3

Workforce, Training, and Technical Assistance

In this chapter, the committee describes the workforce that must be cultivated to effectively select, implement, and sustain prevention programs and practices in all communities, across all settings, and along the life course. The workforce must reflect the local community to best facilitate adoption of evidence-based preventive interventions. This is especially important in populations experiencing the disproportionate burden of mental health (MH) and substance use–related challenges, including communities that are rural, have faced and continue to confront racial discrimination, that experience profound economic hardship, or face language barriers in receiving services.

The U.S. workforce in health care and public health is struggling to keep up with the demand for substance use (SU) and MH treatment. Most primary prevention activities take place outside of clinical settings, and the prevention workforce typically relies on a different set of skills than the behavioral health (BH) treatment workforce. The prevention workforce is widely distributed across multiple systems, including public health, behavioral health, child welfare, juvenile criminal-legal system, and the education system. Many prevention workers—for example, teachers, case managers, and nurses working as home visitors—may not view themselves as such, and may need additional support and resources (e.g., training and technical assistance) to enable them to integrate evidence-based programs as part of their roles.

This chapter describes the need for a prevention workforce; discusses the competencies, certification, training, and technical assistance needs of

practitioners who can deliver the interventions discussed in Chapter 2; and presents the rationale for recommendations to develop and sustain this workforce.

THE WORKFORCE AND CURRENT CHALLENGES

In 2016, the Behavioral Health Workforce Research Center defined the BH workforce as “all workers involved in treatment or prevention of mental health conditions or substance use disorders or both” (Beck et al., 2018, p. 194). The definition includes “licensed and non-licensed workers, peer support workers, and volunteers” and “primary care workers who may be providing behavioral health services” but excludes professionals in other systems (e.g., education, law enforcement) who may provide relevant services (Beck et al., 2018, p. 194).

The committee adopts the broader definition; this report describes several categories of workers in the prevention workforce. The 2019 National Academies report Fostering Healthy MEB Development in Children and Youth outlines five categories of roles relevant to prevention work: (1) community members and partners, (2) funders and policy makers, (3) purveyors and intermediary organizations, (4) intervention developers and researchers, and (5) service providers. Service providers “are leaders, managers, supervisors, and practitioners who have a stake in the adoption, implementation, and outcomes of a program.” (NASEM, 2019, p. 258). This chapter discusses primarily the first, third, and fifth types of roles—that is, the organizations and people that provide training, technical assistance, coaching, and other types of support and the people who deliver or oversee delivery of the interventions. The second and fourth categories refer to the role and organizations relevant to the chapters on governance and partnerships (5), funding (6), evidence for policy (7), and evidence for programs (2).

Prevention workers include a variety of generally non-licensed workers, such as community health workers, aides, and peer workers. Prevention workers also include those responsible for coordination and implementation of prevention programs. In a robust prevention workforce, expertise in prevention and implementation science is essential for selecting, adopting, implementing, evaluating, and sustaining interventions.

Poorly Characterized or Defined Workforce

Both Health Resources and Services Administration (HRSA) workforce projections and a Substance Abuse and Mental Health Services Administration (SAMHSA) workforce report characterize the BH workforce primarily as those in licensed, graduate degree–trained, and clinical BH professions

(HRSA and SAMHSA, 2016).¹ The prevention workforce is not reflected in a comprehensive manner in workforce reports. SAMHSA’s 2021 Behavioral Health Workforce Report largely discusses the occupations and roles concerned with treatment and refers to nonclinical and non-licensed personnel only once—in relation to BH aides in schools (SAMHSA, 2021b). As noted, prevention services may be delivered by a wide variety of workers, but these have not been comprehensively described or enumerated.

Another key issue that shapes the workforce is that governance and funding of prevention efforts are siloed, even though most risk and protective factors for substance use disorder and mental disorders overlap. These silos are evident at federal, state, and local levels. SAMHSA has separate centers for mental health services, and for substance abuse prevention and substance abuse treatment, respectively. At the state level, mental health and substance use prevention are frequently funded by separate agencies and managed by different units in a public health agency (SAMHSA, 2017). Federal funding flows through separate channels to states—from the substance use or the mental health centers in SAMHSA and also from different parts of the Centers for Disease Control and Prevention.

Workforce Shortages and Related Issues

In many settings, such as schools, the prevention workforce is absent or insufficient and there is substantial variation in the non-licensed roles, occupational standards, training and competencies, and state-level certification. Most prevention workforce roles are not listed in the Bureau of Labor Statistics Standard Occupational Classifications (SOC),² which make categories of labor and their role in the economy visible (U.S. Census Bureau, 2019; BLS, 2024). That has implications for the ability to count and track these roles and efforts to professionalize and certify them and develop pathways to career advancement.

Pay and Other Workforce Issues

Some categories of prevention workers, like others in BH, are underpaid, may lack labor protections, and do not receive adequate training or pathways to advance their careers. Community health workers and similar

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¹ Including adult psychiatrists, addiction counselors, child and adolescent psychiatrists, “child, family, and school social workers,” health care “social workers, marriage and family therapists, mental health and substance abuse social workers, mental health counselors, psychiatric aides, psychiatric nurse practitioners, psychiatric physician assistants, psychiatric technicians, psychologists, and school counselors” (HRSA and SAMHSA, 2016).

² See https://data.bls.gov/search/query/results?q=prevention and https://data.bls.gov/search/query/results?q=behavioral (accessed December 30, 2024).

roles experience the same social and economic circumstances as their communities and thus also need additional support and resources (Schriger et al., 2024). Competitive remuneration will help recruit and build career ladders for the full spectrum of prevention workers (Last and Crable, 2024; Schriger et al., 2024).

