Advancing the health of women and newborns: Predictors of patient satisfaction among women attending antenatal and maternity care in rural Rwanda

International Journal for Quality in Health Care, Volume 30, No. 10, Year 2018

Interpretação

Objective: Identify predictors of patient satisfaction with antenatal care (ANC) and maternity services in rural Rwanda. Design: Cross-sectional. Setting: Twenty-six health facilities in Southern Kayonza (SK) and Kirehe districts. Participants: Sample of women ? 16 years old receiving antenatal and delivery care between November and December 2013. Intervention: Survey of patient satisfaction with antenatal and delivery care to inform quality improvement (QI) initiatives aimed at reducing neonatal mortality. Main Outcome Measure: Overall satisfaction with antenatal and delivery care (reported as excellent or very good). Results: In multivariate logistic regression analysis, high perceived quality [odds ratio (OR) = 3.03, 95% confidence intervals (CI): 1.565.88], respect [OR = 4.13, 95% CI: 2.16-7.89], and confidentiality [SK: OR = 7.50, 95% CI: 2.16-26.01], [Kirehe: OR = 1.54, 95% CI: 0.60-3.94] were associated with higher overall satisfaction with ANC, while having ?1 child compared to none [OR = 0.46, 95% CI: 0.25-0.84] was associated with lower satisfaction. For maternity services, <5 years of school versus ?5 years [OR = 0.13, 95% CI: 0.026-0.69] and higher cleanliness [OR = 19.23, 95% CI: 2.22-166.83], self-reported quality [OR = 10.52, 95% CI: 1.81-61.22], communication [OR = 8.78, 95%CI: 1.95-39.59], and confidentiality [OR = 8.66, 95% CI: 1.20-62.64] were all positively associated with high satisfaction. Higher comfort [OR: 0.050, 95% CI: 0.0034-0.71] and Kirehe vs. SK district [OR: 0.21, 95% CI: 0.042-1.01] were associated with lower satisfaction. Conclusions: Patient-centeredness (including interpersonal relationships), organizational factors, and location are important individual determinants of satisfaction for women seeking maternal care at study facilities. Understanding variation in these factors should inform QI efforts in maternal and newborn health programs. The study was conducted in all 16 health centers (HCs) in Kirehe and 8 HCs in Southern Kayonza (SK) districts and the two district hospitals. ANC occurs at the HCs and deliveries at all 26 facilities. These rural districts are located in the Eastern Province of Rwanda, serving a catchment population of ~480 000 [16]. In partnership with the MOH, PIH has provided clinical and infrastructure support to the public health system in SK since 2005, expanding to Kirehe in 2009 [17, 18]. The ABC initiative built on an ongoing district-wide strengthening program started in 2009 to reduce neonatal mortality [17]. A conceptual framework was developed to inform survey design. Using a model created by Donabedian [19], three domains of factors influencing patient satisfaction were identified: (1) organizational components, (2) technical quality and (3) interpersonal factors. These factors have been found to influence patient satisfaction with maternal health services in Sub-Saharan Africa [11, 20, 21]. Our conceptual framework outlines the link between these factors and satisfaction with antenatal and maternity care (Fig. (Fig.1).1). Using this framework, 22 independent variables with potential links to patient satisfaction were identified and included in the survey: (1) patient characteristics, including age, marital status, education level, socioeconomic status, number of children, patient knowledge of danger signs and access (measured by travel time, cost of transportation, difficulty of payment for transport and overall difficulty of obtaining transportation); (2) organizational components, including length of wait time, acceptability of wait time, cleanliness and comfort; (3) reported technical quality of care received, including technical skills and perceived quality of care and (4) interpersonal factors, including understanding, communication, respect, promptness and confidentiality. The primary outcome—overall satisfaction—was assessed through the question: ‘Overall, how satisfied were you with the care that you received?’ Additional survey questions can be found in the Appendix. Conceptual framework for antenatal care (ANC) and maternity service satisfaction. Questions regarding satisfaction and perceptions of care employed a standard 5-point likert scale: excellent, very good, good, fair and poor. Both antenatal and maternity surveys were translated into Kinyarwanda, back-translated to ensure accuracy and conducted in Kinyarwanda. Surveys were administered by four data collectors, who received training in survey administration, data collection and research ethics. Each participant received a written and verbal explanation of purposes, risks, benefits and alternatives to study participation, and provided informed consent (signed or marked if unable to write). No compensation was provided for participation in the study. Data collectors visited health facilities on ANC visit days between November and December 2013, with all women attending ANC eligible for study participation. Additionally, any woman in the maternity ward who had delivered at least 4 h previously was eligible to participate in the maternity survey. Additional inclusion criteria included being at least 16 years of age and willingness and ability to provide consent. Exclusion criteria included acute maternal illness such as clinical instability, and having had a fetal or neonatal death in the current delivery. All surveys were conducted in a private location away from health providers and other patients. The study was approved by the Rwanda National Ethics Committee and the Partners Institutional Review Board. Potential predictors of satisfaction were converted to binary variables. For questions measured on a likert scale (technical skills, quality of care, understanding, communication, respect, promptness, confidentiality and overall satisfaction), responses were divided into positive responses (excellent or very good: EVG) or neutral/negative (good, fair or poor). Our primary outcome was high (EVG) overall satisfaction. Earlier studies in this population revealed differences in measures of quality of care across districts [15], so we included district as a potential effect modifier. Bivariate associations were tested between reported EVG satisfaction and the independent predictors using chi-squared test. Breslow–Day tests of homogeneity were used to test for significant effect measure modification by district of the association between independent predictors and overall patient satisfaction. All variables found to be statistically significant (P < 0.05) in the bivariate analysis were kept for use in regression analysis, except for ‘difficulty obtaining transport’ due to substantial missing responses for this question across surveys. Multivariate logistic regression analysis was used to identify predictors of EVG satisfaction. A backwards, stepwise selection approach was used to select covariates with a threshold of P < 0.05, except for district, which was included in the final model. After fitting the main effects models, interaction terms were tested between district and independent predictors found to have significantly different stratified odds ratios as identified by the Breslow–Day tests, and any interaction terms that were significant were also included in the final model. For goodness-of-fit, calibration using Hosmer–Lemeshow chi-square tests and discrimination using c-statistics were assessed. Statistical analysis was done using STATA version 13 (StataCorp.2013, Stata Statistical Software: Release 13. College station, TX: StataCorp LP). Results are reported as Odds Ratios (OR), 95% confidence intervals (CI) and P-values with alpha = 0.05.

