Cognitive Determinants of Tuberculosis Preventive Behaviors: A Cross- Sectional Study in Iran

Abstract

Background: Tuberculosis (TB) remains a major global public health challenge. Beyond biomedical interventions, understanding the cognitive determinants of preventive behaviors is essential for effective disease control. This study aimed to identify the cognitive factors associated with TB preventive behaviors and assess their predictive power while controlling for sociodemographic characteristics. Methods: A cross-sectional study was conducted among 300 individuals with high-risk conditions in Sarab, Iran, between April and August 2024. Participants were selected using multistage cluster sampling. Data were collected through researcher-developed questionnaires assessing TB-related knowledge, attitude, self-efficacy, health literacy, and preventive behaviors. Hierarchical linear regression was used to identify predictors of preventive behaviors, and structural equation modeling (SEM) was performed to examine direct and indirect relationships among study variables. Results: All cognitive variables were significantly correlated with TB preventive behaviors (p<0.05). Demographic characteristics, including education, marital status, and income, explained 9.7% of the variance in preventive behaviors, while the addition of cognitive factors increased the explained variance to 32.4%. In the final regression model, health literacy (β=0.505, p=0.001) and attitude (β=0.103, p=0.046) emerged as the only significant cognitive predictors. SEM demonstrated that educational attainment positively influenced TB-related knowledge and health literacy, while health literacy exerted both direct and indirect effects on preventive behaviors through attitude. Conclusion: Health literacy was the strongest determinant of TB preventive behaviors and played a central role in the cognitive pathway linking education, knowledge, and preventive actions. TB control programs should prioritize interventions that enhance health literacy and foster positive attitudes toward prevention.

Keywords: Tuberculosis, Health Literacy, Preventive Behavior, Self-Efficacy, Attitude