Background First-level leadership is uniquely positioned to support evidence-based practice (EBP) implementation for behavioral health due to first-level leaders’ access to and relationship with service providers. First-level leaders are individuals who directly supervise and manage frontline employees who do not manage others. However, first-level leadership is underrepresented in existing reviews of the impact of leadership on EBP implementation. This review describes the relationship between first-level leadership and implementation determinants and outcomes. Methods A scoping review was performed to synthesize the literature on the relationship between first-level leadership and inner-context and implementation outcomes. A literature search was conducted in PubMed, Eric, PsycINFO, CINAHL, Scopus, and Web of Science. To be eligible, studies had to examine first-level leadership, be conducted in settings providing behavioral health services, and examine the relationship between first-level leadership and an implementation or inner-context outcome. Data extraction and synthesis were performed to describe study characteristics, leader-outcome relationships, and overlap in leadership frameworks. Results Twenty-one records met our inclusion criteria. Studies primarily relied on observational designs and were often cross-sectional. Studies more often examined general leadership rather than leadership strategically focused on EBP implementation (i.e., strategic implementation leadership). Our findings suggest that several forms of first-level leadership are inconsistently related to a broad set of implementation determinants, with infrequent examination of specific implementation outcomes. The broad set of implementation determinants studied, limited number of replications, and inconsistent findings have resulted in sparse evidence for any specific leadership-outcome relationship. The greatest accumulation of evidence exists for general leadership’s positive relationship with providers’ EBP attitudes, most notably in the form of transformational leadership. This was followed by evidence for strategic implementation leadership facilitating general implementation. Our synthesis revealed moderate conceptual overlap of strategic implementation leadership behaviors described in the theory of implementation leadership and theory of middle managers’ role in implementation. Conclusions Our findings suggest that first-level leadership may play an important role in shaping implementation determinants and outcomes, but consistent empirical support is sparse and confidence dampened by methodological issues. To advance the field, we need studies that adopt stronger methodological rigor, address the conceptual overlap in leadership frameworks, examine a broader set of implementation outcomes, and examine conditions under which leadership impacts implementation. Trial registration This review was not registered.

The global mental health treatment gap has increasingly been addressed using taskshifting; however, very little research has focused on lay counselors' perspectives on the acceptability, feasibility, and appropriateness of mental health interventions in specific government-supported sectors that might scale up and sustain mental health care for children and adolescents. In western Kenya, these sectors include Education and Health. Data come from a large hybrid effectiveness-implementation study examining implementation practices and policies in either or both sectors that support successful implementation of a child-focused intervention, Trauma-focused Cognitive Behavioral Therapy (TF-CBT), for children and adolescents who had experienced parental death. We examined lay counselors' self-report of acceptability, feasibility, and appropriateness of TF-CBT. Lay counselors were teachers (n = 30) from the Education sector and Community Health Volunteers (CHVs; n = 30) from the Health sector, who were part of Sequence 1 of a large stepped-wedge, cluster randomized trial. Lay counselor self-report surveys included reflective and formative measurement of acceptability, feasibility, and appropriateness administered after lay counselors in both sectors had experience delivering the locally-adapted, groupbased TF-CBT intervention. Descriptive statistics (means, standard deviations) were used to understand counselors' perspectives stratified by sector. Both teachers and CHVs endorsed high acceptability, feasibility, and appropriateness of TF-CBT, with lay counselors' responses on items from the formative measures providing some insight into specific aspects of acceptability, feasibility, and appropriateness that may be important to consider when planning for implementation support. These early findings suggest that both sectors may hold promise for task-shifting of mental health care for Frontiers in Psychiatry | www.frontiersin.org

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