Objectives Chest X-ray (CXR) plays an important role in childhood tuberculosis (TB) diagnosis but access to quality CXR remains a major challenge in resource-limited settings. Digital CXR (d-CXR) can solve some image quality issues and facilitate their transfer for quality control. We describe the implementation of introducing d-CXR in twelve district hospitals (DH) in 2021-22 across Cambodia, Cameroon, Ivory Coast, Mozambique, Sierra Leone and Uganda as part of the TB-Speed decentralization study on childhood tuberculosis diagnosis. Methods For digitization of CXR Digital Radiography (DR) plates was set-up on existing analogue radiography machines. D-CXR were transferred to an international server at Bordeaux University and downloaded by sites clinicians for interpretation. We assessed the pre-intervention (baseline situation and d-CXR set-up) and per-intervention (uptake, challenges and health care workers (HCW) perceptions) of d-CXR implementation. We used a convergent mixed method approach utilizing process data, individual interviews with 113 HCWs involved in performing or interpreting d-CXRs and site support supervision reports. Results Of 3104 children with presumptive TB, 1642 (52.9%) had at least one d-CXR including 1505, 136 and 1 children with one, two and three d-CXR respectively, resulting in a total of 1780 d-CXR. Of them, 1773 (99.6%) were of good quality and 1772/1773 (99.9%) were interpreted by sites clinicians. 164 children had no d-CXR performed despite attending the radiography department: 126, 37 and 1 with one, two and three attempts, respectively. D-CXRs were not performed in 21.6% (44/203) due to connectivity problem between the DR plate captor and the computer. HCWs reported good perceptions of d-CXR and of the DR plates provided. The main challenge was the upload to and download from the server of d-CXRs, due to limited internet access. Conclusion D-CXR using DR plates was feasible at district hospital level and provided good quality images but required overcoming operational challenges.

The authors have declared no competing interest.

This study was funded by Unitaid

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This study was approved by each implementing country National Ethics Committees, the World Health Organization Ethical Review Board, and the National Institute of Health and Medical Research Ethics Evaluation Committee. Individual consent was obtained from Parents/Guardians of enrolled children and the childs assent was obtained when the child was old enough as per countries regulation and from interviewed Healthcare Workers.

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