Individual-level mental health and social impacts

NSPs in eight studies reported that intervention training, delivery and supervision led to learning skills that bettered their mental health (Figure 2). They applied intervention skills, such as problem solving, to their own lives (Atif et al., Reference Atif, Bibi, Nisar, Zulfiqar, Ahmed, LeMasters, Hagaman, Sikander, Maselko and Rahman2019). They improved their mental health literacy, coped better with their personal day-to-day stressors, and these personal benefits were useful in helping them stay motivated in delivering the intervention (Abas et al., Reference Abas, Bowers, Manda, Cooper, Machando, Verhey, Lamech, Araya and Chibanda2016; Jacobs et al., Reference Jacobs, Myers, Van Der Westhuizen, Brooke-Sumner and Sorsdahl2021; Wall et al., Reference Wall, Kaiser, Friis-Healy, Ayuku and Puffer2020; Woodward et al., Reference Woodward, de Graaff, Dieleman, Roberts, Fuhr, Broerse, Sijbrandij, Cuijpers, Ventevogel and Gerretsen2022). NSPs in HICs noted how their clients’ stories affected them. For example, NSPs in the Netherlands described that participants sometimes shared “intense” stories that personally impacted them (Woodward et al., Reference Woodward, de Graaff, Dieleman, Roberts, Fuhr, Broerse, Sijbrandij, Cuijpers, Ventevogel and Gerretsen2022). NSPs in Switzerland noted that they could relate to their clients’ sadness and over time became “more resilient and less likely to be negatively affected by people’s stories” (Spaaij et al., Reference Spaaij, Fuhr, Akhtar, Casanova, Klein, Schick, Weilenmann, Roberts and Morina2023). Because NSPs were providing services to fellow refugees and migrants in the Netherlands, they mentioned feeling motivated to provide support knowing that it would be difficult to reach a psychologist in the context of their culture (Woodward et al., Reference Woodward, de Graaff, Dieleman, Roberts, Fuhr, Broerse, Sijbrandij, Cuijpers, Ventevogel and Gerretsen2022). NSPs also noted that over time they were able to be more empathetic (Giusto et al., Reference Giusto, Johnson, Lovero, Wainberg, Rono, Ayuku and Puffer2021; Munodawafa et al., Reference Munodawafa, Lund and Schneider2017). Additional personal benefits included gaining a sense of control over their own lives, increased self-confidence, increased interpersonal skills, sense of self and ability to prioritize self-care (Atif et al., Reference Atif, Lovell, Husain, Sikander, Patel and Rahman2016; Wood et al., Reference Wood, Seevak, Bhatia, McBain and Nadkarni2021).

Figure 2.

Impact of task-sharing interventions on non-specialist providers (NSPs) and recommendations for improving non-specialists’ experiences delivering interventions.

A common theme across seven of the studies was that the NSPs experienced a change in their relationship with their communities. Some NSPs reported that their community status was elevated because of their involvement in task-sharing programs, as they became increasingly recognized for their skills and expertise (Atif et al., Reference Atif, Bibi, Nisar, Zulfiqar, Ahmed, LeMasters, Hagaman, Sikander, Maselko and Rahman2019; Verhey et al., Reference Verhey, Brakarsh, Gibson, Shea, Chibanda and Seedat2021; Wood et al., Reference Wood, Seevak, Bhatia, McBain and Nadkarni2021). NSPs in Vietnam expressed pride in their role as community members increasingly turned to them for consultation and support (Chau et al., Reference Chau, Murphy, Nguyen, Lou, Khanh, Thu, Minas and O’Neil2021). NSPs in Kenya reported being seen as more “approachable” by other community members and strengthening bonds with local institutions, such as churches and schools (Wall et al., Reference Wall, Kaiser, Friis-Healy, Ayuku and Puffer2020). In India, NSPs expressed that their involvement in the training, supervision and delivery of the interventions challenged stereotypical gender norms and led to a sense of empowerment by “not caring what others think and doing the training for themselves” (Abas et al., Reference Abas, Bowers, Manda, Cooper, Machando, Verhey, Lamech, Araya and Chibanda2016). They saw themselves as “agents of change” in their communities and experienced satisfaction and personal reward from their new role (Abas et al., Reference Abas, Bowers, Manda, Cooper, Machando, Verhey, Lamech, Araya and Chibanda2016). Positive endorsement for their role by their own communities and families contributed to their motivation to deliver task-sharing interventions (Atif et al., Reference Atif, Lovell, Husain, Sikander, Patel and Rahman2016).

