Randomized Control Trial Study On The Effect Of Health Education In Promoting Adherence To Treatment Among The Urban And Rural Tuberculosis Patients In Kenya

Background: Tuberculosis is a global health concern and the incident rate in Kenya remains high. Because of the long duration of standard treatment (six months), there is a risk of treatment default by patients. Low adherence to treatment may result in the emergence of resistant strains of the Mycobacterium Tuberculosis in turn increasing mortality and prolonging the treatment duration. The rising TB cases in Kenya have been associated with poor adherence and low cure rate arising from inappropriate health education. Directly Observed Therapy, Short-course (DOTS) Strategy, in combination with patient education have proved to be more effective in reducing TB incident than the DOTS Strategy alone. However, there is lack of Evidence Based Protocol to guide Medical Professionals through the implementation of health education for TB patients. Objective: The main objective of this study was to determine the effect of health education in promoting adherence to treatment among the urban and rural tuberculosis patients in Kenya. The study used the PRECEDE-PROCEED model. Design: The study adopted Randomized Controlled Trial Design with pre-and post-test assessment. The Multi-Stage Sampling Technique was applied to select the study respondents. Random sampling was adopted to select the hospitals, health centers and dispensaries. Simple random sampling method was also used to assign the patients into experimental and control groups. Setting: The study was conducted in fourteen public health facilities in Nairobi and Murang’a Counties; 2 Hospitals, 7 health centers, 5 dispensaries. Participants: A total of 450 patients were recruited from the selected health facilities by random sampling according to probability proportionate to TB patient’s population. Only 373 met the eligibility criteria for the study. the association between


