Ensuring Quality in Psychological Support (WHO EQUIP): developing a competent global workforce
Authors: Brandon A. Kohrt, Alison Schafer, Ann Willhoite, Edith van't Hof, Gloria A. Pedersen, Sarah Watts, Katherine Ottman, Kenneth Carswell, Mark van Ommeren
Journal: World Psychiatry (2020)

Globally, the vast majority of people with mental health conditions do not receive effective care. Among people living with depression, only 1 in 5 persons in high-income countries and 1 in 27 in lower-middle income countries receive minimally adequate treatment1. There is a dearth of health workers trained in mental health care, with only one trained provider per 10,000 people in most countries2. One key action to improve access to mental health care is to expand psychological and psychosocial support services delivered by diverse cadres across settings3. There is now good evidence that persons who are not specialists in mental health can effectively deliver psychological interventions, but they must be adequately trained and supervised4. Non-specialist providers include primary care workers, community workers, psychosocial workers, teachers, family members and peers. However, unlike licensed professionals for whom there are professional associations to assure standards, there are usually no systems or mechanisms in place that check whether non-specialist providers have sufficient training and supervision to achieve minimum competency to effectively and safely deliver interventions. This raises the question: how can governments and the general population be assured that non-specialists provide quality care? One way to address this challenge is to establish competency-based training approaches and competency assessment measures that governments, non-governmental organizations and other institutions can use to benchmark skills for safe and effective care. Competency measures can be used to determine who is or is not competent as well as to tailor supervision and supplementary training to address gaps in skills. Having competency targets in mind can also inform training duration and content that may need to vary across sites or cadres. Competency-based training approaches have already demonstrated success in diverse areas of health care in low resource settings, including surgery and obstetric care5, 6. To facilitate competency-based training in psychosocial support, psychological treatments, and foundational helping skills, the World Health Organization (WHO) is developing the Ensuring Quality in Psychological Support (EQUIP) platform (https://www.who.int/mental_health/emergencies/equip/en/). The EQUIP platform aligns with WHO's work on universal health coverage, that is establishing competency frameworks across fields of health care. EQUIP will be an online resource to help program managers and trainers utilize competency assessments to evaluate trainings and to feedback those competency results to support trainee development and modify curricula. The full suite will comprise tutorials on implementing competency assessments, including how to achieve interrater reliability with global rating standards and how to use role plays to assess competency. It will include guidance for trainers on delivering competency-based training programs, and for implementation and adaptation of psychological interventions. In addition, the EQUIP platform will offer training modules on common factors that can be selected based on competency assessment outcomes. Common factors are general elements of psychosocial support and psychological care – such as communication skills, empathy, collaboration, and helper-client alliance – that are vital ingredients for any intervention to be effective7. Contents of the EQUIP platform have been informed by a theory of change workshop attended by mental health and psychosocial service stakeholders with different practice experiences from diverse global settings. The EQUIP team has reviewed manuals and training materials for interventions delivered by non-specialists with effectiveness demonstrated in randomized controlled trials. This has led to the identification of competencies for both common factors and specific classes of psychological interventions (e.g., cognitive, interpersonal, problem solving, behavioral and trauma-focused techniques). EQUIP will encompass a competency evaluation tool, the Enhancing Assessment of Common Therapeutic Factors (ENACT), that has been developed for role-play based assessment of mental health and psychosocial support skills for non-specialist and specialist providers across cultures, context and types of interventions8, 9. In addition, a suite of competency assessment tools based on ENACT is being developed and tested. Below we briefly outline who, how, where and when EQUIP can be used. Who can use EQUIP? EQUIP is intended for trainers, supervisors and project managers implementing psychosocial support and psychological interventions. How can EQUIP be used? EQUIP can be used to improve implementation plans, competency assessments of trainees, and training and supervision curricula in common factors to accompany manualized interventions. Competency assessments may also be used to aid selection of trainees and to guide institutional certification after achieving minimum skill targets. Where can EQUIP be used? EQUIP will be an online platform of resources with offline formats. When can EQUIP be used? To refine the platform and its materials, EQUIP is being developed using a human-centered design approach to enhance usability and engagement, and piloted in multiple countries. After piloting, materials will be available in English, Arabic and Spanish. Ultimately, EQUIP is intended to be a resource that will undergo iterative transformation based on feedback from the global practitioner community. Addressing mental health and psychosocial needs requires radical growth in the global workforce to ensure safe and effective delivery of psychosocial support and evidence-based psychological interventions. The EQUIP platform will make competency-based training and assessment resources widely available and adaptable to the contexts and needs of local organizations and practitioners.