Epidemiology of emergency and elective caesarean section and its association with early neonatal mortality in sub-Saharan African countries.

INTRODUCTION: Investigating elective and emergency caesarean section (CS) separately is important for a better understanding of birth delivery modes in the sub-Saharan Africa (SSA) region and identifying bottlenecks that prevent favourable childbirth outcomes in SSA. This study aimed at evaluating the prevalences of both CS types, determining their associated socioeconomic factors and their association with early neonatal mortality in SSA. METHODS: SSA countries Demographic and Health Surveys data that had collected information on the CS' timing were included in our study. A total of 21 countries were included in this study, with a total of 155 172 institutional live births. Prevalences of both CS types were estimated at the countries' level using household sampling weights. Multilevel models were fitted to identify associated socioeconomic factors of both CS types and their associations with early neonatal mortality. RESULTS: The emergency CS prevalence in SSA countries was estimated at 4.6% (95% CI 4.4-4.7) and was higher than the elective CS prevalence estimated at 3.4% (95% CI 3.3-3.6). Private health facilities' elective CS prevalence was estimated at 10.2% (95% CI 9.3-11.2) which was higher than the emergency CS prevalence estimated at 7.7% (95% CI 7.0-8.5). Conversely, in public health facilities, the emergency CS prevalence was estimated at 4.0% (95% CI 3.8-4.2) was higher than the elective CS prevalence estimated at 2.7% (95% CI 2.6-2.8). The richest women were more likely to have birth delivery by both CS types than normal vaginal delivery. Emergency CS was positively associated with early neonatal mortality (adjusted OR=2.37, 95% CI 1.64-3.41), while no association was found with elective CS. CONCLUSIONS: Findings suggest shortcomings in pregnancy monitoring, delivery preparation and postnatal care. Beyond antenatal care (ANC) coverage, more attention should be put on quality of ANC, postnatal care, emergency obstetric and newborn care for favourable birth delivery outcomes in SSA.

Women's beliefs about methods and contraceptive discontinuation: Results from a prospective study from Nairobi and Homa Bay counties in Kenya.

Background: Rates of contraceptive discontinuation are high in many low and middle countries contributing to unmet need for contraception and other adverse reproductive health outcomes. Few studies have investigated how women's beliefs about methods and strength of fertility preferences affect discontinuation rates. This study examines this question using primary data collected in Nairobi and Homa Bay counties in Kenya. Methods: We used data from two rounds of a longitudinal study of married women ages 15-39 years (2,812 and 2,424 women from Nairobi and Homa Bay respectively at round 1). Information on fertility preferences, past and current contraceptive behavior, and method-related beliefs about six modern contraceptive methods were collected, along with a monthly calendar of contraceptive use between the two interviews. The analysis focused on discontinuation of the two most commonly used methods in both sites, injectables and implants. We carry out competing risk survival analysis to identify which method related beliefs predict discontinuation among women using at the first round. Results: The percentages of episodes discontinued in the 12 months between the two rounds was 36%, with a higher rate of discontinuation in Homa Bay (43%) than in the Nairobi slums (32%) and higher for injectables than implants. Method related concerns and side effects were the major self-reported reasons for discontinuation in both sites. The competing risk survival analysis showed that the probability of method related discontinuation of implants and injectables was significantly lower among respondents who believed that the methods do not cause serious health problems (SHR = 0.78, 95% CI: 0.62-0.98), do not interfere with regular menses (SHR = 0.76, 95% CI: 0.61-0.95) and do not cause unpleasant side effects (SHR = 0.72, 95% CI 0.56-0.89). By contrast, there were no net effects of three method related beliefs that are commonly cited as obstacles to contraceptive use in African societies: safety for long-term use, ability to have children after stopping the method, and the approval of the husband. Conclusion: This study is unique in its examination of the effect of method-specific beliefs on subsequent discontinuation for a method-related reason, using a longitudinal design. The single most important result is that concerns about serious health problems, which are largely unjustified and only moderately associated with beliefs about side effects, are a significant influence on discontinuation. The negative results for other beliefs show that the determinants of discontinuation differ from the determinants of method adoption and method choice.

Childhood vaccination timeliness following maternal migration to an informal urban settlement in Kenya.