Background
Despite being a curable disease and the availability of effective anti-tuberculosis agents for over thirty years, tuberculosis (TB) remains a major global public health concern with increasing incident rates. [1]. TB treatment spans over a long duration of standard treatment (six months). This poses the risk of treatment default by patients [2]. Adherence to long time treatment, like for tuberculosis, is very challenging because of its long term and drug related side effects. Unfortunately, low treatment adherence may result in the emergence of resistant strains of mycobacterium tuberculosis, increasing mortality and prolonging the treatment duration [3]. As is known, treatment adherence is very important for effective treatment outcomes and prevention of the drug resistant TB Bacilli Strain [2]. In order to improve the TB treatment adherence level, various interventions have been designed and implemented across the globe. Many studies on health education and adherence to tuberculosis treatment indicate that an appropriate health education program helps the patient complete the treatment regime and achieve treatment success [4]. A systematic review suggests that the effects of the DOTS Strategy can be strengthened by combining the Strategy with other interventions, such as provision of health education and incentives [5 Although evidence suggests health education intervention based on social and behavioral science theories are more effective than those without theoretical model base, most of the available interventional studies related to TB treatment adherence lack a health behavioral theoretical model base [4]. Kenya is one of those countries, where information on the appropriate health education intervention, based on social and behavioral science theories, are lacking. This is the basis for this study. Ana et al. (2014), in their study in Panoda, Brazil, found a higher rate of treatment completion and improvement in TB knowledge, in homeless latent TB patients who received nurse case managed education with default tracking over a six months treatment program, as compared to those who received only one lecture on TB knowledge at the time of diagnosis [6].
Yan-Yan Liu (2017) found a signi cantly higher rate of attendance at follow up and general treatment adherence among patients receiving oral and written health education by pharmacists, as well as routine nursing and medical care in China [7]. Habyetes (2016) indicated signi cantly higher adherence to treatment in the intervention group who had received culture speci c health education and culturally relevant education material as compared to those who had received no intervention [8]. Pornsak (2016), in a study conducted in Thailand to investigate the effectiveness of a health education program to improve TB patients' compliance during treatment established that with intervention, there was 76% success compared to 62% in the control group [4]. In this study, health behavior, life style, environment and health status signi cantly improved (p < 0.01). Further, with a comprehensive health education intervention and follow-up every two weeks in a TB clinic or tracing to the TB patient's house and work place, patients completed the treatment regime and achieved treatment success [4]. Andrew et al. (2019) established that lack of knowledge regarding the TB infection process and its treatment; contribute to feelings of helplessness and anxiety, in a similar study in India. With health education intervention, there was self-reported high compliance at 78% against 50% for the control group [9]. Edward et al. (2014) in their study to assess the effectiveness of interventions aimed at reducing TB stigma in patients, health care workers, care givers and general community in Nicaragua, established that health education intervention directed towards attitude change or knowledge shaping reduced stigma [10]. Other studies on the adherence to treatment for tuberculosis patients have established that patient's demographic characteristics are associated with non-adherence of medication. Maria (2019), on determinants of non-adherence to TB treatment and barriers related to access to treatment in Indonesia, noted an increased risk of non-adherence to treatment in male patients (OR = 2.8; 95% CI 1.2-6.7), patients who had medical check-ups at hospitals (OR = 3.4; 95% CI 1.1-10.0), and those who had di culties with transportation costs (OR = 2.5; 95% CI 1.1-5.9) [11].
In yet another study on prevalence of, and factors in uencing anti-TB treatment non-adherence among patients with pulmonary TB in Anhui Province, Eastern China, Xiu (2019) reported that 33.63% of 339 patients missed medication; divorced and widowed patients were more likely to miss medication compared to those who were married or unmarried (p < 0.01). On the characteristics of the study participants, the mean age was 49 years, and males were 259 (76.4%) while females were 80 (23.6%). In regard to occupation, most of them were farmers (77.0%). On the education level, 50.15% were of primary and illiterate levels, 41.89% were of junior level, 49.49% of senior high school or technical level, and only 7.96% were of college level or above [12].
Emesa (2016), in a study whose objective was to measure adherence and determine factors with nonadherence to concurrent TB treatment among co-infected persons in two provinces in South Africa, determined that out of the 1,252 persons receiving concurrent treatment, 138 (11.0%) were not adherent. Non-adherent persons were more likely to have Extra Pulmonary TB (RR: 1.71, 95% CI: 1.12 to 2.60) and had not disclosed their Status (RR: 1.96, 95% CI: 1.96 to 3.76) [13]. Govender & Mash (2009) conducted a study in a District Hospital in KwaZulu-Natal, South Africa, to establish the key factors that affected adherence to TB treatment, and recommend interventions that could improve adherence methods. They observed that from the 159 TB Patients, 105 (66%) were adherent and 54 (34%) non-adherent. Nonadherence was signi cantly associated with the level of education, distance from the hospital, time taken to travel, mode of transport and income [14].
Habatamu (2018) conducted a study whose aim was to assess the prevalence of non-adherence to antituberculosis treatment, reasons and associated factors among TB patients attending Gondar Town Health Centers in Ethiopia. He noted that the rate of non-adherence to anti-TB therapy was 65 (21.2%) (95% CI 17.2, 26.1). The rate was higher (47.0%) among the 'return after default treatment' category and lower (19.1%) among the 'new' category. In the social-demographic characteristics, with a sample of 314 and 97.5% response rate, the mean age was 35.94 years, 166 (54.2%) were male, 135 (44.1%) were single, 193 (63.0%) were orthodox Christians, and 75 (24.5%) were urban dwellers and grade 9-12 by education. Further, the study established that the income level (> 3000 Ethiopian Birr) and patient provider relationship, associated signi cantly with non-adherence to TB treatment (0.004, 0.004) [15]. Fredrick (2004) conducted a study to assess factors contributing to treatment adherence and knowledge of TB transmission among patients on TB treatment in Ndola, Zambia [16]. The study determined that 29.8% of the TB patients failed to comply with TB drug taking regime once they started feeling better [16]. The study further observed that more females (39.1%) than males (33.9%) defaulted on medication. The males were older and more educated than the female respondents. However, age, marital status and education levels were not signi cantly associated with compliance [16]. Muture (2017), on factors associated with default from treatment among TB patients in Nairobi, Kenya, revealed a 16.7% prevalence of treatment default. Default occurred most frequently during the initial three months of treatment. Among defaulters who were smear positive at initiation of treatment, 47.7% defaulted before conversion. Factors associated with default included the male sex (OR 1.43, p < 0.001) and low income (OR 8.67, p = 0.017), among others [17].

Speci c Objective
To determine the effect of Health Education Intervention in promoting adherence to treatment among the urban and rural tuberculosis patients in Kenya.

Hypothesis
Health Education Intervention has no signi cant effect on adherence to treatment among the urban and rural tuberculosis patients in Kenya.

Expected Study Outcome
To ascertain the difference in Adherence to TB Treatment (Rate/Levels) in the interventional and control groups. This was achieved by collecting baseline data for both the experimental and control groups for reference and end-line data after six months of treatment for both groups. Only the experimental group had an intervention administered to it i.e. the health education program. The changes between the groups were assessed using statistical methods to determine if there was indeed a difference between the two groups after the administration of the intervention.

