Sugar-sweetened beverages (SSBs) are major sources of free sugars in diet and have been linked to obesity, chronic diseases, and increased risk of premature deaths. Evidence suggests that the health impacts of SSBs may be greater among females than males; however, there is limited evidence on SSB consumption among women, especially in low-and middle-income countries. Therefore, we aimed to determine the prevalence and factors associated with SSB consumption among women aged 10-49 years in Kenya using secondary data from the first and second rounds of Kenya's Performance Monitoring for Action (PMA) nutrition surveys. We stratified the analysis by residence (rural vs. urban), and used univariable and multivariable logistic regression to assess the determinants of SSB consumption. The prevalence of SSB consumption among women was 52.4% (95% CI 47.9, 56.8). The prevalence of SSB consumption was higher in urban than rural areas (53.2% vs. 51.7%) and was high among women aged 20-29 years (54.1%), women in union (52.9%), women with tertiary level of education (59.1%), and women from the richest households (52.4%). Urban women had 1.29 times higher odds of SSB consumption compared to rural women. Moreover, education level was significantly associated with SSB consumption, with higher education linked to increased odds of consumption. Overall, more than half of women aged 10-49 years reported consuming SSBs. These findings underscore the need for targeted policy interventions to reduce SSB consumption, especially among urban residents and individuals with higher socioeconomic status.

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. 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

Integrated care is increasingly recognised as a key strategy for the management of multimorbidity. However, evidence on the factors associated with the implementation of integrated care models in low- and middle-income countries remains limited. We explored how stakeholders perceived integrated care, existing challenges, and recommendations for integrating cardiovascular disease and diabetes management at primary health care (PHC) level in Kenya. We conducted a qualitative study using key informant interviews with 16 key stakeholders involved in healthcare delivery, research, and policy on non-communicable diseases (NCDs) in Kenya between February and March 2024. All interviews were audio recorded and transcribed; and the data analysed both inductively and deductively within NVivo software. The deductive analysis was guided by the Rainbow Model of Integrated Care (RMIC) framework, which combines key dimensions necessary for successful integrated care with key elements of primary care. The RMIC framework dimensions include systems, clinical, organisational, professional, functional, and normative integration. Out of the six RMIC dimensions, stakeholders' description of integrated care included elements of clinical, systems, and professional integration. Key systems level challenges included disparity between policy and practice, inadequate resource allocation, donor-driven priorities, and limited stakeholder collaboration. Fragmented care delivery was a key organisational challenge. Limited resources for integrated care delivery and inadequate staff numbers and capacity were considered key challenges in the functional and professional dimensions of the RMIC framework. Additional challenges included 'siloed' mindset (normative) and limited evidence on effective or cost-effective integrated care models. To address the identified barriers, policy-makers should develop clear and adaptable how-to county-specific guidelines for implementation and evaluation of integrated care at PHC level. There is a need for advocacy and research on models of integrated care at PHC level to guide prioritization and resource allocation in Kenya.

Understanding the magnitude and determinants of socioeconomic inequalities in ideal cardiovascular health (iCVH) is critical for informing targeted cardiovascular disease (CVD) prevention interventions in Kenya. This study assessed the socioeconomic inequality in iCVH, as defined by the American Heart Association 2010 guideline, in Kenya using data from the 2015 World Health Organization (WHO) STEPwise survey on non-communicable disease (NCD) risk factors. The concentration index (C) and curves were used to assess the magnitude of the inequalities and Wagstaff-type decomposition analysis performed to examine the drivers. Pro-rich inequalities were observed in iCVH (C = 0.08; p = 0.006) and were more pronounced in females than males. Wealth (30.7%), urban residence (31.4%), region (16.5%), and education (8.5%) were the highest contributors to the observed pro-rich inequality in iCVH. This study highlights the need for the design and scale up of equity and gender-focused interventions targeting the poorer and less-educated individuals especially in urban areas.

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.

Background: Kenya is experiencing a rising burden of cardiovascular diseases (CVDs) due to epidemiological and demographic shifts, along with increasing risk factors. Ideal cardiovascular health (iCVH), defined by the American Heart Association (AHA), encompasses eight metrics to evaluate cardiovascular well-being. This study assessed the prevalence and determinants of iCVH in Kenya. Methods: Data from the 2015 Kenya STEPwise survey on non-communicable disease risk factors, including 4,500 adults aged 18–69, were analysed. iCVH was assessed using 2022 AHA criteria based on seven factors: nicotine exposure, physical activity, diet, BMI, blood pressure, glucose, and lipid levels. A cardiovascular health (CVH) CVH score of ≥80% classified individuals as having iCVH. Multivariable binary and ordinal logistic regression identified factors associated with iCVH. Results: The mean CVH score in Kenya was 78.6% (95% CI: 77.9,79.2%), higher in females (79.3%), rural areas (79.5%), and non-drinkers (79.6%) than in males (77.9%), urban residents (77.0%), and alcohol drinkers (75.4%), respectively. The prevalence of iCVH (CVH score ≥80%) was 45.6%, while 6.4% had poor CVH (CVH score <50%). Only 1.2% achieved the maximum CVH score. iCVH prevalence declined with age and was lower among married individuals (43.7%), alcohol drinkers (32.3%), and urban residents (39.7%). Older adults had 50–80% lower odds of iCVH compared to those under 30 years. Alcohol users (AOR 0.5; p < 0.001) and urban residents (AOR 0.6; p < 0.001) were less likely to have iCVH. Residents of Nairobi and Central regions had 40–60% lower odds of iCVH compared to those in Rift Valley. The Kalenjin (AOR 0.5; p = 0.027) and Turkana (AOR 0.3; p = 0.002) ethnic groups had lower odds of iCVH compared to the Kisii. Conclusion: Less than half of Kenyan adults have iCVH, with poorer CVH status among older adults, urban residents, and alcohol users. Targeted public health interventions could mitigate the CVD burden and enhance health outcomes in Kenya.