It is important to acknowledge that because of the nature of many primary prevention interventions, some of the individuals working to deliver them have traditionally been volunteers or had responsibilities added to their job descriptions without additional compensation. This is not a sustainable model. Proper implementation requires a dedicated workforce in addition to task shifting (i.e., delegating specific tasks to less specialized workers) (Kanzler et al., 2024).

A Real-Life Model for Building the Workforce

The United Kingdom has implemented a broad effort to build up the BH workforce to deliver services to its people. Although this workforce is not prevention-focused, the effort illustrates that it is possible to gain and sustain broad-based policy maker support, including investment, for a transformative approach that demonstrated a return on investment (see Box 3-1).

PREVENTION WORKFORCE NEEDS

The prevention infrastructure needs three kinds of workers to move evidence-based prevention interventions for MEB disorders into routine practice. These categories are somewhat fluid, with differences by setting or community and a variety of titles for closely related roles. The workforce includes the following:

(1) Community/prevention coordinators, prevention specialists, implementation facilitators, implementation leads

These individuals can support the selection, adoption, implementation, evaluation, and sustainment of evidence-based interventions. The title may vary across settings. The prevention specialist title is most formalized in substance use prevention settings; the analog for mental health may be mental health promotion leads. These are individuals who may have public health, behavioral health, or related expertise and can help communities and their partners assess needs and assets, identify appropriate interventions, and build capacity toward implementation. Examples include someone who directs prevention programs at the local health department, a prevention coalition coordinator, or a director of a school-based health center. These

individuals have training in selecting evidence-based interventions, identifying best practices for prevention, and assessing the needs of the community in which they work. They also have established relationships with the community partners who will implement the preventive interventions.

Some communities may have implementation leads. These are individuals with specialized training to oversee implementing and delivering one or more evidence-based interventions, such as a specialized worker in a county agency supervised by the prevention specialist or a school-based health center director who oversees implementing evidence-based interventions across multiple schools. They ensure everyone receives training in the

selected intervention(s), secure technical assistance, oversee evaluation and monitoring, and use the findings to inform ongoing program development and implementation. They could be the same person as the prevention specialist in places with fewer resources, but in places with larger populations, specific interventions require people to oversee implementation (see Table 3, Individuals domain, Roles subdomain in Damschroder et al., 2022). The need for different roles and the number of people in them will vary within a community based on population size, social vulnerability, and subgroups within communities (e.g., different ethnic groups, rural communities, refugees, unhoused individuals and families, or different languages spoken).

(2) Trainers

These individuals teach/train how to implement the intervention. They may be managers, coordinators, and other individuals with specific training in the intervention(s) and best practices for training others to use them; they also have training in monitoring adoption, and in consultation strategies to improve uptake and fidelity. Trainers may be associated with academic institutions, Prevention Technology Transfer Centers (PTTCs), other organizations that provide training and technical assistance, such as Centers for Disease Control and Prevention (CDC) Prevention Research Centers, and entities that developed the intervention. They may provide individual, group, or place-based training, in addition to policy-related training (e.g., for advocacy to change environmental policies for alcohol). Intervention developers include training, coaching, and technical assistance in the cost of program materials.

To be effective, the prevention team needs the following:

• A needs assessment that maps the problem areas, strengths, and risk and protective factors on which interventions would focus (this would require gathering or identifying necessary data and measures, as discussed in Chapter 5);
• A strategic plan that identifies prevention and health-promoting priorities and goals; the interventions that will be used to address them; an approach to monitoring, evaluating, and engaging in continuous quality improvement; and training and technical assistance that will be enlisted as support; and
• Ability to support fidelity of implementation and sustainment.

Because this work can be complex—requiring, for example, multisectoral collaboration and engaging diverse community members with different perspectives and agendas—prevention teams may find it beneficial to receive

technical assistance from experts in external planning, implementation, and evaluation frameworks, such as Mobilizing for Action through Planning and Partnerships, Promoting School-Community-University Partnerships to Enhance Resilience (PROSPER), or Communities That Care (CTC). These frameworks can support local prevention teams in selecting, implementing, monitoring, and evaluating one or more interventions aligned with their priorities, strengths, needs, and values (RHIH, 2024b).

Implementing an evidence-based intervention (or a package of interventions) requires partnership with community members and oversight of different teams, each of which may be responsible for a different intervention, population or setting. The team member(s) leading this work are accountable for (and in turn, hold their team members accountable for) deliverables, such as selecting and implementing evidence-based programs (EBPs), getting buy-in and partnership from different community constituents, organizing and conducting training, and addressing other issues related to implementation.

(3) Implementers:

1. Frontline workers in other sectors/systems trained to deliver evidence-based programs (e.g., teachers, clergy, law enforcement);
2. Direct service practitioners (e.g., community health workers, BH support specialists, promotora/es); community health representatives (tribal); and
3. Volunteers.

Frontline workers in other systems or sectors (e.g., education, law enforcement, child welfare, agricultural extension, librarians, barbers, clergy) could integrate a BH promotion program or approach into their practice. They could be trained to deliver specific evidence-based prevention interventions to individuals, families, and various community groups (see Box 3-1 for some examples). For early childhood and K–12 settings, this could also include the classroom (NASEM, 2019).

Workers drawn from the community may have less than a bachelor’s-level education but relevant life experience and can be trained to deliver EBPs in a variety of community settings. In their present roles, they may be titled BH support specialists, community health workers, peer counselors, family support specialists, etc. Two types of non-clinician BH workers in the federal government who deliver some preventive interventions are the BH technicians³ in the Defense Health Agency and peer specialists in the Veterans Health Administration (Kanzler et al., 2024).

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³ For example, Combat and Operational Stress Control training (Health.mil, 2022).

Unpaid lay prevention workers include trained members of religious congregations. This category of worker requires careful consideration of workforce equity issues. The volunteer work of older adults serving as reading tutors to children (e.g., the AARP Experience Corps program) provides benefits to both. In other circumstances, however, unpaid services may be exploitative and perpetuate economic insecurity.

