Volunteer Health Workers Research Articles

ASHA - World’s Largest All-female Frontline Community Health Worker: Features and Challenges

India accounts for the second-highest number of maternal deaths all over the world. India has shown a remarkable decline in MMR (Maternal Mortality Ratio) during the last two decades. According to the SRS (Sample Registration System), MMR dropped from more than 556 per 100,000 in 1990 to 113 in 2018 and the proportion of deliveries attended by skilled health personnel has increased from 58% in the 1990s to 81% in 2019. In the year 2005, the Government of India launched the National Rural Health Mission (NRHM) with the purpose of improving the existing health facilities provided to the community with a special focus on the poor and vulnerable states and societies. NRHM identified ASHA (Accredited Social Health Activist), a voluntary community health worker, to provide services to the community on incentives. ASHA workers are the female health workers who have hailed from the same community where they serve. An ASHA worker acts as a link person between the health system and the community. At present, ASHA services are utilised in a number of programmes including maternal and child health, Various studies have extensively documented about ASHAs dissatisfaction with their pay and workload. ASHA services are widely accepted by societies, especially the poor, but issues like sexual harassment, violence, unsafe working conditions, and cast discrimination were also reported.ASHA programme plays a critical role in implementing Government health programmes, especially on MCH. Therefore keeping the ASHA updated and motivated is very important for performing her duties efficiently and effectively.

SARS-CoV-2 Infection in Health Workers: Analysis from Verona SIEROEPID Study during the Pre-Vaccination Era.

Background: To report the baseline phase of the SIEROEPID study on SARS-CoV-2 infection seroprevalence among health workers at the University Hospital of Verona, Italy, between spring and fall 2020; to compare performances of several laboratory tests for SARS-CoV-2 antibody detection. Methods: 5299 voluntary health workers were enrolled from 28 April 2020 to 28 July 2020 to assess immunological response to SARS-CoV-2 infection throughout IgM, IgG and IgA serum levels titration by four laboratory tests. Association of antibody titre with several demographic variables, swab tests and performance tests (sensitivity, specificity, and agreement) were statistically analyzed. Results: The overall seroprevalence was 6%, considering either IgG and IgM, and 4.8% considering IgG. Working in COVID-19 Units was not associated with a statistically significant increase in the number of infected workers. Cohen’s kappa of agreement between MaglumiTM and VivaDiagTM was quite good when considering IgG only (Cohen’s kappa = 78.1%, 95% CI 74.0–82.0%), but was lower considering IgM (Cohen’s kappa = 13.3%, 95% CI 7.8–18.7%). Conclusion: The large sample size with high participation (84.7%), the biobank and the longitudinal design were significant achievements, offering a baseline dataset as the benchmark for risk assessment, health surveillance and management of SARS-CoV-2 infection for the hospital workforce, especially considering the ongoing vaccination campaign. Study results support the national regulator guidelines on using swabs for SARS-CoV-2 screening with health workers and using the serological tests to contribute to the epidemiological assessment of the spread of the virus.

Research, education and capacity building priorities for violence, abuse and mental health in low- and middle-income countries: an international qualitative survey

PurposeDespite the World Health Organization and United Nations recognising violence, abuse and mental health as public health priorities, their intersection is under-studied in low- and middle-income countries (LMICs). International violence, abuse and mental health network (iVAMHN) members recognised the need to identify barriers and priorities to develop this field.MethodsInformed by collaborative discussion between iVAMHN members, we conducted a pilot study using an online survey to identify research, education and capacity building priorities for violence, abuse and mental health in LMICs. We analysed free-text responses using thematic analysis.Results35 senior (29%) and junior researchers (29%), non-government or voluntary sector staff (18%), health workers (11%), students (11%) and administrators (3%) completed the survey. Respondents worked in 24 LMICs, with 20% working in more than one country. Seventy-four percent of respondents worked in sub-Saharan Africa, 37% in Asia and smaller proportions in Latin America, Eastern Europe and the Middle East. Respondents described training, human resource, funding and sensitivity-related barriers to researching violence, abuse and mental health in LMICs and recommended a range of actions to build capacity, streamline research pathways, increase efficiency and foster collaborations and co-production.ConclusionThe intersection between violence, abuse and mental health in LMICs is a priority for individuals with a range of expertise across health, social care and the voluntary sector. There is interest in and support for building a strong network of parties engaged in research, service evaluation, training and education in this field. Networks like iVAMHN can act as hubs, bringing together diverse stakeholders for collaboration, co-production and mutually beneficial exchange of knowledge and skills.