Introduction: health financing aims to ensure that the overall goal of the health system is attained. Countries with decentralised healthcare systems such as Kenya, face further challenges due to limited public financial management capacity within sub-national governments. While partner support has proved impactful in addressing these challenges, there is a paucity of evidence on the nature and distribution of the support in Kenya. This study sought to examine the current technical support and health financing support offered by partners across the 47 counties in Kenya. Methods: the study used a descriptive crosssectional design with a mixed methods approach. Quantitative data were collected from organisation representatives using semi-structured questionnaires and analysed using Microsoft Excel. Qualitative data were collected through key informants and in-depth interviews involving county Department of Health officials in 15 counties in Kenya. Interview recordings were transcribed and thematically analysed using NVIVO version 14. Results: twenty (20) organisations reportedly provided health financing support to counties with planning, budgeting and health financing advocacy being the most supported work streams by partners. While each county had more than one partner supporting health financing activities, the western counties had more partners compared to other regions of Kenya. Whereas partner support was well acknowledged at the county level, there was a lack of coordination and alignment of partner activities with county priorities. Conclusion: these findings highlight the essential need for national governments to ensure effective coordination of the technical assistance provided by partners to subnational levels and to ensure equitable distribution of support and alignment with county health priorities and needs.

Background : Menstruation is a normal biological process experienced by more than 300 million women globally daily. Women need clean menstrual absorbents that can be changed as often as needed in private and safe place with proper hygiene and disposal facilities. All these needs must be met throughout the duration of the menstrual cycle. Access to menstrual needs of women is important for their health, wellbeing, and human 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) surveys. We defined the unmet need for MHM as “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 a multilevel logistic regression model. Results : In the six countries, majority of women were aged 20-34 years, were married, or cohabiting and had never given birth. The prevalence of unmet need for MHM was high among the uneducated and multiparous women, those who reused MHM materials, practiced open defaecation and lived in rural areas in all the six countries. The prevalence of unmet need for MHM was highest in Burkina Faso (74.8%) and lowest in Ghana (34.2). Age, education level, wealth status and marital status were significantly associated with unmet need for MHM. Reuse of MHM materials and open defaecation increased the odds of unmet need for MHM. Conclusion : More than half of women in five of the six countries have unmet need for MHM withodds of unmet need significantly higher among younger women, those with low wealth status, the unmarried, and those with poor access to sanitary facilities. This study highlights the state of period poverty in Sub-saharan Africa. Efforts to end period poverty should approach MHM needs as a unit as each need is insufficient on its own.

Introduction:Gavi, the Vaccine Alliance, defined a transition roadmap for countries receiving funding support based on their income status projections. According to the latest projections, Kenya will complete their transition from vaccine funding in 2029. While eligible countries are kept informed and supported for a smooth transition process, the extent to which countries understand the significant implications of a complete end of GAVI support on immunization service delivery varies. Furthermore, whereas studies have been conducted to assess national preparedness for transition, there is a paucity of data on the understanding of subnational authorities of this process. In this study, we explored the perspectives of county-level stakeholders on Kenya's preparedness for GAVI transition. Methods:using purposive sampling, 77 senior county officials from 15 counties were selected for in-depth interviews. Data were collected using a semi-structured interview guide, transcribed, and thematically analysed. Ethical approval for the study was granted by Moi University Institutional Ethics and Research Committee. Results:findings reveal a consensus among respondents that both national and county governments are not fully prepared for the end of the Gavi Alliance. Concerns were highlighted around a lack of knowledge about vaccine costs, post-transition funding sources, and potential disruptions in immunization services. Respondents advocated for a phased transition, continued donor support, clear funding allocation, and legislative measures to ensure financial sustainability. Moreover, advocacy and awareness efforts, capacity building, and a robust legal framework were emphasized as essential for a smooth transition. Conclusion:after the end of the financial support provided by Gavi Alliance, Kenya's immunization bill is expected to be significant. This study underscores the importance of effectively engaging the subnational (county) level authorities. Successful transition from Gavi's support requires a strategy that promotes awareness and improves communication regarding the expected impact of the impending transition from Gavi on sustainable immunization financing in Kenya.

