Knowledge, practices, and concerns of tuberculosis healthcare workers at primary settings in western China: a multi-center cross-sectional study

BACKGROUND: Tuberculosis (TB) remains a major global health challenge, and China bearing the world's third-highest burden. TB healthcare workers (TB-HCWs) in primary healthcare (PHC) settings are pivotal for implementing the national TB Control Program (TCP). This study aimed to develop a TB knowledge assessment questionnaire and systematically evaluate TB-HCWs' knowledge, practices, and perceived concerns regarding TCP implementation in western China. METHODS: A 30-item TB knowledge questionnaire was developed through item generation, expert consultation, and pilot testing. A multicenter cross-sectional study was conducted among TB-HCWs in Chongqing Municipality, Guizhou Province, and Xizang Zizhiqu from February 2022 to July 2023, using multistage stratified random sampling. A structured survey assessed demographics, TB knowledge, TCP practices, and perceived concerns. Multilevel logistic regression identified factors associated with TCP implementation. RESULTS: Among 2807 TB-HCWs, overall TB knowledge was low (38.4%), particularly for TB Treatment (25.1%). Rural TB-HCWs performed better in case management (41.3% vs. 40.1%; P < 0.05) and health education (50.0% vs. 47.1%; P < 0.001), while urban TB-HCWs scored higher in case detection and TB treatment (42.3% vs. 40.9%; P < 0.05). TCP practice implementation generally fell short of national standards, though urban HCWs achieved required levels in first-home visiting (≥ 90%) and health education (≥ 85%). Workforce-intensive services, particularly directly observed therapy, were suboptimally delivered in both settings, especially rural (< 70%). Positive working attitudes and working satisfaction predicted higher implementation across all dimensions [odds ratio (OR) > 1], while rural settings and infrequent training (≤ 1/half-year) were negative predictors (OR < 1). Key concerns included inadequate training, poor public/patient cooperation, insufficient workforce, weak coordination with TB-designated hospitals, and lack of incentives. CONCLUSIONS: TB-HCWs in western China face substantial gaps in knowledge and practice that hinder effective PHC-based TCP delivery. Targeted and frequent training, context-specific and patient-centered adherence strategies, improved institutional support, and strengthened community engagement are needed. Future longitudinal studies should evaluate the effectiveness and long-term impact of these interventions to accelerate progress toward national and global End TB targets.