Three Nontraditional Approaches to Improving the Capacity, Accessibility, and Quality of Mental Health Services: An Overview

There is a global scarcity of mental health service providers (1). Although the challenges are often greater in rural and low-income countries, they also persist in urban, high-income environments. In fact, Thomas and colleagues (2) estimated that over 75% of U.S. counties had severe shortages of mental health service providers.

Being unable to meet mental health service needs is especially problematic given the rising incidence and high illness burden of mental illnesses (3). The World Health Organization estimates that by 2030, unipolar depression will be the most burdensome illness worldwide (4). Mental illness does not discriminate, and prevalence rates are high in groups with demographic characteristics that are typically associated with good physical health, such as young people (5). Furthermore, unlike with other common illnesses, such as heart disease, seeking care for mental illnesses may be associated with stigma and a lack of confidence in the effectiveness of mental health services, which can result in reluctance to seek treatment (6). Together these factors create a situation in which large numbers of people from diverse backgrounds are not receiving the mental health services they need.

Difficulties in accessing mental health services can exacerbate illness severity, complexity, and duration, which is not only challenging for the individuals themselves but also undermines any opportunity for early intervention and can increase the strain on the health care system and social services (7,8). Treatment for mental illnesses is underfunded compared with treatment for other illnesses of similar prevalence and severity; however, increased investment alone will not address the service gap (3). More cost-effective and accessible services are needed.

For generations, communities have supported individuals’ mental health in many ways, from religious or spiritual organizations to familial support and care. Although these supports are rarely considered formal mental health services, it is important to recognize their value in providing timely, accessible, and relatively effective support for individuals. Over the past few decades, community members have started to play a larger and more formal role as service providers within the mental health system. Although the need for traditional clinical professionals remains, these community member–based services have been shown to increase service accessibility, without sacrificing service quality, through several program modalities (9,10). The increased accessibility results from several factors: a lower level of stigma associated with seeking help from someone who is not traditionally regarded as a professional; the possibility of relatively immediate service (drop-in basis); and the rapport that can be built between members of the same community, who likely have a similar background or life experience (3,11,12). The costs can be lowered because some mental health services can be delivered by lower-cost or volunteer staff and because the training of these staff members is substantially less lengthy and expensive than the training of traditional professionals. It is important to note, however, that peer support workers (PSWs) have had lengthy “training” in the sense that their lived experience has provided them with some of the expertise needed to be PSWs.

Three Approaches to Utilizing Nontraditional Professionals

There are three primary methods through which community members have been leveraged to provide, or assist in the provision of, mental health services: PSW programs, task-shifting or task-sharing programs, and mental health first-aid and community initiative programs. PSWs are individuals who have experienced a mental disorder and who work with an individual currently seeking treatment for a mental disorder (13). Peer support is presumed to help the individual seeking treatment by connecting him or her with someone who has been in a similar position, has sought care, and has been able to participate in recovery. Second, task shifting or task sharing is an approach that trains lay members of the community to provide basic mental health services, reducing the burden on specialists and allowing service providers to operate at the peak of their scope of practice (14). Greater efficiency can be achieved because providers in the mental health system can devote their time to issues that demand their expertise, rather than to filling multiple roles, some of which would be better suited to another person. Mental health first-aid and community organizations, such as Jack.org in Canada and batyr in Australia, work to hold community events, training sessions, and awareness campaigns. Mental health first-aid also enables trainees to provide a first-aid–style service in the community, where they can support individuals in crisis and provide an interim service until other care providers can reach the scene. Mental health first-aid trainees can also train other community members to provide mental health first-aid themselves, or they can conduct mental health prevention and promotion work in their communities.

Considering these approaches within a single conceptual review ties together three previously separate bodies of evidence, all supporting the use of nontraditional mental health professionals in the provision of mental health services. Doing so not only enables identification of the limitations of each approach but also illustrates the opportunities for synergies between them. Ultimately, in the presence of significant shortages of mental health service providers, nontraditional mental health services can and should be leveraged to increase the capacity, accessibility, and quality of mental health services. Such leveraging not only will bring mental health services to communities that have been without any formal mental health care but also will bolster existing services in both high- and low-resource communities.