The workforce equity considerations for all prevention workers include the need for fair wages, career advancement ladders and opportunities, and continuing education (Barnett et al., 2018; Fernando et al., 2021; NACHW, 2022; Smithwick et al., 2023).

State and local government agencies require prevention specialists similar to the community-specific roles described above.

Prevention specialists or coordinators who support communities in selecting interventions require the knowledge and skills to convene community leaders and members, assess community needs, identify strategies to address the needs by building on community culture and strengths (e.g., social validity, acceptability, appropriateness), and undertake ongoing

evaluation and process improvement. The workforce may not exist in a given setting or community. As efforts are undertaken to develop it, care is needed to ensure that workers are representative of the population they are serving and provide linguistically and culturally appropriate care.

There are many examples of state efforts to build the prevention workforce in a way that reflects the community and provides points of entry for people with varying educational backgrounds. Washington State, for example, offers prevention internship and fellowship programs for people with high school, college, and master’s degrees. It also requires online completion of the Certified Prevention Professional training for the Health Care Authority staff and local providers (Mariani, 2024). Healing City Baltimore, an initiative described in Box 3-2, along with examples from Rhode Island’s Equity Zones, illustrate in broad terms how the different types of prevention workers with varied backgrounds may function in one setting. Alaska developed the Community Health Aide Program in the 1960s to meet Alaska Native community needs in remote villages of the state. The program includes both community health aides and behavioral

health aides, and the latter role includes prevention of behavioral disorders (CHAP Alaska, 2024).

BUILDING THE PREVENTION WORKFORCE PIPELINE

There are multiple strategies for building the pipeline of prevention workers, including expanding training opportunities and resources for frontline workers from other sectors and systems. The first category of workers (prevention specialists and/or implementation leads) is composed of professionals, who lead the implementation of prevention programs. Their educational backgrounds will vary. The presence of the second category, trainers, will depend on context (setting and community) and institutional or system resources. Trainers may be licensed BH or public health professionals, but other types of individuals with relevant training and expertise can train frontline workers (or volunteers) in delivering preventive interventions. Trainers can include university faculty, those who have been trained in prevention science and its application to practice and trainers who train on specific programs. There are graduate and certification programs in prevention science. Some prevention professionals are trained in prevention science, others are not trained specifically in prevention science but have education or training in related fields.

The third group of workers, those who implement interventions, will vary with the setting and population. That is why strategies are needed to build a flexible workforce that can be adapted to a community’s specific range of prevention needs (e.g., rural geography, demographics). Building that workforce would benefit from a convening of stakeholders to discuss assets and gaps, involving the public health agency, behavioral or mental health agency, community mental health centers or behavioral health centers, first responders, hospitals, community health centers, nonprofit organizations, school districts, and other relevant entities to, for example,

1. Inventory existing capabilities, such as the following:
   • What kinds of workers already deliver prevention interventions for MEB disorders or could have prevention-related tasks added to their work,
   • Where/in what settings workers exist who already include prevention in their daily work,
   • What state resources (e.g., prevention technology transfer center, regional prevention resource center, academic institution with relevant departments, extension offices [Brown et al., 2023]) exist to support the effort, and
   • What resources exist to build community capacity (i.e., investment in standardized and experiential training to support knowledge of overarching best practices).

2. Discuss what pathways can be built to better support training of frontline workers in other systems and train community workers.
3. Identify constituents and partners for training and technical assistance to the workforce (including academic institutions, especially community colleges that may offer associate degree programs that lend themselves to community health worker or peer educator or related training and including high schools—perhaps the earliest opportunity to introduce young people to a potential career).

Workforce development programs could include collaboration across federal departments, including Labor, Treasury, and Commerce that focus on training, workforce, and community revitalization as they relate to building the human capital for prevention.

Linkages are needed between school districts that train peer counselors and area community and four-year college and other academic training programs to create pathways to careers in prevention (CSBHA, 2024; Dodd et al., 2022). Minority-serving institutions could also be a key partner in growing the prevention workforce at all levels, including, for example, tribal colleges that can train future prevention professionals in American Indian and Alaska Native communities and at historically Black colleges and universities (HBCUs) (see for example SAMHSA’s HBCU Center for Excellence in Behavioral Health) (AIHEC, 2022; SAMHSA, 2024). SAMHSA’s Voices of Youth program is designed to orient young people to the field, and the federal resource Youth Engaged 4 Change provides information about internship, training, and other opportunities (Youth Engaged 4 Change, n.d.; SAMHSA, 2023). In addition to the need to characterize and enumerate the prevention workforce, institutions of higher education and relevant associations could create pathways to entry-level professions/jobs (e.g., for college students who are already serving as peer counselors) with ladders for continuing education and advancement. Previously incarcerated individuals who are in recovery could also receive training and work as peer workers. For example, in North Carolina’s Formerly Incarcerated Transition program (and 24 clinics across 10 states), formerly incarcerated individuals are trained as peer navigators to work with recently returned individuals, an approach that shows promise (NCCHCA, n.d.; Ray et al., 2021). Many recently returned individuals face an extremely high risk of overdose in the weeks post-release, and navigators play an essential role in supporting their well-being (NCCHCA, 2020).

Many prevention providers are employed by state and tribal⁴ agencies to deliver MH and SUD prevention services, and those agencies or units

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⁴ The Indian Health Service’s four branches that focus on mental health, alcohol and substance abuse, behavioral health initiatives, and tele-behavioral health center of excellence, respectively, refer to I/T/U providers, denoting (“I”) Indian Health Service, (“T”) Tribally operated facility/program, and (“U”) Urban Indian clinics.

within agencies are generally separate. Due to the governance and funding silos discussed in Chapters 5 and 6 respectively, the functions associated with delivering prevention services for MH disorders and SUDs are separate. Prevention workers are also employed by local government, school districts or boards, and nonprofits, such as Boys and Girls Clubs and YMCA organizations, and by other organizations providing preventive services (YMCA of San Diego County, 2024).