Delivering task-sharing interventions increased social networks and the potential for future community facing opportunities, especially for women who previously had little opportunity to socialize outside of their families in conservative and rural settings (Atif et al., Reference Atif, Bibi, Nisar, Zulfiqar, Ahmed, LeMasters, Hagaman, Sikander, Maselko and Rahman2019). Taking part in a training and receiving a certificate was seen as a pathway toward future opportunities (Dev et al., Reference Dev, Lincoln and Shidhaye2022). NSPs reported gaining trust, praise and forming good relationships with neighboring families (Atif et al., Reference Atif, Bibi, Nisar, Zulfiqar, Ahmed, LeMasters, Hagaman, Sikander, Maselko and Rahman2019; Dev et al., Reference Dev, Lincoln and Shidhaye2022). They expanded their social networks by forming friendships and support systems with other peer NSPs (Atif et al., Reference Atif, Lovell, Husain, Sikander, Patel and Rahman2016). NSPs in Pakistan reported gaining new skills and confidence, which increased opportunities for employment and upward mobility. NSPs found jobs as teaching assistants, community health workers and elected village councilors to represent other local women, which they attribute to the expansion of their social networks (Atif et al., Reference Atif, Bibi, Nisar, Zulfiqar, Ahmed, LeMasters, Hagaman, Sikander, Maselko and Rahman2019).

Seven studies described individual-level negative consequences of taking part in task-sharing interventions. NSPs in India shared that their work often lacked flexibility and they were sometimes asked to work long hours, over the weekend or until the evening (Wood et al., Reference Wood, Seevak, Bhatia, McBain and Nadkarni2021). NSPs cited their physical environment as a challenge and described traveling to unfamiliar areas as “the most negative thing” and a “nightmare” (Van de Water et al., Reference Van de Water, Rossouw, Yadin and Seedat2017). Female NSPs shared experiences of gender-based harassment and feeling unsafe, especially when traveling in the dark, conducting sessions in areas with high crime and doing home visits with male clients (Munodawafa et al., Reference Munodawafa, Lund and Schneider2017; Wood et al., Reference Wood, Seevak, Bhatia, McBain and Nadkarni2021). NSPs in India shared scenarios in which they were disrespected by community members for implying that their family members have mental health problems or intruding in personal matters (Dev et al., Reference Dev, Lincoln and Shidhaye2022). NSPs in India also noted that they faced stigma from family and community members for working with people of lower caste (Wood et al., Reference Wood, Seevak, Bhatia, McBain and Nadkarni2021). NSPs in Kenya mentioned experiences of burnout or feeling “so compressed or stretched [by their work] they felt they could not continue working” (Wall et al., Reference Wall, Kaiser, Friis-Healy, Ayuku and Puffer2020). They expressed physical symptoms, such as pain, fatigue and feeling sick, when they were burned out and overwhelmed (Wall et al., Reference Wall, Kaiser, Friis-Healy, Ayuku and Puffer2020). The overwhelming nature of the work led NSPs in the Netherlands to drop out leaving a greater workload for the remaining NSPs (Woodward et al., Reference Woodward, de Graaff, Dieleman, Roberts, Fuhr, Broerse, Sijbrandij, Cuijpers, Ventevogel and Gerretsen2022).

NSPs in South Africa also shared their struggles knowing that outside of the task-sharing program, participants would be returning to “dysfunctional systems” and felt a sense of guilt for not being able to do more (Van de Water et al., Reference Van de Water, Rossouw, Yadin and Seedat2017). Structural and social difficulties, such as problems with daily wages, seasonal work and alcoholism, often felt beyond the NSPs’ influence and they felt guilty for not being able to refer patients to appropriate services, which unfortunately did not exist in their communities (Abas et al., Reference Abas, Bowers, Manda, Cooper, Machando, Verhey, Lamech, Araya and Chibanda2016; Munodawafa et al., Reference Munodawafa, Lund and Schneider2017; Pereira et al., Reference Pereira, Andrew, Pednekar, Kirkwood and Patel2011; Van de Water et al., Reference Van de Water, Rossouw, Yadin and Seedat2017). Because they knew that participants lacked access to other functional services, NSPs approached their work with “grave responsibility” and shared difficulties in keeping a professional distance and navigating boundaries (Van de Water et al., Reference Van de Water, Rossouw, Yadin and Seedat2017).