INTRODUCTION: Timely receipt of recommended vaccines is a proven strategy to reduce preventable under-five deaths. Kenya has experienced impressive declines in child mortality from 111 to 43 deaths per 1000 live births between 1980 and 2019. However, considerable inequities in timely vaccination remain, which unnecessarily increases risk for serious illness and death. Maternal migration is a potentially important driver of timeliness inequities, as the social and financial stressors of moving to a new community may require a woman to delay her child's immunizations. This analysis examined how maternal migration to informal urban settlements in Nairobi, Kenya influenced childhood vaccination timeliness. METHODS: Data came from the Nairobi Urban Health and Demographic Surveillance System, 2002-2018. Migration exposures were migrant status (migrant, non-migrant), migrant origin (rural, urban), and migrant type (first-time, circular [previously resided in settlement]). Age at vaccine receipt (vaccination timeliness) was calculated for all basic vaccinations. Accelerated failure time models were used to investigate relationships between migration exposures and vaccination timeliness. Confounding was addressed using propensity score weighting. RESULTS: Over one-third of the children of both migrants and non-migrants received at least one dose late or not at all. Unweighted models showed the children of migrants had shorter time to OPV1 and DPT1 vaccine receipt compared to the children of non-migrants. After accounting for confounding only differences in timeliness for DPT1 remained, with the children of migrants receiving DPT1 significantly earlier than the children of non-migrants. Timeliness was comparable among migrants with rural and urban origins and among first-time and circular migrants. CONCLUSION: Although a substantial proportion of children in Nairobi's informal urban settlements do not receive timely vaccination, this analysis found limited evidence that maternal migration and migration characteristics were associated with delays for most doses. Future research should seek to elucidate potential drivers of low vaccination timeliness in Kenya.

Prevalence of uncontrolled hypertension in people with comorbidities in sub-Saharan Africa: a systematic review and meta-analysis.

BACKGROUND: The burden of uncontrolled hypertension in sub-Saharan Africa (SSA) is high and hypertension is known to coexist with other chronic diseases such as kidney disease, diabetes among others. This is the first systematic review and meta-analysis to determine the burden of uncontrolled hypertension among patients with comorbidities in SSA. METHODS: A comprehensive search was conducted on MEDLINE, Excerpta Medica Database (Embase) and Web of Science to identify all relevant articles published between 1 January 2000 and 17 June 2021. We included studies that reported on the prevalence of uncontrolled hypertension among people in SSA who report taking antihypertensive treatment and have another chronic condition. A random-effects meta-analysis was performed to obtain the pooled estimate of the prevalence of uncontrolled hypertension among patients with comorbid conditions while on treatment across studies in SSA. RESULTS: In all, 20 articles were included for meta-analyses. Eleven articles were among diabetic patients, five articles were among patients with HIV, two were among patients with stroke while chronic kidney disease and atrial fibrillation had one article each. The pooled prevalence of uncontrolled hypertension among patients with comorbidities was 78.6% (95% CI 71.1% to 85.3%); I² 95.9%, varying from 73.1% in patients with stroke to 100.0% in patients with atrial fibrillation. Subgroup analysis showed differences in uncontrolled hypertension prevalence by various study-level characteristics CONCLUSION: This study suggests a high burden of uncontrolled hypertension in people with comorbidities in SSA. Strategies to improve the control of hypertension among people with comorbidities are needed. PROSPERO REGISTRATION NUMBER: CRD42019108218.

Wealth-related inequalities in demand for family planning satisfied among married and unmarried adolescent girls and young women in sub-Saharan Africa.