Atrial fibrillation prevalence and risk profile from novel community-based screening in Thailand: A prospective multi-centre study.

BackgroundIn Thailand, almost one-quarter of strokes are related to atrial fibrillation (AF), and many could be prevented if AF were diagnosed and treated prior to the stroke. Therefore, we tested a novel strategy to screen large numbers of community residents using village health volunteers and primary care nurses.MethodsLocal primary care nurses and village health volunteers in Phetchaburi and Lopburi provinces, Thailand were trained to perform AF screening using a blood pressure device with AF algorithm (Microlife A200 AFib). 10% of residents aged ≥ 65 years were randomly selected for screening during home-visits. Participants with possible AF were given follow-up appointments for further testing, including 12-lead ECG and echocardiogram.ResultsOver two-months, 9.7% (13,864/143,478) of the target population were screened: mean age 73.2 ± 6.4 years, 32.4% male. The estimated AF prevalence (detected by Microlife A200 AFib) was 2.8% (95% CI, 2.6–3.1%) for age ≥ 65 years (i.e. 393/13,864 participants). Prevalence increased with age from 1.9% (65–69 years) to 5.0% (≥85 years) (p < 0.001). Only 58% (226/393) of participants with suspected AF attended the follow-up appointment (1–3 months after initial screen): mean CHA2DS2-VASc score 3.2 ± 1.2; 86.3% (195/226) had Class-1 oral anticoagulation recommendation, and 33% (75/226) had AF on 12-lead ECG.ConclusionsIn Thailand, large-scale AF screening in the community is feasible using trained volunteer health workers, allowing screening of large numbers in a short time-period. Further investigation of this strategy is warranted, ensuring mechanisms to obtain a timely rhythm strip or 12-lead ECG locally, and a designated pathway to treatment.

Impact of Peer-Led Cancer Education Program on Knowledge, Health Beliefs, Practice, and Self-Esteem Among Pairs of Nepalese High-School Students and Their Knowledge-Sharing Partners.

Raising cancer awareness among adolescents can increase their confidence in identifying cancer symptoms and develop healthy habits. This study tested the effectiveness of cancer education based on a new model among high schoolers. A non-randomized control group pre-post-test design study was conducted among 313 pairs of adolescent students and their knowledge-sharing partners in Lalitpur, Nepal. A baseline test was conducted before the education program, and it was followed up at two weeks and three months. Results were measured using a chi-square test, binary logistic regression, and a two-way repeated-measures ANOVA. There was a significant interaction effect of intervention and time on students’ knowledge, beliefs, self-esteem, and practice, along with a change in some scores of knowledge-sharing partners. Joint assignment supported the idea of diffusion of information within the family and in the neighborhood. The peer group discussion could encourage active learning and help students to participate visibly in problem-solving and reflecting more sustainably. Time constraints, lack of human resources, and support groups, might limit this program’s usage; however, preparing guidelines, and connecting communities, organizations, hospitals, volunteer health workers, and survivors can help make it more sustainable and approachable.

Interventions to increase adherence to micronutrient supplementation during pregnancy: a systematic review.

Prenatal micronutrient supplements are cost‐effective in reducing nutritional deficiencies and adverse pregnancy and birth outcomes. However, poor adherence remains a potential barrier to the successful implementation of these supplementation programs. This systematic review assessed the effectiveness of interventions designed to increase adherence to prenatal micronutrient supplementation. Following the Cochrane Collaboration Methodology, literature searches were conducted in six electronic databases and gray literature (on July 24, 2020), and abstract screening, data extraction, and risk of bias assessment were conducted independently by two reviewers. We included 22 studies. Interventions that resulted in increased adherence were most of the education‐based strategies, consumption monitoring by volunteer health workers or family members, SMS reminders, free provision of supplements, a multicomponent intervention with community mobilization, and a participatory action research intervention. In several studies, increased adherence was accompanied by beneficial effects on pregnancy and birth outcomes. Given the heterogeneity of study designs and methods used to define and measure adherence, a meta‐analysis was not appropriate. We identified several potentially effective strategies to improve supplementation adherence, which may need to be adapted to specific contexts when considered for program implementation. However, additional high‐quality studies are critically needed to effectively guide policies and programs.