Study design
The study adopted the Randomized Controlled Trial Design with pre-and post-test data assessments of the TB patients. The TB clinics that were identi ed for the study were selected randomly. The patients who participated in the study were recruited from the TB attendance and treatment registers in the respective health facilities. Thereafter, they were assigned to experimental and control groups on a 1:1 ratio. The pre-test was conducted on the two groups to establish baseline data of the patients. Health education intervention was then introduced to the experimental group. No intervention was given to the control group. However, both groups continued to receive the normal TB treatment medication. The health education intervention was delivered in the form of individualized health messages and counseling. The health education intervention was conducted during patients' monthly follow-up appointments in outpatients' clinics. The two groups were then followed for the entire period (six months) of TB treatment. After the study period (six months), both groups were then assessed (post-test) to observe the differences in the treatment effect as a result of the health education intervention.

Eligibility Criteria of participants
To qualify as a TB case for inclusion into the study, the patient had to be an adult (18 years and above) undergoing full course of TB treatment and under DOTS Strategy. Further, the patient had to have been registered in the TB attendance and treatment register for at least two weeks in those health facilities. The study excluded patients that were underage (below 18 years), those diagnosed with Multiple Drug Resistant TB, TB patients diagnosed with HIV and those who were already participating in other interventional studies

Study setting
The study was carried out in public health facilities in Nairobi and Murang'a Counties in the Republic of Kenya. Kenya was identi ed for the study due to its rising TB burden among the high burden countries. Nairobi County was chosen due to its TB burden nationally and its urban setting. Murang'a County was chosen due to its rural setting and a TB prevalence rate similar to that of Nairobi County (4.9%).

Study population
The study targeted 4149 TB patients who attended TB clinics of the public health facilities in Nairobi and Murang'a counties for treatment. Out of these, Nairobi County had 3319 patients while Murang'a County had 830.

Sample size and sampling technique
The targeted sample size was 450 TB patients, randomly selected from the health facilities which had been identi ed for the study. The study adopted the Multi-Stage Sampling methodology. Kenya was purposively selected due to its large and rising TB burden. Nairobi County was purposively selected due to its TB burden nationally and its urban setting. Murang'a County was also purposively selected due to its TB prevalence rate (4.9%) which was similar to that of Nairobi County, and also for its rural setting.
Random sampling method was used to select the hospitals, health centers and dispensaries (2 hospitals, 5 health centers and 7 dispensaries = 14 public health facilities). Random sampling proportionate to TB patients' population was adopted in selecting the study patients (Additional les). And by Hypothesizing p2 = 95% (0.95) and considering 95% Con dence Interval, 80% power, 5% Margin of Error and equal Sample Size for each Group, then the Sample Size will be 137 for each Group.
To overcome the design effect we assumed Design effect 1.5. The Sample Size was then :137 x 1.

Patients' recruitment
TB patients were recruited from the fourteen selected health facilities with the help of the clinical staff in the facilities. In each of these facilities, the TB patient was identi ed through the TB attendance and treatment registers. To ensure that patients started and ended the health program intervention at the same time, patients who had been on treatment for at least two weeks at the time of selection were recruited. The potential participants were then provided with detailed explanation about the study objectives. After assurance of con dentiality those e willing to participate in the study were asked to sign the Informed Consent Form (additional les).\

Data collection
The Standard Questionnaire was the main instrument for data collection from the patients. Data was collected on the social-demographic characteristics of the patients. This comprised age, sex, income, education level, employment, residence, household income and household size. Furthermore, data on self-reported adherence to TB treatment was collecting using the Morisky Medication Adherence Scale (MMAS) (Additional les) which measures the drug taking behavior of the patient and reasons for the patient to likely default on medication (18). To capture the TB Patient case management details, a structured Hospital Data Treatment Form was developed. The key parameters for this review included: Name of Health Facility, TB Case, Date Registered, Age, Sex, Residence, TB Supporter, and Contact Details of the Patient. Based on this information, the patients were divided into experimental and control groups.

Ethical Considerations
Permission was sought from the Kenyatta National Hospital, University of Nairobi Ethics Review Committee, National Commission for Science, Technology and Innovation (NACOSTI), and Nairobi and Murang'a Health Services. The participant's consent was voluntary, free of any coercion, intimidation or in ated promise of bene ts from participation. Care was taken to ensure that the consent form was administered by someone who did not hold authority over the participant. Anonymity, Con dentiality, Secrecy and Privacy were safeguarded with regard to information about Treatment, Medical records and drugs for the TB Patient.