AI Digest

Study Justification:

The objective of this study was to identify predictors of patient satisfaction with antenatal care (ANC) and maternity services in rural Rwanda. The study aimed to inform quality improvement initiatives aimed at reducing neonatal mortality. This study is important because understanding the factors that influence patient satisfaction can help improve the quality of maternal and newborn health programs.

Highlights:

– The study was conducted in 26 health facilities in Southern Kayonza and Kirehe districts in rural Rwanda.
– The study identified several factors that were associated with higher overall satisfaction with ANC and maternity services, including high perceived quality, respect, and confidentiality.
– Having at least one child compared to none was associated with lower satisfaction with ANC.
– For maternity services, higher cleanliness, self-reported quality, communication, and confidentiality were all positively associated with high satisfaction.
– Lower comfort and being in the Kirehe district were associated with lower satisfaction with maternity services.
– The study findings suggest that patient-centeredness, organizational factors, and location are important determinants of satisfaction for women seeking maternal care.

Recommendations:

– Improve the perceived quality of care, respect, and confidentiality in ANC and maternity services to enhance patient satisfaction.
– Focus on cleanliness, self-reported quality, communication, and confidentiality to improve satisfaction with maternity services.
– Address factors that contribute to lower satisfaction, such as longer wait times and lower comfort.
– Consider district-specific interventions to address variations in satisfaction levels between districts.

Key Role Players:

– Ministry of Health (MOH)
– Public health system
– Health facility staff
– Community health workers
– Non-governmental organizations (NGOs) involved in maternal and newborn health programs

Cost Items for Planning Recommendations:

– Training and capacity building for health facility staff on improving quality of care, communication, and patient-centeredness.
– Infrastructure improvements to enhance cleanliness and comfort in health facilities.
– Community engagement and awareness campaigns to educate women about their rights and expectations in maternal care.
– Monitoring and evaluation activities to assess the impact of quality improvement initiatives on patient satisfaction.
Please note that the cost items provided are general suggestions and may vary depending on the specific context and resources available.

Força da prova

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study design is cross-sectional, which limits the ability to establish causation. However, the study includes a large sample size and uses multivariate logistic regression analysis to identify predictors of patient satisfaction. To improve the strength of the evidence, future research could consider using a longitudinal design to establish causal relationships and include a control group for comparison. Additionally, conducting the study in multiple settings or countries could enhance the generalizability of the findings.

