Shedding light on quality of care: a study protocol for a randomized trial evaluating the impact of the Solar Suitcase in rural health facilities on maternal and newborn care quality in Uganda

Impact of reliable light and electricity on job satisfaction among maternity health workers in Uganda: A cluster randomized trial

BACKGROUND

Maintaining a motivated health workforce is critical to health system effectiveness and quality of care. Scant evidence exists on whether interventions aimed to strengthen health infrastructure in low-resource settings affect health workers. This study evaluated the impact of an intervention providing solar light and electricity to rural maternity facilities in Uganda on health workers' job satisfaction.

METHODS

We used a mixed-methods design embedded in a cluster randomized trial to evaluate whether and how the We Care Solar Suitcase intervention, a solar electric system providing lighting and power, affected health workers in rural Ugandan maternity facilities with unreliable light. Facilities were randomly assigned to receive the intervention or not without blinding in a cluster-randomized controlled trial. Outcomes were assessed through two rounds of surveys with health workers. We used regression analyses to examine the intervention's impact on job satisfaction. We used an inductive approach to analyze qualitative data to understand the study context and interpret quantitative findings.

RESULTS

We interviewed 85 health workers across 30 facilities, the majority of whom were midwives or nurses. Qualitative reports indicated that unreliable light made it difficult to provide care, worsened facility conditions, and harmed health workers and patients. Before the intervention, only 4% of health workers were satisfied with their access to light and electricity. After the installation, satisfaction with light increased by 76 percentage points [95% confidence interval (CI): 61-92 percentage points], although satisfaction with electricity did not change. Experience of negative impacts of lack of overhead light also significantly decreased and the intervention modestly increased job satisfaction. Qualitative evidence illustrated how the intervention may have strengthened health workers' sense of job security and confidence in providing high-quality care while pointing towards implementation challenges and other barriers health workers faced.

CONCLUSIONS

Reliable access to light and electricity directly affects health workers' ability to provide maternal and neonatal care and modestly improves job satisfaction. Policy makers should invest in health infrastructure as part of multifaceted policy strategies to strengthen human resources for health and to improve maternal and newborn health services. Trial registration socialscienceregistry.org: AEARCTR-0003078. Registered June 12, 2018, https://www.socialscienceregistry.org/trials/3078 Additionally registered on: ClinicalTrials.gov: NCT03589625, Registered July 18, 2018, https://clinicaltrials.gov/ct2/show/NCT03589625 ).

Impact of Solar Light and Electricity on the Quality and Timeliness of Maternity Care: A Stepped-Wedge Cluster-Randomized Trial in Uganda

Lack of access to reliable energy is a major neglected health system challenge to maternal and child health. We found that installing a solar energy system intervention in rural Ugandan maternity facilities led to modest increases in the quality of maternity care and reductions in delays in care.

Background:

We evaluated the impact of solar light installation in Ugandan maternity facilities on implementation processes, reliability of light, and quality of intrapartum care.

Methods:

We conducted a stepped-wedge cluster-randomized trial of the We Care Solar Suitcase, a complete solar electric system providing lighting and power for charging phones and small medical devices, in 30 rural Ugandan maternity facilities with unreliable lighting. Facilities were randomly assigned to receive the intervention in the first or second sequence in a 1:1 ratio. We collected data from June 2018 to April 2019. The intervention was installed in September 2018 (first sequence) and in December 2018 (second sequence). The primary effectiveness outcomes were a 20-item and a 36-item index of quality of intrapartum care, a 6-item index of delays in care provision, and the percentage of deliveries with bright light, satisfactory light, and adequate light.

Results:

We observed 1,118 births across 30 facilities. The intervention was successfully installed in 100% of facilities. After installation, the intervention was used in 83% of nighttime deliveries. Before the intervention, providers on average performed 42% of essential care actions and accumulated 76 minutes of delays during nighttime deliveries. After installation, quality increased by 4 percentage points (95% confidence interval [CI]=1,8) and delays in care decreased by 10 minutes (95% CI=−16,−3), with the largest impacts on infection control, prevention of postpartum hemorrhage, and newborn care practices. One year after the end of the trial, 90% of facilities had LED lights in operation and 60% of facilities had all components in operation.

Conclusions:

Reliable light is an important driver of timely and adequate health care. Policy makers should invest in renewable energy systems for health facilities; however, even when reliable lighting is present, quality of care may remain low without a broader approach to quality improvements.

Know-do gaps in obstetric and newborn care quality in Uganda: a cross-sectional study in rural health facilities

OBJECTIVES

Variable and inadequate quality of maternity care is a critical factor in persistently high rates of maternal and neonatal mortality in Uganda. We investigated whether provider quality of care deviates from knowledge and the factors associated with these 'know-do gaps' in Ugandan maternity facilities.

METHODS

Data were collected from 109 providers in 40 facilities. Quality was measured using direct observations of intrapartum care, and scores were based on the percentage of essential care actions provided out of a 20-item validated quality index. Knowledge was measured based on the percentage of items that providers reported knowing to do using vignette surveys. The know-do gap was the difference between knowledge and quality. Multivariable models were used to assess the association between provider- and facility-level characteristics and knowledge, quality and know-do gaps.

RESULTS

The average quality score was 45%, with quality varying widely within and across providers. The mean knowledge score was 70%, yielding a mean know-do gap of 25%. Know-do gaps were largest for practices related to infection control, vitals monitoring, and prevention of postpartum haemorrhage. The association between quality and knowledge scores was positive but small (P = 0.08), so know-do gaps were largest for providers with the highest knowledge scores. Greater provider training was positively associated with knowledge (P = 0.005) but not with quality (P = 0.60). Having 10 or more years of work experience was associated with higher quality scores (5.3, 95%CI: 0.6 to 10.1), while higher patient volumes were associated with lower quality scores (-2.2, 95%CI: -3.7 to - 0.07). None of the factors of provider motivation, cadre, availability of essential medicines and supplies or facility staffing were associated with quality or know-do gaps.

CONCLUSIONS

Our results indicate that, in Uganda, gaps between knowledge and quality do not appear to be explained by factors such as lack of motivation, education, training or supplies. Gaps are particularly large for essential practices related to prevention of postpartum haemorrhage, a leading cause of maternal mortality in Uganda and similar settings.