Wall et al. (Reference Wall, Kaiser, Friis-Healy, Ayuku and Puffer2020) reported that a key component of this burnout experience was a mismatch between NSPs’ genuine desire to help and their clients sometimes not engaging or making progress. This led to NSPs to question their counseling capabilities and feel “burdened in my heart” (Wall et al., Reference Wall, Kaiser, Friis-Healy, Ayuku and Puffer2020). NSPs also felt a sense of helplessness (Dev et al., Reference Dev, Lincoln and Shidhaye2022). However, seeing positive changes in their clients led NSPs to feel proud of their accomplishments (Dev et al., Reference Dev, Lincoln and Shidhaye2022; Giusto et al., Reference Giusto, Johnson, Lovero, Wainberg, Rono, Ayuku and Puffer2021; Spaaij et al., Reference Spaaij, Fuhr, Akhtar, Casanova, Klein, Schick, Weilenmann, Roberts and Morina2023; Wall et al., Reference Wall, Kaiser, Friis-Healy, Ayuku and Puffer2020) and even reduced feelings of burnout (Wall et al., Reference Wall, Kaiser, Friis-Healy, Ayuku and Puffer2020).

Only two studies explored rates of distress among NSPs using quantitative methods. Post-traumatic stress disorder and common mental health disorder were identified among 6% and 11% of 204 NSPs in Zimbabwe (Verhey et al., Reference Verhey, Brakarsh, Gibson, Shea, Chibanda and Seedat2021). Almost half of the LHWs were widowed (49%) and 79% relied on their own salary for income. Many reported suffering from a chronic illness (70%) and 9.3% reported currently living with HIV. Several NSPs reported negative life events within the last 6 months including death of a family member, serious illness, loss of accommodation, domestic violence and assault. Wall et al., Reference Wall, Kaiser, Friis-Healy, Ayuku and Puffer2020 used Participatory Risk Mapping to identify that poverty, family issues, providing counseling and balancing their roles were categorized as top issues among NSPs. Authors highlighted that though NSPs are tasked with the heavy lift of reducing the mental health treatment gap, they often face similar daily stressors and simultaneously are exposed to vicarious trauma through their clients (Verhey et al., Reference Verhey, Brakarsh, Gibson, Shea, Chibanda and Seedat2021).

Family- and community-level mental health and social impacts

Three studies highlighted that the skills NSPs learned also impacted their family members. This was seen as a personal benefit and helped NSPs stay motivated (Abas et al., Reference Abas, Bowers, Manda, Cooper, Machando, Verhey, Lamech, Araya and Chibanda2016). In Kenya, NSPs reported positive changes in how they interacted with their spouses and disciplined their children (Wall et al., Reference Wall, Kaiser, Friis-Healy, Ayuku and Puffer2020) (Figure 2). Male NSPs in Kenya mentioned that they practiced more open communication and increased attention to their families (Giusto et al., Reference Giusto, Johnson, Lovero, Wainberg, Rono, Ayuku and Puffer2021). They also shared skills, such as time management, with their children and reported using problem-solving and communication skills, to control personal reactions to negative emotions, leading to positive changes in their families (Wall et al., Reference Wall, Kaiser, Friis-Healy, Ayuku and Puffer2020). NSPs reported decreased fighting, increased time spent together, and overall “increased love and togetherness” in their homes (Wall et al., Reference Wall, Kaiser, Friis-Healy, Ayuku and Puffer2020).

One study noted that NSPs had an important impact on community mental health. Prior to receiving services from NSPs in Vietnam, families had previously attributed mental health conditions to sorcery and infections but NSPs helped to reduce stigma about mental illness within clients’ families and the wider community (Chau et al., Reference Chau, Murphy, Nguyen, Lou, Khanh, Thu, Minas and O’Neil2021). NSPs were able to make this impact through client home visits and building “good relationships” with community members.

Three studies mentioned the negative impacts that NSP work had on their own families. NSPs shared that the reality of “sacrificing time” to work left less time for familial responsibilities (Wall et al., Reference Wall, Kaiser, Friis-Healy, Ayuku and Puffer2020). NSPs in India mentioned that the expectation of working long hours, over the weekend or during evenings led them to miss spending quality time with their families (Wood et al., Reference Wood, Seevak, Bhatia, McBain and Nadkarni2021). They also found it challenging to start a position in a field they were new to and to balance expectations of this role with the needs of their own families (Giusto et al., Reference Giusto, Johnson, Lovero, Wainberg, Rono, Ayuku and Puffer2021; Wall et al., Reference Wall, Kaiser, Friis-Healy, Ayuku and Puffer2020). For a majority of NSPs (79%) in Verhey et al.’s (2019) study, a small monthly salary from delivering mental health care was their only source of income and because of the high unemployment rate in Zimbabwe, this income was a source of financial stability that supported their families as well. However, as the sole provider of their families, some NSPs had to balance their time delivering mental health interventions with other income generating activities, especially if they were not paid for their involvement (Wall et al., Reference Wall, Kaiser, Friis-Healy, Ayuku and Puffer2020).

