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Development of a scoring system for non-specialist ratings of clinical competence in global mental health: a qualitative process evaluation of the Enhancing Assessment of Common Therapeutic Factors (ENACT) scale

  • B. A. Kohrt (a1) (a2) (a3), M. K. Ramaiya (a3) (a4), S. Rai (a1) (a3), A. Bhardwaj (a3) and M. J. D Jordans (a5) (a6)...

Task-sharing is the involvement of non-specialist providers to deliver mental health services. A challenge for task-sharing programs is to achieve and maintain clinical competence of non-specialists, including primary care workers, paraprofessionals, and lay providers. We developed a tool for non-specialist peer ratings of common factors clinical competency to evaluate and optimize competence during training and supervision in global mental health task-sharing initiatives.


The 18-item EN hancing A ssessment of C ommon T herapeutic factors (ENACT) tool was pilot-tested with non-specialists participating in mental health Gap Action Programme trainings in Nepal. Qualitative process evaluation was used to document development of the peer rating scoring system. Qualitative data included interviews with trainers and raters as well as transcripts of pre- and post-training observed structured clinical evaluations.


Five challenges for non-specialist peer ratings were identified through the process evaluation: (1) balance of training and supervision objectives with research objectives; (2) burden for peer raters due to number of scale items, number of response options, and use of behavioral counts; (3) capturing hierarchy of clinical skills; (4) objective v. subjective aspects of rating; and (5) social desirability when rating peers.


The process culminated in five recommendations based on the key findings for the development of scales to be used by non-specialists for peer ratings in low-resource settings. Further research is needed to determine the ability of ENACT to capture the relationship of clinical competence with client outcomes and to explore the relevance of these recommendations for non-specialist peer ratings in high-resource settings.

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This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (, which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
* Address for correspondence: B. A. Kohrt, MD, PhD., Duke Global Health Institute, 213 Trent Hall, 310 Trent Drive, Durham, NC 27708, USA. (Email:
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