This qualitative study was conducted among stakeholders at 2 clinical sites in Northern Tanzania, the Kilimanjaro Christian Medical Centre (KCMC) in Moshi and the Kibong’oto Infectious Disease Hospital (KIDH) in Siha. At both facilities, patients may be admitted for the introduction of intensive phase treatment and then discharged once healthy enough to complete continuation phase treatment at district or regional health facilities, either with facility-directed or home-based directly observed therapy (DOT) with a treatment supporter [25,26]. Most patients do not require admission, and when admitted, the duration is usually days to weeks until clinical stabilization.

Patients were recruited from KIDH and KCMC using convenience sampling, with purposive sampling of at least 5 individuals with HIV and tuberculosis coinfection. For providers, purposive sampling was used to capture diverse roles, employment duration, and site, with recruitment continued in parallel with the coding process until adequate thematic saturation was reached [27]. Eligible patients were (1) 18 years or older, (2) diagnosed with drug-susceptible or multidrug-resistant tuberculosis, and (3) undergoing treatment for tuberculosis (for at least one month) at the time of enrollment, or completed treatment within the past 5 years. Eligible patients identified by site clinic staff were approached by study staff for participation, provided study background, and enrolled in this study, either by telephone outreach (up to 3 attempts) or in-person during routine clinic visits. Providers, clinic, and hospital staff (including clinicians, support staff, laboratory staff, and other patient-facing roles) were identified through referrals from collaborating site clinicians and leadership and were approached either in-person or by phone.

Semistructured in-depth interview guides were developed using Bury’s framework for chronic illness [28,29], which examines the impact of chronic illness on daily life, relationships, expectations, and identity. Additional probes were adapted from prior formative studies of the PositiveLinks platform and related prior adaptations (eg, smartphone and internet access, familiarity, or usage; perspectives on existing features and additional possible features) [9,17,30]. Provider interview guides applied the Consolidated Framework for Implementation Research (CFIR) [31,32] to probe for context-specific implementation determinants [33]. Participants completed a brief baseline demographic survey at the start of the interview. Interviews were conducted in Kiswahili. Translation was conducted by 3 trained study team members (KN, KW, and MS) fluent in the language as well as English. All translations were subsequently cross-checked for accuracy and consistency by a senior member of the research team (KN). During interviews, participants were given a descriptive verbal overview of the PositiveLinks platform and existing features based on a standardized script, with corresponding interview guide probes related to perceptions of core features (self-monitoring including medications, laboratory results, stress and mood check-ins, appointment reminders, in-app communication, and community chat board). Interviews were conducted by a study team member in person at KCRI and Kibong’oto Hospital. Demographic information was collected at the beginning of each interview.

Interviews were audio-recorded, transcribed, and translated by KCRI study team members and were uploaded to qualitative analysis software NVivo (version 14.23.2; Lumivero). A preliminary codebook was developed by study team members deductively from the applied frameworks and iteratively refined with emergent inductive codes. All transcripts were coded by 2 study team members, including at least 1 senior researcher (JH and KN). Coding discrepancies were resolved through consensus among the coding team until intercoder agreement (κ score of 61%, indicating substantial agreement) [34,35] was reached consistently (double-coding of 11/25, 44%, of the transcripts) for all coding pairs. This threshold was selected based on the breadth of the interview guide topics and the exploratory nature of the current study [34]. The κ score was calculated in NVivo using coding comparisons. The coding team met regularly to review codes and related analytic memos throughout the coding process, noting observations, preliminary patterns, and theories in the data, as well as discussing potential implications of reflexivity across the diverse coding team with distinct backgrounds and perspectives [36]. These reflections were applied with further iteration of the codebook until thematic saturation was achieved. Thematic analysis was performed by 2 formally trained qualitative researchers on the current study’s team (KN and JH) [37]. The current study’s team prioritized themes and subthemes that were commonly identified and conceptually relevant. Illustrative supportive quotes were selected based on team consensus. We then mapped themes to the IMB skills model and SAT to develop a mechanistic understanding of PositiveLinks adaptation for the context, including “platform-modifiable” contextual determinants identified as either a facilitator or barrier to implementation, or impacting implementation outcomes positively or negatively (eg, related platform feature usability or acceptability).

Descriptive statistics were used to summarize baseline demographic data from surveys completed by participants at the start of the interview. Baseline variables of interest were summarized as sample means or proportions for each respondent type (people with tuberculosis or providers and staff members). Statistical analysis was performed using Microsoft Excel (Microsoft Corp) and R (version 4.1.2; R Foundation).

