Abstract
BACKGROUND: Low adherence to tuberculosis (TB) treatment remains a major driver of adverse health outcomes in high-burden countries. While guidelines recommend routine client education, its effectiveness and the knowledge constructs that influence adherence remain poorly defined. METHODS: We conducted a prospective cohort study of adults (≥18 years) initiating treatment for drug-susceptible TB in Kampala, Uganda. We assessed clients' TB knowledge before and after routine education and at the two-week, two-month, and five-month follow-up visits. We recorded self-reported seven-day medication adherence at each visit and final treatment outcomes. We used paired t-tests to compare knowledge scores (0-100) before and after education. We constructed multivariable Poisson and logistic regression models to examine the association of knowledge with the outcomes of nonadherence and WHO-defined treatment success. RESULTS: We enrolled 80 participants (28% female; 36% living with HIV). Overall TB knowledge scores increased by 25 points (95% CI 22-28), from 53 to 78, yet only 9% achieved TB literacy (an overall TB knowledge score ≥90) after TB education, peaking at 18% at two weeks, before declining to just 3.6% at five months. Each 10-point increase in post-education knowledge was associated with a reduction in nonadherence of 15% (IRR0.1 0.85; 95% CI 0.72-1.00, p = 0.048) at the two-week visit and 32% (IRR0.1 0.68; 95% CI 0.50-0.89, p = 0.005) at the two-month visit. Ultimately, 71% completed treatment, but knowledge was not a significant predictor of treatment success (OR = 1.77, 95% CI 0.01-314.6, p = 0.83). CONCLUSIONS: Routine client education significantly increased TB knowledge, yet less than 10% achieved TB literacy. Post-education knowledge was independently associated with better early adherence, highlighting the need for more robust education interventions to optimize TB treatment outcomes.