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Background Family planning (FP) is a key intervention for preventing unplanned pregnancies, unsafe abortions, and maternal death. Involvement of both women and their partners promotes contraceptive acceptance, uptake and continuation, couple communication and gender-equitable attitude. Partner involvement is a key strategy for addressing about 17.5% of the unmet needs in FP in Kenya. This study assessed the prevalence and factors associated with covert contraceptive use (CCU) in Kenya. Methods We used data from the sixth and seventh rounds of the performance monitoring for accountability surveys. We defined CCU as “the use of contraceptives without a partner’s knowledge”. We used frequencies and percentages to describe the sample characteristics and the prevalence of CCU and assessed the associated factors using bivariate and multivariable logistic regressions. Results The prevalence of CCU was 12.2% (95% CI: 10.4–14.2%); highest among uneducated (22.3%) poorest (18.2%) and 35–49 years-old (12.8%) women. Injectables (53.3%) and implants (34.6%) were the commonest methods among women who practice CCU. In the bivariate analysis, Siaya county, rural residence, education, wealth, and age at sexual debut were associated with CCU. On adjusting for covariates, the odds of CCU were increased among uneducated women (aOR 3.79, 95% CI 1.73–8.31), women with primary education (aOR 1.86, 95% CI 1.06–3.29) and those from the poorest (aOR 2.67, 95% CI 1.61–4.45), poorer (aOR 1.79, 95% CI 1.05–3.04), and middle (aOR 2.40, 95% CI 1.52–3.78) household wealth quintiles and were reduced among those with 2–3 (aOR 0.49, 95% CI 0.33–0.72) and ≥ 4 children (aOR 0.62, 95% CI 0.40–0.96). Age at sexual debut (aOR 0.94, 95% CI 0.89–0.99) reduced the odds of CCU. Conclusion About one in 10 married women in Kenya use contraceptives covertly, with injectables and implants being the preferred methods. Our study highlights a gap in partner involvement in FP and calls for efforts to strengthen their involvement to increase contraceptive use in Kenya while acknowledging women’s right to make independent choices.

Background Effective public financial management (PFM) is a foundational enabler of sustainable progress toward Universal Health Coverage (UHC). Achieving UHC requires not only increased funding for the health sector but also the efficient, equitable, and accountable use of resources. In 2019, Kenya piloted a UHC initiative across four counties to generate evidence to inform national scale-up. This study examines the PFM processes underpinning the pilot implementation, with a focus on how financial planning, budget execution, and accountability mechanisms influenced the delivery of UHC interventions at the county level. Methods This study employed a qualitative research design to explore PFM processes during the implementation of Kenya’s UHC pilot in four counties. Data were collected through 51 in-depth interviews and five focus group discussions with key stakeholders, including healthcare workers, patient representatives, and senior members of the County Health Management Teams (CHMTs). An inductive thematic analysis approach was employed to identify patterns and themes that emerged from the data. The analysis was facilitated using Dedoose software (Version 9.0.17), which enabled systematic coding and organization of the qualitative data. Results The UHC pilot program in Kenya featured a hybrid planning model, combining top-down directives from the national government with bottom-up inputs from county stakeholders. Despite this collaborative approach, county budgeting processes remained governed by the stipulations of the PFM Act. While counties welcomed additional UHC funds, the removal of user fees led to reduced facility-level revenue, increased service demand, and strain on human and material resources. Delays in fund disbursement, rigid budget structures, and limited financial autonomy further constrained implementation. These experiences underscore the need for a more coherent integration of PFM and health financing policies at the subnational level to ensure sustainable and equitable health service delivery. Conclusion The UHC pilot offers critical lessons for future health financing reforms. Addressing PFM bottlenecks—particularly those related to timely disbursement, budget flexibility, and local revenue generation—is essential to ensure the sustainability of UHC in Kenya and similar contexts. The study’s limitations necessitate further research before scaling up nationwide.