To effectively consider these three approaches, which have not previously been considered together, this review outlines the current state of each of the three approaches, discusses the efficacy of each approach, and identifies similarities and differences between them. To obtain relevant articles, we searched PubMed, MEDLINE, and Google Scholar databases with key words such as “peer support,” “community member,” “task shifting,” “mental health first-aid,” “lived experience,” and “lay health provider.” Additional articles were obtained by searching references of review and primary articles obtained through the searches of these databases. No restrictions were placed on year of publication; however, only articles in English were reviewed. Selected gray literature referenced in the identified academic literature and found through Web searches was also reviewed, because studies of the interventions of interest are not reported entirely in the academic literature.

PSWs: Using Lived Experience to Support Others

Even though it seems that using individuals with lived experience to support others who are currently dealing with a mental illness is a relatively recent phenomenon, the first report about peer-based support was published in 1991 (15). Furthermore, in a seminal review of peer work, Davidson and colleagues (16) included historical descriptions of peer-based support dating back to 1793 (15–17). Although the definition of “peer” varies and the difference between peer support and peer work has not been clearly articulated, we use the term PSWs to refer to individuals with lived experience who are working, independently or alongside another care provider, to support others dealing with a mental illness. As noted above, part of the “training” PSWs obtain is through their own lived experience with a mental illness. Nevertheless, PSWs receive additional training before beginning work. Although several PSW training programs exist, such as the META Peer Employment Training Program and the Canadian Association of Mental Health training program, perhaps the most well-reported training program is Intentional Peer Support (IPS) (11,18). IPS was developed by Sherry Mead and works not only to inform participants about mental health but also to help them develop skills, such as active listening, negotiating power, striving toward mutuality, and sharing risk and responsibility (18).

The role and efficacy of PSWs have been assessed in three primary ways. The first is by using PSWs as a complement to other professional service providers by adding PSWs to the traditional or preexisting mental health care team. PSWs are appreciated as being able to empathize and build rapport with persons seeking treatment for a mental disorder, particularly in cases of severe mental disorders (19). Several randomized controlled trials (RCTs) have shown that the performance of teams comprising a PSW and a case manager was equal to that of a team comprising a nonpeer staff member and a case manager in regard to outcomes of symptom reduction, quality of life, and medication compliance (15,20). Other studies have reported that using PSWs to assist case managers achieved equal if not slightly improved outcomes of symptom reduction, time to homelessness and arrest, and service satisfaction (21,22). However, an RCT conducted by Rivera and colleagues (23) showed no real difference between services provided with or without PSWs in regard to outcomes of symptom reduction, quality of life, and service satisfaction. Several other studies have reported that PSWs and nonpeer staff achieved similar outcomes; however, study design, PSW role clarity, level of training, and integration of the PSW into the health care team could have influenced the results and make comparison between the studies challenging (24–27). It is also important to note that even if PSWs’ performance is equal to that of nonpeer staff, hiring PSWs could provide an added benefit because of their unique perspective on living with a mental illness. Other added benefits include the greater availability of PSWs and their lower salary requirements.

PSWs have also been tasked with fulfilling roles traditionally assigned to social services staff, such as case management and outreach. Most studies have found that PSWs can achieve the same or better outcomes as nonpeer staff (28–32). PSWs have been shown to outperform nonpeer staff on specific outcomes measures, including reduced rates of hospital admission and inpatient days and better engagement with individuals with severe and persistent illness (20,33–35). A study by Lawn and colleagues (36) in which 49 individuals with mental illness received support from PSWs showed a savings of nearly AU$90,000 in costs associated with hospital admission and inpatient stays, after the analysis accounted for the costs of program set-up and operation. In a vet-to-vet peer support program in which military veterans support one another, individuals who received peer support showed significantly higher empowerment and confidence scores, compared with veterans in a control group, as well as improved scores on more traditional clinical measures, such as cognitive functioning and alcohol use (37). Given the apparent strengths of PSWs, more recent studies have focused on better understanding how and why PSWs are able to outperform more traditional mental health care staff on certain measures.

Although this area of study is still developing, work to date suggests that some primary strengths unique to PSWs stem from the fact that they have struggled with and recovered from mental illnesses. These experiences give PSWs insight into the way other persons may be experiencing their own mental disorder, enabling increased empathy, and provide living proof that people who have struggled with mental illness can make a full recovery (13,15). Furthermore, PSWs can provide practical information that, although not part of a formal treatment plan, can help individuals reach remission and reintegrate into their communities (29).