BACKGROUND: The use of modern contraception has increased in much of sub-Saharan Africa (SSA). However, the extent to which changes have occurred across the wealth spectrum among adolescents is not well known. We examine poor-rich gaps in demand for family planning satisfied by modern methods (DFPSm) among sexually active adolescent girls and young women (AGYW) using data from national household surveys. METHODS: We used recent Demographic and Health Surveys and Multiple Indicator Cluster Surveys to describe levels of wealth-related inequalities in DFPSm among sexually active AGYW using an asset index as an indicator of wealth. Further, we used data from countries with more than one survey conducted from 2000 to assess DFPSm trends. We fitted linear models to estimate annual average rate of change (AARC) by country. We fitted random effects regression models to estimate regional AARC in DFPSm. All analysis were stratified by marital status. RESULTS: Overall, there was significant wealth-related disparities in DFPSm in West Africa only (17.8 percentage points (pp)) among married AGYW. The disparities were significant in 5 out of 10 countries in Eastern, 2 out of 6 in Central, and 7 out of 12 in West among married AGYW and in 2 out of 6 in Central and 2 out of 9 in West Africa among unmarried AGYW. Overall, DFPSm among married AGYW increased over time in both poorest (AARC = 1.6%, p < 0.001) and richest (AARC = 1.4%, p < 0.001) households and among unmarried AGYW from poorest households (AARC = 0.8%, p = 0.045). DPFSm increased over time among married and unmarried AGYW from poorest households in Eastern (AARC = 2.4%, p < 0.001) and Southern sub-regions (AARC = 2.1%, p = 0.030) respectively. Rwanda and Liberia had the largest increases in DPFSm among married AGYW from poorest (AARC = 5.2%, p < 0.001) and richest (AARC = 5.3%, p < 0.001) households respectively. There were decreasing DFPSm trends among both married (AARC = - 1.7%, p < 0.001) and unmarried (AARC = - 4.7%, p < 0.001) AGYW from poorest households in Mozambique. CONCLUSION: Despite rapid improvements in DFPSm among married AGYW from the poorest households in many SSA countries there have been only modest reductions in wealth-related inequalities. Significant inequalities remain, especially among married AGYW. DFPSm stalled in most sub-regions among unmarried AGYW.

Intimate partner violence against adolescents and young women in sub-Saharan Africa: who is most vulnerable?

BACKGROUND: Intimate partner violence (IPV) is a global public health and human rights issue that affects millions of women and girls. While disaggregated national statistics are crucial to assess inequalities, little evidence exists on inequalities in exposure to violence against adolescents and young women (AYW). The aim of this study was to determine inequalities in physical or sexual IPV against AYW and beliefs about gender based violence (GBV) in sub-Saharan Africa (SSA). METHODS: We used data from the most recent Demographic and Health Surveys (DHS) conducted in 27 countries in SSA. Only data from surveys conducted after 2010 were included. Our analysis focused on married or cohabiting AYW aged 15-24 years and compared inequalities in physical or sexual IPV by place of residence, education and wealth. We also examined IPV variations by AYW's beliefs about GBV and the association of country characteristics such as gender inequality with IPV prevalence. RESULTS: The proportion of AYW reporting IPV in the year before the survey ranged from 6.5% in Comoros to 43.3% in Gabon, with a median of 25.2%. Overall, reported IPV levels were higher in countries in the Central Africa region than other sub-regions. Although the prevalence of IPV varied by place of residence, education and wealth, there was no clear pattern of inequalities. In many countries with high prevalence of IPV, a higher proportion of AYW from rural areas, with lower education and from the poorest wealth quintile reported IPV. In almost all countries, a greater proportion of AYW who approved wife beating for any reason reported IPV compared to their counterparts who disapproved wife beating. Reporting of IPV was weakly correlated with the Gender Inequality Index and other societal level variables but was moderately positively correlated with adult alcohol consumption (r = 0.48) and negative attitudes towards GBV (r = 0.38). CONCLUSION: IPV is pervasive among AYW, with substantial variation across and within countries reflecting the role of contextual and structural factors in shaping the vulnerability to IPV. The lack of consistent patterns of inequalities by the stratifiers within countries shows that IPV against women and girls cuts across socio-economic boundaries suggesting the need for comprehensive and multi-sectoral approaches to preventing and responding to IPV.

Inequalities in early marriage, childbearing and sexual debut among adolescents in sub-Saharan Africa.

BACKGROUND: Adolescent sexual and reproductive health (ASRH) is a major public health concern in sub-Saharan Africa (SSA). However, inequalities in ASRH have received less attention than many other public health priority areas, in part due to limited data. In this study, we examine inequalities in key ASRH indicators. METHODS: We analyzed national household surveys from 37 countries in SSA, conducted during 1990-2018, to examine trends and inequalities in adolescent behaviors related to early marriage, childbearing and sexual debut among adolescents using data from respondents 15-24 years. Survival analyses were conducted on each survey to obtain estimates for the ASRH indicators. Multilevel linear regression modelling was used to obtain estimates for 2000 and 2015 in four subregions of SSA for all indicators, disaggregated by sex, age, household wealth, urban-rural residence and educational status (primary or less versus secondary or higher education). RESULTS: In 2015, 28% of adolescent girls in SSA were married before age 18, declined at an average annual rate of 1.5% during 2000-2015, while 47% of girls gave birth before age 20, declining at 0.6% per year. Child marriage was rare for boys (2.5%). About 54% and 43% of girls and boys, respectively, had their sexual debut before 18. The declines were greater for the indicators of early adolescence (10-14 years). Large differences in marriage and childbearing were observed between adolescent girls from rural versus urban areas and the poorest versus richest households, with much greater inequalities observed in West and Central Africa where the prevalence was highest. The urban-rural and wealth-related inequalities remained stagnant or widened during 2000-2015, as the decline was relatively slower among rural and the poorest compared to urban and the richest girls. The prevalence of the ASRH indicators did not decline or increase in either education categories. CONCLUSION: Early marriage, childbearing and sexual debut declined in SSA but the 2015 levels were still high, especially in Central and West Africa, and inequalities persisted or became larger. In particular, rural, less educated and poorest adolescent girls continued to face higher ASRH risks and vulnerabilities. Greater attention to disparities in ASRH is needed for better targeting of interventions and monitoring of progress.