Supervision of community health nurses in Ghana: a mixed-methods study on experiences and mentorship needs.

Adequate supervision is critical to maintain the performance of health workers who provide essential maternal and child health services in low-resource areas. Supportive supervision emphasizing problem-solving, skill development and mentorship has been shown to improve the motivation and effectiveness of health workers, especially at the community level, but it is not always routinely provided. Previous studies have assessed the uptake of supportive supervision among volunteer health workers and paid health centre staff, but less is known about the supervision experiences of paid community-based staff, such as community health nurses (CHNs) in Ghana. This mixed-methods study explores the frequency and content of CHN supervision in five districts in the Greater Accra and Volta regions of Ghana. We analysed quantitative data from 197 satisfaction surveys and qualitative data from 29 in-depth interviews (IDIs) and four focus group discussions (FGDs) with CHNs. While the majority of CHNs received supervision at least monthly, they reported that supervision was primarily focused on meeting clinical targets (48%) rather than on handling specific cases or patients (23%). Over a third (34%) of CHNs did not agree that supervisors help them with job-related challenges and nearly half (43%) were unsatisfied with their jobs. When asked about their mentorship needs, CHNs reported wanting feedback on how to improve their job performance (40%) and encouragement (30%). There were only slight variations in the frequency and content of supervision based on type of supervisor. During IDIs and FGDs, CHNs offered ideas for how to improve supervision, including more frequent field visits so that supervisors could see the on-the-ground realities of their work, greater respect and positive reinforcement. Overall, CHN motivation and job satisfaction may be strengthened by aligning supervision more closely with the principles of supportive supervision.

Evaluation of the attitudes about patient safety in perioperative care

BackgroundImproving patient safety is an increasing priority for health workers having roles in perioperative care about patient safety. Also, patient safety initiatives aimed at creating a safe operating room culture are increasingly being adopted. This study aims to evaluate the attitudes of health workers who having roles in perioperative care about patient safety. MethodsThis cross-sectional study was conducted in a state hospital in the eastern part of Turkey between January 2018 and March 2018 with the participation of 129 volunteer health workers including surgeons, surgical technicians, nurses and other health workers who have roles in perioperative care by using the SAQ-OR instrument. This study aligns with the STROBE checklist. ResultsAn analysis of the relationship between SAQ-OR total and sub-scales scores and age indicated a positive, significant relationship between Teamwork Climate, Job Satisfaction, Safety Climate, Working Conditions and SAQ-OR total scores (p<0.05). Besides, Job Satisfaction, Perceptions of Management, Safety Climate sub-scales and weekly working hours indicated a positive, statistically significant relationship (p<0.01). ConclusionParticipating health personnel's attitudes towards operating rooms were found to be low. More attention should be attached on the issue by the hospital administration in order to improve patient safety culture, which was not found at good levels.

Effect of the BASNEF-based Educational Intervention on the Prevention of Cutaneous Leishmaniasis Disease in the Volunteer Health Workers and Families Covered by Them: A Quasi-Experimental Prospective Study

Effect of the BASNEF-based Educational Intervention on the Prevention of Cutaneous Leishmaniasis Disease in the Volunteer Health Workers and Families Covered by Them: A Quasi-Experimental Prospective Study

Human Rights Perspectives on Voluntary Health Workers Nurses Who Work at Government Agencies

Nurses as professionals whose existence is recognized by the State have rights that should be fulfilled and protected as professionals and general citizens. The rights that have been guaranteed by various laws and regulations are supposed to remain insufficient to comprehensively accommodate voluntary health worker nurses spreading over the country. Various Indonesian laws and regulations on human rights have guaranteed the rights to work and decent life as well as the rights to recognition, legal certainty, and legal protection. This study aimed to know about the rights to obtain work and decent life viewed from the human rights perspective besides knowing about the guarantee of recognition, legal certainty, and legal protection to voluntary health worker nurses at Bima City, West Nusa Tenggara Province. This study was conducted at Bima City’s General Hospital and Paruga Health Center (Puskesmas). It applied a socio-legal approach and explicative-analytical specification. The data-gathering technique was carried out through interviews with informants, namely the Head of General and Personnel Affairs of Health Office of Bima City, the Head of General and Personnel Affairs of Personnel and Human Resources Office of Bima City, the Head of General and Personnel Affairs of Bima City’s General Hospital and Puskesmas Paruga beside twenty voluntary health worker nurses. The results of this study showed that there was no written legal regulation regarding the procedure of recruiting voluntary health worker nurses in the form of regional regulation nor the Mayor’s Decree that could be used as a legal basis for recruiting voluntary health worker nurses. This led to implications of the fulfillment of the rights to the voluntary health worker nurses, especially in the matters of work and decent life beside guaranteed legal recognition, certainty, and protection.