PSWs are also employed in youth-specific contexts. Although evidence of their effectiveness with youths is sparse compared with evidence of their effectiveness with adults, the benefits conferred by PSWs are similar to those conferred in the treatment of adults, and given the challenges that adult providers experience in engaging youths and the merit of early intervention in adolescence, youth-specific peer support programs have the potential to be more effective than adult programs (38). The three main studies that compared outcomes of youths served by mental health teams with and without PSWs reported improvements in mental health, positive social behavior, and everyday living skills for youths served by teams with PSWs (39–41). However, the studies included broad samples of youths, including those with behavioral disorders, developmental disabilities, and issues related to substance use, in addition to those with mental illnesses. Therefore, although these studies demonstrated the efficacy of PSW programs for youths, more research is needed with samples of youths with various mental illnesses.

In studies in which PSWs have independently delivered care to youths, improvements have been reported in measures associated with substance use, delinquency, job retention, confidence, hopefulness, empowerment, academic success and school completion, interpersonal skills, and relationships (42–47). A recent study also reported positive outcomes in shared decision making among youths who received support from a PSW compared with those who did not (48). The consistently beneficial results of utilizing PSWs for youth mental health care is of particular interest because studies examining the benefits of PSWs in the treatment of adults have reported results that are less intense, clear, and consistent. The literature appears to support the idea that PSWs may be especially effective in youth populations. Further evaluation of the effectiveness of PSWs in youth programs is needed. A review by Gopalan (38) identified only three RCTs, and more are needed before definitive conclusions can be drawn.

Some barriers to implementing PSW programs in adult and youth populations are important to consider. The first involves issues of role clarity and definition; PSWs' roles and responsibilities may not be clearly outlined and shared with other members of the health care team. Second, this lack of definition creates challenges in establishing appropriate payment and benefits schemes and supervision for employed PSWs. Third, the unique role of a PSW as someone who is both a provider and who has lived experience can create role confusion, blurring the line between service user and provider. Additional challenges are associated with defining which model to use, delivering adequate training modules, and finding sufficient funding to start and maintain PSW programs.

Overall, both adult and youth PSW programs are being widely implemented, and utilizing individuals with lived experience is not without challenges. However, utilizing PSWs to deliver services appears to improve key outcomes for persons seeking treatment and for the overall health care system.

Task Shifting: Training Community Members to Provide Basic Services

Task shifting is an approach to improving mental health care delivery by shifting tasks from more highly trained providers to individuals with less training. Task shifting allows providers to work at the peak of their scope of practice; nonspecialist workers or community members can perform basic tasks, freeing up specialists to oversee a larger caseload and deal directly with more complex cases (49). By allowing specialists to serve as supervisors, trainers, and leaders of the health care team, task shifting is a way to quickly and cost-effectively address provider shortages (49). Task shifting was first used to address HIV/AIDS in Africa but has since spread to many other medical fields, including mental health. Task-shifting approaches have most often been applied in low- and middle-income countries and rural settings, where shortages of mental health care providers are most marked (14). Such approaches have begun to be used in high-resource countries in recognition of the fact that in most settings task shifting can enhance traditional mental health services.

Recently, the term “task shifting” has been linked to the term “task sharing.” Although the terms are often used interchangeably, more recent work has favored “task sharing” because mental health care is usually provided by a team of providers (14). For simplicity, “task shifting” is used in this review to refer to both task shifting and task sharing. “Task shifting” has also been used to refer to collaborative care models in which the tasks are shared by a multidisciplinary team of health professionals (nurses, psychiatrists, social workers, pharmacists, and so forth) (50). Use of task shifting in collaborative care models is recommended in high-resource settings where health care professionals struggle to serve individuals in rural areas and individuals with complex needs (51,52). Because this review focuses on use of community members as service providers, only models that involve collaboration between community members and mental health specialists are discussed.

Most studies of task shifting in mental health care have been conducted in low- and middle-income countries and have focused on training lay community members. RCTs in Haiti, Kenya, and India have investigated the efficacy of various task-shifting approaches to enable community members to provide mental health services (53–55). An RCT by Patel and colleagues (55) conducted in primary care settings in Goa, India, showed that community members—referred to in the study as “lay health counsellors”—were as effective as primary care providers in leading a collaborative care model and providing psychoeducation and support. Participants treated by teams that included lay health workers had significantly higher rates of recovery as assessed by ICD-10 diagnoses at six months. Another RCT showed that community members trained to deliver a problem-solving therapy were able to reduce symptoms of depression and common mental disorders (as assessed by the Shona Symptom Questionnaire) (56).

