Skip to main content

Research Repository

Advanced Search

“Like a doctor, like a brother”: achieving competence amongst lay health workers delivering community-based rehabilitation for people with schizophrenia in Ethiopia

Asher, Laura; Birhane, Rahel; Teferra, Solomon; Milkias, Barkot; Worku, Benyam; Habtamu, Alehegn; Kohrt, Brandon A.; Hanlon, Charlotte


Clinical Associate Professor

Rahel Birhane

Solomon Teferra

Barkot Milkias

Benyam Worku

Alehegn Habtamu

Brandon A. Kohrt

Charlotte Hanlon


There are gaps in our understanding of how non-specialists, such as lay health workers, can achieve core competencies to deliver psychosocial interventions in low- and middle-income countries.

We conducted a 12-month mixed-methods study alongside the Rehabilitation Intervention for people with Schizophrenia in Ethiopia (RISE) pilot study. We rated a total of 30 role-plays and 55 clinical encounters of ten community-based rehabilitation (CBR) lay workers using an Ethiopian adaptation of the ENhancing Assessment of Common Therapeutic factors (ENACT) structured observational rating scale. To explore factors influencing competence, six focus group discussions and four in-depth interviews were conducted with 11 CBR workers and two supervisors at three time-points. We conducted a thematic analysis and triangulated the qualitative and quantitative data.

There were improvements in CBR worker competence throughout the training and 12-month pilot study. Therapeutic alliance competencies (e.g., empathy) saw the earliest improvements. Competencies in personal factors (e.g., substance use) and external factors (e.g., assessing social networks) were initially rated lower, but scores improved during the pilot. Problem-solving and giving advice competencies saw the least improvements overall. Multimodal training, including role-plays, field work and group discussions, contributed to early development of competence. Initial stigma towards CBR participants was reduced through contact. Over time CBR workers occupied dual roles of expert and close friend for the people with schizophrenia in the programme. Competence was sustained through peer supervision, which also supported wellbeing. More intensive specialist supervision was needed.

It is possible to equip lay health workers with the core competencies to deliver a psychosocial intervention for people with schizophrenia in a low-income setting. A prolonged period of work experience is needed to develop advanced skills such as problem-solving. A structured intervention with clear protocols, combined with peer supervision to support wellbeing, is recommended for good quality intervention delivery. Repeated ENACT assessments can feasibly and successfully be used to identify areas needing improvement and to guide on-going training and supervision.


Asher, L., Birhane, R., Teferra, S., Milkias, B., Worku, B., Habtamu, A., …Hanlon, C. (2021). “Like a doctor, like a brother”: achieving competence amongst lay health workers delivering community-based rehabilitation for people with schizophrenia in Ethiopia. PLoS ONE, 16(2), Article e0246158.

Journal Article Type Article
Acceptance Date Feb 12, 2021
Online Publication Date Feb 25, 2021
Publication Date Feb 25, 2021
Deposit Date Feb 22, 2021
Publicly Available Date Feb 25, 2021
Journal PLoS ONE
Electronic ISSN 1932-6203
Publisher Public Library of Science
Peer Reviewed Peer Reviewed
Volume 16
Issue 2
Article Number e0246158
Keywords General Biochemistry, Genetics and Molecular Biology; General Agricultural and Biological Sciences; General Medicine
Public URL
Publisher URL