Even in places with training programs, the number of prevention workers is often insufficient to meet the need. For example, the director of New York State’s Office of Addiction Services and Supports, Chinazo Cunningham, stated at a public meeting of the committee that her office funds 175 credentialed prevention professionals (at least bachelor’s level plus 4,000 hours supervised work experience) and 15 credentialed prevention specialists (at least high school diploma or GED plus 2,000 hours supervised work experience) for a state of over 18 million people. They deliver services through 306 state-contracted programs at private nonprofit organizations, schools and boards of cooperative educational services,⁵ local prevention councils, and local governments. Cunningham shared that “the workforce is really struggling; 175 people for the state of New York, which is 18 million people, is nothing . . . [W]e really need to continue to expand and support the workforce. . . But we’re decades behind in investing in the workforce in this field” (Cunningham, 2024).

The lack of data about workers who deliver prevention interventions for MEB disorders makes it difficult to ascertain adequacy, but given the shortages of related or overlapping workforces—direct care, public health, and BH—it is likely that the supply of trained workers is inadequate (Lyons and O’Malley Watts, 2024; NCHWA, 2024; NCSL, 2024; Yeager and Krasna, 2024).

Burnout is a related consideration that reflects both an input challenge and an outcome challenge related to the workforce, along with general retention, turnover, and attrition (NCHWA, 2023). Burnout manifests as sustained feelings of exhaustion, professional inefficiency, and depersonalization, evident in a sense of cynicism, withdrawal, and related behaviors (SAMHSA, 2022). Workforce development strategies should involve supporting worker well-being and resilience. Improving the mental health/resilience of existing behavioral health professionals can likely be facilitated by creating a more efficient system of early detection and support that is less dependent on higher levels of education/degrees. Building a stronger prevention workforce could include approaches to stepped care, with different levels of workers delivering different types of interventions or overseeing frontline workers, and the building of a larger workforce that ensures better worker-to-community ratios.

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⁵ NY state arrangement that allows schools to share the costs of certain educational and administrative services.

Coalitions

Coalitions are community-based, multisector collaborations that play an important role as grantees, conveners, planning entities and accountability mechanisms, and prevention champions. Coalitions may be led by community coordinators who can effectively lead and support the selection, adoption, implementation, evaluation, and sustainment of preventive interventions. Thousands of community-based coalitions across the United States work to improve health, reduce youth risk factors, and address social issues that affect community health, from community violence to homelessness. In the domain of MEB disorder prevention, the coalitions represented by CADCA (formerly the Community Anti-Drug Coalitions of America) can serve as hubs of prevention delivery systems. Many of the coalitions receive ONDCP Drug Free Communities funding.

With adequate financial and technical supports (and as informed by community needs), many of these coalitions could expand their focus on prevention to include mental disorders, which share many risk and protective factors with SUDs. Their potential to play a broader role in prevention will be enhanced by CDC funding to CADCA, which announced in October 2024 that it was awarded a 5-year grant under CDC’s National Partners Cooperative Agreement Funding to Strengthen Public Health Infrastructure that would help it “enhance public health infrastructure, improve workforce capacity, and address equity-based public health priorities” (CADCA, 2024).

Research comparing multisector community coalition models to individual program technical assistance in the delivery of MH interventions found that the coalition approach was more effective in “reducing the probability of having poor mental health-related quality of life, behavioral health hospitalization, and homelessness risk factors” (Arevian et al., 2019, p. S206).

It is essential that primary prevention of MEB disorders be the central focus of community-based, multisector coalitions. Despite coalitions often working to address issues along the MEB disorder prevention-treatment spectrum, it is important to recognize that prevention requires devoted attention to ensure the delivery of effective interventions.

The coalition workforce—people leading and supporting coalitions to strengthen protective factors and mitigate risk factors for MEB disorders—needs the following key ingredients:

• Adequate financial resources to support coalition providers who are credentialed in the prevention field with adequate pay and benefits to encourage longer tenure and avoid the knowledge and relational loss of frequent turnover associated with prevention professionals;

• Trained people on the ground doing the work of primary prevention, providing information that is easy to understand so that it can facilitate the work; and
• Monitoring of data systems to assess delivery of evidence-based interventions with fidelity.

Coalitions also engage community members who have lived expertise with MEB disorders in themselves or their family members. Proposals for funding, and funding programs of government, health care, or philanthropic organizations need to include consideration of compensation needs for community members (Spencer and Scannelli Jacobs, 2023).

Getting a Complete Picture of the Workforce Status and Needs

Developing a complete picture of the state of the prevention workforce and ascertaining the gaps will require federal leadership, especially from HRSA, the agency that has historically led the characterization and enumeration of workforces in the health sector. It will be necessary to understand the full range of prevention roles, variety of job titles used across communities and states, responsibilities and duties of the various prevention jobs that exist, and range of state approaches to recognizing and supporting these categories of workers. Gathering this baseline information will inform efforts to build up the workforce, align standards, and facilitate sustainable payment mechanisms for programs in all communities and across all settings.

HRSA descriptions of the BH workforce are not expansive enough to include the prevention-focused occupations and roles noted in this report and outlined by Beck et al. (2018) in their description of the Minimum Data Set needed to fully describe the workforce. These roles include the following elements: enumeration (total count of provider type), demographics, education, training, licensure, certification, occupational category, area of practice, and employment setting. One challenge for non-licensed BH and prevention occupations is that few have SOCs. As a result, these occupations are “largely unidentifiable in BLS Occupation Employment Statistics, American Community Survey, and similar national databases” (Beck et al., 2018. p. 193). This makes it difficult to establish the legitimacy of a newer role for reimbursement, for example, and identify staffing needs, gaps in services, and risks for cessation of services.

