Evaluating implementation of nurse-led community-based ultrasound screening for developmental dysplasia of the hip in Japan: A mixed-methods RE-AIM study

Abstract

Background

Developmental dysplasia of the hip remains a preventable yet underdiagnosed condition. Conventional screening strategies that rely on physical examination demonstrate limited sensitivity and fail to achieve comprehensive population coverage. Although universal ultrasound screening has shown promise, evidence supporting scalable, sustainable, and nurse-led community-based implementation models within real-world public health systems remains limited.

Objective

To evaluate a nurse-led community-based ultrasound hip screening program integrated into routine maternal and child health services in Japan using the Reach, Effectiveness, Adoption, Implementation, Maintenance framework.

Design

A prospective cohort study with a mixed-methods design.

Settings

Three rural Japanese municipalities (February 2024 to August 2025).

Participants

Public health nurses, midwives, infants, and their caregivers who underwent routine newborn home visits or child-rearing consultations in the participating municipalities.

Methods

The existing maternal and child health services evaluated across the following dimensions: Reach (coverage rate); Effectiveness (the proportion and mean age of infants referred early to medical institutions, and caregiver-reported outcomes following referral); Adoption (nurse adoption rate); Implementation (the proportion of ultrasound images meeting Graf's criteria, examination time, operational challenges, and cost); and Maintenance (continuation and policy integration). Ultrasound images were uploaded to a secure encrypted cloud server and interpreted remotely by Graf-certified pediatric orthopedic surgeons, with structured feedback provided to nurses throughout the implementation process.

Results

A total of 818 examinations were performed in 349 infants. The estimated coverage rate was 95.6%, indicating a near-universal range. Standard-plane images meeting Graf's criteria were obtained in 85.8% of examinations. Non-Type I hips accounted for 8.7% of cases, and 7.0% of infants were referred for further evaluation. Of these referred infants, 97.6% visited medical institutions, 54.8% required continued follow-up, and 4.8% required treatment. Adoption was high, with 95.5% of trained nurses conducting screenings. Implementation challenges included infant positioning, data-upload errors, and limited digital integration; however, interprofessional feedback from orthopedic surgeons improved technical performance. Ultrasound visualization enhanced caregiver understanding and facilitated timely adherence to referral recommendations. All municipalities continued screening, demonstrating strong maintenance.

Conclusions

Nurse-led ultrasound hip screening can be feasibly integrated into routine maternal and child healthcare systems. This model enables early identification of suspected developmental dysplasia of the hip without clinical signs, and offers an equitable approach in resource-limited settings from a precision public health nursing perspective.

Registration

University Hospital Medical Information Network Clinical Trial Registry; UMIN000051929 (https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_his_list.cgi?recptno=R000059248).

Registration date: September 16, 2023. Start of recruitment: November 01, 2023.

Social media abstract

Nurse-led community ultrasound hip screening achieved 95.6% coverage, and 8.7% of the screened infants had a suspected dislocation or hip dysplasia.