The Health Education Intervention Program (PRECEDE-PROCEED) Model)
The PRECEDE-PROCEED Model of study (Additional les) was used to implement the health education intervention activities. The various activities and tasks that were carried out were designed to coincide with the time the Patient was seeking TB treatment. Out of 450 respondents the TB patients were divided into two study groups. The experimental group (225) patients who received the health education intervention and the control group which consisted of (225) patients and who did not receive the health education intervention. TB Patients and their Supporters were engaged in a Health Education Program for 10-15 minutes on average. The Health Education Interaction was twice a month for the next 6+ months as the Patient went for the weekly drug ration. For better outcomes, the research encouraged team work among the medical/health staff at facility level in the delivery of the health education program particularly in the mobilization of the patients. However, the main researcher took lead in the entire process. The health education technique used was in form of teaching, questions and answers, interview, discussion and scenario analysis. Education materials consisted of interactive tools including pictures and cards with topics for discussion on basic issues about TB.
The components of the health education provided essential facts about the disease, diagnosis and treatment, potential barriers to treatment adherence, possible adverse effects of the medication, provision of support through counseling and encouragement of social support from family and friends. Pre-test assessment data and post-test assessment data on patient's demographic characteristics (age, sex, education, marital status, occupation, income etc.) and TB medication and adherence were collected at baseline ( rst month) and end-term (six months) of the study.

Statistical methods used
Both descriptive and inferential statistics were used in analyzing data. SPSS v.20 and excel were used to conduct the analysis. Statistical signi cance was evaluated at p<0.05.
Patient's social/demographic characteristics (age, sex, education level, marital status, occupation, household size and household incomes) were summarized using descriptive statistics. This was presented in tables showing frequencies, standard deviation and percentages.
MANOVA was used to show the effects of the health education program on TB Patient's Medication Adherence. The null hypotheses in each of the objectives were tested using Wilk's Λ followed by ANOVA tests for each of the variables. Levene's test for equality of variances was used for assumption testing to determine existing variances in the pre and post-test phases.
Chi-square test and Odds Ratio were also calculated for the post-test results to determine the effectiveness of the health education program and ascertain if the patients subjected to health education were faring better than those who were not subjected to the health education program. Chi-square test was also used to test for the associations between socio-demographic factors and adherence to treatment for the post-test phase results.

Assumptions and Limitation of the Study
The study assumed that all TB cases which were recorded in the counties Public Health facilities and who participated in the study gave the correct information about their social/demographic characteristics, case, treatment and treatment outcomes. It was also assumed that the patients who participated in the study followed the Health Education Intervention Program objectively and honestly shared the effect of the health education experiences. However, there were the possibilities of having obtained less accurate information or biases due to the health state of the patient. Awareness creation and randomization at cluster level ensured bias was minimized.
TB Patients are known to experience stigma. For this reason, discussions about the disease with outsiders may experience some level of rejection. With this knowledge, the researcher worked closely with the TB clinic managers in the health facilities and community health volunteers assigned to the patients.

Generalization of the Study
This was a Randomized Controlled Trial Design study which ensures bias is minimized hence allowing generalization. The review study was conducted in outpatient TB clinics which were similar to the target setting. The participants of the reviewed studies were also comparable to the target audience. The reviewed studies focused on both male and female adults of varied ethnicity. Public health facilities in Kenya attend to patients of similar characteristics. Furthermore, patients in the review studies were similar to the target population in terms of diagnosis and treatment of the disease. The patients in both the review studies and the present study received standard or Prophylactic Treatment for six months. Therefore, the similarity in setting and target populations in both the review studies and our study meant that ndings could be generalized the TB Patients in the proposed settings.

Introduction
The study sought to determine effect of health education in promoting adherence to treatment among the urban and rural TB patients in Kenya. To achieve this goal, the public health facilities that treat TB patients in Nairobi and Murang'a counties were identi ed for the study. The study took six months with baseline data collected for both groups in September 2019 and end-line data collected from the patients in February 2020 marking the end of the study. The Health Education Interaction was twice a month for the next 6 + months as the Patient went for the weekly drug ration during the normal course of treatment. All of the patients under review received standard or Prophylactic Treatment for six months thus the study ended after the six months that are standard treatment duration for TB.