Individual-level facilitators and barriers

Two studies identified several individual characteristics that facilitated success for NSPs and protected against burnout. NSPs shared a general desire and motivation to better the mental health of others (Woodward et al., Reference Woodward, de Graaff, Dieleman, Roberts, Fuhr, Broerse, Sijbrandij, Cuijpers, Ventevogel and Gerretsen2022). Some shared a “deep-rooted calling from God,” especially after witnessing widespread problems in their communities (Wall et al., Reference Wall, Kaiser, Friis-Healy, Ayuku and Puffer2020). Ability to give and receive critical feedback, desire to challenge oneself and ability to persist in following up with clients were seen as personal qualities that were helpful in overcoming barriers in delivering care (Wood et al., Reference Wood, Seevak, Bhatia, McBain and Nadkarni2021).

Ability to compartmentalize work and home life and strong communication skills were identified as protective skills against burnout (Wood et al., Reference Wood, Seevak, Bhatia, McBain and Nadkarni2021). NSPs in India shared that some family members were opposed to them continuing their role but support from at least one family member, such as a spouse or child, helped NSPs face family resistance and provided them with practical and emotional support (Wood et al., Reference Wood, Seevak, Bhatia, McBain and Nadkarni2021). Respect, encouragement and empowerment from fellow NSPs, supervisors, family and community members were helpful in sustaining motivation, especially when clients were not progressing (Wall et al., Reference Wall, Kaiser, Friis-Healy, Ayuku and Puffer2020).

Training and supervision facilitators, barriers and recommendations

NSPs in three studies reported that supervision and peer support strengthened confidence and enhanced protective factors against burnout (Figure 2). Training methods, such as role-plays of difficult scenarios, helped NSPs gain confidence to overcome potential challenges (Pereira et al., Reference Pereira, Andrew, Pednekar, Kirkwood and Patel2011). Supervision made NSPs feel like they were part of a team and were receiving recognition for their hard work (Wall et al., Reference Wall, Kaiser, Friis-Healy, Ayuku and Puffer2020). Expressing feelings of guilt and regret to supervisors and peers were seen as stress relievers and supported in managing personal reactions and navigating professional boundaries (Wall et al., Reference Wall, Kaiser, Friis-Healy, Ayuku and Puffer2020). An NSP in South Africa mentioned that she learned to stop internalizing difficult stories that her clients shared with her and manage her own anxiety through breathing and other techniques during supervision (Van de Water et al., Reference Van de Water, Rossouw, Yadin and Seedat2017). NSPs also found reassurance in supervision, knowing that adolescents would be referred appropriately and that supervisors would step in to support more difficult cases (Van de Water et al., Reference Van de Water, Rossouw, Yadin and Seedat2017).

NSPs across five studies expressed various levels of satisfaction with training and supervision (Chau et al., Reference Chau, Murphy, Nguyen, Lou, Khanh, Thu, Minas and O’Neil2021; Van de Water et al., Reference Van de Water, Rossouw, Yadin and Seedat2017). They expressed wanting to feel better equipped to handle difficult problems and requested additional trainings and support to enhance their counseling skills (Wall et al., Reference Wall, Kaiser, Friis-Healy, Ayuku and Puffer2020). Because NSPs often had a range of backgrounds, prior occupations and limited experience with short-term trainings, strong training and supervision were necessary to assure that the trainees delivered care of similar quality and to avoid implementation barriers (Chau et al., Reference Chau, Murphy, Nguyen, Lou, Khanh, Thu, Minas and O’Neil2021; Spaaij et al., Reference Spaaij, Fuhr, Akhtar, Casanova, Klein, Schick, Weilenmann, Roberts and Morina2023). NSPs also valued receiving support from peers during group supervision sessions (Van de Water et al., Reference Van de Water, Rossouw, Yadin and Seedat2017; Verhey et al., Reference Verhey, Brakarsh, Gibson, Shea, Chibanda and Seedat2021). However, an NSP in South Africa noted that while supervision was helpful, she found it difficult to receive supervision only in group-based settings because other peers were more extroverted than her (Van de Water et al., Reference Van de Water, Rossouw, Yadin and Seedat2017). NSPs sometimes felt that they could not meet the expectations of their supervisors, which led to feeling hopeless and wanting to avoid supervision (Wall et al., Reference Wall, Kaiser, Friis-Healy, Ayuku and Puffer2020).

