Our study presents the perspectives of multiple type of users and decision makers for Truenat implementation. Overall, the platform and TB assays demonstrated high usability and acceptability among recipients, HCPs and DMs. The ability to provide same-day results and the option to run the device without a continuous electricity supply were seen as advantageous for its use in decentralized settings and contributed to the perceived fit to the evaluated settings. Despite the low infrastructure requirements, users described challenges related to supply chain management, throughput, and local infrastructure, such as dedicated bench space for sample processing. These infrastructure improvements are necessary to ensure safe and effective use, particularly for healthcare providers, who face a high risk of workplace infection [19]. The need for ongoing training and support was also identified.

In terms of usability, our findings align with a previous systematic review on molecular TB testing [5], a recent study among operators of Truenat in Nigeria [11] and reports of operational research for Truenat implementation by the STOP TB partnership [20]. The most frequently reported issues were related to sample processing with Trueprep, similar to previous operational studies [11, 21–23]. Although not widely discussed in the interviews, issues with invalid and a high proportion of indeterminate results were identified at trial sites. Interviewees mostly discussed the additional time and effort required to reprocess samples. To overcome this challenge, continued training, support and champions (superusers) to mentor local healthcare providers are recommended, along with continuous site monitoring and retraining as needed to reduce error rates and unsuccessful results [23].

In terms of recipient preferences, sputum remained the preferred sample, despite common descriptions of challenges to produce, handle and transport it. HCPs also mentioned issues with sputum quality, as reported in other studies [5]. Differences in the perceived trustworthiness of non-sputum samples have been reported for urine LAM, stemming from how people associate pulmonary TB and coughing, with sputum [24]. The long history and familiarity of sputum-based testing may also explain its preference, as seen in a multi-country Discrete Choice Experiment regarding TB testing [25]. However, the use of alternative samples may help overcome barriers related to sputum quality and risk of infection [26].

Supply chain challenges and reagent shortages, similar to those seen with GeneXpert, could also hinder Truenat’s implementation [27]. Both providers and decision-makers emphasized the importance of securing a reliable supply chain to meet program goals, thus, tailored procurement strategies are important for implementing Truenat [20]. Engaging multiple suppliers could lower costs and enhance supply sustainability by fostering competition [28]. Expanding the range of available diagnostic tools, including Truenat and other novel tests, would help achieve this. Understanding the local testing needs may also guide the type of device most suitable to the context, since the throughput of the molecular test platforms like GeneXpert and Truenat may affect the workflow at the facility and the ability to offer same-day results. This has been described previously for molecular and other tests like urine LAM [5, 29].

This study has several strengths. First, it benefits from a multi-country evaluation, providing insights into the implementation of Truenat in diverse healthcare settings across Tanzania and Mozambique. The involvement of local investigators, who are knowledgeable of the local languages and context, ensured that the interviews were culturally appropriate and well-understood by participants. Furthermore, the use of standard topic guides and regular debriefings [15] helped maintain consistency across sites and improve the reliability of the data. The analysis was guided by the updated CFIR framework [17], a widely known and utilized tool for understanding the determinants of implementation, enhancing the rigor and depth of the findings and helping to identify key factors that influence the successful integration of Truenat into existing health systems.

This study also has some limitations. The timing of the interviews, conducted during the early stages of implementation, may have limited our ability to capture later-stage challenges that could emerge as the program matures. Additionally, the topic guide did not include aspects such as waste management, the impact of negative test results (not being diagnosed with TB) on recipients and clinical decision making, which could have provided further insights into the operational environment. Participant feedback on the findings was not collected; however, findings were discussed with local investigators and presented to local audiences as part of the study dissemination efforts. Finally, the study did not include children, a population that faces unique diagnostic challenges, such as difficulty producing sputum, and may require further research.