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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.

In Sub Saharan Africa, there is a growing burden of non-communicable diseases, which poses a big challenge to the resource-limited health system in these settings. The aim of this study was to determine the feasibility and preliminary efficacy of a community health workers (CHWs) home-based lifestyle interventions to improve blood pressure (BP) control and body composition among hypertensive patients in low-income populations of Kiambu County, Kenya. This was a randomized controlled trial (RCT) involving 80 patients with uncontrolled high BP (systolic BP (SBP) ≥140mmHg and/or diastolic BP (DBP) ≥90) randomized to either a CHW homebased intervention or a usual care (control) arm and followed up for 6 months. The intervention involved monthly CHW home-visits for health education and audits on behavioral risk factors that affect BP. An adapted WHO stepwise questionnaire and international physical activity questionnaire was used to collect data on behavioral cardiovascular risk factors. To assess the main outcomes of BP, body mass index (BMI) and waist-height-ratio (WHtR), a survey was conducted at baseline, 3 months, and 6 months. Data regarding univariate, bivariate and multivariate (repeated measurements between and within groups) analysis at 5% level of significance were analyzed using STATA 18. Generalized estimating equations (GEE) for repeated measures were used to estimate changes in BP, BMI and WHtR, and to examine the association between the CHW intervention and BP control. The study revealed that 77.5% and 92.5% of the participants in usual care and intervention groups completed the follow-up, respectively. After 6 months of follow-up, there was a reduction in the mean SBP and DBP for both arms, and reductions in BMI and WHtR only in the intervention arm. The adjusted mean reduction in SBP (-8.4 mm Hg; 95% CI, -13.4 to -3.3; P = 0.001) and DBP (-5.2 mm Hg 95% CI, -8.3 to -2.0; P<0.001) were significantly higher in the intervention group compared to the control group. The proportion of participants who achieved the controlled BP target of <140/90 mm Hg was 62.2% and 25.8% for the intervention and usual care arm, respectively. The proportion with controlled BP was significantly higher in the intervention arm compared to the usual care arm after adjusting for baseline covariates (AOR 2.8, 95% CI 1.3-6.0, p = 0.008). There was no significant effect of the intervention on BMI and WHtR. A home-based CHW intervention was significantly associated with reduction in BP among hypertensive patients compared to usual care. Future fully powered RCTs to test the effectiveness of such interventions among low-income populations are recommended. Trial registration number: PACTR202309530525257.

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.

ObjectiveThe burden of non-communicable diseases is rising in low-and-middle-income countries, with diet being a key risk factor. This study aimed to assess the patterns, socioeconomic inequalities and determinants of eating healthy in Kenya. The study is the first in Kenya to use a healthy diet index to assess dietary patterns.Design and methodsWe analysed cross-sectional data from the 2015/16 Kenya Integrated Household Budget Survey. The study’s outcome variable was a continuous healthy diet index (HDI) constructed using principal component analysis from nine WHO/Food and Agriculture Organization (FAO) healthy diet recommendations. The HDI score and WHO/FAO healthy diet recommendations met were summarised for Kenyan households. Using the concentration index, we examined the socioeconomic disparities in healthy eating. In addition, multivariable linear regression was used to determine factors that influence healthy eating in Kenya.ResultsA total of 21 512 households in Kenya were included, of which 60% were rural and about two-thirds headed by males. The HDI score ranged between −1.13 and 1.70, with a higher value indicating healthier eating. Overall, the average HDI score was 0.24 (95% CI: 0.24 to 0.25), interpreted as moderate. We identified key determinants including socioeconomic status and urban–rural residency differences. Healthy eating was concentrated among higher socioeconomic households, regardless of gender or location. Higher socioeconomic status (β=0.28, 95% CI 0.26 to 0.30), rural residence (β=0.18, 95% CI 0.15 to 0.20), household head being in union (β=0.04, 95% CI 0.02 to 0.06) or employed (β=0.05, 95% CI 0.02 to 0.08) were significantly associated with increased HDI scores, whereas male-headed households and lack of education were associated with significant decreases in HDI scores on average.ConclusionsMost Kenyan households do not meet all the healthy dietary recommendations, and socioeconomic inequalities exist in eating healthy. Targeted interventions that promote healthy eating based on key determinants in Kenya are required.

Background Adequate nutrition is a cornerstone of healthy ageing, yet malnutrition is an escalating concern among older adults in sub-Saharan Africa (SSA). Despite its impact on independence and chronic disease risk, empirical syntheses of the relationship between nutritional status and physical function in this region remain scarce. Objective To systematically review the prevalence of malnutrition among older adults in sub-Saharan Africa and its relationship with physical function. Methods A systematic search was conducted across five electronic databases for peer-reviewed studies published in English between 2000 and 2025. Study selection, data extraction, and quality assessment were performed independently by two reviewers. The review targeted studies that assessed nutritional status (e.g., body mass index, Mini Nutritional Assessment) and physical function (e.g., activities of daily living, handgrip strength) in SSA populations aged 60+. Narrative synthesis was used to synthesise and report data outcomes. Results Fifteen studies met the inclusion criteria. The prevalence of undernutrition (malnutrition) varied widely, ranging from 1.7% to 75%. Functional impairment was significant: dependency in activities of daily living (ADL) ranged from 9% to 76.5%, while instrumental ADL dependency ranged from 29% to 72.7%. Notably, low to moderate handgrip strength (< 16 kg; ≤27 kg) was also reported. Conclusion The included studies reported associations between nutritional status and physical function among older adults in SSA. However, the predominantly cross-sectional nature of the included studies precludes establishing a causal relationship. Furthermore, the high variation in prevalence observed across studies may arise from true population differences and methodological differences. A geographical bias toward urban settings was identified, underscoring the need for longitudinal research and data from rural populations to inform targeted healthy ageing interventions. PROSPERO registration CRD42023430056.

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.