Response rate
Though 450 patients were identi ed and recruited for the study, only 373 patients were included in the study. The remaining 77 did not meet the eligibility criteria due to being underage (less than 18 years), having MDR-TB and those diagnosed with HIV. Of the 373 patients included in the study, 186 patients were in the experimental group and 187 patients were in the control group both at the beginning (baseline) and end (end-line) of the study. None of the patients in the baseline dropped out of the study (Table 1).

Demographic characteristics of the respondents
The demographic factors considered included sex, age, level of education, marital status, occupation, and place of residence (urban or rural). As indicated in Table 4 below, 63% of the respondents were male while 37% were female. Most (17.4%) of the respondents were aged between 25-29 years followed by 15.6% of respondents aged 30-34 years. Those with primary and secondary school levels of education were 32.5% and 41.8%. Most of the respondents were household heads (61.7%) and were married (55.5%). The ndings also indicate that most of the respondents were employed in the informal sector (33.8%) or unemployed (30%). Statistical comparison between the experimental and control groups for each of the socio-demographic characteristics showed no differences between the groups, as indicated by the pvalues on the table. To ascertain levels of adherence, responses in a scale of 8 were scored and grouped into high, low and medium adherence. The Morisky Adherence Medication Scale (MMAS-8) grading was used to assess the non-adherence to medication amongst patients [18]. The MMAS-8 was used by patients to self-report adherence to medication during TB treatment. In compliance with this tool, the levels of adherence were classi ed as low adherence (< 6), medium adherence (6-<8) and high adherence (8). According to the WHO, a rate of 80% is considered high adherence [3].
In the pre-test phase, those with low adherence were 8.6% (experimental) and 18.7% (control), while those with high adherence were 32.8% (experimental) and 17.7% (control). Majority of the patients in both the experimental (58.6%) and control (63.6%) groups had medium adherence. In the post-test phase, majority of the patients had high adherence in both the experimental (83.3%) and control (60.4%) groups. Those with low adherence were 1.1% in the experimental group and 8.6% in the control group. There was a 50.5% increase in high adherence patients in the experimental group, and 42.8% increase in high adherence patients in the control group, indicating that the health education intervention had an impact on adherence to TB medication (Fig. 1). In both the low and medium adherence groups, there was a reduction in the proportion observed in the pretest for both the control and treatment groups.
Levels of adherence were further compared between urban (Nairobi) and rural (Murang'a) patients. In urban facilities, in the pre-test phase, majority of the patients were in the medium adherence category in both the experimental (52.98%) and control groups (65.36%). In the post-test phase, majority of the patients were in the high adherence category in both the experimental (83.44%) and control (67.97%) groups. There was a 43.05% increase in high adherence patients in the experimental group while the control group had a 51.63% increase in high adherence patients (Fig. 2).
In rural facilities, in the pre-test phase, majority of the patients were in the medium adherence category in both the experimental (82.86%) and control groups (55.88%). In the post-test phase, however, the majority of patients in the experimental group (82.86%) were in the high adherence category, while in the control group, majority of the patients (58.82%) were in the medium adherence category. There was an 82.86% increase in high adherence patients in the experimental group while the control group had only a 0.94% increase in high adherence patients. The change in the pre and post-test TB adherence in the experimental group were more enhanced in the rural facilities compared to urban facilities, indicating that the health education intervention had greater impact among rural patients compared to urban patients ( Fig. 3).

