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. 2025 Aug 11;20(8):e0322969.
doi: 10.1371/journal.pone.0322969. eCollection 2025.

Exploring two-way text messages for post-discharge follow-up and quality improvement in rural Uganda

Charly Huxford  1   2 , Bella Hwang  2 , Dustin Dunsmuir  1   2 , Yashodani Pillay  1   2 , Fredson Tusingwire  3 , Florence Oyella Otim  4 , Beatrice Akello  4 , Aine Ivan Aye Ishebukara  3 , Stefanie K Novakowski  1   2 , Bernard Opar Toliva  3 , Nathan Kenya-Mugisha  3 , Abner Tagoola  5 , Matthew O Wiens  1   2   3 , Niranjan Kissoon  2   6 , J Mark Ansermino  1   2
Affiliations

Exploring two-way text messages for post-discharge follow-up and quality improvement in rural Uganda

Charly Huxford et al. PLoS One. .

Abstract

Introduction: Automated messaging through text (SMS) and instant messaging services (IMS) offers low-cost solutions for patient follow-up in resource-constrained contexts. This study aims to evaluate a quality improvement (QI) initiative to improve caregiver response rates to an automated messaging system for post-discharge follow-up of children in rural Uganda.

Methods: From June 2022 to June 2024, caregivers of children triaged through the Smart Triage platform at Gulu Regional Referral Hospital were invited to participate in an automated follow-up program. Messages were sent seven days after discharge via SMS and IMS (WhatsApp), prompting caregivers to report if their child had "improved" or "not improved". Non-responders and "not improved" cases were followed up with a phone call from a study nurse. From April 2023 to November 2023, a QI initiative refined the messaging system to improve response rates and a post-QI period then continued the intervention with no changes until June 2024. Response rates were analyzed over three periods: historical (pre-QI, June 2022 - March 2023), QI intervention, and post-QI. Additionally, data on message delivery rates, improvement strategies, and health outcomes were analyzed.

Results: Of 6826 participants, 6469 (95%) messages were successfully delivered. Response rates improved from 20% in April 2023 to 40% in June 2024 and remained stable between 33% and 41% during the post-QI period. Compared to the historical period, post-QI response rates were significantly higher (95% CI: 12.5% to 18.2%, p < 0.001). This improvement reflected a statistically significant positive trend during the QI period. Overall, 1856 caregivers responded: 1244 (67%) reported improvement and 612 (33%) reported no improvement. Follow-up phone calls for those "not improved" revealed 58 (9%) sought care, 12 (2%) were readmitted, and no deaths occurred. For non-responders, 206 (5%) sought care, 33 (0.7%) were readmitted, and 3 (0.07%) deaths occurred.

Discussion: Automated two-way text messages for post-discharge pediatric follow-up yielded high delivery and moderate response rates. Iterative QI efforts increased response rates, highlighting the importance of tailored communication strategies. Automated messages can facilitate timely intervention for high-risk children and enable efficient collection of health outcomes, offering a viable alternative to in-person follow-up in resource-poor settings.

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Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. Response rate change by month.
Fig 2
Fig 2. Messages sent and received.
See this image and copyright information in PMC

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