Background Caesarean section (CS) is an important medical intervention for reducing the risk of poor perinatal outcomes. However, CS trends in sub-Saharan Africa (SSA) continue to increase yet maternal and neonatal mortality and morbidity remain high. Rwanda, like many other countries in SSA, has shown an increasing trend in the use of CS. This study assessed the trends and factors associated with CS delivery in Rwanda over the past two decades. Methods We used nationally representative child datasets from the Rwanda Demographic and Health Survey 2000 to 2019–20. All births in the preceding 3 years to the survey were assessed for the mode of delivery. The participants’ characteristics, trends and the prevalence of CS were analysed using frequencies and percentages. Unadjusted and adjusted logistic regression analyses were used to assess the factors associated with population and hospital-based CS in Rwanda for each of the surveys. Results The population-based rate of CS in Rwanda significantly increased from 2.2% (95% CI 1.8–2.6) in 2000 to 15.6% (95% CI 13.9–16.5) in 2019–20. Despite increasing in all health facilities over time, the rate of CS was about four times higher in private (60.6%) compared to public health facilities (15.4%) in 2019–20. The rates and odds of CS were disproportionately high among women of high socioeconomic groups, those who resided in Kigali city, had multiple pregnancies, and attended at least four antenatal care visits while the odds of CS were significantly lower among multiparous women and those who had female babies. Conclusion Over the past two decades, the rate of CS use in Rwanda increased significantly at health facility and population level with high regional and socio-economic disparities. There is a need to examine the disparities in CS trends and developing tailored policy guidelines to ensure proper use of CS in Rwanda.

Background Menstruation is a normal biological process experienced by more than 300 million women globally every day. Women require clean menstrual absorbents that can be changed as often as needed in a private and safe place with proper hygiene and disposal facilities. These needs must be met consistently throughout the duration of the menstrual cycle. Access to menstrual needs is crucial for women’s health, wellbeing, and dignity. This study assessed the prevalence and factors associated with unmet need for menstrual hygiene management (MHM) in Ethiopia, Kenya, Uganda, Burkina Faso, Ghana, and Niger. Methods We used data from the Performance Monitoring for Action (PMA) 2020 surveys. We defined the unmet need for MHM as the “ lack of resources, facilities and supplies for MHM .” Sample characteristics were summarised using frequencies and percentages, while prevalence was summarised using proportions and their respective confidence intervals (CI). Factors associated with unmet need for MHM were assessed using multilevel logistic regression models. Results The study included 18,048 women of reproductive age from the six countries. The prevalence of unmet need for MHM was highest in Burkina Faso (74.8%), followed by Ethiopia (69.9%), Uganda (65.2%), Niger (57.8%), Kenya (53.5%), and lowest in Ghana (34.2%). Unmet need for MHM was consistently higher among uneducated and multiparous women, those who reused MHM materials, practiced open defecation, and lived in rural areas across all six countries. The odds of unmet need for MHM were higher among younger women under 35 years, unmarried women, those with lower education levels, and those from poorer households. Similarly, the reuse of MHM materials, use of shared or non-improved toilet facilities, and open defecation increased the odds of unmet need for MHM. In contrast, the presence of handwashing facilities reduced the odds of unmet need for MHM. Conclusion More than half of the women in five of the six countries have an unmet need for MHM, with significantly higher odds among younger women, those with low wealth status, the unmarried, and those with inadequate access to sanitary facilities. This study highlights the state of period poverty in Sub-Saharan Africa. Efforts to end period poverty should consider MHM needs as an integrated whole, as addressing each need in isolation is insufficient.

Background Decentralisation has increasingly been adopted by countries as an important health sector reform aimed at increasing community participation in decision making while enhancing swift response at decentralised levels, to accelerate the attainment of health system goals. Kenya adopted a devolved system of government where health services delivery became a function of the 47 semi-autonomous county governments with planning and budgeting functions practised at both levels of government. This study sought to explore challenges facing health sector planning and budgeting and how they affect immunisation service delivery at the county level. Methods Data were collected through 77 in-depth interviews of senior county department of health officials across 15 counties in Kenya. We applied an inductive thematic approach in analysing the qualitative data using NVIVO software. Findings The study found a lack of alignment between planning and budgeting processes, with planning being more inclusive compared to budgeting. Inadequate capacity in conducting planning and budgeting and political interference were reported to hinder the processes. Limited budget allocations and delayed and untimely disbursement of funds were reported to affect execution of health and immunisation budgets. Low prioritisation of preventive health interventions like immunisation due to their perceived intangibility influenced resource allocation to the programs. Conclusion The findings highlight the need for effective strategies to align planning and budgeting processes, increased technical support to counties to enhance the requisite capacity, and efforts to improve budget execution to improve budget credibility. Counties should plan to increase their funding commitment toward immunisation to ensure sustainability of the program as Kenya transitions from GAVI support.

