Background The deployment of Community Health Workers (CHWs) is widely promoted as a strategy for reducing health inequities in low- and middle-income countries (LMIC). Yet there is limited evidence on whether and how CHW programmes achieve this. This systematic review aimed to synthesise research findings on the following questions: (1) How effective are CHW interventions at reaching the most disadvantaged groups in LMIC contexts? and (2) What evidence exists on whether and how these programmes reduce health inequities in the populations they serve? Methods We searched six academic databases for recent (2014–2020) studies reporting on CHW programme access, utilisation, quality, and effects on health outcomes/behaviours in relation to potential stratifiers of health opportunities and outcomes (e.g., gender, socioeconomic status, place of residence). Quantitative data were extracted, tabulated, and subjected to meta-analysis where appropriate. Qualitative findings were synthesised using thematic analysis. Results One hundred sixty-seven studies met the search criteria, reporting on CHW interventions in 33 LMIC. Quantitative synthesis showed that CHW programmes successfully reach many (although not all) marginalized groups, but that health inequalities often persist in the populations they serve. Qualitative findings suggest that disadvantaged groups experienced barriers to taking up CHW health advice and referrals and point to a range of strategies for improving the reach and impact of CHW programmes in these groups. Ensuring fair working conditions for CHWs and expanding opportunities for advocacy were also revealed as being important for bridging health equity gaps. Conclusion In order to optimise the equity impacts of CHW programmes, we need to move beyond seeing CHWs as a temporary sticking plaster, and instead build meaningful partnerships between CHWs, communities and policy-makers to confront and address the underlying structures of inequity. Trial registration PROSPERO registration number CRD42020177333.

Background Conflict regions bear the heaviest brunt of food insecurity and undernutrition. South Sudan is one of the fragile countries following years of conflict that led to large displacements. Moderate to severe undernutrition among under-five children has been associated with elevated morbidity and mortality. This study, therefore, was conducted to assess the magnitude and factors influencing undernutrition (wasting, underweight and stunting) among children aged 6 to 59 months in Yambio County, South Sudan. Methods A cross-sectional study was conducted from 26 October to 6 November 2018 in Yambio County, South Sudan among 630 children aged 6–59 months from the 348 households surveyed in 39 clusters using two-stage cluster sampling design. Data were collected using questionnaires and nutritional anthropometric measurements. The Standardized Monitoring and Assessment of Relief and Transitions (SMART) Methodology was followed to obtain the prevalence of wasting, underweight and stunting based on respective z scores and according to the 2006 world health organization child growth standards. Data were exported to Stata version 16 for further analysis. Bivariate analysis of independent variables and undernutrition was done using binary logistic regression. Mixed effects logistic regression analysis was conducted to control for possible confounders and account for random effects at household and cluster levels. Unadjusted and adjusted odds ratios (cOR and aOR) with 95% confidence intervals (CI) and p-values were computed. P-values of ≤0.05 were considered statistically significant. Results The prevalence of undernutrition explained by wasting (weight-for-height Z-score (WHZ) < − 2), underweight (weight-for-age z-scores (WAZ) < − 2) and stunting (height-for-age z-scores (WHZ) < − 2) were 2.3% (1.3–4.1, 95% CI), 4.8% (3.1–7.5, 95% CI) and 23.8% (19.1–29.2, 95% CI). Male sex (aOR [95% CI], p-value: 5.6 [1.10–30.04], p = 0.038), older child’s age (aOR [95% CI], p-value: 30.4 [2.65–347.60], p = 0.006) and non-residents (cOR [95% CI], p-value: 4.2 [1.4–12.2] p = 0.009) were associated with increased risk of wasting. Household size (cOR [95% CI], p-value: 1.09 [1.01–1.18] p = 0.029) and younger child age (cOR [95% CI], p-value: 4.2 [1.34–13.23] p = 0.014) were significantly associated with underweight. Younger child age (aOR [95% CI], p-value: 5.4 [1.82–16.44] p = 0.003) and agricultural livelihood (aOR [95% CI], p-value: 3.4 [1.61–7.02] p = 0.001) were associated with stunting. Conclusion Based on a cut off of less than − 2 standard deviations for 2006 World Health Organization (WHO) child growth standards, the wasting prevalence was very low, underweight prevalence was low while stunting prevalence was high. The county lies in the only livelihood region in South Sudan with bimodal reliable rainfall pattern and it seems that the impact of the 2016 conflicts that lead to large displacements may not have greatly affected under-five undernutrition. Interventions targeted at improving food diversity, increasing nutrition knowledge and enhancing resilience in male children might reduce undernutrition. In the short-term, investment in continued surveillance of nutritional status should be a main focus.

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Background Mental health (MH) remains a neglected priority in many low and middle-income countries compounded by huge inequity in the distribution of skilled human resources for MH services and inadequate data. Inadequate knowledge about MH and negative attitudes towards people with MH disorders is widespread among the general public. Methods This was a descriptive cross-sectional survey that utilised mixed methods for data collection. A total of 535 community members and 109 healthcare workers (HCWs) were targeted for the study. Simple random sampling was used to select healthcare workers in selected health facilities. Data were collected using household surveys, Key Informant Interviews (KIIS) with facility in-charges; Focus Group Discussions (FGD) with community members particularly community Health Volunteers (CHVs) and youth; and In-depth Interviews(IDI) with community gate keepers. Data analysis included simple univariate frequencies of questions chosen to reflect the key concepts on mental health. Descriptive statistics were used to determine frequencies and percentages for the different variables under study. For qualitative data, thematic analysis was applied to generate themes through deductive and inductive methods. Triangulation of qualitative and quantitative data was conducted. Results Approximately 39.1% of respondents reported to have had a family member with mental illness. 68% of HCWs reported to have diagnosed a patient with mental illness. 64% of respondents cited causes of mental disorders as witchcraft; generational curses in some families; genetic factors; drug and substance abuse social and economic/financial pressures and injuries from accidents. 93.3% of HCWs reported to have referred patients to a MH facility. Only 29.4% of the HCWs reported having counselling services for MH patients. Majority (90.8% HCWs and 62.3% community members) reported that it is convenient for patients with MH needs to access the health care facilities. MH services are mainly offered at the Teaching and Referral Hospital (81.7% HCWs and 53.8% community members). Majority of HCWs (89.9%) reported that MH services were affordable contrary to community members (44.4%). HCWs reported that drugs were given for free while community members reported stock-outs leading to purchase of MH drugs from pharmacies. Majority (96.4% HCWs and 62.5% community members) reported that MH patients are treated with respect in the facilities. Community members also seek MH services from religious leaders and traditional healers who are approached for cleansing. Additionally, some families did not seek any kind of help for their relatives with mental health illness and needs, with some even detaining them. Conclusion This study adds to the global knowledge on MH among healthcare workers and community members at service delivery level from a developing country. There is evidence of high burden of MH with very few facilities offering MH services. The existence of myths and misconceptions on causes of MH is evident.  Disparities in perception of HCWs and Community members in MH on availability, affordability of  services and access to drugs is evident. There is need to build the capacity of health care workers and sensitize community members as well as strengthen health systems to tackle MH.