Chatterjee and colleagues (57) compared a task-shifting program with usual outpatient services in a longitudinal study of individuals with schizophrenia in India. The community-based task-shifting program was more effective than the outpatient service in reducing disability and had higher retention rates among male participants. Wright and Chiwandira (58) reported on a task-shifting intervention across a population of more than 600,000 people in Malawi that could effectively create another tier of health care providers by training community members in local villages to provide basic mental health services. The trained villagers were able to effectively recognize and respond to common and severe mental health issues and execute widespread mental health promotion events in the community. Similarly, Vijayakumar and Kumar (59) reported that individuals who had lost a family member during a tsunami in India were less likely to report depressive symptoms and psychological distress when they received support from community members who were trained in crisis response and psychosocial support. Studies have shown that community members trained to provide crisis response, case management, and outreach services achieve outcomes similar to or better than outcomes achieved when no services are delivered or when services are delivered without trained community members (60–63). Trained community members were also shown to be useful in directly assisting a health care professional in providing mental health services and in assisting mothers with peripartum depression (64–66). A review by Montgomery and colleagues (67) concluded that community members were able to be trained to effectively deliver cognitive-behavioral therapy to treat anxiety and depressive symptoms.

Despite the success of these task-shifting approaches in implementing relatively fast, cost-effective services in regions across the globe, the approach is not without challenges. Reviews of the merits of task-shifting approaches remind us that an investment of resources is needed to enable task shifting. That is, even though task shifting appears to be effective in low-resource settings, resources are needed to address concerns regarding the task-shifting workforce, including mental health support for the workers themselves, acceptance of the workers by other providers, confidentiality, and incentives to ensure worker retention (14,49).

Increasing Mental Health Literacy and Help Seeking in the Community

The previous two sections focused on PSWs and trained community members directly providing or assisting with the provision of mental health services. This section focuses instead on initiatives designed to facilitate early intervention, improve overall mental health literacy, reduce stigma, and encourage help seeking. Mental health first-aid is one of the most well-developed and widely used programs in the promotion of early intervention (68). Mental health first-aid was first developed in 2001 in Australia and has since been applied globally in a variety of care settings and communities (69). Fundamentally, mental health first-aid functions in the same capacity as general medical first-aid, in that individuals are trained to provide immediate assistance to someone in crisis or in need of mental health services until he or she can be supported professionally or the crisis resolves (12). Mental health first-aid also has a train-the-trainer approach that enables exponential growth in the number of individuals trained in a community (70).

Mental health first-aid programs have also been tailored to provide more specific training suitable to individuals in certain situations. For example, mental health first-aid programs have been adapted to the workplace for people working with youths (teachers), for non–mental health professionals, for specific minority cultures, and for aboriginal populations (71–78). Mental health first-aid programs for specific types of illness, such as depression and psychosis, have been developed, and additional programs on eating disorders, alcohol abuse, and crisis and suicidal ideation are in development (68). Mental health first-aid training has been effectively delivered remotely through an e-health training program. The ability to disseminate training materials remotely greatly increases accessibility, which is particularly relevant in rural and low-resource settings (79).

Mental health first-aid has been consistently shown to reduce stigma, increase recognition and awareness of mental health issues, and encourage help seeking. Furthermore, in a survey-based study, Mendenhall and colleagues (80) found that 82% of participants remembered key elements of their first-aid training and that 52% actually used mental health first-aid in caring for their own mental health. In a meta-analysis of 15 studies Hadlaczky and colleagues (12) reported that participants in mental health first-aid training had increased knowledge of mental health and less negative views of mental illness and were more likely to support individuals with mental health challenges.

However, no program is without challenges and limitations. For mental health first-aid, the primary challenges are that few studies are RCTs, that several studies have used self-report questionnaires to assess outcomes, and that many studies measured outcomes among individuals who received the training rather than among those who received first-aid care. Finally, and perhaps most important, the effectiveness of mental health first-aid in community settings needs to be assessed over the long term to determine whether participants can continue to apply their training long after they received it.

