Organisational and individual readiness for change to respectful maternity care practice and associated factors in Ibadan, Nigeria: a cross-sectional survey

Objectives This study assessed health providers’ organisational and individual readiness for change to respectful maternity care (RMC) practice and their associated factors in Ibadan Metropolis, Nigeria. Design A cross-sectional survey using standardised structured instruments adapted from the literature. Setting Nine public health facilities in Ibadan Metropolis, Nigeria, 1 December 2019–31 May 2020. Participants 212 health providers selected via a two-stage cluster sampling. Outcomes Organisational readiness for change to RMC (ORCRMC) and individual readiness for change to RMC (IRCRMC) scales had a maximum score of 5. Multiple linear regression was used to identify factors influencing IRCRMC and ORCRMC. We evaluated previously identified predictors of readiness for change (change valence, informational assessments on resource adequacy, core self-evaluation and job satisfaction) and proposed others (workplace characteristics, awareness of mistreatment during childbirth, perceptions of women’s rights and resource availability to implement RMC). Data were adjusted for clustering and analysed using Stata V.15. Results The providers’ mean age was 44.0±9.9 years with 15.4±9.9 years of work experience. They scored high on awareness of women’s mistreatment (3.9±0.5) and women’s perceived rights during childbirth (3.9±0.5). They had high ORCRMC (4.1±0.9) and IRCRMC (4.2±0.6), both weakly but positively correlated (r=0.407, 95% CI: 0.288 to 0.514, p<0.001). Providers also had high change valence (4.5±0.8) but lower perceptions of resource availability (2.7±0.7) and adequacy for implementation (3.3±0.7). Higher provider change valence and informational assessments were associated with significantly increased IRCRMC (β=0.40, 95% CI: 0.11 to 0.70, p=0.015 and β=0.07, 95% CI: 0.01 to 0.13, p=0.032, respectively), and also with significantly increased ORCRMC (β=0.47, 95% CI: 0.21 to 0.74, p=0.004 and β=0.43, 95% CI: 0.22 to 0.63, p=0.002, respectively). Longer years of work experience (β=0.08, 95% CI: 0.01 to 0.2, p=0.024), providers’ monthly income (β=0.08, 95% CI: 0.02 to 0.15, p=0.021) and the health facility of practice were associated with significantly increased ORCRMC. Conclusion The health providers studied valued a change to RMC and believed that both they and their facilities were ready for the change to RMC practice.

previous study they conducted in the area, for which they need to provide some idea of the quantum and nature of disrespectful maternity care in the area that justify the study.
• The background to the paper needs to be better elucidated. I believe more international, regional, and national data on disrespectful maternity care ought to be provided to provide substantive justification for the study. By contrast, the introduction focused to a large measure on describing the conceptual framework, without providing sufficient evidence on previous studies undertaken on the subject matter. I believe that the aspects dealing with conceptual framework should be removed from the introduction; the introduction should be expanded to justify the study; while the conceptual framework should be provided in a separate sub-heading after the introduction. I also suggest that some form of a theory of change should be embedded to explain how this potentially novel study can lead to change in promoting respectful maternity care in the hospitals. • The method section needs some revision. As an example, the sample size of 210 was determined by using the one-sample test mean in Stata. This needs to be explained further by identifying the variables and forecasts that enabled the sample size determination • The paragraph of the methods beginning with "For the predictors, Weiner"----and ending with "perception of women's rights" (beginning from line 150) should be removed from the methods section as it does not explain the methods used for the study. If possible, the section could be moved to the Discussion part of the paper.
• My serious concern with this paper is that the authors used the composite indicators of "commitment to change" and "change efficacy" to measure organizational readiness for change. I seriously doubt if these two components can explain organizational readiness in full. I believe organizational readiness would be better explored by assessing the organizational governing structure, and the extent to it is willing and able to deploy resources to manage the change process. While individuals may be committed to change, they will be unable to drive the change if the organization and its managers do not commit themselves to management of the change process • I believe that this study would have been more informative if it included a qualitative component and interviews with the heads and managers of the institutions (mixed study design) to enable the substantive assessment and determination of organizational readiness.
• The discussion part of the paper needs considerable improvement to explain the method used as well as the results. • Also, the policy implications and public health relevance of the study should be better presented. • There are several typos and grammatical errors in various parts of the paper that need to be corrected.