Obesity is a major risk factor for most non-communicable diseases whose burden has been rising rapidly in low and middle-income countries. To develop public health interventions to address the increasing burden of overweight and obesity, estimates of the prevalence and associated factors are needed in specific populations. The study sought to determine the prevalence and factors associated with total obesity and abdominal obesity among low-income adults in Kiambu County, Kenya. This community-based cross-sectional survey involved 1656 adults residing in Kiambu County. Multistage sampling was used in the selection of participants. Data were collected by trained community health volunteers (CHVs) in their respective sub-counties using an interviewer-administered questionnaire. The CHVs also took anthropometric measurements using relevant tools and standard procedures. Descriptive statistics were used to describe the participants’ characteristics and proportions of adults with obesity. Multivariable logistic regression analyses were performed to assess the factors associated with obesity. The mean age of participants was 40.8 (±14.3) years The overall prevalence of total obesity (body mass index [BMI] > 30 kg/m2) was 28.8% (95% CI, 26.6%-30.9%), with a higher prevalence observed among females [33.6% (95% CI, 31.1%-36.2%)] than males [12.5% (95% CI, 9.6%-16.3%)]. A third (33.3%) of the participants were overweight (25 < BMI < 30 kg/m2). The prevalence of abdominal obesity as measured by waist-height-ratio (WHtR) was 79.8%, by waist circumference (WC) was 74.0%. Obesity/overweight by BMI was associated with female gender, increasing age, monthly income, while abdominal obesity by WHtR/WC was associated with female gender, increasing age and cigarrete smoking. In conclusion, the prevalence of total obesity and abdominal obesity was high in the population. Public health strategies focusing on weight reduction and maintenance strategies are urgently needed among low-income adults. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This research was supported by the Consortium for Advanced Research Training in Africa (CARTA). CARTA is jointly led by the African Population and Health Research Center and the University of the Witwatersrand and funded by the Carnegie Corporation of New York (Grant No. G-19-57145), Sida (Grant No:54100113), Uppsala Monitoring Center, Norwegian Agency for Development Cooperation (Norad), and by the Wellcome Trust [reference no. 107768/Z/15/Z] and the UK Foreign, Commonwealth & Development Office, with support from the Developing Excellence in Leadership, Training and Science in Africa (DELTAS Africa) programme. The statements made and views expressed are solely the responsibility of the authors. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethical approval for the study was obtained from Jomo Kenyatta University of Agriculture and Technology (JKUAT) Institutional ethics committee approval number; JKU/IERC/02316/0652. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All relevant data are within the manuscript and its Supporting Information files.

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 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: Family planning (FP) is a key intervention in improving maternal and child health. Hence, we assessed the factors associated with utilisation and unmet need for modern contraceptives among urban women in Kenya. Methods: The study used pooled data on 10,474 women 15–49 years from the seven rounds of the performance monitoring for accountability surveys collected between 2014 and 2018. The surveys were conducted in 11 of the 47 counties of Kenya using a multistage cluster design. Sample characteristics were described using frequencies and percentages while factors associated with utilisation and unmet need for modern contraceptives were assessed using multivariable logistic regressions. Results: The prevalence of modern contraceptives use and unmet need for FP among urban women in Kenya was 53.7% [95% confidence interval (CI) 52.1–55.3%] and 16.9% (15.8–18.1%), respectively. The use of modern contraceptive was associated with the county of residence, age, marital status, parity, education, household wealth quintile, exposure to media, and survey year. Teenagers, poorest urban women, women with no formal or primary level of education and those who seek services at a dispensary or health centres had higher odds of unmet need for FP while women who resided in Kitui and Nyamira counties had reduced odds of unmet need for FP. The odds of unmet need decreased with the survey year while that of modern contraceptive use had an inverse trend. Conclusion: Overall modern contraceptive use in urban areas is lower than the national average while the unmet need for FP is higher than national average, highlighting a potential urban-rural disparity in FP indicators in Kenya. Individual sociodemographic and socioeconomic and contextual factors are associated with the use of modern contraceptive and unmet need for FP among urban women in Kenya. Urban family planning policies and programmes in Kenya need to focus on strengthening urban healthcare systems to provide equal and accessible FP services, especially targeted towards teenagers and young women and those of low socioeconomic status.

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. It is a key strategy for addressing about 17.5% of the unmet needs in FP in Kenya. This study assessed the prevalence and determinants of 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 determinants using bivariate and multivariable logistic regressions. Results : Of the 3,892 married women using contraceptives included in this study, 62.9% were 20−34 years, 65.4% lived in rural areas, 51.3% had primary education and 82.4% had two or more children. The mean age at first sexual encounter was 17.3 years (standard deviation: 3.0). The prevalence of CCU was 12.2% (95% CI: 10.4%−14.2%) and was high among 35−49 years (12.8%), uneducated (22.3%) and poorest (18.2%) women. Siaya (22.9%), Kericho (16.7%) and Kakamega (13.1%) counties had the highest prevalence of CCU. Injectables (53.3%) and implants (34.6%) were the commonest methods among women who practice CCU. County of residence, education, wealth, parity, and age at sexual debut were associated with CCU. Conclusion : About one in 10 married women in Kenya use contraceptive 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 the rights of women to make independent choices.