All study procedures were conducted according to a protocol approved by the National Institute of Medical Research, Tanzania (NIMR/HQ/R.8a/Vol. IX/4328) and the University of Virginia Institutional Review Board (IRB HSR230405). Written informed consent was obtained for all study participants using procedures outlined in the institutional review board–approved study protocol. Data collection, storage, and management followed all outlined procedures (eg, deidentification of baseline survey data and use of an assigned study ID with a separate link log). No monetary compensation was provided to participants for study activities described in this paper.

A total of 14 people with tuberculosis were enrolled from KIDH (n=8, 57%) and KCMC (n=6, 43%; Table 1). A total of 11 providers and staff members were enrolled from KIDH (n=5, 50%) and KCMC (n=6, 55%). Emergent themes are summarized for people with tuberculosis and provider and staff interviews in Figure 2, and findings are described further below.

People with tuberculosis described several challenges shaping their illness and treatment experiences, and related impacts on daily life (Table 2).

People with tuberculosis described significant losses of income and productivity following diagnosis, particularly for physically demanding jobs, resulting in reduced ability to support their households. Stigma was reported to influence many aspects of patients’ experience of illness, maintained by community members, leading to selective diagnosis disclosure, social isolation, lack or loss of support, and decreased quality of life and mental health. Protective behaviors such as physical separation within households increased feelings of isolation. Some individuals noted that after their diagnosis was disclosed, partners ended relationships and friends distanced themselves. Living environments were also described, with rural residents facing long travel distances and a lack of transportation. Housing (eg, overcrowded or poorly ventilated) and employment (eg, mining or farming) exposed some patients to harsh conditions and physical strain counter-productive to recovery.

People with tuberculosis described the frequency of follow-up visits (facility-based or home-based DOT) and facilitation by family members to coordinate follow-up visits and handle logistics. Patients cited various reasons for continuing medications, such as religious beliefs, responsibility to children, and witnessing the decline of peers who have gone untreated (poor health and unemployment). Facilitators for ongoing adherence included upfront counseling from the clinical team about side effects and the need to continue medications despite the absence of symptoms.

The current factors describing how patients engage with care, including their experience with the quality of their treatment and their medication habits, are summarized in Table 3.

The relationship between people with tuberculosis and providers plays a key role, with variable experiences reported around counseling on treatment needs, such as laboratory tests and complex medication routines. Most participants shared positive experiences with their providers, especially appreciating the ability to communicate directly with their doctors during times when symptoms worsened or their condition changed. Patients’ personal level of motivation/activation was described by several as an important determinant. On the other hand, perceived health improvements or treatment fatigue often caused patients to stop treatment early.

Daily medication adherence was supported by various reminders and personalized routines, such as aligning medication times with meals, setting phone alarms, using visual aids, writing detailed notes in treatment cards, exercise books, or notebooks, and seeking support from family members. Various clinic support strategies (SMS text reminders from the clinic or phone check-ins) and digital adherence technologies (alarm devices provided by the clinic, personal device alarms, or digital pill boxes) were described as initially helpful to improve accountability, with some noting they needed the reminder less as their treatment course went on.

While many aspects of tuberculosis treatment are subsidized by the government (eg, medications or physician services) [32], the cost of care remains a significant barrier (eg, transportation or follow-up care). Financial support services (eg, transportation vouchers, food, or stipends) facilitate visit attendance and were described to encourage continued engagement in care. Access to transportation and distance to clinics (ie, geographic remoteness) were critical determinants—people with tuberculosis reported selling assets or relying on social networks for related expenses, including relatives, neighbors, and religious communities:

People with tuberculosis described various barriers related to personal access to test results, including delays from collection to release to the patient, lack of detail or direct access to results (eg, quantitative viral load counts, chest X-ray interpretations, etc). Several participants noted an inability to review results with their provider during medical visits due to inadequate internet connectivity. Patients who must physically return for laboratory results face unpredictable, long wait times once they arrive. Some participants reported that follow-up care done at local facilities makes receiving laboratory results easier, but facilities lack other complex care capabilities valued at KCMC and KIDH.

Key additional themes emerged relating to experiences with current care delivery and medical needs (Table 3). People with tuberculosis highlighted several positive aspects of care delivery, including flexibility (eg, family members can collect medications), clear communication, and positive rapport with their care team. Patients noted broader challenges encountered in the tuberculosis care continuum (delays in initial disease recognition, testing, and treatment initiation). Tuberculosis diagnoses often came after prolonged, misinterpreted symptoms and multiple clinical encounters.

