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.