Illnesses Encountered During Medical Volunteering in Takeo Province, Cambodia.

Background and Objectives: Medical volunteering seeks to meet the clinical needs of underserved areas, but has been criticized for difficulties in addressing local health issues and resultant lack of sustainability. Our team has visited rural Cambodia annually since 2012. This study reports the illnesses encountered during the recent mission and share our experiences to improve the efficiency of medical volunteering. Materials and Methods: Infrastructure, such as public electricity or water, was unavailable, hence most medical care and records were hand-performed. We categorized (1) primary diagnoses (chief complaints) by duration of symptoms, and (2) primary and secondary diagnoses (illnesses that were not related to the chief complaint) by severity of illness since patients commonly reported multiple symptoms. Blood pressure and anthropometric values were also checked and analyzed. Results: We encountered 317 adult and 141 pediatric patients. Among adults, 61.3% had persistent chronic (>6 month) symptoms of their chief complaints. The commonest diagnoses of chronic symptoms were musculoarthritis (31.5%) and gastroesophageal reflux disease and/or gastritis (21.7%). Hypertension and/or cardiac problems were relatively common among males (13.6%). The most common diagnosis among the severest cases (specialized or intensive care recommended) was cardiac problems (14.8%), often with abnormalities in sonography or electrocardiogram. For children, the overwhelming majority of diagnoses were related to acute symptoms and low severity, and approximately half were cases of the common cold. Commonly prescribed drugs were antacids or mucosal protectors (31.3%), Non-steroidal anti-inflammatory drugs (NSAIDs) or other painkillers (27.6%), and antiparasites (17.7%) in adults, and NSAIDs (44.7%) and antiparasites (23.2%) in children. Among adults, 32.7% were diagnosed with hypertension, and body mass index (p = 0.003) and age (p < 0.001) were both correlated with hypertension and its grade. Conclusions: Our study offers practical help to volunteer health workers planning to visit Southeast Asia.

The Effect of Paternalist Leadership on Work Engagement a research on health workers

The aim of this study was to determine whether paternalistic leadership behavior shown by health managers has an effect on work engagement behavior of health workers. A total of 410 volunteer health workers participated in this study. In this study, paternalistic leadership scale and work engagement scale (UWES-TR) were used. SPSS (Statistical Package for Social Sciences) program was used for the analysis of the data obtained as a result of the survey application and descriptive statistical methods were used. Correlation Analysis and Simple Linear Regression Analysis were used to examine the relationship between the measured variables. As a result of the study, it was found that paternalist leadership had a positively and medium level effect on work engagement behavior. In addition, in this study, it was found that paternalist leadership had a positively effect on all dimensions of work engagement. As a result, it can be said that paternalist leadership can be an effective leadership model in health sector in terms of work engagement. Health managers can demonstrate paternalistic leadership behavior and enable healthcare workers to exhibit more work engagement behavior. There are not many studies investigating the relationship between paternalistic leadership and work engagement. This study investigated the influence of paternalistic leadership on work engagement of health workers is the first study in Turkey.

Salaried and voluntary community health workers: exploring how incentives and expectation gaps influence motivation

BackgroundThe recent publication of the WHO guideline on support to optimise community health worker (CHW) programmes illustrates the renewed attention for the need to strengthen the performance of CHWs. Performance partly depends on motivation, which in turn is influenced by incentives. This paper aims to critically analyse the use of incentives and their link with improving CHW motivation.MethodsWe undertook a comparative analysis on the linkages between incentives and motivation based on existing datasets of qualitative studies in six countries. These studies had used a conceptual framework on factors influencing CHW performance, where motivational factors were defined as financial, material, non-material and intrinsic and had undertaken semi-structured interviews and focus group discussions with CHWs, supervisors, health managers and selected community members.ResultsWe found that (a mix of) incentives influence motivation in a similar and sometimes different way across contexts. The mode of CHW engagement (employed vs. volunteering) influenced how various forms of incentives affect each other as well as motivation. Motivation was negatively influenced by incentive-related “expectation gaps”, including lower than expected financial incentives, later than expected payments, fewer than expected material incentives and job enablers, and unequally distributed incentives across groups of CHWs. Furthermore, we found that incentives could cause friction for the interface role of CHWs between communities and the health sector.ConclusionsWhether CHWs are employed or engaged as volunteers has implications for the way incentives influence motivation. Intrinsic motivational factors are important to and experienced by both types of CHWs, yet for many salaried CHWs, they do not compensate for the demotivation derived from the perceived low level of financial reward. Overall, introducing and/or sustaining a form of financial incentive seems key towards strengthening CHW motivation. Adequate expectation management regarding financial and material incentives is essential to prevent frustration about expectation gaps or “broken promises”, which negatively affect motivation. Consistently receiving the type and amount of incentives promised appears as important to sustain motivation as raising the absolute level of incentives.