Patients described variable access to integrated tuberculosis and HIV outpatient care—those accessing it (eg, at KCMC) expressed satisfaction with the coordination and efficiency of integrated care, appreciating access to a single provider managing both conditions, whereas integration was less commonly described at smaller, local facilities. Patients’ detailed experiences with provider competency, approach, and level of commitment generally describe care team members (physicians, nurses, or staff) as competent, trustworthy, and attentive. Patients reported positive experiences with counseling and education, noting that educational materials and seminars provided by the clinics were helpful. In one instance, however, inadequate anticipatory guidance led to premature self-discontinuation of treatment with resolution of symptoms.

Personal smartphone ownership was self-reported by 5 of 14 people with tuberculosis, 36% (5/14), with 3 of 8 patients with comorbid HIV reporting ownership (3/8, 38%). The remaining people with tuberculosis (n=9) instead reported owning feature phones (eg, “button phones” or “flip phones”). Most participants without personal ownership reported using a smartphone app at some point on another person’s phone (8/9, 89%). Nonowners described a perception of a typical smartphone owner as young-to-middle aged, employed, and well-educated. Some people with tuberculosis, without their own smartphones, noted that younger family members owned smartphones for school or work, and described borrowing a smartphone from a peer to use as needed.

People with tuberculosis noted that consistent internet connectivity was a challenge, particularly for rural residents, describing access primarily through increasingly expensive data “bundles.” Patients described mobile phone usage, primarily for communication with peers and family members (calling, texting, WhatsApp [Meta], or Facebook [Meta]), while others noted minimizing data usage due to cost (eg, urgent calls or checking the time). Specific usage for different aspects of tuberculosis care was described (communication with providers, setting phone alarms, and internet searches for disease-related information).

Positive perceptions of acceptability of the proposed mHealth program and platform features were coded in 13 of 14 interviews (Table 4).

Recognized benefits included enhanced convenience, reduced need for transportation and associated costs, and opportunities to receive additional, timely support from peers and providers. Patients generally described the features as intuitive and simple to understand, though some felt other patients may struggle depending on their literacy level. Patients noted that even for those without smartphone access, most would be eager to participate in the program if offered, with adequate upfront training “to the public” (eg, group seminars or campaigns), and one-on-one training suggested over a period as long as a month to ensure understanding.

Several concerns were identified related to feasibility and personal costs to the patient, including limitations in consistent personal access to smartphones and continuous data and internet connectivity:

Among existing platform features, patient-provider communication was most frequently coded, with many patients noting the benefit of communicating with care team members in between visits, addressing concerns as they arise (eg, side effects), and receiving support. One patient noted that this type of “virtual clinic” has already been commercialized by individual doctors within the context:

Perceptions of the peer message board feature were the next most frequently coded. Patients noted the benefits of a private space to give and receive support when the illness can be so isolating, and opportunities for shared learning with peers sharing their own experiences with treatment challenges. Patients note providers should also have access to the chat, which was the case for app implementation in Siberia but not in the United States [9]. Appointment and medication reminders and daily “check-ins” were found to be desirable features to support adherence, but it may be overwhelming to receive frequent information through the platform.

Patients noted already using internet resources (eg, Google [Google LLC]) for health information, and that tailored educational resources within the app would be desirable. Patients found the laboratory dashboard feature superior to current methods to track their own laboratory results (eg, “exercise book”). Patients provided several suggestions for additional novel functionality, including expanded self-monitoring options (weight, vitals, symptoms, and laboratory results beyond tuberculosis-specific results) and a feature to send photos to providers along with messages. They also suggested functionality for convenient referral of peers and contacts with concerning symptoms for tuberculosis screening and treatment, and asserted the importance of the availability of app features in multiple languages.

Determinants of care engagement and medication adherence that emerged during provider and staff interviews are summarized in Table 5.

Patient knowledge was described as critical for encouraging long-term adherence and preventing early treatment discontinuation, including around other facets of health (eg, maintaining adequate nutrition or cessation of smoking), with variable literacy levels observed among their patients. As with interviews with people with tuberculosis, daily medication adherence and the patient-provider relationship were highlighted, noting both were insufficient without adequate patient motivation and self-efficacy. Patient-provider relationships were described as patient-centered with shared decision-making by some, and more directive approaches by others.