A number of advocacy organizations have used other methods to attempt to educate and involve the entire community in mental health. Instead of training individuals to provide a given service, these efforts more often target all members of a specific community, such as students attending a university. However, many core objectives are shared with mental health first-aid, including raising awareness, encouraging help seeking, reducing stigma, and building mental health literacy. Of the hundreds of advocacy programs around the world, few have been critically evaluated or described in the academic literature. Nevertheless, a few representative examples are discussed here to draw parallels between them and elements of mental health first-aid programs.

Jack.org in Canada focuses on facilitating peer-to-peer engagement among young people, particularly students. Jack.org hosts a number of community events focused on stigma reduction, including the Jack Summit to bring together youth leaders in mental health and Jack Talks to facilitate sharing of mental health stories by young people. No formal evaluation has been conducted of Jack.org’s programming. However, more than 100 Jack chapters have been opened across Canada, and they have helped many young people share their story of mental illness to reduce stigma. Similarly, Let’s Erase the Stigma Educational Foundation held a summit in Los Angeles to help facilitate conversations and reduce stigma. Another community program is batyr, which operates in Victoria, Australia, and works to address the “elephant in the room” by enabling young people to share their story of how mental illness has affected them. To facilitate the spread of the movement, batyr also facilitates development of local chapters. A formal evaluation of batyr is under way in collaboration with Orygen Youth Health in Melbourne. Youth Move in the United States is an organization that facilitates community education about mental health, hosts events to engage youths in matters of mental health, and works to provide a peer support service. Youth Move is bridging the gap between a community advocacy organization and a provider of peer support services. In this way, Youth Move might serve as an example for other advocacy organizations to leverage the experience, connections, and name recognition developed through advocacy to create a community member–based mental health service.

Similarities and Differences of the Three Approaches

Similarities

Peer-based services.

The first, and most obvious, similarity among these approaches is that they all leverage some form of peer-based support, given the experiences shared by providers and clients. Although PSWs have the obvious shared experience of having a mental illness, task-shifting staff and mental health first-aid providers can also be peers of the individuals they serve, based on age, location, environment, developmental stage, or occupation (13,14,68). It is important to note that task-shifting and mental health first-aid approaches do not exclude individuals with lived experience, they simply do not select for them. A report commissioned by the Department for Education in the United Kingdom highlighted numerous programs in schools and other settings that are targeted toward youths in which other youths are trained as volunteer peer supporters and crisis counselors. The fact that the youth volunteers are peers of the individuals whom they serve affords many of the same benefits associated with PSWs (81).

Cost-effectiveness.

All three approaches are cost-effective compared with traditional services. This is especially true for task-shifting approaches, in which a short-term investment in training can create a substantial increase in direct service providers (49,54). In the same way, PSWs can be highly cost-effective; however, challenges related to formally employing them, integrating them into the health care system, and managing their mental health can make such cost-savings harder to realize (29).

Wide applicability.

All three approaches are also widely applicable in a variety of health care settings. Mental health first-aid and task shifting have been effectively applied in both high- and low-resource environments, and PSWs, although typically employed in high-resource settings, can also be effective in lower-resource environments (14,58).

Implementation time.

Each approach can also have a relatively immediate impact, in which the delay between recognizing a need, recruiting and training a workforce, and beginning to provide a service can be brief. This is particularly advantageous in communities with severe shortages of mental health providers and when additional system capacity is needed on short notice (such as disaster relief).

Differences

It is also important to identify some of the key differences between the approaches, recognizing that each approach is not perfectly suited to all situations.

Assisting traditional providers.

Mental health first-aid trainees are less likely than PSWs or task-shifting staff to directly assist another service provider. Mental health first-aid trainees instead provide a kind of interim service until another provider is available (69). PSWs and trained task-shifting staff can operate independently or as assistants to other providers (58,82).

Design and purpose of training programs.

Training for PSWs and task-shifting staff is principally designed to create effective service providers, whereas mental health first-aid also seeks to improve participants’ mental health literacy, attitudes toward mental health, and help seeking (80). Logically, PSW and task-shifting training programs should also be able to achieve these outcomes; however, they are not reported in the literature. Furthermore, as community members become increasingly involved in their roles as nontraditional professionals, their presence could shift perceptions of mental health services and attitudes about help seeking. Engagement of community members as providers may make mental health services appear more accessible and comfortable and less clinical for individuals in need of care.