A comparative analysis of the influences of specialized and non-specialized emotional intelligence training on patient satisfaction

ABSTRACTPurpose: This study determines which of specialized and non-specialized training has a stronger association with emotional intelligence and patient satisfaction in general practice.Design/methodology/approach: The study's population was health care personnel in some hospitals in Accra, Ghana. Participants were 403 volunteer health workers, including patients vising the outpatient departments of the hospitals. A self-reported questionnaire was used to gather data and confirmatory factor analysis was used to present findings.Findings: The study found that both specialized and non-specialized training make a positive influence on EI after controlling for the confounding variables. Emotional intelligence also makes a positive influence on patient satisfaction under both specialized and non-specialized training. Specialized training makes a significant positive effect on patient satisfaction but non-specialized training does not.Practical implications: Specialized training is more strongly associated with emotional intelligence of health workers as compared to non-specialized training; hence hospital administrators would have to apply it rather than non-specialized training if their goal is to augment emotional intelligence and its application in patient care.Originality/value: This study is the first in a developing country context to compare specialized and non-specialized emotional intelligence training programmes with respect to their impacts on patient satisfaction and thus makes way for a possible theoretical adjustment in the literature.

Soluble CD163 is a biomarker for accelerated atherosclerosis in systemic lupus erythematosus patients at apparent low risk for cardiovascular disease

Objective: This study aimed to determine whether sCD163, a soluble macrophage marker up-regulated in numerous inflammatory disorders, is predictive of accelerated atherosclerosis associated with systemic lupus erythematosus (SLE).Methods: Carotid ultrasound was prospectively performed, at baseline and during follow-up, in 63 consecutive SLE patients asymptomatic for cardiovascular disease (CVD) and 18 volunteer health workers. Serum sCD163 level was determined at baseline using enzyme-linked immunosorbent assay. The primary outcome was the presence of a carotid plaque. Factors associated with carotid plaques were identified through multivariate analysis.Results: Despite a low risk for cardiovascular events according to Framingham score in both groups (2.1 ± 3.8% in SLE vs 2.1 ± 2.9% in controls; p = 0.416), ultrasound at baseline showed a carotid plaque in 23 SLE patients (36.5%) and two controls (11.1%) (p = 0.039). Multivariate analysis showed that SLE status increased the risk for carotid plaque by a factor of 9 (p = 0.017). In SLE patients, sCD163 level was high (483.7 ± 260.8 ng/mL vs 282.1 ± 97.5 ng/mL in controls; p < 0.001) and independently associated with carotid plaques, as assessed by stratification based on sCD163 quartile values (p = 0.009), receiver operating characteristics (p = 0.001), and multivariate analysis (p = 0.015). sCD163 at baseline was associated with the onset of carotid plaque during follow-up (3 ± 1.4 years) in SLE patients who had no carotid plaque at the first evaluation (p = 0.041).Conclusion: sCD163 is associated with progressing carotid plaque in SLE and may be a useful biomarker for accelerated atherosclerosis in SLE patients at apparent low risk for CVD.