New Vaccine Introduction and Childhood Vaccination Timeliness in Two Urban, Informal Settlements in Nairobi, Kenya.

New vaccine introduction accompanied by social mobilization activities could contribute to improved routine immunization timeliness. This study assesses the impact of Kenya's introduction of pneumococcal conjugate vaccine (PCV) on the timeliness of routine childhood vaccination in two informal, urban settlements in Nairobi. Data collected from 2007 to 2015 as part of a demographic surveillance system were used to estimate annual vaccination delays of ≥ 4 weeks among children aged 12-23 months in the period before and after the introduction of PCV in Kenya. Binomial segmented regression models using generalized estimating equations examined the association between vaccine introduction and timeliness of routine immunization. Over half of all children vaccinated in the two urban areas received one or more doses ≥ 4 weeks after the recommended age. The timeliness of routine immunization showed slight improvements or nonsignificant changes during the years following PCV introduction compared with the preceding years (adjusted prevalence ratio [aPR]: 0.67, 95% CI: 0.45-0.99 for Bacille Calmette-Guerin receipt; aPR: 0.59, 95% CI: 0.41-0.83 for third dose Pentavalent receipt; aPR: 1.19, 95% CI: 0.99-1.42 for measles). However, as of 2015, delayed vaccination remained prevalent in children, particularly among the poorest residing in the settlements. Many sub-Saharan African countries have introduced new life-saving vaccines into their routine childhood immunization schedule. Additional evidence regarding the positive or neutral influence of new vaccine introduction on the performance of delivery systems provides further justification to sustain the inclusion of these more costly vaccines in the immunization schedule.

The influence of maternal migration on child vaccination in Kenya: An inverse probability of treatment-weighted analysis.

OBJECTIVES: Kenya has substantially improved child mortality between 1990 and 2019, with under-5 mortality decreasing from 104 to 43 deaths per 1000 live births. However, only two-thirds of Kenyan children receive all recommended vaccines by 1 year, making it essential to identify undervaccinated subpopulations. Internal migrants are a potentially vulnerable group at risk of decreased access to healthcare. This analysis explored how maternal migration within Kenya influences childhood vaccination. METHODS: Data were from the 2014 Kenya Demographic and Health Survey, a nationally representative cross-sectional survey. Logistic regressions assessed relationships between maternal migration and full and up-to-date child vaccination using inverse probability of treatment weighting. Two exposure variables were examined: migration status and stream (e.g. rural-urban). Multiple imputation was used to impute up-to-date status for children without vaccination cards to reduce selection bias. RESULTS: After accounting for selection and confounding biases, all relationships between migration status and migration stream and full and up-to-date vaccination became statistically insignificant. CONCLUSIONS: Null findings indicate that, in Kenya, characteristics enabling migration, rather than the process of migration itself, drive differential vaccination behavior between migrants and non-migrants. This finding is an important deviation from previous literature, which did not rigorously address important biases.

Inequities in On-Time Childhood Vaccination: Evidence From Sub-Saharan Africa.