Introduction: Integrated care is increasingly adopted to address the needs of patients with multimorbidity, but cost-effective configuration of integrated healthcare pathways remains unclear. This study reviewed decision analytic models (DAMs) used in economic evaluations of integrated care interventions for cardiometabolic multimorbidity. Methods: A systematic search of eight electronic databases was conducted to identify peer-reviewed articles published in English until November 2024. Studies using DAMs to evaluate integrated care interventions for patients at risk or having cardiometabolic multimorbidity were included. Data on DAMs characteristics, integrated care models evaluated, and diseases were summarised. The quality of reporting was assessed using Philips (2006) checklist. Results: Sixteen studies met inclusion criteria. Most studies (81%) were cost utility analyses, focused on hypertension and/or diabetes concordant multimorbidity (69%). High-income countries accounted for 69% of the studies. Markov models were used the most (63%), with only three studies employing individual patient simulation (microsimulation) models. Few studies were explicit about data validation and reporting uncertainty. Conclusion: Economic evaluations of integrated care cardiometabolic multimorbidity should adopt microsimulation to better capture patient-level interactions and health outcomes. Better reporting of validation and uncertainty is needed. There is limited application of DAM-based economic evaluations of integrated care in low- and middle-income countries.

Background Female genital mutilation (FGM) presents a dual challenge in The Gambia, constituting a human rights abuse and a major public health concern. Despite legislative efforts and global advocacy, the magnitude of FGM among women of reproductive age remains high. This study examined the prevalence and factors associated with the generational transition of FGM in The Gambia. Methods The study analysed data from the 2019–2020 Gambia Demographic and Health Survey (GDHS). We included a final sample of 5272 mother–daughter pairs. We defined generational transition of FGM as ‘women of reproductive age (15–49 years) who were circumcised and had at least one daughter circumcised’. Sample characteristics and prevalence of generational transition FGM among women and their daughters were summarised using frequencies and percentages. Bivariate and multilevel logistic regression analyses were used to examine the factors associated with the generational transition of FGM in The Gambia. Results The prevalence of generational transition FGM in The Gambia was 69.7% (95% CI: 66.9, 72.5). The prevalence was highest among women aged 35–49 years, 72.3% (95% CI: 68.5–75.9), those with no formal education, 74.5% (95% CI: 70.9–77.8), and those in union 71.6% (95% CI: 68.6, 74.5). The prevalence was fairly distributed across the wealth index quintile. Factors associated with increased odds of generational transition FGM included women aged 35–49 years (adjusted odds ratios [aOR]: 3.88, 95% CI: 2.93–5.52), being in a marital union (aOR: 1.96, 95% CI: 1.45–2.64), and living in clusters with high FGM support (aOR: 1.89, 95% CI: 1.31, 2.73). Conversely, secondary and higher education levels (aOR = 0.71, 95% CI: 0.57–0.89) and the richest wealth index (aOR = 0.42, 95% CI: 0.28–0.64) were protective factors against transitional FGM. Conclusion FGM persists in The Gambia due to a complex interplay of maternal characteristics, cultural expectations and community norms. Targeted multilevel interventions, particularly those that expand access to education, engage male partners and challenge collective attitudes, are essential to disrupt this generational transmission. Future studies should qualitatively explore the reasons behind the generational transition to inform the design of targeted interventions that can interrupt the FGM cascade.

