Abstract
Energy poverty is prevalent in resource-limited settings, leading households to use inefficient fuels and appliances that contribute to household air pollution. Randomized controlled trials of household energy interventions in low and middle income countries have largely focused on cooking services. Less is known about the adoption and impact of clean lighting interventions. We conducted an explanatory sequential mixed methods study as part of a randomized controlled trial of home solar lighting systems in rural Uganda in order to identify contextual factors determining the use and impact of the solar lighting intervention. We used sensors to track usage, longitudinally assessed household lighting expenditures and health-related quality of life, and performed cost-effectiveness analyses. Qualitative interviews were conducted with all 80 trial participants and coded using reflexive thematic analysis. Uptake of the intervention solar lighting system was high with daily use averaging 8.23 ± 5.30 hours per day. The intervention solar lighting system increased the EQ5D index by 0.025 [95% CI 0.002 - 0.048] and led to an average monthly reduction in household lighting costs by -1.28 [-2.52, -0.85] US dollars, with higher savings in users of fuel-based lighting. The incremental cost-effectiveness ratio for the solar lighting intervention was $2025.72 US dollars per quality adjusted life year (QALY) gained making the intervention cost-effective when benchmarked against the gross domestic product (GDP) per capita in Uganda. Thematic analysis of qualitative data from individual interviews showed that solar lighting was transformative and associated with numerous benefits that fit within a Social Determinants of Health (SDOH) framework. The benefits included improved household finances, improved educational performance of children, increased household safety, improved family and community cohesion, and improved perceived household health. Our findings suggest that household solar lighting interventions may be a cost-effective approach to improve health-related quality of life by addressing SDOH.