What about lay counselors’ experiences of task‐shifting mental health interventions? Example from a family‐based intervention in Kenya

Abstract

A major issue facing health systems in low- and mid- dle-income countries (LMICs) is improving healthcare accessibility resulting from health care professional short- ages, especially for mental healthcare [1, 2]. Much work advocates for health systems strengthening through task-shifting, or task-sharing, by training non-special- ists or non-professionals to provide services [3–5]. Most often, such programs employ community health work- ers (CHWs), more broadly referred to as lay providers, who deliver services ranging from HIV-Tuberculosis care and management [6] to mental healthcare, the topic of the current study [7, 8]. Task-shifting has become the de facto model of much mental healthcare delivery in low- resource settings globally due to the one-million-person shortage of mental health specialists [4, 9]. Despite the many benefits of task-shifting for increas- ing healthcare accessibility, a growing body of research points to challenges lay providers face. A key chal- lenge is socioeconomic inequities between lay provid- ers and employed health professionals. This reality is largely driven by interventionists pushing an ethic of volunteerism for lay provider programs [10, 11]. Some policymakers and community program leaders claim that lay providers are “priceless” and might lose intrin- sic motivation to fulfill their responsibilities if paid [12, 13]. Additionally, many programs emphasize their cost- effectiveness in increasing healthcare accessibility, which is premised on not paying lay providers [14, 15]. This is a topic of ongoing debate in the field and has important implications for intervention delivery [11, 16]. Beyond economic impacts, the four most common areas of concern regarding lay provider experiences are motiva- tion, self-efficacy, stress, and burnout (Table 1), any of which can contribute to poor retention among lay providers [17]. These are concerning from an individual well-being per- spective and because they might reduce quality and effec- tiveness of interventions. These outcomes are even more concerning among lay counselors, a specific type of lay provider focused on mental healthcare, which often requires more time commitment and raises the risk for unique stressors, including compassion fatigue. One proposed root cause of these problems is that lay providers are sometimes treated as a “means to an end,” rather than as individuals who may need support to optimize their services [18–20]. Therefore, some researchers propose fostering a humanistic view of lay providers, encouraging global health actors not to approach lay providers as technocratic solutions, but as people with unique skills, desires, and perspectives [21]. Although past studies have pointed toward workload and socioeconomic inequities as driving problems of de- motivation and burnout among lay providers, another possible cause is the stress of taking on the new role itself [26]. Role identity theory provides a useful framing for exploring shifts in identity that lay providers may expe- rience because of taking on a new role, and how these shifts relate to stress or resilience. The theory posits that all people have multiple, hierarchically arranged identi- ties and roles that motivate behaviors [27]. The roles are thought to be intimately related to each other, often influ- encing how other roles are performed and shaping the personal meaning of individual identities [28]. As indi- viduals learn new skills and interact socially, they con- stantly acquire new roles that add to their “role set,” like adding tools to a toolkit. Role shifts are then defined as change or reshaping of a role set because of new relation- ship interactions, social positions, or duties. For lay pro- viders, such shifts in social roles occur after they receive training and take on new health worker roles. The cur- rent study applies this theory with the goal of generating potential avenues for better lay provider support.