Measuring Competency in Global Mental Health
Open Access DepositedFindings from the WHO/UNICEF Ensuring Quality in Psychosocial and Mental Health Care (EQUIP) Initiative
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This dissertation is presented in two parts. Research study 1 assessed baseline and post training competency in foundational helping skills among primary health care providers (PCPs) trained using the World Health Organizations (WHO) Mental Health Gap Action Programme (mhGAP-IG) Nepal Module 2 curriculum, and proposed recommendations to optimize curricula to address areas of low competency. The study used an explanatory sequential mixed method study design to explore four research questions. First, descriptive analyses were used to explore the most frequent unhelpful or potentially harmful behaviors demonstrated by trainees, and common helpful or basic behaviors not demonstrated by trainees, at baseline. Second, McNemar analyses were conducted to explore change in both harmful and competent outcomes across time for each of the 15 items assessed on the ENACT assessment tool. Third, multivariate generalized estimating equation (GEE) logistics regression models including time and covariates were used to determine if change in harmful outcomes was significantly influenced by key covariates, accounting for the clustering of repeated measures within each participant. Quantitative data included ENACT assessments collected from PCPs as part of the Reducing Stigma among Healthcare Providers (RESHAPE) study (n=224). Quantitative findings were used to guide the design of qualitative data collection tools. A focus group (n=6) and individual interviews (n=8) assessed if quantitative findings aligned with the experiences of key stakeholders, how they explained key results, and best practices for improving current curricula. Research Study 2 explored how competency items rated through the ENACT assessment tool correlated at baseline and post training time points. This study used ENACT pre- and post- assessment data collected from 1700 unique trainees (n=3400). Exploratory and confirmatory factor analyses determined and then confirmed the underlying dimensions/factors of the measures on competency items assessed through the ENACT assessment. We also assessed if there was measurement invariance for the latent factor between pre and post training. Results
Background
There is a substantial gap between the need for mental health services and the number of specialist providers. Task sharing, training non-specialists to deliver care, helps expand access, but ensuring quality and safety is critical. Foundational helping skills are core therapeutic competencies considered fundamental for the effective and safe delivery of psychosocial interventions. The Enhancing Assessment of Common Therapeutic factors (ENACT) tool assesses competency in fifteen foundational helping skills and has been adapted to local contexts to support safe, high-quality task shared mental health care. Aims and Methods
For Research Study 1, not talking about self-harm (ENACT 7) was the most frequent unhelpful or potentially harmful behavior demonstrated at baseline (82%). Across all 15 ENACT items, competent outcomes were low (<50%), with a majority of health workers not demonstrating helpful or basic behaviors at baseline. McNemar analyses showed moderate change across time in harmful outcomes (7 of the ENACT items) and minimal change in not competent outcomes (4 of the ENACT items) from pre- to post training. There were no significant covariates that were related to the systematic change of harmful outcomes across time. Qualitative data supported the quantitative analysis list of top harmful and basic behaviors at baseline and attributed these to cultural norms, existing training and curricula, and limitations in the Nepali health system. Respondents advocated for more content on foundational helping skills and adding more active, experiential learning. Data supported incorporating the Foundational Helping Skills Training Manual (FHS Manual) to bolster current curricula but raised concerned about the limited training time. Findings for Research Study 2 supported a three-factor model for basic communication, assess clients’ needs, and support clients. Although this three-factor structure was similar to the three theoretical tiers that informed EQUIP ENACT’s design and training, there were competencies that loaded differently between the empirical analyses reported here and the theoretical framing (WHO-UNICEF, 2025). For the first tier “Engage”, which covers basic communication, the conceptual model included seven competencies, whereas our factor analysis results suggest only four competencies. These four competencies were non-verbal (ENACT 1), verbal (ENACT 2), rapport building (ENACT 4) and exploring and normalizing feelings (ENACT 5). In the factor analysis, the “Understand” factor included three competencies from the “Engage” tier in the conceptual model (confidentiality, empathy, and self-harm/suicide assessment), as well as two competencies from the “Understand” tier in the conceptual model (impact on life and explanation of the problem). The remaining three competencies in the “Understand” tier in the conceptual model loaded together with all of the “Support” tier competencies in the third factor of our model. The model demonstrated good fit at both pre- and post-training assessments and showed excellent internal consistency across factors. Longitudinal factor analyses supported scalar measurement invariance, indicating stable measurement over time. Significant increases in each factor score from pre- to post-training suggested improvements in competency following training (p <0.001) Conclusions
Research Study 1 provided preliminary empirical evidence that current mhGAP -IG Nepal Module 2 curricula do not adequately address training needs in foundational helping skills. It also generated stakeholder driven insights and recommendations to strengthen and improve these curricula to better support competency development. Research Study 2 contributed novel statistical evidence supporting the reliability, and structural validity of ENACT and its utility for guiding training, supervision, and quality improvement in global mental health services. Overall, this dissertation generated practical, actionable evidence to help ensure that non-specialist mental health providers achieve minimum competency standards and deliver care safely without causing harm. Future research should build on these findings to further strengthen implementation and support the delivery of safe, high quality mental health services that continue progress to closing the mental health treatment gap.
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