Stigma was widely described as a barrier, influencing the degree of social support received by family members and community members. Providers described stigma fueled by inadequate understanding of how tuberculosis is acquired (eg, misperceptions around sexual transmission or assumption that a patient with tuberculosis automatically has HIV) and further transmitted (eg, even after the patient has been on treatment for some time). Several providers stressed the importance of proactive counseling and education of the patient and family members to reduce stigma, foster family support, and reduce early treatment discontinuation and patient isolation. Cost of care (eg, transportation fees or laboratory tests) was a major determinant, as with patient interviews. Providers described competing costs (eg, feeding their families) and the difficulty of frequent in-person medical appointments for maintaining employment. Several providers mentioned that incentives (transportation or food vouchers) would greatly improve care engagement.

A variety of methods were described to encourage medication adherence and appointment attendance (Table 5). Provider-initiated phone calls are the primary method. Providers and staff note that patients can be difficult to reach (data bundle runs out or family members must be contacted), and repeat outreach attempts are time-consuming for providers. Other methods of adherence monitoring were described with some concerns about efficacy, including blister packs (patients bring in to visits inconsistently) and digital adherence tools (eg, patient opens an electronic pill box but does not take the medication). Providers and staff noted limitations with home-based DOT, or a trade-off between patient access and accurate monitoring of daily adherence.

Experiences with implementation of laboratory diagnostic testing were highlighted by many providers, including challenges with releasing results to patients, causing delays in treatment initiation, and additional service delivery costs when patients cannot be reached by phone or do not return to the facility to receive results (eg, staff must arrange transportation to find the patient out in the community). Respondents at both sites noted care integration for HIV and tuberculosis facilitates appropriate medical management (eg, adjusting HIV medications for drug-drug interactions), but that collocating care has resulted in additional HIV-related stigma for people with tuberculosis mono-infection. Providers and staff at both KIDH and KCMC described off-hours calls, noting they are open to receiving calls outside of work hours or seeing patients who present outside of the providers’ scheduled clinic hours, as it contributes to better care, but it presents a burden on their time and energy. Providers and staff described current outreach services performed by community liaisons, including moderating patient support groups and education seminars, checking in with phone calls, doing home visits, and contact tracing.

Personal access to a smartphone was reported by all 11 providers, with broad access among peer and family networks. As with patients, they described most frequently accessing the internet via data bundles over Wi-Fi, both for work and personal use. High levels of comfort and familiarity with smartphone apps were noted, including for personal use (communication with peers, social media, and news) and for work (reviewing medical literature, clinical guidelines, communicating with patients by phone call, and with colleagues and coworkers by WhatsApp or calls). Providers and staff noted use of their personal smartphone over other devices (desktop computer or laptops) for these work tasks, and the inability to access hospitals’ digital systems via these devices. The cost of bundles is also often not subsidized (with spending reported between 10‐100,000 Tsh or ≈3.8‐38 US $/mo).

Determinants of implementation emerging from provider interviews are categorized for salient domains, subdomains, and constructs using CFIR version 2.0 [28] with illustrative quotations (Table 6).

Perspectives on various platform features are categorized within the “innovation” domain. Positive perceptions of acceptability surrounding the design of the app’s features were coded among all 11 provider and staff interviews. Providers and staff noted potential benefits including minimizing adherence challenges and treatment interruptions, reducing the frequency of in-person visits and patient travel, and the potential to enhance existing community outreach efforts. Positive perceptions of usability or user-friendliness were coded among 5 interviews based on the platform overview provided.

Providers and staff describe the utility of daily check-ins of mood, stress, and medication adherence, which should be effectively summarized for all members of the care team. They emphasized the importance of mood and stress on medication adherence and current limitations in assessing with intermittent face-to-face visits. Some respondents note that reminders should not be overly frequent, but can, over time, increase motivation, as well as create an opportunity for providers to initiate discussions around observed increased levels of stress. Suggested additions included a video feature for observed doses to ensure adherence beyond self-report (eg, video-DOT), check-ins for symptoms and side effects, and additional reminders to eat nutritious meals to support medication tolerance.

