Tuberculosis (TB), an ancient disease caused by Mycobacterium tuberculosis (MTB), maintains its daunting position as the 13th leading cause of death worldwide and the leading cause of death from a single infectious agent since 2019 (1). Among the 22 high-burden countries, China ranks third and faces challenges in protecting high-risk, vulnerable, and special populations from TB (1). In 2018, nationwide TB cases reported among students reached 48,289, with an incidence rate of 17.97/100,000, representing a 29.19% increase compared to 2014 (13.91/100,000) (2). In many provinces of China, the number of students with TB ranks second, just behind farmers and herdsmen (3).

In recent years, the number of college students in China has been increasing due to the dramatic expansion of college enrolment (4). Hence, TB prevention and control among colleges have become increasingly important (5). Previous studies have identified college and university students aged 19–22 years as the main population at high-risk for TB (6). Factors such as high population density, close contact, and increased mobility contribute to TB infection and transmission among college students. Additionally, a lack of awareness about TB is considered an essential factor that increases the risk of exposure to the disease (7). However, a previous survey indicated inadequate knowledge of TB among students (8). Several studies have shown that even when many 1^st-year students exhibited suspicious symptoms of TB, such as coughing and sputum for more than 2 weeks (9–11), both patients themselves and their fellow classmates lacked awareness of TB. This led to delays in seeking medical care and reporting to the school medical staff, resulting in a high prevalence of TB in the colleges (12).

Zhejiang Province in southeastern China serves as a representative province, which is composed of 11 prefectures and 90 county-level administrative regions. It is one of the most densely populated provinces in China, with the fourth highest gross domestic product (GDP) and a continuously growing migrant population. According to the report of the fourth provincial TB key awareness investigation, the total awareness rate of the public in Zhejiang Province was 48.0%, of which only 38.0% was among students, the lowest among all walks of life (13). In 2021, the Tuberculosis Information Management System (TBIMS) reported more than 30 school-related TB outbreaks in the province, with approximately one-third of these outbreaks occurring in colleges. College students come from diverse regions across the country, and their living environments and study patterns have changed significantly compared to those of high school students. In particular, junior students who have recently entered college may struggle to adapt to a new environment and may become prone to TB once their resistance decreases. A study showed that the prevalence rates of active TB among college students in China ranged from 0.40 to 1.52%, with outbreak rates as high as 2.89–4.20%, significantly higher than the rate in the general population (14). Currently, TB prevention in colleges mainly relies on TB health education, which is widely considered an effective approach to promote TB knowledge among students. College students, being a population with a high incidence of TB possess a higher level of knowledge and acceptance and a stronger sense of social responsibility. Therefore, health education on TB is easily implementable and accepted among them, yielding efficient results in the prevention of TB. However, there have been limited studies specifically investigating the level of TB awareness among low-grade college students in recent years. This lack of research impedes the scientific evaluation of the effectiveness of current TB education methods. Hence, this study targeted low-grade college students to assess their level of TB awareness and explore the sociodemographic determinants associated with their perception of this infectious disease. The findings of this study will provide a basis for optimizing TB prevention and control strategies in colleges and universities.

Students constitute a pivotal demographic in the prevention and control of TB, and their comprehension of this disease is indispensable in curbing its incidence among them. In this study, a deeper understanding of the actual circumstances faced by lower-grade college students regarding TB knowledge was obtained through a validated questionnaire. The overall awareness rate of key TB knowledge among low-grade college students in Zhejiang Province in 2022 was 81.6%, which was lower compared to 89.02% in Jiangsu Province (17) but higher than 73.3% in Guangxi Zhuang Autonomous Region (4). Nevertheless, a gap remains to be bridged to achieve the target (≥85%) among populations proposed by the “13^th Five-Year” National TB Control Plan in China. This indicates that educational interventions are still necessary to improve TB knowledge among college students.

Assessing students' knowledge of TB based solely on total knowledge is flawed as the overall knowledge rate decreases with increasing key knowledge questions (17). Therefore, It should be evaluated in conjunction with the entire awareness rate. In our study, the overall awareness rate among all low-grade college students was only 25.3%, which was lower than the score (43.45%) reported in a previous study conducted in Hunan Province (18), but higher than the 16.03% reported in a survey conducted in Beijing (19). A survey assessing students' knowledge of four infectious diseases (Hepatitis B, Hepatitis C, AIDS, and TB) revealed a high error rate in the awareness of these diseases, except for AIDS (20), which was consistent with the results of our study.

Our survey revealed an imbalanced in the awareness levels of eight key aspects of TB knowledge among lower-grade college students, with awareness rates ranging from 51.0 to 96.2%. This indicates that the students' understanding of TB prevention and control is not comprehensive, necessitating the implementation of various forms of education to address these knowledge gaps. Specifically, students demonstrated confusion regarding the definition of TB, particularly in distinguishing whether it is an acute or a chronic infectious disease. Consequently, this key message had the lowest awareness rate among all items of TB core knowledge. Some students expressed uncertainty about the curability of TB, while others were unsure about the preventive measures against TB transmission. Despite these gaps, lower-grade students exhibited a high level of awareness about TB transmission routes, suspicious symptoms, the importance of not concealing physical conditions, seeking immediate treatment from designated medical institutions for TB consultation upon illness, and adopting an immune-enhancing lifestyle. These findings were consistent with previous research (4, 8, 21), indicating a positive trend in health-seeking behavior among our students. Notably, several studies have established an association between TB perceptions and early treatment-seeking (22, 23).