RECOMMENDATION 3-1: In consultation with Substance Abuse and Mental Health Services Administration (SAMHSA), the Health Resources and Services Administration should describe and enumerate the workforce for mental, emotional, and behavioral (MEB) health promotion and prevention of MEB disorders. SAMHSA should add

the newly defined roles to its behavioral health workforce estimates and reports.

RECOMMENDATION 3-2: The Department of Labor should use the most up-to-date description of the prevention workforce for mental, emotional, and behavioral disorders as the basis for updates to the Standard Occupational Classifications for behavioral and public health jobs.

For example, prevention specialists would be listed as a Department of Labor occupation, which will help inform the certification process and pathway from education to careers. In Chapter 5, focused on Governance and Partnership, the committee makes a recommendation on the founding of a new SAMHSA Center for Mental Health Promotion or a joint Center for Prevention of Behavioral Disorders that combines MH and SUD-related prevention activities, which will have bearing on what the committee recommends to further support the development of the workforce for MEB prevention.

In addition to counting and defining the workforce, there is an opportunity for federal agencies to estimate the relative need and forecast the supply. Part of this could also involve analyzing current wages and what wages (and thus reimbursement and funding) would be needed for adequate workforce supply.

COMPETENCIES AND TRAINING

The categories of workers who support the delivery of preventive programs are referred to as “coaches, improvement advisors, technical assistance providers, facilitators, consultants, mentors, and implementation specialists” (Metz et al., 2021, p. 239). This range in terminology reflects the fragmented literature base describing individuals who provide implementation support. Identifying and operationalizing the competencies needed for this broad category in the prevention workforce for MEB disorders will be necessary for effective implementation that will benefit individuals and communities (Metz et al., 2021).

States have varied requirements regarding competencies needed for certifying prevention specialists. SAMHSA’s Prevention Core Competencies were developed based on its Prevention Strategy and integrate information from state requirements for certification: (1) crosscutting competencies: interdisciplinary foundations, multiple systems, family dynamics, ethical practice, basic knowledge, and communication; and (2) competencies in five domains (SAMHSA, 2021a):

1. Assessment (data gathering, needs and resource identification, problem definition, analysis),

2. Capacity building (collaboration, organizational advocacy, organizational cultural proficiency),
3. Planning (collaborative planning, cultural inclusion, systematic thinking, evidence-informed approaches, facilitation, strategic planning),
4. Implementation (cultural responsiveness, collaboration, change management), and
5. Evaluation (evaluation methods, data interpretation and use).

All of these are competency-based skills. The International Certification & Reciprocity Consortium Prevention Candidate Guide (IC&RC, 2022) provides a similar list of performance domains that has some overlap with the competencies above, and comprises:

1. Planning and evaluation
2. Prevention education and service delivery
3. Communication
4. Community organization
5. Public policy and environmental change
6. Professional growth and responsibility

Training and Pathways to Competency Attainment

People in adjacent professions already have these competencies and could start working in this area with minimal training. Further developing the workforce involves recruiting or identifying potential candidates who need competencies built, including investing in youth/young adults.

Community Health Workers are increasingly well studied and extensively discussed in the literature. A community health worker is a “frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served” (APHA, 2024). There have been many new developments in this workforce, which, according to the Bureau of Labor Statistics, was estimated at approximately 60,000 around the country (ASTHO, 2024a). The National Community Health Worker Core Consensus Project identified 10 core roles and competencies for the role—all of which apply to the MEB health context and most of which may apply to BH support specialists and other non-licensed or non-postsecondary-degree-trained occupations:

1. Cultural mediation among individuals, communities, and service systems;
2. Providing culturally appropriate health education and information;
3. Care coordination, case management, and system navigation;

4. Providing coaching and social support;
5. Advocating for individuals and communities;
6. Building individual and community capacity;
7. Providing direct service;
8. Implementing individual and community assessments;
9. Conducting outreach; and
10. Participating in evaluation and research

This list of competencies seems sufficiently broad and comprehensive to apply to or at least warrant serious consideration for other community-based prevention worker roles.

Training and Technical Assistance

Training and technical assistance for the prevention workforce requires integrating knowledge about evidence-based programs (St. George, 2023). Education and training ranges from graduate degrees in BH, public health prevention science, or related fields (e.g., public administration, public policy) to program-specific training given to non-licensed prevention workers, also known as “direct service practitioners,” who may deliver preventive interventions in a variety of community settings (see Box 3-3 for an example). The training paths for the former are already well developed, although a graduate of a Master of Public Health program will still need additional training to be able to identify prevention best practices and implementation supports needed to move those into practice. For teachers, resources include Classroom WISE (n.d.), a free 3-part training package for K–12 educators and other school staff, developed by the Mental Health Technology Transfer Centers (MHTTC) Network⁶ and National Center for School Mental Health. The PTTC Network catalog offers 714 resources for educators on substance use prevention, along with free training courses on core competencies and prevention ethics that are key to supporting the prevention workforce. Educators can also use resources from the National Center on Safe Supportive Learning Environments from the U.S. Department of Education (NCSSLE, 2025).

The National Implementation Research Network at the University of North Carolina at Chapel Hill and the National Council for Mental Well-Being both offer training on how to effectively strengthen protective factors (MHFA, 2024). Other sources of training and resources for educators, community coalitions, and a variety of prevention workers include the National Associations of State Mental Health Program Directors, National

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⁶ As noted, the MHTTC Network was ended in September 2024, but its resources remain available on the webpage.

Association of State Alcohol and Drug Abuse Directors, CADCA, and academic–community partnerships.