Participants noted the benefits of direct communication between people with tuberculosis and providers and staff through the in-app messaging tool, including a “pool” of providers that can respond if the primary provider is unavailable. Providers and staff participants, such as people with tuberculosis interviewed, noted that the peer messaging board creates an opportunity for shared learning and building community. Educational resources were described as useful to demonstrate the benefits of adherence and set expectations around possible side effects. The laboratory results dashboard was felt to be desirable to reduce delays in treatment initiation/modification and prevent loss to follow-up following an initial diagnosis. One respondent noted the app could improve upon the current lack of security for current laboratory entry, whereby multiple people can enter a laboratory result without tracking who modified it and when. Direct delivery of a positive result/diagnosis via the app without associated counseling was a shared concern among respondents, noting potential implications of direct delivery of laboratory results to people with tuberculosis via the dashboard without appropriate counseling.

Relevant themes emerged for the “inner setting” domain—the hospital/clinic settings where providers/staff are employed—including compatibility with clinic processes and available resources (eg, smartphone, electronic device, internet access at work, or as described previously). Instability of electricity and power outages were noted as an issue that might impact implementation. Providers and staff noted that the program would need to be well integrated early on between the clinic, pharmacy, and laboratory settings. For the “individuals” domain (individual characteristics and roles), providers and staff (innovation deliverers) generally noted feeling confident in their own ability and those of their colleagues to effectively use the app, possessing appropriate knowledge and skills. Several respondents noted that, in addition to meeting care delivery needs, the app may allow for increased capacity to reach patients, increased efficiency, and time saved on other outreach activities.

Provider and staff availability to engage with the app was felt by some to be contingent on additional funding and engagement of multiple collaborating team members. While some respondents felt physicians should lead program implementation and field concerns from patients via the app (eg, direct messaging or chat board moderation), others felt nurses or community health workers might be better suited based on their current roles. The IT, training, and quality departments were noted as key for implementation facilitation and support, and that patients should be represented in decision-making processes. A physician provider noted that additional compensation should be considered to incentivize involvement. Providers and staff anticipated patients (innovation recipients) would be supportive and capable of receiving the intervention, contingent on factors such as age, place of residence (eg, rural vs urban), educational level, and financial means, each shaping personal smartphone and data bundle access and “digital literacy.” Some anticipated challenges include personal cost to the patient (eg, bundle to support usage or need for provision of smartphone), privacy concerns (eg, by whom and how will the patient’s data be accessed), and a need for translation to multiple languages (eg, English, Kiswahili, or local languages).

For the “implementation process” domain, planning and continuous engagement of high-level leadership and IT staff, in addition to patient-facing staff, were highlighted by providers, as well as proactive training and engagement of patients to ensure adequate awareness and buy-in. The importance of a physical presence (eg, direct observation) in implementation settings early on to assess progress and challenges in real-time was also noted by one provider.

Salient themes emerging from our contextual assessment are summarized in Figure 2. Stakeholders engaged by this study demonstrated a high level of perceived acceptance for the proposed app and program as described, with significant barriers emerging related to feasibility in this “real-world” context. Smartphone ownership was uniformly described among providers and staff members and their networks, whereas people with tuberculosis described considerably lower access. Our findings suggest that a provider-facing smartphone tool to assist with interstaff communication, sharing of results, and other functionalities independent of hospitals’ electronic systems was perceived to be feasible and acceptable. Current bidirectional features requiring smartphone and data bundle access may also perform well in funded pilot trial conditions for a select patient persona (urban residence, young to middle-aged, etc); however, broad real-world reach and sustainability of patient-facing smartphone tools would require significant infrastructure development and financial support within the context.

Our application of CFIR in this study was limited to the providers and staff members at KCMC and KIDH, without representation of high-level leadership or external stakeholders (eg, government, network providers, etc) who could elaborate on potential mechanisms to support sustainability and financial viability in the context. There is growing evidence for cash transfers and other forms of financial support to provide person-centered tuberculosis care, among which digital access could be further prioritized (eg, provision of a smartphone and data bundle for the duration of treatment) [38,39]. The phenomenon of widening health care inequities through the broad roll-out of person-centered digital health interventions—without a parallel process of design and planning to support implementation and reach among individuals with lower digital access—is increasingly observed as broader population-level trends suggest growing digital access [40,41]. Our findings show that barriers to tuberculosis care intersect with digital access barriers, stressing the importance of conducting thorough contextual assessments to inform equitable implementation, as opposed to relying on broader-level population trends.