Resumo

The study was conducted in all 16 health centers (HCs) in Kirehe and 8 HCs in Southern Kayonza (SK) districts and the two district hospitals. ANC occurs at the HCs and deliveries at all 26 facilities. These rural districts are located in the Eastern Province of Rwanda, serving a catchment population of ~480 000 [16]. In partnership with the MOH, PIH has provided clinical and infrastructure support to the public health system in SK since 2005, expanding to Kirehe in 2009 [17, 18]. The ABC initiative built on an ongoing district-wide strengthening program started in 2009 to reduce neonatal mortality [17]. A conceptual framework was developed to inform survey design. Using a model created by Donabedian [19], three domains of factors influencing patient satisfaction were identified: (1) organizational components, (2) technical quality and (3) interpersonal factors. These factors have been found to influence patient satisfaction with maternal health services in Sub-Saharan Africa [11, 20, 21]. Our conceptual framework outlines the link between these factors and satisfaction with antenatal and maternity care (Fig. (Fig.1).1). Using this framework, 22 independent variables with potential links to patient satisfaction were identified and included in the survey: (1) patient characteristics, including age, marital status, education level, socioeconomic status, number of children, patient knowledge of danger signs and access (measured by travel time, cost of transportation, difficulty of payment for transport and overall difficulty of obtaining transportation); (2) organizational components, including length of wait time, acceptability of wait time, cleanliness and comfort; (3) reported technical quality of care received, including technical skills and perceived quality of care and (4) interpersonal factors, including understanding, communication, respect, promptness and confidentiality. The primary outcome—overall satisfaction—was assessed through the question: ‘Overall, how satisfied were you with the care that you received?’ Additional survey questions can be found in the Appendix. Conceptual framework for antenatal care (ANC) and maternity service satisfaction. Questions regarding satisfaction and perceptions of care employed a standard 5-point likert scale: excellent, very good, good, fair and poor. Both antenatal and maternity surveys were translated into Kinyarwanda, back-translated to ensure accuracy and conducted in Kinyarwanda. Surveys were administered by four data collectors, who received training in survey administration, data collection and research ethics. Each participant received a written and verbal explanation of purposes, risks, benefits and alternatives to study participation, and provided informed consent (signed or marked if unable to write). No compensation was provided for participation in the study. Data collectors visited health facilities on ANC visit days between November and December 2013, with all women attending ANC eligible for study participation. Additionally, any woman in the maternity ward who had delivered at least 4 h previously was eligible to participate in the maternity survey. Additional inclusion criteria included being at least 16 years of age and willingness and ability to provide consent. Exclusion criteria included acute maternal illness such as clinical instability, and having had a fetal or neonatal death in the current delivery. All surveys were conducted in a private location away from health providers and other patients. The study was approved by the Rwanda National Ethics Committee and the Partners Institutional Review Board. Potential predictors of satisfaction were converted to binary variables. For questions measured on a likert scale (technical skills, quality of care, understanding, communication, respect, promptness, confidentiality and overall satisfaction), responses were divided into positive responses (excellent or very good: EVG) or neutral/negative (good, fair or poor). Our primary outcome was high (EVG) overall satisfaction. Earlier studies in this population revealed differences in measures of quality of care across districts [15], so we included district as a potential effect modifier. Bivariate associations were tested between reported EVG satisfaction and the independent predictors using chi-squared test. Breslow–Day tests of homogeneity were used to test for significant effect measure modification by district of the association between independent predictors and overall patient satisfaction. All variables found to be statistically significant (P < 0.05) in the bivariate analysis were kept for use in regression analysis, except for ‘difficulty obtaining transport’ due to substantial missing responses for this question across surveys. Multivariate logistic regression analysis was used to identify predictors of EVG satisfaction. A backwards, stepwise selection approach was used to select covariates with a threshold of P < 0.05, except for district, which was included in the final model. After fitting the main effects models, interaction terms were tested between district and independent predictors found to have significantly different stratified odds ratios as identified by the Breslow–Day tests, and any interaction terms that were significant were also included in the final model. For goodness-of-fit, calibration using Hosmer–Lemeshow chi-square tests and discrimination using c-statistics were assessed. Statistical analysis was done using STATA version 13 (StataCorp.2013, Stata Statistical Software: Release 13. College station, TX: StataCorp LP). Results are reported as Odds Ratios (OR), 95% confidence intervals (CI) and P-values with alpha = 0.05.

Materiais

https://efashare.b-cdn.net/materials/aa443678f6aa0b11775b2795369a18190ddcb84df83a96cb8ced72b1298de1e4/mzy103antenatalcare.docx

Inovações

Based on the information provided, here are some potential innovations that could be used to improve access to maternal health:

1. Mobile health clinics: Implementing mobile health clinics that can travel to rural areas, providing antenatal and maternity care services to women who may not have easy access to healthcare facilities.

2. Telemedicine: Utilizing telemedicine technology to connect healthcare providers with pregnant women in remote areas, allowing them to receive consultations and guidance without having to travel long distances.

3. Community health workers: Training and deploying community health workers who can provide basic antenatal and maternity care services in rural areas, acting as a bridge between the community and healthcare facilities.

4. Improving infrastructure: Investing in improving the infrastructure of healthcare facilities in rural areas, ensuring that they have the necessary equipment and resources to provide quality maternal health services.

5. Health education programs: Implementing health education programs that focus on raising awareness about the importance of antenatal and maternity care, as well as providing information on healthy pregnancy practices and danger signs to watch out for.