A spotlight on cross-sectional research: Addressing the issues of confounding and adjustment

ABSTRACT Purpose: This study attempted to conceptualize confounding and guide healthcare management researchers to identify and adjust for potential confounders from the point of view of their theoretical frameworks as a basis of achieving internal validity. Design/methodology/approach: A comprehensive statistical procedure was applied to demonstrate how likely it is for misleading effect sizes to be reached in a cross-sectional healthcare management study as a result of failing to adjust for potential confounders. Participants of the study were 403 volunteer health workers in selected hospitals in Accra, Ghana. A self-reported questionnaire was used to gather data. Confirmatory factor analysis and linear regression analyses were used to present findings. Findings: The study revealed that failing to adjust for potential confounders can over- or under-estimate the ‘ultimate effect’, which was under-estimated in this study by a value of β = .006. The auxiliary regression estimates (e.g. the variance) were also wrongly estimated owing to failure to adjust for potential confounders. Originality/value: This study is the first of its kind to address the issue of confounding in healthcare management research and justifies how necessary it is for every study to control for all confounding variables.

Model Revitalisasi Pondok Kesehatan Desa (Ponkesdes) dan Pos Pembinaan Terpadu (Posbindu) untuk Promosi Kesehatan dan Deteksi Dini Faktor Risiko Penyakit Jantung di Desa Sepanjang Kecamatan Gondanglegi Kabupaten Malang

This study aims to develop a model for revitalizing community based health care intervention for strengthening cardiovascular diseases preventive services. The case of CBHI in Sepanjang village was used to test whether the proposed model is suitable implemented. The findings show that the model was effectively implemented as indicated by the full acceptance of health workers and voluntary health workers as well as the effectiveness of screening and health promotion intervention.

Module development and its effectiveness for improving the competencies of voluntary health workers in communicating safe complementary feeding to caregivers in Indonesia

Module development and its effectiveness for improving the competencies of voluntary health workers in communicating safe complementary feeding to caregivers in Indonesia

Job satisfaction of the accredited social health activists in a community development block of Purba Bardhaman district, West Bengal

Background: Job satisfaction of accredited social health activist (ASHA), a voluntary health worker under national health mission, is not yet documented in many areas of the country. The present study assessed the job satisfaction of ASHA in Bhatar community development block of Purba Bardhaman district, West Bengal.Methods: A cross sectional study was undertaken during September–November 2017 among all the 191 ASHAs in Bhatar block. With prior consent, interviews were conducted using a questionnaire developed based on measures of job satisfaction (MJS) tool. The questionnaire contained total 28 items in six individual facets of satisfaction-personal component, workload, professional support, training, incentive and care providing. Responses for each item were recorded in 3-point Likert’s scale, total score ranging from 28–84. Overall satisfaction was categorised as dissatisfied (score=28), neutral (29-56) and satisfied (57-84) and similar categorisation was done for individual facets. Chi square test was applied to determine associated factors.Results: Overall 93.7% ASHAs were satisfied with their work, 6.3% were neither dissatisfied nor satisfied. Majority were satisfied regarding individual facets except incentive; 73.3% were rather dissatisfied. Overall satisfaction was significantly associated with the service duration of ASHA (p=0.001).Conclusions: Overall satisfaction level among ASHAs in the area though are quite high, some individual aspects like incentives needs to be looked into. Further studies will be helpful to delineate many unexplored reasons or aspects which might be necessary for developing strategies.

The salt between the beans: a qualitative study of the role of auxiliary midwives in a hard-to-reach area of Myanmar

BackgroundAuxiliary Midwives (AMWs) are unpaid volunteer health workers assisting qualified paid midwives in maternal and child health care mainly in hard-to-reach areas of Myanmar. This paper describes the relationship between AMWs and the health system in providing maternal and child services as perceived by the community, AMWs themselves and health care providers in one remote township of Myanmar.MethodA qualitative study was conducted in Ngape Township, Myanmar. A total of 15 focus group discussions with midwives, AMWs, community members and mothers were conducted. Ten key informant interviews were performed with national, district and township level health planners and implementers of maternal and child health services. Thematic analysis was done using the ATLAS.ti software.ResultsAMWs occupy a unique position between the community and the health sector in the study township. The relationship and trust with the community is built upon prolonged presence providing health care, skill building and fulfilling community expectations. Health care providers’ expectations to provide only preventive care, health promotion and education and childbirth care are often exceeded in reality when emergencies occur in hard-to-reach areas. This challenge to handle emergency situations with no support and limited skills and training is considered as most difficult by the AMWs. This mismatch of service provision expectations by both the community and other health care providers has put AMWs in a position which they describe as being the “salt between the beans” an essential ingredient but often invisible between the beans.ConclusionThe trust and relationship developed by AMWs over four decades of community practice serving as the mediator role is an untapped resource that can facilitate future community-based maternal and child health interventions in Myanmar.