The Role of Lay Health Workers to Address Disparities in Access to Evidence-Based Practices Domestically and Globally

This SCP blog piece by Dr. Miya Barnett  discusses a recent article published in the Annual Review of Clinical Psychology on the role of lay health workers in addressing disparities in access to evidence-based practices.

Multiple evidence-based practices have been developed and shown to be effective for treating common mental health disorders, such as anxiety, depression, trauma, and disruptive behavior disorders. However, the vast majority of individuals who would benefit from these evidence-based practices are not receiving them, limiting their public health impact. Certain populations are especially unlikely to receive evidence-based practices, including individuals who live in low- and middle-income countries and disadvantaged ethnic minority and linguistically isolated communities in high-income countries. One limitation to reaching these populations is the lack of a trained workforce, capable of delivering evidence-based practices in ways that meet cultural and language needs. A potential workforce solution to this issue could be incorporating lay health workers in the support or delivery of evidence-based mental health services.

Lay health workers do not have formalized mental health training and generally come from the communities they serve. As members of the community, they can fulfill roles that improve access to care. These roles range from conducting outreach services to providing the evidence-based practices. In our recently published article in the Annual Review of Clinical Psychology we proposed a conceptual model as to how different lay health worker roles can impact supply and demand drivers of disparities in the provision of evidence-based practices for underserved, low-resource communities (Barnett, Lau, & Miranda, 2018).

Interest in mobilizing lay health workers in mental health care has grown exponentially in recent years, with the majority of studies focusing on evidence-based practice delivery in low- and middle-income countries. Given differences in the available mental health workforce, lay health workers are more likely to be involved as the primary providersof evidence-based practices in low- and middle-income countries. Encouragingly, multiple studies have demonstrated that lay health workers can successfully deliver evidence-based practices, such a Trauma-Focused Cognitive Behavioral Therapy and Interpersonal Therapy, with improved clinical outcomes for the clients.  As such, these task-shifting studies indicate that lay health workers can directly improve the supply of complex behavioral interventions. On the other hand, in domestic settings, there is a larger professional mental health workforce with varying degrees of involvement in efforts to scale-up evidence-based practices in community mental health settings. However, even when concerted implementation efforts are launched, challenges still remain in engaging underserved communities in evidence-based practices. Due to logistical (e.g., transportation), informational (e.g., low mental health literacy), and attitudinal (e.g., stigma) barriers to care, ethnic minority families may still have limited access to evidence-based practices. In domestic settings, efforts have been made to train lay health workers to help increase consumer demand for evidence-based practices through outreach/ navigator roles. In these roles, lay health workers are responsible for conducting screenings, community presentations, and facilitating referrals to help more families access evidence-based practices. This can be especially important in settings that provide evidence-based practices, but struggle to have enough appropriate clients seek services and persist in care once they start.  Lay health workers also can serve in auxiliary care roles, in which they support treatment engagement through case management and the promotion of treatment related behaviors (e.g., homework and skills practice). There has been little investigation of the potential impact of deploying lay health workers in these auxiliary roles on client treatment engagement and persistence.

Overall, research and practice suggest that lay health workers could serve as an important part of the workforce to increase the reach of evidence-based practices to marginalized populations. Increasing evidence suggests that lay health worker-delivered care can lead to improved clinical outcomes. However, many important questions remain about how to best mobilize lay health workers in global and domestic settings to decrease mental health service disparities. Furthermore, it is unclear what types of implementation supports (e.g., training and consultation) lay health workers require to deliver or support the delivery of evidence-based practices with fidelity. Finally, it remains to be seen what roles are best for lay health workers in settings, such as the United States, which have a larger though still inadequate mental health workforce as compared to low- and middle-income countries. Based on evidence to date, further research is warranted to assess the potential impact of lay health workers in efforts to reduce mental health disparities.

Discussion Questions

  1. What roles should Lay health workers have in the delivery of evidence-based practices in domestic settings? How can these roles be financed within current funding structures?
  2. What level of training and supervision do lay health workers need to successfully deliver or support EBTs to fidelity and how does this compare to professional mental health providers?

Reference Article

Barnett, M. L., Lau, A. S., & Miranda, J. (2018). Lay health worker involvement in evidence-based treatment delivery: A conceptual model to address disparities in care. Annual Review of Clinical Psychology, 14. https://doi.org/10.1146/annurev-clinpsy-050817-084825

Author Bio

Miya Barnett, Ph.D. is a licensed clinical psychology and Assistant Professor in the Department of Counseling, Clinical, and School Psychology at the University of California, Santa Barbara. Her research primarily focuses on strategies to decrease mental health disparities for ethnic minority children and families and the dissemination and implementation of evidence-based practices to community mental health settings. She currently has a Mentored Research Scientist Development Award from the NIMH, which seeks to develop and test a Lay Health Worker delivered implementation intervention to increase Latino families’ access to and engagement in Parent-Child Interaction Therapy.

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