INTRODUCTION: Vaccination coverage has improved in the past decade, but inequalities persist: the poorest, least educated, and rural communities are left behind. Programming has focused on increasing coverage and reaching the hardest-to-reach children, but vaccination timeliness is equally important because delays leave children vulnerable to infections. This study examines the levels and inequities of on-time vaccination in the Sub-Saharan African region. METHODS: The most recent Demographic and Health Surveys or Multiple Indicator Clusters Surveys since 2000 from Sub-Saharan Africa were used to assess on-time vaccination and inequalities by household wealth, maternal education, and place of residence. Inequalities were quantified using slope index of inequality and concentration index. RESULTS: The analysis included 153,632 children aged 12-36 months from 40 Sub-Saharan Africa countries. Median on-time vaccination coverage was <50% in all the 4 subregions. Differences in on-time vaccination were observed by place of residence in the Southern (20.8 percentage points, 95% CI=0.8, 40.8), West (17.5 percentage points, 95% CI=5.1, 29.9), and Eastern (20.9 percentage points, 95% CI=6.5, 35.2) regions. Wealth-related inequities were observed in the Southern (22.6 percentage points, 95% CI=4.0, 41.2), Western (30.6 percentage points, 95% CI=19.1, 42.1), and Eastern (26.1 percentage points, 95% CI=8.2, 44.0) regions. Significant education-related differences in on-time vaccination were observed in the Western (20.7 percentage points, 95% CI=10.9, 30.5) and Eastern (21.2 percentage points, 95% CI=7.0, 35.4) regions. CONCLUSIONS: On-time vaccination coverage was low in all subregions and nearly all countries. Inequalities in on-time immunization by household wealth, place of residence, and education existed in most countries. Concrete strategies to improve levels of timeliness are needed. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Global Vaccination Equity, which is sponsored by the Global Institute for Vaccine Equity at the University of Michigan School of Public Health.

Vaccine Delay and Its Association With Undervaccination in Children in Sub-Saharan Africa.

INTRODUCTION: Improving the timeliness and completion of vaccination is the key to reducing under-5 childhood mortality. This study examines the prevalence of delayed vaccination for doses administered at birth and age 6 weeks, 10 weeks, 14 weeks, and 9 months and its association with undervaccination among infants in Sub-Saharan Africa. METHODS: Pooling data across 33 Sub-Saharan Africa countries, vaccination timing and series completion were assessed for children aged 12-35 months who were included in the immunization module of the Demographic and Health Surveys conducted between 2010 and 2019. Survey design-adjusted logistic regression modeled the likelihood of not fully completing the basic immunization schedule associated with dose-specific delays in vaccination. Data were obtained and analyzed in May 2020. RESULTS: Among children with complete date records (n=70,006), the proportion of children vaccinated with delays by ≥1 month was high: 25.9% for Bacille Calmette-Guerin (at birth); 49.1% for the third dose of pentavalent combination vaccine (at 14 weeks); and 63.9% for the first dose of measles vaccines (at 9 months). Late vaccination was more common for children born to mothers with lower levels of educational attainment (p<0.001) and wealth (p<0.001). Controlling for place, time, and sociodemographics, vaccination delays at any dose were significantly associated with not completing the immunization schedule by 12 months (Bacille Calmette-Guerin: AOR=1.93, [95% CI=1.83, 2.02]; pentavalent 3: AOR=1.50 [95% CI=1.35, 1.64]; measles: AOR=3.76 [95% CI=3.37, 4.15]). CONCLUSIONS: Timely initiation of vaccination could contribute to higher rates of immunization schedule completion, improving the reach and impact of vaccination programs on child health outcomes in Sub-Saharan Africa. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Global Vaccination Equity, which is sponsored by the Global Institute for Vaccine Equity at the University of Michigan School of Public Health.

Women's Empowerment and Child Vaccination in Kenya: The Modifying Role of Wealth.

INTRODUCTION: Although vaccination coverage is high in Kenya relative to other African nations, undervaccinated children remain, making it important to identify characteristics of these children and their caregivers. Potentially relevant but understudied factors are women's empowerment and early marriage. Women who marry older and have more autonomous decision-making authority may be better able to ensure their children receive health services, including immunizations. This analysis examines the relationship between early marriage and multiple dimensions of women's empowerment and child vaccination status in Kenya and explores whether these relationships are modified by wealth. METHODS: Data were from the 2014 Kenya Demographic and Health Survey. The analysis was completed in 2020 using updated data made available to researchers in 2019. Logistic regressions assessed relationships among early marriage, 3 dimensions of women's empowerment (enabling conditions, intrinsic agency, and instrumental agency), and child vaccination. Analyses were stratified by wealth to explore potential effect modification. RESULTS: For women in the middle wealth tertile, the odds of having a fully vaccinated child were 3.45 (95% CI=1.51, 7.91) times higher for those with higher versus lower empowerment. Further, among the wealthiest women, those with middle empowerment were 5.99 (95% CI=2.06, 17.40) times more likely to have a fully vaccinated child than women with lower empowerment. CONCLUSIONS: Results suggest a threshold effect of wealth's role in the relationship between empowerment and vaccination. Enabling conditions may not influence immunization among the poorest women but exert a stronger positive influence on childhood vaccination among wealthier women. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Global Vaccination Equity, which is sponsored by the Global Institute for Vaccine Equity at the University of Michigan School of Public Health.