Regarding the factors influencing TB awareness level, it was found that the discipline of study was one of the crucial factors affecting the awareness level toward TB knowledge among low-grade college students. Medical students had significantly higher awareness levels than students in other disciplines, similar to the findings of surveys conducted at 15 Italian and Jordanian universities (24, 25). This may be related to the possibility that medical students are exposed to more medical knowledge and exhibit more interest in medical-related content during their study practice. However, medical students' awareness of the definition (57.2%) and curability (81.2%) of TB was relatively weak. This might be because 1^st-year and 2^nd-year medical students have just started to come into contact with clinical professional knowledge, and their mastery of the specialty is not yet comprehensive. However, medical students in universities or colleges can be exposed to TB infections during clinical rotations (26), and an inadequate knowledge of TB can increase their risk of infection. As potential future physicians or leaders in the fight against TB, medical students' knowledge toward TB will directly impact future efforts aimed at controlling the disease. Therefore, raising awareness of TB among medical students should be considered an important issue in medical education. Besides, in this study, lower-grade students with a higher overall awareness rate of the eight core knowledge of TB were those who had suffered TB or received TB health education before enrolment, which is consistent with similar studies findings (27–29). TB health education is a crucial strategy in China's effort to control TB, aiming to raise awareness of TB control policies and knowledge among diverse groups, enabling them to adopt appropriate behaviors and implement effective TB control strategies. By doing so, the ultimate goal of bringing the TB epidemic under control can be achieved. Although, there has been continuous focus on TB health education and promotion for the general public, particular attention has been given to TB patients and students in China (30). However, the state of TB health education and promotion in universities and colleges remains sub-optimal. This current scenario indicates the urgent need to strengthen theoretical and practical health education on TB from the beginning of university or college enrolment. Since students are accustomed to receiving education while in school, they are more receptive and responsive to targeted health education messages and are more inclined to absorb the information and disseminate TB knowledge to their families and communities through the “teacher-student-parent-community” chain (4, 31). This, in turn, has a significant impact on raising TB awareness throughout society.

College students are currently in the midst of a digital age, where mobile phones and computers have become the primary means of socializing and acquiring knowledge (32). Our study revealed that students were more likely to receive TB health education through news media and the Internet, compared to traditional promotional materials. Therefore, taking advantage of the above-mentioned means and methods of publicity can be effectively implemented. In addition, focus should be placed on the development and use of news media platforms such as the Internet, Weibo, and WeChat- to promote TB education, cultivate more student volunteers to promote TB prevention, and facilitate peer education. The rapid development of the Internet has broadened students' access to the world; however, the quality of information in the cyber world cannot be guaranteed, and students are susceptible to receiving inaccurate information. Thus, agencies involved in disease control and prevention should increase online publicity and strengthen the supervision of false disease information on the Internet to ensure students obtain accurate knowledge on disease prevention.

This study employed an innovative approach in the Internet Era by utilizing an electronic questionnaire, which provides new ideas and methods for disseminating knowledge and investigating TB prevention and control in schools. However, this study has some limitations. First, due to geographical constraints, economic conditions, and low prevalence of TB in Zhejiang Province, our findings may not fully represent TB awareness among lower-grade college students nationwide, especially in economically disadvantaged and high-prevalence areas of the disease. Second, since this study involved 20 colleges, we had to use an open online questionnaire platform and did our best to ensure that the survey reached only the target population. Nevertheless, we acknowledge the possibility of non-students receiving the survey link and completing the questionnaire. Third, as this was a cross-sectional study, we could not draw a causal relationship between the factors and their effects.

The total awareness rate of key TB knowledge among college students in Zhejiang Province fell short of national requirements, indicating a generally low level of awareness. Schools face significant and arduous tasks in TB prevention and control. To improve TB awareness among students, it is necessary to constantly innovate the content and delivery of health education and carry out comprehensive and multi-dimensional publicity activities suitable for school health education and promotion, with particular attention given to addressing the weak points in students' TB knowledge. Targeted health education on key TB knowledge should be provided, taking into account the preferences and needs of students at different levels and grades. This approach will contribute to fostering improved behavioral habits and strengthening the ability to prevent and control TB.

The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding authors.

The studies involving human participants were reviewed and approved by Zhejiang Provincial Centre for Disease Control and Prevention. The participants provided their written informed consent to participate in this study.

XC: Formal analysis, Funding acquisition, Methodology, Writing—original draft, Writing—review & editing. YP: Formal analysis, Methodology, Writing—review and editing. LZ: Formal analysis, Writing—review & editing. FW: Formal analysis, Writing—review & editing. BC: Conceptualization, Funding acquisition, Project administration, Supervision, Writing—review & editing. YQ: Conceptualization, Project administration, Supervision, Writing—review & editing.