Helpers’ well-being and workload: from expectations to reality. The development of a new Tool

The global mental health treatment gap constitutes one of the most significant public health challenges of the twenty-first century, particularly in low- and middle-income and humanitarian settings. Task- sharing approaches, where trained non-specialists deliver evidence-based psychosocial interventions, represent a key strategy to bridge this gap. However, the psychological well-being of the helpers, who often work under conditions of chronic stress, insecurity, and limited supervision, has received minimal empirical attention despite their crucial role in intervention sustainability. This doctoral research addresses this gap by examining the determinants, experiences, and measurement of helpers’ well-being across diverse humanitarian and low-resource contexts, and by developing a novel assessment tool for this purpose. The project integrates theoretical perspectives from ecological systems theory, occupational health psychology, and implementation science, and comprises six interrelated studies employing systematic, qualitative, mixed-method, and psychometric methodologies. A systematic review of a WHO’s scalable intervention established the evidence base for implementation outcomes, revealing strong feasibility and acceptability but limited data on sustainability and workforce support. Subsequent qualitative and mixed-method studies conducted in Haiti, Sub-Saharan Africa, Eastern Europe, and Europe explored contextual barriers and facilitators, confirming that helpers’ well-being is both a determinant and a consequence of effective intervention delivery. Across studies, supportive supervision, balanced workload, and organisational recognition emerged as critical to sustaining motivation and fidelity, while a recurrent provider support paradox was identified: those responsible for supporting others often receive insufficient emotional and organisational support themselves. Building upon these findings, the Well-being and Workload Assessment Tool (WWAT) was developed and psychometrically validated to provide a reliable, contextually grounded measure of helper well-being, workload, and support systems. The WWAT demonstrated strong internal consistency, a four-factor structure, and theoretical coherence with established constructs, offering a practical means for ongoing workforce monitoring. This thesis contributes to global mental health and implementation science by conceptualising helper well-being as a core implementation outcome essential to ethical, effective, and sustainable delivery of scalable psychological interventions. It advances a multi-level, systems-oriented model linking individual, organisational, and systemic determinants of well-being to programme quality and sustainability. The identification of the provider support paradox further underscores the need to embed structured mechanisms of supervision, recognition, and psychological support within humanitarian and public health systems, ensuring that those who provide care are themselves adequately cared for.