Reasons for not responding.

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.