Social Determinants of Maternal and Child Health Outcomes in Busia County, Kenya: Implications for Nursing Practice and Health Systems Strengthening

Abstract

Background: Persistent maternal and child health (MCH) inequities in low- and middle-income countries are driven not only by service delivery gaps but also by structural social determinants of health (SDOH), including housing, water and sanitation, poverty, and governance fragmentation. In Kenya’s devolved health system, county governments bear primary responsibility for service delivery, yet multisectoral coordination remains uneven. Generating local evidence on household-level determinants is critical for informing county policy and strengthening primary health care systems. Aim: To assess household- and system-level social determinants influencing maternal and child health in Busia County, Kenya, and to identify policy and governance implications for nursing practice and county health systems strengthening. Methods: A cross-sectional mixed-methods study was conducted between May and June 2025 across four sub-counties of Busia County. Data were collected from 103 households using a structured observational checklist covering five SDOH domains: housing quality, water and sanitation (WASH), access to health services, health behaviours, and community environment. Fifteen Key Informant Interviews with county officials, health managers, and civil society actors examined governance, financing, and intersectoral coordination barriers. Quantitative data were analysed descriptively using SPSS (Version 26), while qualitative data were thematically analysed and triangulated. Results: Structural vulnerabilities—including semi-permanent housing, inadequate WASH infrastructure, and persistent financial constraints—were widespread. Although geographic access to facilities was relatively adequate, effective utilisation of antenatal, delivery, and postnatal services was constrained by indirect costs, transport limitations, and weak cross-sector coordination. Community health structures were active but insufficiently embedded within formal county planning and budgeting frameworks. Conclusion: Improving maternal and child health in Busia County requires policy shifts beyond facility expansion toward integrated, multisectoral action. Strengthening nurse-led primary health care, institutionalising interdepartmental coordination, aligning WASH and health investments, and embedding community health structures within county governance and financing mechanisms are critical for advancing equitable MCH outcomes under devolution.