A central challenge in the delivery of evidence-based interventions to promote child survival is the coordination of care across the multiple tiers of th health system, from frontline health workers, to primary care clinics, to district hospitals, to specialty providers. Mobile technologies, coupled with effective management strategies, may enhance implementation and coordination of evidence-based interventions, but few controlled trials exist to validate this. Particularly lacking are strategies that incorporate mobile technologies in an integrated manner across the health system. Here, we propose a randomized trial evaluating a mobile health care coordination and quality improvement intervention to increase the timely engagement in care for children under the age of five. The study will take place in a remote rural district of Nepal, where child mortality rates remain high and coordination of child health care is poor. Intervention: The intervention focuses on two primary strategies to improve district healthcare delivery: structured quality improvement at primary clinics and mobile phone care coordination. These activities are coordinated via hospital-based clinicians and village-based frontline health workers. The focus of the intervention is the delivery of evidence-based World Health Organization protocols aimed at reducing child mortality-Integrated Management of Pregnancy and Childbirth, Integrated Management of Childhood Illness, Integrated Management of Emergency and Essential Surgical Care, and Community-based Management of Severe Acute Malnutrition. Analysis: We will conduct a stepped-wedge, cluster randomized controlled trial. The primary outcome of this trial will be under-five mortality. We will use both quantitative and qualitative methods to assessthe scalability of the intervention in terms of logistics, human resources, costs, and utilization.We will assess the feasibility of using data routinely collected for this intervention for the purposes of public health surveillance. Impact: Rigorous evaluations of systems-level child healthcare interventions are needed to drive global healthcare policies and their implementation. The trial proposed here will inform the potential impact and scalability of health systems strengthening interventions. Furthermore, should child health data collected routinely by frontline health workers correlate with those collected by the more time-intensive household surveys, such data could be used at a national scale for monitoring, evaluation, and logistics management of child healthcare programs.

Public Health Relevance

Globally; over seven million children under the age of five die each year. Evidence-based protocols for safe delivery care; neonatal care and resuscitation; emergency and surgical care; and the management of childhood diarrhea; malnutrition; and pneumonia together can prevent many of these deaths. This study; conducted in rural Nepal; will include the first randomized controlled trial of a quality improvement and care coordination mobile health intervention aimed at improving care delivery and communication across the tiers of the healthcare system; from frontline health workers to primary clinics to hospitals.

National Institute of Health (NIH)
Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD)
Career Transition Award (K99)
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Pediatrics Subcommittee (CHHD)
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King, Rosalind B
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Brigham and Women's Hospital
United States
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