Seven studies recommended the integration of additional components in training and supervision including time to troubleshoot expected challenges before seeing clients, teaching coping skills for NSPs, opportunities for NSPs to share their responses to client interaction (Wall et al., Reference Wall, Kaiser, Friis-Healy, Ayuku and Puffer2020); supervision by more experienced social workers, refresher trainings and long-term supervision (Chau et al., Reference Chau, Murphy, Nguyen, Lou, Khanh, Thu, Minas and O’Neil2021); structured “real-life” role-plays (Spaaij et al., Reference Spaaij, Fuhr, Akhtar, Casanova, Klein, Schick, Weilenmann, Roberts and Morina2023); additional instruction on building strong counselor–client relationships, tracking behavioral changes in clients (Giusto et al., Reference Giusto, Johnson, Lovero, Wainberg, Rono, Ayuku and Puffer2021); non-specialist competency assessments (Spaaij et al., Reference Spaaij, Fuhr, Akhtar, Casanova, Klein, Schick, Weilenmann, Roberts and Morina2023); additional training managing suicide risk and interacting with hostile clients (Abas et al., Reference Abas, Bowers, Manda, Cooper, Machando, Verhey, Lamech, Araya and Chibanda2016); structured opportunities for self-reflection and de-briefing (Jacobs et al., Reference Jacobs, Myers, Van Der Westhuizen, Brooke-Sumner and Sorsdahl2021; Munodawafa et al., Reference Munodawafa, Lund and Schneider2017) and emotional support services to prevent and reduce secondary traumatization (Jacobs et al., Reference Jacobs, Myers, Van Der Westhuizen, Brooke-Sumner and Sorsdahl2021). NSPs in South Africa attended workshops that focused on trauma debriefing and managing personal finances (Munodawafa et al., Reference Munodawafa, Lund and Schneider2017). These workshops assisted NSPs in coping with their roles and preventing them from feeling burned out or overwhelmed.

NSPs across six studies noted the importance of training materials and innovative supervision models. Training manuals and supervision handouts provided additional reassurance for NSPs that they were delivering care with fidelity (Munodawafa et al., Reference Munodawafa, Lund and Schneider2017; Wall et al., Reference Wall, Kaiser, Friis-Healy, Ayuku and Puffer2020). Studies also emphasized the importance of collaborative peer support through formalized meetings or informal communication (e.g., WhatsApp groups) (Verhey et al., Reference Verhey, Brakarsh, Gibson, Shea, Chibanda and Seedat2021; Wall et al., Reference Wall, Kaiser, Friis-Healy, Ayuku and Puffer2020). Supervisors also expressed a need for supervision and support for themselves (Abas et al., Reference Abas, Bowers, Manda, Cooper, Machando, Verhey, Lamech, Araya and Chibanda2016; Munodawafa et al., Reference Munodawafa, Lund and Schneider2017; Spaaij et al., Reference Spaaij, Fuhr, Akhtar, Casanova, Klein, Schick, Weilenmann, Roberts and Morina2023). To address this, a study in South Africa used a cascading supervision model where NSPs provided supervision to NSPs, which was monitored by a psychologist (Jacobs et al., Reference Jacobs, Myers, Van Der Westhuizen, Brooke-Sumner and Sorsdahl2021). It was noted that supervision by NSPs rather than psychologists may have reduced power differentials leading to improved supervision. If NSPs were to be trained as supervisors, helpers in Switzerland noted that they would need additional training on facilitating dialog, trainings and workshops, as well as planning and time management skills (Spaaij et al., Reference Spaaij, Fuhr, Akhtar, Casanova, Klein, Schick, Weilenmann, Roberts and Morina2023).