For early childhood care and education providers, child care health consultants are an important potential training resource. Their competencies are described by the Head Start Early Childhood Learning and Knowledge Center in the Administration for Children and Families, and resources include a toolkit to governors developed by the Departments of Education and Health and Human Services on the use of federal resources to improve child health and well-being (HSS, 2022).

Other opportunities exist to train staff of community-serving organizations in mental, emotional, and behavioral health promotion. For area agencies on aging and nonprofit organizations working with older adults, training (e.g., developed by SAMHSA) could be included as a condition for receiving Older Americans Act funding. To support faith communities, relevant programs could be packaged for integration into their congregations (ideally) with others in the community. SAMHSA could work with the Department of Agriculture to package and disseminate programs to extension offices. Coordination about disseminating EBPs could be one priority for the interagency taskforce to promote MEB health that could be convened by a White House advisor on prevention as proposed in Chapter 5.

For frontline workers from other sectors and systems, training on delivering prevention interventions could be integrated into pre-service

training or through professional development and continuing education requirements.

Recruiting direct service practitioners (e.g., CHWs) from the community can solve multiple problems concurrently. It can serve as an effective preventive intervention in itself, providing employment, harnessing workers’ knowledge of and commitment to their community (and earned trust), and contributing to community economic stability.⁷ Established and ongoing research demonstrates that professionals without a formal degree can effectively support change with the appropriate training (Smithwick et al., 2023).

Community health worker training varies greatly nationwide, and varied delivery models have been catalogued by the National Association of Community Health Workers. In addition to training in core skills/competencies described, specific modules could be developed. Training could also include a basic orientation to prevention and implementation sciences. Training direct service practitioners in prevention needs to include at least the following broad domains or standards:

1. Community-based participatory action and other community-engaged approaches;
2. Prevention science and how it is applied in evaluating evidence-based interventions;
3. Implementation science and implementation facilitation—including evaluation strategies and process frameworks, such as a two- or three-part course on frameworks, models, and theories and evaluation with a practice-based component;
4. Delivery of evidence-based interventions through a community implementation process (e.g., CTC, PROSPER, Getting to Outcomes, the Icelandic model, CDC frameworks); and
5. Data best practices (e.g., brief primer on locally available data, use of other data sources, such as state surveys, and strategies for collecting and analyzing data relevant to the program being implemented).

These training standards and competencies can form the basis for building knowledge and skills that can be delivered in a variety of settings, whether associated with a hiring entity or an education setting in an institution that may or may not partner with a hiring entity.

Informal opportunities to promote well-being in the community can be a powerful way to address social isolation and support social connection

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⁷ See, for example, https://www.newyorkfed.org/newsevents/events/regional_outreach/2023/0623-2023 (accessed October 2, 2024).

across the life course. Volunteers play an important role in prevention and related work (Namkung, 2024; Benson, 2024), and in some settings there may be an overreliance on them (Cohen, 2024). There are concerns about community or peer workers being expected to provide services on a volunteer basis, without pay. This can be exploitative in many contexts. There may be circumstances where the financial and occupational/professional incentive of a paid, formalized role working in the community does not apply, such as when members of a religious congregation provide some services as a part of a desire to serve as volunteers (English, 2024; Neigel, 2024) or communities where individuals volunteer to help older members (Ormel et al., 2019). For example, the Public Health AmeriCorps program, launched in 2023, is a volunteer opportunity (with a modest “living allowance”) to work in communities to improve public health, and also connect with pathways to community health worker certification (AmeriCorps, n.d.).⁸

Technical Assistance

Providing technical assistance for prevention workers is generally not a function appropriate for local-level government agencies or entities for reasons of capacity, efficiency, and effectiveness. Well-established resources and technical assistance are available from several sources, including SAMHSA, in collaboration with state agencies, and academic institutions, including those with SAMHSA-supported technology transfer centers. Technical assistance may also be part of the purchase cost for a specific evidence-based intervention, so intervention developers provide technical assistance to organizations and entities.

Like other aspects of the landscape, technical assistance itself is siloed, with state substance use agencies providing it on prevention of substance use and state MH agencies providing it primarily on treatment of mental illness and related issues (most prevention efforts appear focused on suicide prevention). On the SUD side, New York State’s Office of Addiction Services and Supports, for example, has several prevention resource centers that work with community coalitions and schools to implement evidence-based prevention strategies.

The PTTC Network provides technical assistance to the “substance misuse prevention field” (PTTC Network, 2024). Its services include providing learning resources and technical assistance on prevention science and implementation and training to emerging prevention professionals.

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⁸ AmeriCorps and CDC provided $76 million to 89 Public Health AmeriCorps grant recipients to support more than 4,000 AmeriCorps members across most states, Washington, DC, Guam, and Puerto Rico (AmeriCorps, n.d.)

The PTTC Network comprises 10 regional centers and a coordinating office that serve all 50 states, the District of Columbia, and the U.S. territories.

The MHTTC Network was closed in September 2024, but its focus, like that of the National Association of State Mental Health Program Directors, had been largely on the treatment of mental illness and suicide prevention. Some recent research findings from the MHTTCs have broader relevance, however. Gotham and colleagues surveyed the MH workforce and learned their top technical assistance needs were “equitable and culturally responsive services,” “co-occurring mental and substance use disorders,” and “mental health awareness and literacy” (Gotham et al., 2024, p. 1). Regarding the top technical assistance need, the authors observed that “this finding reflects continued inequities in mental health services, particularly for communities of color that face long-standing disparities in health care, racism, and stressors” (Gotham et al., 2024 p. 3).

