The feasibility and acceptability of an early warning score system for preterm and low-birth weight infants in Kenya Background: Globally 15 million babies are born preterm or "born too soon" each year. Nearly two-thirds of such births happen in sub-Saharan Africa and Asia. Premature birth is the cause for a third of all deaths in the first month of life. In Kenya, over 200,000 babies are "born too soon" and despite recent reductions, deaths in the first month of life remain high at 20 per 1000; 7 times higher than in the UK. Kenya suffer from a shortage of resources including lack of trained neonatal doctors and nurses. Poor record keeping in hospital causes delays in recognising poorly babies, in providing treatment and leads to poor outcomes. Early warning scores (EWS) are a streamlined way to monitor patients and prompt treatment to prevent deterioration that could lead to death. The "Newborn Early Warning Track and Trigger" (NEWTT) used in the UK uses a simple paper-based form, which has a "traffic-light system" to easily plot infants' vital signs (temperature, heart rate and respiratory rate). This promptly alerts healthcare professionals to take actions if signs are in the red or amber zones. Closer monitoring of preterm infants with a system that more easily identifies sicker infants could help resource-limited staff to reduce deaths and illness in this very vulnerable group.  Previous work: To understand how doctors and nurses care for preterm and low birth weight (LBW) infants in Kenya, we recently completed a study at a large hospital in Nairobi, Kenya. We collected data on 294 babies over 8 weeks and recorded vital signs on the NEWTT. We also spoke to 19 mothers and 20 stakeholders to explore their views of newborn care. The data were presented at a large meeting in Nairobi in July 2019 attended by around 80 people involved in care of preterm infants. The idea of implementing a EWS for preterm infants in Kenya was discussed and feedback was positive. They liked the simplicity of documentation using a traffic-light system for quick identification of high risk infants. Some barriers were discussed such as a recognition of need for training and resources such as nursing time and colour printed charts.  Current study: This study aims to test how feasible and acceptable it is to implement an EWS in neonatal units in Kenya. We will implement the paper-based EWS in three neonatal units and ask staff to complete this for all preterm or LBW infants over a 4-week period. When a vital sign is entered onto one red or two amber trigger zones, they will alert a more senior member of staff to assess the infant and advise further action. The EWS will temporarily replace the current documents to avoid duplication of work. We will also conduct interviews a range of healthcare professionals involved in caring for preterm infants. In order to include a range of opinions, we will aim to include 2-3 interviews with each type of staff, resulting in around 24-30 interviews.  Skills development: We will develop capacity to conduct research and increase the skills of our Kenyan partners. Three researchers, one from each hospital in Kenya, will visit the UK They will attend the well established Nottingham Fundamentals of Clinical Trials course (https://www.nottingham.ac.uk/nctu/short-courses/fundamentals-of-clinical-trials.aspx). Here they will learn basic skills in the design and conduct of clinical trials via a mixture of classroom style teaching and workshops and network with other course attendees. They will also spend time at Nottingham Clinical Trials Unit and the Liverpool School of Tropical Medicine to gain hands-on experience of clinical trials and discuss future opportunities.  Future work: The current study is a step in a longer-term programme of work to establish a practical and useful EWS for reducing death among preterm infants in resource-limited hospitals. If shown to be feasible and acceptable, we will undertake an appropriately designed clinical trial to test if using such an EWS will help save lives of those "born too soon". The Global Challenges Research Fund (GCRF) supports cutting-edge research to address challenges faced by developing countries. The fund addresses the UN sustainable development goals. It aims to maximise the impact of research and innovation to improve lives and opportunity in the developing world.