Demographic factors associated with adherence to TB treatment
All the demographic factors were cross tabulated against the established levels of adherence to TB medication.  The results were subjected to multivariate analysis of variance to test for the effects of the health education program on adherence to medication. The MMAS-8 variables were the dependent variables in this study while the independent variable was the TB treatment program which had two categories; the experimental (interventional) group who were exposed to the health education intervention and the control group who were not exposed to the health education intervention. Wilk's Λ test had an F value of 18.540, p < 0.001 and partial η² was 0.522, indicating that 52.2% of the changes observed in the experimental group were accounted for by the health education intervention. This clearly indicates overwhelming evidence to reject the null hypothesis that health education has no effect on adherence to TB medication (Table 6). Levene's test of equality of error variances was carried out to test homogeneity of variance assumption.
Based on Levene's F tests, the homogeneity of variance was satis ed with all of the variables being statistically signi cant in the post-test phase further indicating evidence to reject the null hypothesis that health education has no effect on adherence to TB medication (Table 7). Multivariate Analysis of Variance (MANOVA) was carried out modeling various adherence variables to compare the experimental and control groups separately on their pre and post-test scores. In the pre-test phase, the differences between the experimental and control groups were not signi cant except for the variables "Do you sometimes forget to take your medicine" (p = 0.002), "Have you missed your medication on any days in the past two weeks" (p = 0.025), and "How often do you have di culty remembering to take all your medication" (p = 0.000). The results for the post-test phase were signi cant for most variables (p < 0.05) Education and Adherence to TB treatment (χ²=24.189, p < 0.001). Odds ratio calculations also showed that patients who were exposed to Health Education were three times more likely to adhere to treatment than those who did not go through the Health Education Intervention (OR 3.274) with 95% CI [2.017-5.315] ( Table 8). success compared to 62% in the control group [4]. The ndings are also in agreement with the study by Andrew et al. (2019) which established that lack of knowledge regarding TB infection process and its treatment contribute to feelings of helplessness and anxiety. With health education intervention, selfreported compliance was high (78%) against 50% for the control group [9].
These ndings were consistent with the observations of Nagras et al. (2016) in South Africa whose objective was to measure adherence and determine factors associated with non-adherence to concurrent TB treatment and ART, among Co-infected in two provinces. They determined that out of the 1,252 persons receiving concurrent treatment, 138 (11.0%) were not-adherent [5]. Ana et al (2014) in their study in Panoda, Brazil, to establish key factors that affected adherence to TB treatment, recommended interventions that could improve adherence methods observed in 159 patients, 105 (66%) adhered [6].
Another study by Muture (2017) on factors associated with default from treatment among TB patients in Nairobi Province revealed a 16.7% prevalence of treatment default. The study further noted that default occurred most frequently during the initial three months of treatment [17]. A study in Iran, whose aim was to assess the prevalence, reasons and associated factors for non-adherence to anti-Tuberculosis In this study the sex of the respondents was not signi cantly associated with the adherence to TB treatment. However, it was observed that female respondents (91.7%) adhered more than the males (67.9%) after the health education intervention. These ndings were in line with those of the study by Edward et al (2014) that assessed factors contributing to treatment adherence and knowledge of TB transmission among patients on TB treatment [10]. They also agree with those of a study by Maria (2019) on determinants of non-adherence to TB treatment and barriers related to access to treatment.

Marital status of the respondents and adherence to TB treatment
The study demonstrated that the married respondents (93.3%) adhered to medication more than the separated respondents (65.7%) after the health education intervention. Single respondents (80.9%) also had notably high adherence. This agreed with a study by XUI, H.F. (2019) on prevalence of, and factors in uencing anti-TB treatment non-adherence among patients with pulmonary TB. The study observed that divorced and widowed patients were more likely to miss medication compared to those who were married or single (p < 0.01) [12].

Occupation of the respondents and adherence to TB treatment
In regard to the primary occupation of the respondents, the TB patients in the formal (82.4%) and informal (82.5%) sectors as well as those who are unemployed (91.2%) showed enhanced adherence to treatment following health education intervention. Those who were students (69.2%) adhered least.
Respondents in the agriculture sector also had notably high adherence (80%). These ndings largely agreed with XUI, H.F. (2019) on prevalence of and factors in uencing anti-TB treatment non-adherence among patients with pulmonary TB in China. The ndings of this study were that farmers (77.0%) adhered more than the other respondents [12].

Age of the respondents and adherence to TB treatment
The study determined that there was no signi cant association between the age of the respondents and the adherence to TB treatment. However, it was observed that the age category 35-39 years (90%) and age 25-29 with 86.5% had the highest improvement in adherence to treatment after intervention. This study, however, agreed with the ndings by Edward et al. (2014) which assessed factors contributing to treatment adherence and knowledge of TB transmission among patients on TB treatment, and established that age, marital status and education levels were not associated with compliance to TB treatment [10].

Conclusion
The study concluded that health education intervention enabled the patients to adhere to treatment regime.

Recommendations
The study recommends the development of a comprehensive and multipronged approach in the provision of health education on TB and the importance of treatment adherence in all health facilities and health care settings providing TB treatment services in Kenya. Additionally, there is need to adopt a more personalized approach involving counseling and support needs targeting marginalized and vulnerable groups such as students, the uneducated, divorced, separated and widowed patients as well as those in rural areas.

Declarations
Ethics approval and consent to participate