Developing competencies for the WHO mhGAP Intervention Guide Version 2.0 training package
Authors: Sarah Michael, Neerja Chowdhary, Patrick Rawstorne, Tarun Dua
Journal: World Psychiatry (2020)

Mental, neurological and substance use (MNS) conditions contribute significantly to global burden of disease, accounting for 10.4% of total all-cause disability adjusted life years (DALYs), and being the third leading cause worldwide1. The World Health Organization (WHO) has developed the mental health Gap Action Programme (mhGAP) to help close the treatment gap that exists in low- and middle-income countries (LMIC), through task-shifting care for MNS conditions to non-specialist health care ­providers2. The mhGAP Intervention Guide Version 2.0 (mhGAP-IG V2.0) includes evidence-based interventions for depression, psycho­ses, epilepsy, child and adolescent mental and behavioural dis­orders, dementia, substance use disorders, suicide and self-harm, and other disorders2. Training in the first version of mhGAP-IG demonstrated improvements in pre- and post-training knowledge testing, but with the need for ongoing supervision3, 4. Feedback collected by the WHO requested more experiential learning; a focus on building skills; easier access to training materials; shorter training of six days maximum with post-training supervision, and the addition of clinician competencies. This feedback has been incorporated into the updated mhGAP-IG V2.0 training package5, which for the first time includes core competencies. Competency-based education uses outcomes to inform curriculum and assessment, involving the consideration of knowledge, skills and attitudes needed to perform a task6, 7. For mhGAP-IG V2.0, these competencies tell us what non-specialist health care providers should be able to do in their clinical practice after training and supervision. Competency development in health education is often a multi-step process involving literature review, looking for repetitive themes or ideas, and review by key stakeholders, before incorporation into curriculum and assessment7. The evidence-based mhGAP-IG V2.0 identified key aspects of practice, supplemented by recent literature on competency development for non-specialist health care providers treating MNS conditions in LMIC. As a next step, core competencies were broadly identified. These included an attitude of respect and dignity towards those with an MNS condition, knowledge around identifying and managing priority MNS conditions, and accompanying skills to assess and deliver psychosocial (psychoeducation and basic supportive counselling skills) and pharmacological interventions. Additionally, mhGAP-IG V2.0 included the assessment and management of emergency presentations, performing follow-up, assessment and management of physical health, and referral and linkage to specialists and other sectors such as employment, education and social services. Each competency was then broken down to outline the exact tasks it requires, and standardized and mapped to each module of mhGAP-IG V2.0. A common theme in competency development is achieving stakeholder consensus7. Initially, we reviewed the draft competencies with our mhGAP expert team, reaching consensus on these and adding the skill of effective communication. The skills of self-care and reflection were raised, but deferred for coverage in supervision. The competencies were then distributed for broader stakeholder feedback, including thought-leaders, partner organizations, and field experts. Once complete, the competencies fed into curriculum development and instructional methods in the training package. Training to improve knowledge will be through group lectures and persons’ stories of lived experience. Training to develop skills will be through interactive methods, including videos and multiple role-plays across assessment, management and follow-up scenarios. Attitude will be developed through the use of persons’ stories, class discussion, and time for reflection and feed­back. Assessment can be defined as either formative, used to guide and motivate future learning, or summative, providing a potential barrier to practice if competency is not demonstrated8. In LMIC, summative assessment may exclude non-specialist health care providers who, with ongoing supervision, can improve their skills and treat large numbers of patients with MNS condi­tions, who would otherwise remain untreated. For this reason, the mhGAP-IG V2.0 assessment is only formative. Accordingly, instead of grading competency through traditional stages of novice through to expert7, a more pragmatic approach was taken to focus on areas of strength and areas for improvement. For ease and simplicity, all twelve mhGAP-IG V2.0 core competencies can be assessed using the same standardized form. The form outlines the exact tasks needed for each competency, is intuitive to use, suited to multiple settings, and can be kept by the trainee for future reference. Competencies should be assessed by methods that are tailored for their specific purpose, with sound psychometric properties, practicality and acceptability8. The multiple methods across mhGAP-IG V2.0 training enhance competency assessment. For knowledge assessment, multiple-choice questions show high reliability and easy administration8, and familiarity to LMIC. A bank of questions has been developed, utilizing techniques to improve validity. Skills can be assessed by using the multiple role-play scenar­ios available in the training package. These lack the formality and resource-intensiveness of observed structured clinical examinations, which have high reliability and validity in clinical skill assessment8, but share similarities, such as instructions on discrete clinical scenarios, timing, checklists for candidate demonstration, and capacity for multiple role-plays to improve reliability and cover various skills. Role-plays also have the advantage of established acceptability in LMIC training settings3, 4, and can utilize peer assessment to manage limited assessor availability8. Finally, attitudes can be assessed using multi-method and longitudinal formats8, involving role-plays, some multiple-choice questions, and direct observation throughout the training program and supervision. This variety of teaching and assessment methods ensures a truly blended training package that is more interactive and experiential. As competencies are a new addition to the mhGAP-IG training, principles of competency-based education for future trainers and supervisors are taught in the “training of trainers and supervisors” package5. The importance of ongoing supervision has not been overlooked, with inclusion of a participant logbook and multiple supervision options in the training package, to account for all resource settings5. The training package is now freely available online, to begin up-skilling the non-specialist health care workforce in LMIC5. Early feedback confirms usability of these resources. More rigorous field-testing may include improvements and retention seen on pre- and post-testing, and a review of validity and reliability, by correlating test results for participants, or between peer and trainer assessments. Such information will help future development of mhGAP-IG training material. Developing core competencies for the mhGAP-IG V2.0 training package clearly outlines what non-specialist health care providers should be able to do after the training, with ongoing supervision. Core competencies break down the individual steps needed to be able to assess and manage priority MNS conditions, providing a framework for training and assessment. These are supplemented by the WHO’s EQUIP: Ensuring Quality in Psychological Support, an initiative to develop and disseminate resources that support trained non-specialist health care providers to reach a standard of competency to be able to deliver manualized psychological interventions9. We hope that these materials will be valuable tools in the ongoing training of non-specialist health care providers in delivering care for MNS conditions.