Do inequalities exist in the disadvantaged populations? Levels and trends of full and on-time vaccination coverage in two Nairobi urban informal settlements.

There has been an improvement in childhood vaccination coverage over the last two decades worldwide. However, inequities exist among different populations. Vaccination programs should focus not only on increasing coverage but as also in timeliness to ensure maximum protection. This study examined the levels, inequities, and trends of full and on-time vaccination coverage in two urban informal settlements in Nairobi. The study used longitudinal data from the Nairobi Urban Health and Demographic Surveillance System from 2003 to 2017 to estimate full and on-time vaccination coverage and assess inequalities by background characteristics. The frailty shared Cox model was used to assess time to full- and on-time- immunization coverage. Out of 32,018 children aged 12 to 59 months, less than half (46.7%) produced a vaccination card during the interview. Full and timely immunization coverage was higher in Viwandani site, among Kikuyu and Kamba ethnic groups, and children from the richest quintile. Timely vaccination was below 50% throughout the survey periods. After accounting for the intragroup correlations, for a given level of frailty, the hazard for being fully immunized was 10% more likely among the wealthiest compared to the poorest children. The hazard for being fully immunized was 16%, 16% to 19% less likely for Luhya, Luo, and others as compared to the Kikuyu ethnicity respectively. In conclusion, the study has shown that coverage has been increasing over the years but inequalities exist in immunization coverage among the most disadvantaged populations. More focused intervention approaches that target the disadvantaged groups are needed.

Complete and on-time routine childhood immunisation: determinants and association with severe morbidity in urban informal settlements, Nairobi, Kenya.

Background: Completion of the full series of childhood vaccines on-time is crucial to ensuring greater protection against vaccine-preventable diseases.Aim: To examine determinants of complete and on-time vaccination and evaluate the relationship between vaccination patterns and severe morbidity outcomes.Subjects and methods: Vaccination information from infants in Nairobi Urban Health and Demographic Surveillance System was used to evaluate full and on-time vaccination coverage of routine immunisation. Logistic regression was used to identify determinants of full and on-time vaccination coverage. Cox regression model was used to evaluate the relationship between vaccination status and subsequent severe morbidity. A shared frailty cox model was fitted to account for the heterogeneity in hospitalisation episodes.Results: Maternal age, post-natal care, parity, ethnicity, and residence place were identified as determinants of vaccination completion. Institutional deliveries and residence place were identified as the determinants of on-time vaccination. A significant 58% (confidence interval [CI]: 15-79%) (p = .017) lower mortality was observed among fully immunised children compared with not fully immunised. Lower mortality was observed among on-time immunised children, 64% (CI: 20-84%) compared to those with delays.Conclusions: Improving vaccination timeliness and completion schedule is critical for protection against vaccine preventable diseases and may potentially provide protection beyond these targets.

Comparative performance of pooled cohort equations and Framingham risk scores in cardiovascular disease risk classification in a slum setting in Nairobi Kenya.

BACKGROUND: Cardiovascular diseases (CVD) cause 18 million deaths annually. Low- and middle-income countries (LMICs) account for 80% of the CVD burden, and the burden is expected to grow in the region in the coming years. Screening for and identification of individuals at high risk for CVD in primary care settings can be accomplished using available CVD risk scores. However, few of these scores have been validated/recalibrated for use in sub-Saharan Africa (SSA). METHODS: Pooled cohort equations (PCE) and Framingham risk scores for 10-year CVD risk were applied on 1960 men and women aged 40 years and older from the AWI-Gen (Africa, Wits-INDEPTH Partnership for GENomic studies) study 2015. Low, moderate/intermediate or high CVD risk classifications correspond to <10%, 10-20% and >20% chance of developing CVD in 10 years respectively. Agreement between the risk scores was assessed using kappa and correlation coefficients. RESULTS: High CVD risk was 10.3% in PCE 2013, 0.4% in PCE 2018, 2.9% in Framingham and 3.6% in Framingham non-laboratory scores. Conversely, low CVD risk was 62.2% in PCE 2013 and 95.6% in PCE 2018, 84.0% and 80.1% in Framingham and Framingham non-laboratory scores, respectively. A moderate agreement existed between the Framingham functions (kappa = 0.64, 95% CI 0.59-0.68, correlation, rs = 0.711). There was no agreement between the PCE 2013 and 2018 functions (kappa = 0.05, 95% CI 0.04-0.06). CONCLUSIONS: Newer cohort-based data is necessary to validate and recalibrate existing CVD risk scores in order to develop appropriate functions for use in SSA.