CDC’s Prevention Research Centers can also play a role in delivering training and technical assistance, in addition to conducting applied research in collaboration with community-based organizations and community residents. Of the 26 PRCs operating during the 2019–2024 funding cycle, nearly a dozen performed research that addressed one or more dimensions of preventing MEB disorders. Their 2019–2024 work focused on partnerships in varied settings and with a range of collaborators, including schools, afterschool providers, aging services providers, and the criminal-legal system (CDC, 2024).

Other academic centers, such as the EPIS Center at Pennsylvania State University, can provide technical assistance to community-based coalitions and other groups working in prevention of MEB disorders (J. Welsh, personal communication, June 18, 2024). The EPIS Center works closely with the Pennsylvania state agencies and receives funding from the state’s Commission on Crime and Delinquency Office of Children, Youth, and Services. Academic providers of technical assistance are crucial because they are knowledgeable about the state, value community-engaged research and community partnerships, and play a key role as part of a triad of crucial relationships: academic entity, state agency, and community organization(s) or coalition(s). EPIS oversees the Prevention Learning Portal at Penn State, a key resource to everyone working in substance use prevention (PSU, 2024).

The U.S. Department of Health and Human Services Administration for Children and Families provides technical assistance from its National Center on Substance Abuse and Child Welfare, which is funded by SAMHSA, ACF, and the Children’s Bureau. The center’s resources are focused on “strategies for working with families affected by substance use and involved in the child welfare and family courts systems” (NCSACW, n.d.).

The significance of technical assistance in achieving gains in MEB health cannot be understated. Multiple studies have shown, for example, that when communities received technical assistance through PROSPER or CTC, more young people and families were reached with preventive interventions, and better and enduring MEB outcomes were attained. These improvements have been demonstrated in both rural and urban communities (Chilenski et al., 2019; Crowley et al., 2024; Gorman-Smith et al., 2024) and underscore the importance of good implementation practice, particularly preimplementation processes, or “taking the time to get it right” (see Box 3-4). The last decade has provided evidence in support of the critical role of pre-implementation. Without such support, less than one third of implementation efforts succeed (Wong et al., 2022). Multiple studies have found a significant positive association between pre-implementation completion and program competency (Alley et al., 2023). Thus, it is critical to engage in appropriate training and technical assistance and implementation support to maximize the likelihood of success. That period before implementation can be a huge contributor to whether the eventual effort is successful. Blended implementation organizations and other kinds of technical support can help the workforce, and their community partners identify needs, make decisions about next steps, and plan for sustained implementation, also supporting monitoring and evaluation (or de-implementation, if appropriate).

Certification

Certification has implications for both funding and legitimizing and professionalizing newer roles in the prevention workforce. For community health workers, or community health representatives in tribal communities, certification is linked with payment because Medicaid reimbursement also requires certification, and not all states certify them (APHA, 2014; ASTHO, 2024b; NASHP, 2019). As one example, New Mexico offers both state generalist certification and three kinds of certifications with specialized training: community health representative, BH/MH specialty track, and peer support workers (in collaboration with the state’s Department of Human Services) (Jones et al., 2021; Kelly, 2024). The state has reported that developing paths to certification is allowing more community health workers and representatives to bill Medicaid (Kelly et al., 2024).

For prevention specialists, most states provide certification and have a heterogeneous but overlapping list of requirements (PTTCN, 2024). In general, that includes passing the International Certification & Reciprocity Consortium (IC&RC) Prevention Specialist exam. Some states only require IC&RC certification, but most require certification by a state board (Jones et al., 2021). IC&RC certification has specific education and training and experience and supervision requirements (Jones et al., 2021).

Building an effective workforce will require review of competencies, training and certification needs, strategies for developing a pipeline and pathways to professional development, opportunities to expand and support the prevention workforce to implement EBPs in a variety of settings, and fair pay and labor protections. To begin, several changes are needed to better characterize and enumerate the prevention workforce, and a SAMHSA office devoted to the prevention workforce could provide a point of coordination and support for all workforce matters, including better integration of prevention related to mental health and to substance use (NASEM, 2024).

RECOMMENDATION 3-3: The Substance Abuse and Mental Health Services Administration should establish a Coordinating Office on the Mental, Emotional, and Behavioral Prevention Workforce or designate a lead office to coordinate prevention to delineate core competencies, develop a strategic plan, review agency programs and grants for workforce linkages, coordinate with the Centers for Disease Control and Prevention and accrediting and licensure bodies, and strengthen academic–community partnerships.

Specifically, the new or designated office would

• Delineate, with input from local community that centers lived experience, how the prevention core competencies described in SAMHSA’s 2021 Prevention Core Competencies report apply to each set of prevention workforce roles, especially those that help communities select evidence-based programs and train implementers to deliver them (SAMHSA, 2021a).
• Develop a strategic plan for the prevention workforce, with a focus on fair treatment of different types of workers and nurturing workforce pathways for community members.
• Review SAMHSA prevention programs and grants to ensure they support and enable a distinct workforce for prevention of MEB disorders in communities.
• Collaborate with CDC and relevant accrediting and licensure bodies (e.g., Council for Education in Public Health, Society for Public Health Education, IC&RC) to ensure that academic institutions and training programs equip prevention workers with the knowledge, skills, and competencies needed to implement evidence-based preventive interventions in a variety of settings and age groups.
• Strengthen academic–community partnerships that provide technical assistance to communities and community-based prevention workers to support implementation of preventive interventions for MEB disorders (i.e., MH and SUD together).

The office will ideally be a collaboration of the Center for Substance Abuse Prevention and a new, parallel Center for Mental Health Promotion or a joint Center for Prevention of Behavioral Disorders, options suggested in Chapter 5. If creating a new office is not feasible, SAMHSA could conduct an analysis of its current capacity and resources, and of the additional resources, needed to support the building of a prevention workforce for MEB disorders.

