Abstract:
Background: A key focus of health systems strengthening in low‑ and middle‑income countries is increasing reach
and access through task‑shifting. As such models become more common, it is critical to understand the experiences
of lay providers because they are on the forefront for delivering care services. A greater understanding would improve
lay provider support and help them provide high‑quality care. This is especially the case for those providing mental
health services, as providing psychological care may pose unique stressors. We sought to understand experiences of
lay counselors, focusing on identity, motivation, self‑efficacy, stress, and burnout. The goal was to understand how
taking on a new provider role influences their lives beyond simply assuming a new task, which would in turn help
identify actionable steps to improve interventions with task‑shifting components.
Methods: Semi‑structured interviews (n = 20) and focus group discussions (n = 3) were conducted with three
lay counselor groups with varying levels of experience delivering a community‑based family therapy intervention
in Eldoret, Kenya. Thematic analysis was conducted, including intercoder reliability checks. A Stress Map was cre‑
ated to visualize stress profiles using free‑listing and pile‑sorting data collected during interviews and focus group
discussions.
Results: Counselors described high intrinsic motivation to become counselors and high self‑efficacy after training.
They reported positive experiences in the counselor role, with new skills improving their counseling and personal
lives. As challenges arose, including client engagement difficulties and balancing many responsibilities, stress and
burnout increased, dampening motivation and self‑efficacy. In response, counselors described coping strategies,
including seeking peer and supervisor support, that restored their motivation to persevere. At case completion, they
again experienced high self‑efficacy and a desire to continue.
Conclusions: Findings informed suggestions for ways to incorporate support for lay providers into task‑shifting inter‑
ventions at initiation, during training, and throughout implementation. These include acknowledging and preparing
counselors for challenges during training, increasing explicit attention to counselor stress in supervision, fostering
peer support among lay providers, and ensuring a fair balance between workload and compensation. Improving and
building an evidence base around practices for supporting lay providers will improve the effectiveness and sustain‑
ability of lay provider‑delivered interventions.