitude Scores: Attitudes toward antitubercular drugs were assessed using a 5-point Likert scale (total score range: 4–20), with higher scores indicating better medication-related perceptions. (C) Practice Behaviors: Patients who responded ‘yes’ to medication-related behavioral choices were considered to demonstrate correct practice behaviors.

Attitude

The attitude questionnaire yielded a median score of 13 (11,14). 14.4% believed self-discontinuing medication was acceptable when symptoms improved, 47.9% perceived no treatment impact from missed doses, and 20.2% denied links between medication adherence and drug resistance (Table S2).

Subgroup disparities were significant. Age: Participants aged <60 years scored higher than those ≥60 years (P = 0.001). Education: Junior college-educated individuals scored higher than those with ≤secondary education (P < 0.001). Occupation: Farmers scored lower than non-farmers (P = 0.004). No associations were observed with gender, income, or drug formulation (P > 0.05). Complete statistical outcomes are detailed in Table 3 and Figure 1B.

Table 3 Attitude Score in Subgroups

Practice

Through patient self-reports and clinical record verification, most (81.9%, 154/188) respondents continued to take medicine according to the anti-TB treatment plan given by the doctor, while 18.1% deviated. For adverse drug reactions (ADRs), 81.9% respondents sought medical treatment immediately after drug-related ADRs, but 18.1% self-monitored or self-adjusted doses. Only 52.7% compensated for missed doses, and 48.9% actively sought drug-related knowledge (Table S3).

Women were more likely than men to compensate for missed doses (P = 0.005) and seek drug knowledge (P = 0.011). Younger participants (<60 years) compensated for missed doses (P = 0.026) and sought drug knowledge (P < 0.001) more frequently than older adults (≥60 years). Low-income participants (<1000 yuan/month) sought medical care for ADRs more promptly (P = 0.022). Junior college-educated participants actively acquired drug knowledge compared to those with ≤secondary education (P < 0.001). Fixed-dose combination (FDC) users sought drug knowledge more than single-drug users (P = 0.014). Farmers lagged in knowledge-seeking (P < 0.001). No factors significantly predicted overall treatment adherence (ie, continued adherence to the treatment plan as scheduled) (P > 0.05). Full results are presented in Table 4 and Figure 1C.

Table 4 Practice in Subgroups

Discussion

To the best of our knowledge, this is the first knowledge, attitude, and practice (KAP) study to explore first-line antitubercular drugs in patients with active pulmonary TB. Our finding demonstrate significant differences and deficiencies in the KAP toward antitubercular drugs among patients with active pulmonary TB in southwestern China, particularly among older, less educated, and low-income rural populations. These results are similar to previous studies in other low-resource settings.^4,10

Although most single-drug formulations are given once on an empty stomach, pyrazinamide is often recommended three times a day due to its gastrointestinal side effects,^11–13 which may easily confuse patients. Our study found that patients with active TB had less than 70% correctly identified their drug name, dosage, frequency, time, or ADRs. This contrasts with higher awareness rates reported in urban Chinese cohorts,^10,14 underscoring the need for tailored education in rural areas.^15,16 Our research suggests that more efforts to be focused on educating the elderly, low-education, low-income, and peasant groups about antitubercular drugs.^17,18 Patients using FDC alone demonstrated better medication knowledge, potentially attributable to simplified dosing schedules and reduced pill burden.^19–21 These findings support WHO recommendations for FDCs to improve adherence,² though challenges remain in regions where single-drug formulations dominate. Therefore, doctors are recommended to prioritize FDC prescriptions, which may have a positive impact on improving patients’ knowledge about drugs, compliance, and treatment outcomes.^19–21 New regimens, such as the WHO-recommended 4-month rifapentine regimen with moxifloxacin (2HPMZ/2HPM), may also reduce drug side effects and shorten treatment time.^2,17 Furthermore, the use of new media technologies, such as social media applications (APPs), for health education is becoming widely accepted by patients.^22–24

Some studies on the causes of drug resistance in pulmonary TB show that irregular medication is the significant cause of drug resistance.^25–27 Nearly half (47.9%, 90/188) of the patients believed that missing doses did not affect the effect of antitubercular treatment, and 41.0% (77/188) of the respondents perceived TB drugs as disruptive to daily life—attitudes strongly associated with older age and lower education levels, this finding aligns with previous studies on treatment adherence.^15,18 This may reflect systemic issues such as limited access to healthcare resources in rural southwestern China,^28–31 compounded by stigma and financial constraints.^18,32,33 Targeted TB awareness programs for the public could alleviate societal prejudice against patients,^15,18 fostering better adherence to treatment.

In our study, 18.1% (34/188) of patients experiencing ADRs chose to self-monitoring, reduce the dose, or treatment discontinuation. Although studies have shown that most ADRs are mild and do not warrant treatment stoppage, there are also serious and even fatal reports.^13,34 Our study found that higher-income patients were not active in seeking medical attention after experiencing ADRs, inconsistent with the findings of some studies on the effect of income on compliance,^35,36 but consistent with reports of suboptimal health-seeking behavior in high-income people.^33,37 Therefore, education on ADRs should be strengthened for higher-income patients to avoid fluke-related adverse consequences. Our data further showed that a significant proportion of respondents neglected to compensate for missed doses (47.3%, 89/188) or proactively acquire drug-related knowledge (51.1%, 96/188), with these behaviors being more pronounced among elderly male patients. Therefore, doctors or community volunteers should pay more attention to elderly male patients when providing treatment support.^27,38 Conversely, patients with junior college education or above demonstrated greater initiative, aligning with global evidence on education’s role in health literacy (15,16). Farmers, representing 28.7% (54/188) of our cohort, rarely sought drug-related knowledge and scored lowest in KAP domains. This mirrors China’s high TB burden in underdeveloped regions.²⁸ To address this, combining material incentives with community health worker programs could improve outcomes.³⁹

Conclusion

In summary, this study unravels significant differences and deficiencies in the knowledge, attitude, and practice toward first-line antitubercular drugs among patients with active pulmonary TB. Older, less educated and farmers demonstrated markedly lower knowledge and attitude scores, coupled with higher rates of non-adherent practices. Therefore, providing appropriate health education on antitubercular drugs is paramount to improving patients’ cognitive levels, changing bad practice behaviors, and obtaining good treatment outcomes.