Adolescent sexual and reproductive health in sub-Saharan Africa: who is left behind?

Adolescent sexual and reproductive health (ASRH) continues to be a major public health challenge in sub-Saharan Africa where child marriage, adolescent childbearing, HIV transmission and low coverage of modern contraceptives are common in many countries. The evidence is still limited on inequalities in ASRH by gender, education, urban-rural residence and household wealth for many critical areas of sexual initiation, fertility, marriage, HIV, condom use and use of modern contraceptives for family planning. We conducted a review of published literature, a synthesis of national representative Demographic and Health Surveys data for 33 countries in sub-Saharan Africa, and analyses of recent trends of 10 countries with surveys in around 2004, 2010 and 2015. Our analysis demonstrates major inequalities and uneven progress in many key ASRH indicators within sub-Saharan Africa. Gender gaps are large with little evidence of change in gaps in age at sexual debut and first marriage, resulting in adolescent girls remaining particularly vulnerable to poor sexual health outcomes. There are also major and persistent inequalities in ASRH indicators by education, urban-rural residence and economic status of the household which need to be addressed to make progress towards the goal of equity as part of the sustainable development goals and universal health coverage. These persistent inequalities suggest the need for multisectoral approaches, which address the structural issues underlying poor ASRH, such as education, poverty, gender-based violence and lack of economic opportunity.

Uncontrolled hypertension among patients with comorbidities in sub-Saharan Africa: protocol for a systematic review and meta-analysis.

BACKGROUND: Uncontrolled hypertension is the most important risk factor and leading cause of cardiovascular diseases. It is predicted that the number of people with hypertension will increase, and a large proportion of this increase will occur in developing countries. The highest prevalence of uncontrolled hypertension is reported in sub-Saharan Africa, and treatment for hypertension is unacceptably low. Hypertension commonly co-exists with comorbidities and this is associated with poorer health outcomes for patients. This review aims to estimate the prevalence of uncontrolled hypertension among patients with comorbidities in sub-Saharan Africa. METHODS AND ANALYSIS: All published and unpublished studies on the prevalence of uncontrolled hypertension among patients with comorbidities in sub-Saharan Africa will be included. MEDLINE via OVID, Embase, and Web of Science will be searched to identify all relevant articles published from January 2000 to June 2019. Experts in the field will be contacted for unpublished literature, and Open SIGLE will be reviewed for relevant information. No language restriction will be imposed. Two reviewers will select, screen, extract data, and assess the risk of bias while a third reviewer will arbitrate the disagreements. A meta-analysis will be performed on variables that are similar across the included studies. Proportions will be stabilized before estimates are pooled using a random effects model. The presence of publication bias will be assessed using Egger's test and visual inspection of the funnel plots. This systematic and meta-analysis review protocol will be reported in accordance with the PRISMA-P protocol guidelines. Results will be stratified by country, comorbidity, and geographic region. DISCUSSION: This systematic review and meta-analysis is expected to quantify the magnitude of uncontrolled hypertension among patients with certain comorbid conditions in sub-Saharan Africa to guide policies and interventions. This review is registered in PROSPERO International Prospective Register of Systematic reviews CRD42019108218.

Prevalence and factors associated with health insurance coverage in resource-poor urban settings in Nairobi, Kenya: a cross-sectional study.

