{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,6]],"date-time":"2026-10-06T05:58:45Z","timestamp":1791266325755,"version":"4.1.0"},"reference-count":38,"publisher":"Public Library of Science (PLoS)","issue":"7","license":[{"start":{"date-parts":[[2026,7,2]],"date-time":"2026-07-02T00:00:00Z","timestamp":1782950400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100006492","name":"Division of Intramural Research, National Institute of Allergy and Infectious Diseases","doi-asserted-by":"publisher","award":["R01AI147129"],"award-info":[{"award-number":["R01AI147129"]}],"id":[{"id":"10.13039\/100006492","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000056","name":"National Institute of Nursing Research","doi-asserted-by":"publisher","award":["K23NR017210"],"award-info":[{"award-number":["K23NR017210"]}],"id":[{"id":"10.13039\/100000056","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100012375","name":"School of Nursing, University of Washington","doi-asserted-by":"publisher","award":["RIFP"],"award-info":[{"award-number":["RIFP"]}],"id":[{"id":"10.13039\/100012375","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosdigitalhealth.org"],"crossmark-restriction":false},"short-container-title":["PLOS Digit Health"],"abstract":"<jats:p>Digital adherence technologies (DATs) may improve health behaviors only when users engage, but links between engagement, user factors, and outcomes are unclear. TB Treatment Support Tools (TB-TST) is a DAT with a smartphone app connecting patients to treatment supporters and weekly drug metabolite testing. We evaluated TB-TST app engagement in a pragmatic randomized controlled trial and identified factors associated with adherence and treatment outcomes. Engagement was measured from app interactions by 277 participants over 180-days of TB treatment. Adherence was assessed via daily self-reports and weekly metabolite-test photo submissions. Participants could also message treatment supporters, report side effects, or request help. We modeled time to non-adherence (28 consecutive days without reporting) using survival analysis. Logistic regression tested associations of adherence and engagement with treatment outcomes. A latent engagement score was derived using confirmatory factor analysis (CFA) from medication reports, photo submissions, side-effect reports, messaging, and overall adherence. Participants submitted 24,902 medication reports, 2,926 messages, 2,465 photos, 1235 side effect reports, and 128 help requests. Adherence declined over time (78% at 60 days; 50% at 180 days). Non-adherence was more common among males, participants living at or below the poverty line, those without stable employment, and those treated at certain hospitals. Non-adherence was associated with lower odds of treatment success (OR 0.48, 95% CI: 0.22 - 0.94) and higher odds of loss to follow-up (OR 2.1, 95% CI: 1.03 - 4.7), adjusting for sex, age, education, income, and employment. Higher engagement scores were associated with higher odds of success (OR 2.2 times per standard deviation increase). Engagement with TB-TST was associated with improved TB treatment outcomes. Strategies to increase and sustain engagement, particularly among high-risk groups, may improve adherence and maximize DAT benefits.<\/jats:p>","DOI":"10.1371\/journal.pdig.0001457","type":"journal-article","created":{"date-parts":[[2026,7,2]],"date-time":"2026-07-02T17:42:51Z","timestamp":1783014171000},"page":"e0001457","update-policy":"https:\/\/doi.org\/10.1371\/journal.pdig.corrections_policy","source":"Crossref","is-referenced-by-count":2,"title":["User engagement in the tuberculosis treatment support tools intervention and its impact on treatment outcomes: A secondary analysis of a pragmatic trial"],"prefix":"10.1371","volume":"5","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2980-0717","authenticated-orcid":true,"given":"Sarah 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