6. Financial incentives: Introducing financial incentives for pregnant women in rural areas to encourage them to seek antenatal and maternity care services, such as transportation vouchers or subsidies for healthcare expenses.

7. Partnerships with non-governmental organizations (NGOs): Collaborating with NGOs that specialize in maternal health to provide additional support and resources to healthcare facilities in rural areas.

It’s important to note that these are just potential recommendations based on the information provided. The feasibility and effectiveness of these innovations would need to be further assessed and evaluated before implementation.

AI Innovations Description

The study titled “Advancing the health of women and newborns: Predictors of patient satisfaction among women attending antenatal and maternity care in rural Rwanda” aimed to identify predictors of patient satisfaction with antenatal care (ANC) and maternity services in rural Rwanda. The objective was to inform quality improvement initiatives aimed at reducing neonatal mortality.

The study was conducted in 26 health facilities in Southern Kayonza (SK) and Kirehe districts in Rwanda. The participants were women aged 16 years and older who received antenatal and delivery care between November and December 2013. The study used a cross-sectional design and collected data through a survey of patient satisfaction with antenatal and delivery care.

The main outcome measure was overall satisfaction with antenatal and delivery care, reported as excellent or very good. The study identified several factors associated with higher overall satisfaction with ANC and maternity services. These factors included high perceived quality, respect, and confidentiality. Having at least one child compared to none was associated with lower satisfaction for ANC, while

AI Innovations Methodology

The study mentioned aims to identify predictors of patient satisfaction with antenatal care (ANC) and maternity services in rural Rwanda. The objective is to inform quality improvement initiatives aimed at reducing neonatal mortality. The study used a cross-sectional design and surveyed women aged 16 years and older who received antenatal and delivery care between November and December 2013 in 26 health facilities in Southern Kayonza and Kirehe districts.

The methodology used in the study involved the following steps:

1. Conceptual Framework: A conceptual framework was developed based on factors influencing patient satisfaction, including organizational components, technical quality, and interpersonal factors. This framework guided the survey design.

2. Survey Design: A survey was designed to collect data on various factors related to patient satisfaction. The survey included 22 independent variables, such as patient characteristics, organizational components, reported technical quality of care, and interpersonal factors. The primary outcome measure was overall satisfaction with care.

3. Translation and Administration of Surveys: The surveys were translated into Kinyarwanda, the local language, and back-translated to ensure accuracy. Trained data collectors administered the surveys to eligible participants, providing written and verbal explanations of the study and obtaining informed consent.

4. Data Collection: Data collectors visited health facilities on ANC visit days and in the maternity ward to collect data from women attending ANC and those who had delivered at least 4 hours previously. The surveys were conducted in a private location away from health providers and other patients.

5. Data Analysis: Bivariate associations were tested between reported satisfaction and independent predictors using chi-squared tests. Variables with statistically significant associations were included in multivariate logistic regression analysis to identify predictors of high satisfaction. Backwards, stepwise selection approach was used to select covariates with a threshold of P < 0.05. Interaction terms were tested, and goodness-of-fit and discrimination were assessed.

6. Statistical Analysis: The statistical analysis was performed using STATA version 13. Odds ratios (OR), 95% confidence intervals (CI), and P-values were reported.

The study findings revealed that high perceived quality, respect, and confidentiality were associated with higher overall satisfaction with ANC. For maternity services, higher cleanliness, self-reported quality, communication, and confidentiality were positively associated with high satisfaction.

In terms of potential recommendations to improve access to maternal health, based on the study findings, it would be beneficial to focus on improving the perceived quality of care, ensuring respectful and confidential treatment of patients, and maintaining cleanliness in health facilities. These factors were found to be important determinants of patient satisfaction and can contribute to improving access to maternal health services.

To simulate the impact of these recommendations on improving access to maternal health, a possible methodology could involve conducting a pilot intervention in selected health facilities. The intervention could include training healthcare providers on improving the perceived quality of care, promoting respectful and confidential treatment, and implementing measures to enhance cleanliness. Data could be collected before and after the intervention to assess changes in patient satisfaction and access to maternal health services. Surveys similar to the one used in the mentioned study could be administered to measure patient satisfaction, and additional data on service utilization and patient experiences could be collected. Statistical analysis could then be performed to evaluate the impact of the intervention on improving access to maternal health.

Autor

Dima Health

Statistics:

Citations: 9

Identifiers:

DOI: 10.1093/intqhc/mzy103

ISSN: 13534505

Research Areas:

Community Interventions, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Social Determinants

Study Countries:

Rwanda

Study Design:

Case-Control Study, Cross Sectional Study, Grounded Theory, randomised-control-trial

Study Approach:

Quantitative

Participants Gender:

Female

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