Recommendation
Accept after major revision Remarks to the editor The data analysis section is rather detailed. As I am not an expert in data analysis, I would advise that this section should be reviewed by a statistician The 244 is the total study population, the denominator. The total number of health workers in the sampled facilities.

VERSION 1 -AUTHOR RESPONSE
The calculated sample size is 210 (86% of the study population) While 212 were interviewed (101%) of the sample size.
These have also been clarified in the text.
Lines 139, page 6 Line 141-142-153, page 6 Lines 219-220, page 9 9 Some of the information in the discussion would fit the background. You may need to re-check These have been re-checked All the information provided in the discussion section was to discuss the findings.

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The authors need to explain the rationale for the choice of Ibadan as the location for the study. Perhaps, this can be linked to the previous study they conducted in the area, for which they need to provide some idea of The rationale for the choice of Ibadan as the study location has been provided in the method section Lines 213-215, page 9 the quantum and nature of disrespectful maternity care in the area that justifies the study

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The background to the paper needs to be better elucidated. I believe more international, regional, and national data on disrespectful maternity care ought to be provided to provide substantive justification for the study. By contrast, the introduction focused to a large measure on describing the conceptual framework, without providing sufficient evidence on previous studies undertaken on the subject matter. I believe that the aspects dealing with conceptual framework should be removed from the introduction; the introduction should be expanded to justify the study; while the conceptual framework should be provided in a separate sub-heading after the introduction. I also suggest that some form of a theory of change should be embedded to explain how this potentially novel study can lead to change in promoting respectful maternity care in the hospitals.
An introductory paragraph has been added to the background section addressing national data on the mistreatment of women.
We described the concept of readiness for change. This was to give a background to understanding the study.
And it was intertwined with the justification of the study. So we could not cut out a separate section for the conceptual framework.
We have added a paragraph describing the proposed Theory of Change for the research.

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The method section needs some revision.
As an example, the sample size of 210 was determined by using the one-sample test mean in Stata. This needs to be explained further by identifying the variables and forecasts that enabled the sample size determination More detail has been added to address this comment.

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The paragraph of the methods beginning with "For the predictors, Weiner"---and ending with "perception of women's rights" (beginning from line 150) should be removed from the methods section as it does not explain the methods used for the study. If possible, the section could be moved to the Discussion part of the paper.
We tried moving the sections as advised, but they could not fit the discussion nor the background sections.
We have rewritten the section to properly read and describe the methodology that it is. The section described the variables (predictors) measured. The section described both the previously defined predictors and the newly proposed or added ones measured in this study.

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My serious concern with this paper is that the authors used the composite indicators of "commitment to change" and "change efficacy" to measure organizational readiness for change. I seriously doubt if these two components can explain organizational readiness in full. I believe organizational readiness would be better explored by assessing the organizational governing structure, and the extent to it is willing and able to deploy resources to manage the change process. While individuals may be committed to change, they will be unable to drive the change if the organization and its managers do not commit themselves to management of the change process Thank you for this comment We explored the contextual factors and barriers that may limit readiness for change to RMC practice qualitatively by conducting However, the findings are to be published in another article.
This is because of the limited word count and because there are lots of issues to be addressed from the findings. While the readiness for change assessed and presented here was a lot to address already.
So, we have added the need to identify and address the contextual factors and barriers before the expected change can indeed be actualised. We also recommended the need for future research on these.

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The discussion part of the paper needs considerable improvement to explain the method used as well as the results.

This has been done.
We have also introduced a paragraph that discussed the methods used.

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Also, the policy implications and public health relevance of the study should be better presented.
We have elucidated some of the programmatic and policy implications of some of the findings the more.

GENERAL COMMENTS
Congratulations on your successful and elegant revision of the paper