<p>Supporting information.</p>

Staff interviews, analyzed thematically, explored provider-side implementation challenges. Of 884 enrolled participants, 197 had both valid recordings and TB status (101 community, 96 facility). Median cough frequency was higher among those with TB: 2.2 coughs/hour (IQR 0.8–6.1) vs 0.9 (0.4–2.0) in the community, and 6.7 (2.6–27.5) vs 2.4 (0.9–4.8) in facilities (Wilcoxon P < 0.0001 for both).

AUCs were 0.69 (95% CI 0.58–0.79) in the community and 0.76 (95% CI 0.60–0.88) in facilities. For self-reported cough at 90% sensitivity, specificities were 55% (95% CI 29–88%) and 36% (95% CI 17–68%), respectively. Recorded cough frequency correlated moderately with self-reported cough severity, Saint George’s Respiratory Questionnaire scores, and staff-observed coughs.

Staff cited device visibility, stigma, and security concerns as barriers. Smartphone-recorded cough frequency was associated with TB status but did not meet accuracy thresholds for stand-alone screening or triage, and implementation problems limited data collection. Addressing these operational barriers will be critical to future development and deployment of cough monitoring tools for TB screening.</p></div>