RECOMMENDATION 3-4: The Substance Abuse and Mental Health Services Administration and Centers for Disease Control and Prevention

should work with the Administration for Community Living, Administration for Children and Families, U.S. Department of Education, and Department of Justice to incorporate strategies for training on prevention of mental, emotional, and behavioral disorders for frontline personnel in those settings.

Options for training include collaboration with colleges and universities to build or expand prevention programming in their curriculum.

The recommended Coordinating Office on the MEB Prevention Workforce could build on existing competencies, such as SAMHSA’s own prevention competencies, to

• Define and adopt a common set of national competencies for prevention-focused community coordinators, with aligned national training and supportive infrastructure;
• Develop a tracking system to understand the achievement of competencies for community coordinators who have the responsibility for facilitating community decision making to carry out steps in the implementation process; and
• Work with relevant entities, such as the Association of State and Territorial Health Officials, to provide guidelines for certification of non-licensed workers.

Brief Overview of Workers in Different Settings

This section provides several examples of how, with the appropriate training, practitioners working in different systems, community workers, or lay or peer workers can deliver evidence-based preventive interventions. For family-focused and parenting interventions, the workforce may include trained community workers in addition to specially licensed workers; additional consultation or support may be needed for the former (CEBC, 2024b). A program in Wisconsin trained both home visitors and community MH providers to deliver the evidence-based Mother-Infant Therapy Group screening and treatment for postpartum depression (IMI, 2023; UW-Madison PRC, 2024). Program implementers and community liaisons in the Strong African American Families and Pathways to African American Success programs were originally required to have a college degree in a related field, but that requirement was removed to acknowledge that it was not necessary for implementer effectiveness (Murry and Brody, 2004; Kogan et al., 2012).

Nonprofit organizations (e.g., Boys and Girls Clubs) that provide afterschool programming may have a variety of staff who can be trained to deliver preventive interventions. Box 2-4 in Chapter 2 provides an example where one staff member for each club received specific training in delivering

evidence-based interventions. In community and 4-year college settings, campus prevention professionals, counselors, teaching assistants, and other personnel can be trained to deliver Question, Persuade, Refer (QPR) Suicide Prevention Gatekeeper Training, and other evidence-based interventions, but additional training may be needed for cultural competence (Harris et al., 2022).

Non-degreed workers in community-based organizations that work with older adults can be trained to deliver evidence-based interventions, such as the Program to Encourage Active, Rewarding Lives (PEARLS) (see Box 2-6), which has been shown to be effective when delivered by these staff (UW PRC, 2025). Older adults themselves can be trained to be peer interventionists with dual benefit (Benson, 2024). Professionals in some types of workforce settings could be trained to deliver preventive interventions. For example, agricultural extension agents in rural Georgia were trained to deliver MH first aid to agricultural workers (who experience higher rates of risk factors for suicide) and to train additional extension agents.

Clergy and congregation members can deliver evidence-based prevention interventions, as has long been demonstrated around the country. In one region of Pennsylvania, INTERSECT trainers provide evidence-based MH and prevention training to clergy, social services providers, and community members, including MH first aid, Applied Suicide Intervention Skills Training, and QPR, while in San Antonio, a multisector (faith community, public health, health care, and nonprofit organization) partnership trains congregation members to deliver evidence-based interventions and certifies congregations as “Behavioral Friendly” (Access Services, 2024; NAMI, 2024). As faith community partnerships that deliver mental health intervention are becoming more common, so are evaluation and research to ascertain their effectiveness (Perez et al., 2024). Although more research is needed, there are promising findings of improved outcomes, as well as insights about facilitators and barriers in implementing such partnerships (Perez et al., 2024).

Exploring funding needs for the workforce

A well-trained and competent workforce requires funding, although given the lack of a workforce description and enumeration, there is limited information about workforce costs.

The 2017 SAMHSA profile of single state agencies (SSAs, focused on substance use) and mental health agencies (SMHAs) highlighted several workforce needs:

• Out of 47 SMHAs 96 percent rated “provider readiness to deliver an evidence-based program” as a barrier “sometimes to always” and 91 percent rated “shortage of an appropriately trained

• workforce” as a barrier “sometimes to always” (SAMHSA, 2017, p. 67).
• Approximately 30 SSAs reported that they do not have “sufficient workforce to meet current SUD demands.” It is unclear what proportion of the workforce provides SUD-related prevention services, but the workforce shortage is notable nonetheless (SAMHSA, 2017, p. B-2 – B-125).
• According to the SAMHSA report, 2,450 primary prevention providers were funded with the 20 percent set-aside from the Substance Use Prevention, Treatment, and Recovery Services Block Grant (SUBG) (then called the Substance Abuse Prevention and Treatment Block Grant) funds through the SSAs. In 2024, the 20 percent set-aside amounted to approximately $400 million (from the $2 billion SUBG; see Appendix C).

The following examples of potential workforce costs are provided solely for illustration as to what prevention dollars could pay for.

Prevention coordinators are one important role in the prevention workforce, and the cost for a coordinator will range depending on qualifications and setting (e.g., local vs. state government, college or graduate degree required or not, local cost of living). Taking as an example a county-level position in the Midwest requiring a bachelor’s degree, the pay (roughly $65,000) plus benefits could reach $90,000. Having each county in the United States have a prevention coordinator would result in annual costs of approximately $280 million ($90,000 × 3,142 counties) (Wisconsin Counties, 2023).

The salary and benefits for a community health worker or equivalent are estimated at approximately $65,000 (median CHW pay of $48,200 plus approximately 30 percent of salary spent on benefits) (Mayer, 2023; BLS, 2024). Direct service practitioners such as community health workers may work in a variety of community settings but will also require supervision—such as from prevention coordinators. If every county had a community health worker promoting MEB health, that would cost approximately $205 million (Gurley-Calvez and Williams, 2020; U.S. Census Bureau, 2023).

REFERENCES