Implementing user-centered design (UCD) principles and conducting usability testing is especially critical in projects where developers do not originate from the deployed environment. However, traditional usability testing techniques in cross-cultural settings can be problematic and may produce unexpected results. Measures should be taken to identify and mitigate any cultural factors that may influence UCD testing and deployment . In this paper, we focus on the think-aloud method. We use a current mHealth development and research project in Tanzania as a case study to highlight issues in UCD in cross-cultural settings. We offer recommendations for UCD methods and cultural considerations for low to middle income countries.