Background This systematic review sought to examine the application of decision analytic models (DAMs) to evaluate cardiovascular disease (CVD) prevention interventions in sub-Saharan Africa (SSA), a region that has experienced an increasing CVD burden in the last two decades. Methods We searched seven databases and identified model-based economic evaluations of interventions targeting CVD prevention among adult populations in SSA. All articles were screened by two reviewers, data was extracted, and narrative synthesis was performed. Quality assessment was performed using the Philips checklist. Results The review included 27 articles from eight SSA countries. The majority of the studies evaluated interventions for primary CVD prevention, with primordial prevention interventions being the least evaluated. Markov models were the most commonly used modelling method. Seven studies incorporated equity dimensions in the modelling, which were assessed mainly through subgroup analysis. The mean quality score of the papers was 68.9% and most studies reported data challenges while only three studies conducted model validation. Conclusions The review finds few studies modelling the impact of interventions targeting primordial prevention and those evaluating equitable strategies for improving access to CVD prevention. There is a need for increased transparency in model building, validation and documentation. Plain language summary Cardiovascular Disease (heart disease) is an increasing problem in countries in sub-Saharan Africa. There are strategies in place to prevent disease and this review examined how mathematical tools for decision making are used to calculate how well prevention strategies are working. We performed a review of the literature on this topic and included 27 studies from eight SSA countries. We found common decision models used in many of the studies and very few studies with equity considerations (fairness to all). Challenges with data quality and limited real-world testing to show how well these tools work in practice were also found. These findings highlight the need for better mathematical tools and a greater focus on preventive strategies that are fair to all to help reduce heart disease in this region and improve public health. Oguta et al. explores the use of decision-analytic models in cardiovascular disease (CVD) prevention in sub-Saharan Africa, revealing a focus on primary prevention and a lack of equity considerations. The findings underscore the need for improved modelling transparency, validation, and equitable strategies to address the region’s growing CVD burden.

This paper presents the effects of using digital games on improving language learning in Tanzanian preschools. A gamified learning prototype system was developed for making alphabetical sound articulation more engaging and fun. The study was conducted with twelve preschools in Tanzania. The results revealed that preschoolers’ learning performance was improved when the game-based learning approach was incorporated into the sound articulation lesson. The findings inform educational stakeholders about the potential use of gamification in preschool education and propose ideas and means to standardize sound articulation and language learning to improve the overall quality of education.

Introduction Adequate nutrition is essential for proper growth, development, and disease prevention during the first 1000 days of life. Introducing solid, semi-solid, or liquid foods in addition to breast milk, also known as complementary feeding (CF), earlier or later than the recommended 6 months, is associated with poor nutritional outcomes in children under the age of two. Given the limited evidence, this study aimed to determine the factors associated with timely complementary feeding in children aged 6–23 months. Methods We used data from the first round of Kenya’s 2017 Performance Monitoring for Action (PMA) survey. The dependent variable, timely CF, was defined as “the introduction of other feeds apart from breast milk at 6 months.” Frequencies, percentages, and 95% confidence intervals were used to describe the sample characteristics and prevalence of timely CF. Univariable and multivariable logistic regression analyses were performed to examine the determinants of timely complementary feeding. Results Of the 3,084 mothers included in the study, most were married (82.1%), aged 20–34 years (78.8%), and unemployed (75.5%). The overall weighted prevalence of timely CF was 51.7% (95% CI 47.6, 55.9), with a higher prevalence among the richest (66.6%), urban residents (60.6%), and mothers with a tertiary education (61.1%). After adjusting for other covariates, mothers aged 20–34 years had lower odds of practicing timely complementary feeding than those aged 35–49 years (aOR = 0.72, 95% CI: 0.52–0.99). Similarly, children from wealthier households were more likely to receive timely complementary feeding, with the odds increasing across wealth quintiles from the poorer (aOR = 1.69, 95% CI: 1.30–2.19) to the richest (aOR = 3.32, 95% CI: 1.97–5.60). Conclusion Timely complementary feeding remains suboptimal in Kenya despite strong policy frameworks, indicating implementation gaps and the need for targeted interventions to address socioeconomic and regional disparities.