Challenges in systemwide application and integration.

In trying to provide a mental health service, PSW and task-shifting programs also encounter implementation challenges not encountered by mental health first-aid programs. First, although PSW and task-shifting programs are very cost-effective, more resources, particularly up front, are needed to effectively establish these programs. Furthermore, scaling these two programs can pose more difficult administrative and logistical challenges, compared with mental health first-aid programs, because a new provider needs to be integrated into the service setting rather than being positioned as an adjunct to the pre-existing service offering. Second, PSWs and task-shifting staff can experience specific challenges regarding role clarity, being accepted by other providers, and managing their own mental health. Finally, acting as a service provider, especially full-time, requires greater commitment and responsibility from the PSW or task-shifting staff, which might decrease the number of individuals willing and able to fulfill this role in a given community.

Effective Elements and Outcome Measurement

Despite these similarities and differences, each approach is effective in its own right. Thus the question becomes, what shared characteristics of these programs fundamentally make them successful? Peer work allows a space for people to interact outside of a deficit-medical model; the power dynamic between the two peers is minimized, and the mutuality between the peers is emphasized (28,31). These approaches can also improve accessibility, because large numbers of providers can be on staff providing high capacity, low wait times, and broader coverage across communities. The peer connection or shared experience between the provider and the service user also facilitates development of rapport, empathy, and mutuality, which can improve the quality and accessibility of care (11,13).

As noted above, the outcomes measured and the methods used to measure them varied for each approach. Because the literature has not addressed these three approaches together, this variation is not surprising; however, it makes comparison of the outcomes between the approaches difficult. In PSW and mental health first-aid programs, the outcomes were relatively consistent. PSW programs regularly reported on symptom reduction and satisfaction with services, and mental health first-aid programs reported outcomes such as reductions in stigma and greater mental health literacy among trainees (19,29,31). The outcomes reported in the literature on task-shifting programs were less homogeneous (14). Reduction in symptoms of depression and service satisfaction were reported in some studies, and other studies reported outcomes such as number of patients reached, recovery rates, improved coping skills, presence of social support, levels of stigma, and treatment seeking (57–59,67). Although measuring these outcomes provides some idea of the effect of these approaches, more consistent measurement tools within and between approaches would improve comparisons and inform the extent to which each approach influences a standard set of outcomes.

Limitations

This is the first time that these approaches have been considered together, and given the variation in approaches and outcomes measured, a conceptual review rather than a meta-analysis was deemed appropriate. Although we searched the important databases, we did not systematically search secondary sources, and because we included only articles in English, our search was not exhaustive.

Future Directions

Future research should attempt to understand the mechanisms of each of these interventions. These approaches should also be applied more broadly in populations such as youths, in which the body of evidence is smaller. Added clarity in the terminology, particularly regarding peer work, and more explicit descriptions of how PSWs and task-shifting staff are integrated into existing mental health systems would also enable further dissemination and application of these approaches.

Research should also be conducted into how elements of these approaches can be combined or how the approaches could work in concert. For example, because mental health first-aid can readily be applied in almost any community setting and requires relatively little investment, this approach is a suitable “baseline” for any community. However, given this baseline, the number of direct service providers could be increased by layering task-shifting approaches in specific settings or areas where the shortages of providers are greatest. PSWs could also be included, particularly when their lived experience may be most helpful, such as when other providers find it particularly difficult to work with a client (poor rapport or engagement).

Conclusions

All three approaches to leveraging community members as service providers show promise in addressing the global shortage of mental health care providers. Such shortages undermine the quality and accessibility of mental health services both in low- and middle-income countries and in lower-resourced communities in high-income countries, such as the United States, Canada, the United Kingdom, and Australia. Further research, particularly the enhancement of ad-hoc studies with an RCT design, would significantly strengthen the evidence about the effectiveness of using trained community members to provide mental health services.

However, data from existing studies make it quite clear that mental health systems across the globe would greatly benefit from supplementing professional service providers with trained community members. Doing so would improve key patient outcomes, lower health care costs, boost mental health literacy, encourage help-seeking behavior, and reduce stigma. Although increased investment is needed up front, these approaches can provide a relatively immediate and cost-effective boost in service capacity, accessibility, and reach across adult and youth populations in rural, urban, and high- or low-income communities.