OBJECTIVE: To determine the prevalence of health insurance and associated factors among households in urban slum settings in Nairobi, Kenya. DESIGN: The data for this study are from a cross-sectional survey of adults aged 18 years or older from randomly selected households in Viwandani slums (Nairobi, Kenya). Respondents participated in the Lown scholars' study conducted between June and July 2018. SETTING: The Lown scholars' survey was nested in the Nairobi Urban Health and Demographic Surveillance System in Viwandani slums in Nairobi, Kenya. PARTICIPANTS: A total of 300 randomly sampled households participated in the survey. The study respondents comprised of either the household head, their spouses or credible adult household members. PRIMARY OUTCOME MEASURE: The primary outcome of this study was enrolment in a health insurance programme. The households were classified into two groups: those having at least one member covered by health insurance and those without any health insurance cover. RESULTS: The prevalence of health insurance in the sample was 43%. Being unemployed (adjusted OR (aOR) 0.17; p<0.05; 95% CI 0.06 to 0.47) and seeking care from a public health facility (aOR 0.50; p<0.05; 95% CI 0.28 to 0.89) was significantly associated with lower odds of having a health insurance cover. The odds of having a health insurance cover were significantly lower among respondents who perceived their health status as good (aOR 0.62; p<0.05; 95% CI 1.17 to 5.66) and those who were unsatisfied with the cost of seeking primary care (aOR 0.34; p<0.05; 95% CI 0.17 to 0.69). CONCLUSIONS: Health insurance coverage in Viwandani slums in Nairobi, Kenya, is low. As universal health coverage becomes the growing focus of Kenya's 'Big Four Agenda' for socioeconomic transformation, integrating enabling and need factors in the design of the national health insurance package may scale-up social health protection.

Childhood vaccination in Kenya: socioeconomic determinants and disparities among the Somali ethnic community.

OBJECTIVES: Kenya has a significant refugee population, including large numbers of Somali migrants. This study examines the vaccination status of Kenyan children and sociodemographic predictors of vaccination, including Somali ethnicity. METHODS: Using the 2014 Kenyan Demographic and Health Survey, we calculated the proportion of non-vaccinated, under-vaccinated, and fully vaccinated children, defining full vaccination as one dose Bacille Calmette-Guerin, three doses polio, three doses pentavalent, and one dose measles. We assessed associations among various factors and vaccination status using multinomial logistic regression and explored the effect of Somali ethnicity through interaction analysis. RESULTS: The study sample comprised 4052 children aged 12-23 months, with 79.4% fully, 19.0% under-, and 1.6% non-vaccinated. Among Somalis, 61.9% were fully, 28.7% under-, and 9.4% non-vaccinated. Somalis had significantly greater odds of under- and non-vaccination than the Kikuyu ethnic group. Wealth and birth setting were associated with immunization status for Somalis and non-Somalis. CONCLUSIONS: Disparities persist in pediatric vaccinations in Kenya, with Somali children more likely than non-Somalis to be under-vaccinated. Health inequalities among migrants and ethnic communities in Kenya should be addressed.

Prevalence, awareness, treatment and control of hypertension and their determinants: results from a national survey in Kenya.

BACKGROUND: Hypertension is the most important risk factor for cardiovascular diseases and the leading cause of death worldwide. Despite growing evidence that the prevalence of hypertension is rising in sub-Saharan Africa, national data on hypertension that can guide programming are missing for many countries. In this study, we estimated the prevalence of hypertension, awareness, treatment, and control. We further examined the factors associated with hypertension and awareness. METHOD: We used data from the 2015 Kenya STEPs survey, a national cross-sectional household survey targeting randomly selected people aged 18-69 years. Demographic and behavioral characteristics as well as physical measurements were collected using the World Health Organization's STEPs Survey methodology. Descriptive statistics were used to estimate the prevalence, awareness, treatment and control of hypertension. Multiple logistic regression models were used to identify the determinants of hypertension and awareness. RESULTS: The study surveyed 4485 participants. The overall age-standardized prevalence for hypertension was 24.5% (95% confidence interval (CI) 22.6% to 26.6%). Among individuals with hypertension, only 15.6% (95% CI 12.4% to 18.9%) were aware of their elevated blood pressure. Among those aware only 26.9%; (95% CI 17.1% to 36.4%) were on treatment and 51.7%; (95% CI 33.5% to 69.9%) among those on treatment had achieved blood pressure control. Factors associated with hypertension were older age (p < 0.001), higher body mass index (BMI) (p < 0.001) and harmful use of alcohol (p < 0.001). Similarly, factors associated with awareness were older age (p = 0.013) and being male (p < 0.001). CONCLUSION: This study provides the first nationally-representative estimates for hypertension in Kenya. Prevalence among adults is high, with unacceptably low levels of awareness, treatment and control. The results also reveal that men are less aware of their hypertension status hence special attention should focus on this group.