PositiveLinks features were designed based on the IMB skills model. The IMB model posits that to change a habit or promote health, a person must use cognition to understand information and build motivation for action and deploy behavioral skills to reduce an unhealthy behavior. PositiveLinks provides information about daily medication adherence and helps the user track behavior over time, enhances motivation through secure messaging with providers and social support from peers, and encourages behavioral skills in HIV care self-management via self-monitoring of mood and stress in addition to medication adherence. Interacting contextual determinants identified in this study are highlighted as both (1) impacting individual abilities to understand information and build motivation and (2) integral to the SAT that further guides PositiveLinks platform design, by shaping the contextual influences and social interactions that further influence individual behavior change as described by the IMB model (Figure 2).

Existing theory-based platform features developed for PositiveLinks address many needs endorsed by people with tuberculosis and providers in this context (eg, low barrier communication, direct in-app laboratory result release, peer support, educational resources for stigma reduction, and prevention of early treatment discontinuation). Several additional suggestions for novel features and adaptations were provided for patient-facing features specific to tuberculosis care in the context, such as video-DOT, which has some evidence for efficacy over traditional DOT, but is limited by access and connectivity barriers [3]. Added self-management features (eg, check-ins for symptoms, side effects, or reminders for nutrition intake) and availability in multiple languages were suggested by both patients and providers and will be considered in future prototypes. To date, most platforms tested or disseminated in Sub-Saharan Africa focus on daily medication adherence support and monitoring. This study indicates that more intensive digital wraparound support is desired and could enhance the impact of digital adherence technologies for tuberculosis care, mitigating barriers related to additional mechanisms of behavior change related to patient knowledge, motivation, activation, and related behavioral skills of self-management and peer support.

Several adaptations for the associated implementation strategy were identified for consideration for future implementation of PositiveLinks and other mHealth technologies to support tuberculosis treatment among people with tuberculosis in this context (Figure 2), distinct from prior implementations in other contexts [9]. Existing usage and degree of digitization of records was described in multiple themes across interviews (eg, use of personal print records for visits, including “exercise books,” digital records accessible only by devices located within clinics) and represents an important consideration for digital health intervention compatibility within care settings in the context. Additional distinct emergent needs identified for the context will need to be considered for intervention and program adaptation and implementation among innovation recipients (digital literacy, access, and income) and deliverers (integration between departments, personal provider and staff cost of device usage, existing provider and staff burden, and community outreach infrastructure).

Our findings related to broader determinants of tuberculosis care, care experiences, and unmet needs in the context align with those previously reported within Tanzania and similar contexts to date, including barriers related to stigma and social support, transportation, geographic access to facilities, indirect costs (transportation, nutritious meals, and laboratory results), and competing demands of employment and basic needs [42-46]. Our study expands on limited literature by exploring real-world smartphone ownership, access, and familiarity within the context and perceptions surrounding the implementation of smartphone-based and other mHealth technologies to support the delivery of person-centered tuberculosis care in the region [47,48], as well as key considerations for designing compatible implementation strategies for the context.

Our study had several limitations. The sample size for each stakeholder group is the result of a combination of thematic saturation reached early on in recruitment and limitations surrounding study funding and staffing, with a long recruitment time needed—a common barrier for rigorous implementation research [49]. Certain provider and staff roles were consequently underrepresented (eg, physician) or overrepresented (eg, laboratory scientist). We included people with tuberculosis up to 5 years posttreatment to be inclusive of potential long-term care experiences and consequences of incomplete or poor-quality tuberculosis treatment that take time to emerge. Accounts for participants farther out from treatment complications may be limited by recall bias, which could limit accuracy and comparability with more recently treated participants. We also elected to apply CFIR only to provider and staff interviews, as we felt that other probes related to context adequately captured salient CFIR constructs and domains for people with tuberculosis (eg, patient needs or characteristics). Future studies to develop prototypes and further engage stakeholders in program design and implementation should deepen the involvement of both people with lived experience and stakeholders external to potential implementing organizations.

A contextual assessment conducted among stakeholders at KIDH and KCMC in the Kilimanjaro region of Tanzania demonstrated high acceptability for the proposed adaptation of the PositiveLinks mHealth, smartphone-based strategy to deliver multidimensional, person-centered care of tuberculosis within the context. Several assets were identified to support PositiveLinks implementation, including a robust existing community outreach infrastructure and provider and staff commitment to patient care outside of scheduled appointments. Providers and staff demonstrated high subjective capability, motivation, and need, though several shared inconsistent current infrastructure to support smartphone app use for clinical care (power outages, network availability, and unsupported cost of personal device usage). Implementation determinants challenging the feasibility for patient-facing tools (baseline digital access, literacy, and associated costs among people with tuberculosis) necessitate further adaptations to the existing PositiveLinks core implementation strategy components.