Organization- and systemic-level facilitators, barriers and recommendations

NSPs across five studies expressed a need for additional compensation for their work ( FIGURE 2 ). Altruism and personal satisfaction were not enough to sustain NSPs’ motivation and involvement in task-sharing interventions (Abas et al., Reference Abas, Bowers, Manda, Cooper, Machando, Verhey, Lamech, Araya and Chibanda2016; Woodward et al., Reference Woodward, de Graaff, Dieleman, Roberts, Fuhr, Broerse, Sijbrandij, Cuijpers, Ventevogel and Gerretsen2022). Having sufficient resources, such as salary, travel allowance, lunch allowance and health insurance, was cited as a facilitator for NSPs to carry out their work (Wood et al., Reference Wood, Seevak, Bhatia, McBain and Nadkarni2021). Abas et al. (Reference Abas, Bowers, Manda, Cooper, Machando, Verhey, Lamech, Araya and Chibanda2016) hypothesized that the lack of financial incentives for the NSPs may have impacted performance, such as lower-than-expected follow-up appointments and poor documentation. Though recruiting NSPs was challenging because of the difficult nature of the work, NGOs that paid competitive salaries were able to more easily recruit and retain NSPs (Wood et al., Reference Wood, Seevak, Bhatia, McBain and Nadkarni2021). Remuneration was cited as a source of job satisfaction, motivation and empowerment (Verhey et al., Reference Verhey, Brakarsh, Gibson, Shea, Chibanda and Seedat2021) and allowed many NSPs, especially women, to gain financial stability and independence outside of their families’ influence (Dev et al., Reference Dev, Lincoln and Shidhaye2022).

Five studies pointed to the need for a change in health systems to better integrate NSP work into existing health structures. NSPs in South Africa discussed the importance of educating facility staff in primary care and other governing bodies on the basics of mental health, the work that the NSPs are doing and the resources, such as adequate compensation, time and confidential space, that is needed for their success (Jacobs et al., Reference Jacobs, Myers, Van Der Westhuizen, Brooke-Sumner and Sorsdahl2021). NSPs reported feeling emotionally burdened when they lacked sufficient supplies and were not welcomed in certain venues such as schools and clinics to carry out their work (Munodawafa et al., Reference Munodawafa, Lund and Schneider2017; Van de Water et al., Reference Van de Water, Rossouw, Yadin and Seedat2017). Increasing mental health literacy among primary health-care workers may create a more welcoming climate for NSPs for task-sharing implementation (Jacobs et al., Reference Jacobs, Myers, Van Der Westhuizen, Brooke-Sumner and Sorsdahl2021). Strong referral systems (Munodawafa et al., Reference Munodawafa, Lund and Schneider2017) and comprehensive primary care (Abas et al., Reference Abas, Bowers, Manda, Cooper, Machando, Verhey, Lamech, Araya and Chibanda2016) provided additional institutional backing for NSPs. For example, NSPs suggested additional support from primary care centers to help them navigate systemic challenges, such as linking clients to additional services (Jacobs et al., Reference Jacobs, Myers, Van Der Westhuizen, Brooke-Sumner and Sorsdahl2021). A study noted that their NSPs were “inadequately compensated and overburdened with multiple responsibilities” and additional coordination with the Ministry of Health and other governing bodies is needed to strengthen policies related to NSPs’ roles, training and compensation (Chau et al., Reference Chau, Murphy, Nguyen, Lou, Khanh, Thu, Minas and O’Neil2021).

Two studies recommended establishing a clear pathway for progression and continued career development for NSPs. NSPs described that their overall morale and stress levels were negatively impacted by the lack of job security, especially since their work was often funded by time-limited grants (Atif et al., Reference Atif, Bibi, Nisar, Zulfiqar, Ahmed, LeMasters, Hagaman, Sikander, Maselko and Rahman2019; Wood et al., Reference Wood, Seevak, Bhatia, McBain and Nadkarni2021). Atif et al., Reference Atif, Bibi, Nisar, Zulfiqar, Ahmed, LeMasters, Hagaman, Sikander, Maselko and Rahman2019 recommended for governmental and nongovernmental agencies to adopt mental health programming to provide a sense of certainty for career progression after completion of a task-sharing study. For example, NSPs in Pakistan, who received strong community feedback and scored high on competency assessments, shadowed supervisors to become peer-supervisors. The authors stressed the importance of systemic approaches to evaluating competency that could lead NSPs to take part in scaled-up programming. NSPs in India also suggested for NGOs to provide a certification of skills gained in delivering task-sharing interventions that could help with future employment (Wood et al., Reference Wood, Seevak, Bhatia, McBain and Nadkarni2021). Professional development opportunities and having a clear career path would incentivize NSPs as well as increase the sustainability of programming (Atif et al., Reference Atif, Bibi, Nisar, Zulfiqar, Ahmed, LeMasters, Hagaman, Sikander, Maselko and Rahman2019).