Selection of PHCWs

Despite the support of key stakeholders and well-defined criteria, we found the recruitment of PCPs challenging. As in other studies, ^{Reference Tarannum, Elshazly, Harlass and Ventevogel28} our objective was also to select those who are motivated to learn, have an interest in mental healthcare, and are willing to manage cases and seek supervision. Faregh et al ^{Reference Faregh, Lencucha, Ventevogel, Dubale and Kirmayer29} have pointed out that relegating the task of trainee selection to the beneficiary organisation does not yield best results in terms of training outcomes. Like Faregh et al, we also found that it is more convenient for district health offices to nominate PCPs who are readily available rather than identifying those who meet eligibility criteria. This challenge is further compounded by Pakistan’s under-resourced and challenging healthcare system, which has led many doctors to emigrate for better job opportunities. Nadir et al ^{Reference Nadir, Sardar and Ahmad30} highlighted that one-third of medical students aspire to move overseas after graduation, leading to a critical loss of qualified medical practitioners, attributed to suboptimal remuneration, hectic work schedules, job insecurity, non-recognition of services and ineffective management. ^{Reference Meo and Sultan31} There is an imminent need to invest in younger, ‘tech-savvy’ doctors who choose to work in their districts, are interested in expanding their skills and are more likely to have overcome stigma associated with mental disorders to restore the socio-medical landscape of Pakistan. ^{Reference Nadir, Sardar and Ahmad30,Reference Meo and Sultan31}

This marked the first initiative in Pakistan in which PCPs and clinical psychologists participated as both trainers and trainees, which is consistent with mhGAP implementation in some other regions. ^{3,Reference Kokota, Lund, Ahrens, Breuer and Gilfillan32} Given the growing number of training programmes for clinical psychologists in Pakistan, they represent an underutilised mental health resource whose existing training gaps can be overcome through mhGAP training. ³ The mixed group of participants helped shift discussions from a pure biomedical to a biopsychosocial approach and aligned with other task-sharing models. ^{Reference Spagnolo and Lal33,Reference Raviola, Naslund, Smith and Patel34}

Training methodology

Consistent with earlier studies, the availability of training resources in the form of our printed guide and mobile app proved to be valuable during training. ^{Reference Tarannum, Elshazly, Harlass and Ventevogel28,Reference Momotaz, Ahmed, Jalal Uddin, Karim, Khan and Al-Amin35} The hard copies minimised reliance on technology and the internet, helped in better knowledge retention with personalised annotations, and enabled continuous learning outside the formal training sessions. ^{Reference Mehnaz, Baig and Aly36} The Urdu translation of interview questions and psychosocial techniques in the guide were particularly helpful for trainees during role-play to build their confidence and improve skills to elicit symptoms and offer psychosocial interventions. Our efforts were aligned with existing literature, recommending the contextual adaptation of mhGAP training resources into local languages to enhance comprehension and clinical applicability. ^{3,Reference Faregh, Lencucha, Ventevogel, Dubale and Kirmayer29} We also agree that role-play with cultural examples of clinical presentations can help non-specialists to elicit symptoms better. ^{Reference Tarannum, Elshazly, Harlass and Ventevogel28,Reference Momotaz, Ahmed, Jalal Uddin, Karim, Khan and Al-Amin35} The availability of the printed guide helped the trainers to avoid didactic teaching and the trainees to avoid taking notes. The workshops became more interactive and hands-on as the trainees engaged proactively in clinical discussions and skills demonstrations. Like Momotaz et al, ^{Reference Momotaz, Ahmed, Jalal Uddin, Karim, Khan and Al-Amin35} we also observed that the PHCWs were effectively engaged with the trainers’ competence using a bilingual approach and facilitation skills. Having stated that, we found it difficult to cover the complete guide in 5 days, as this did not allow adequate time for desirable practice of clinical skills in role-play. ^{Reference Engelhard, Haack and Alik37} To compensate for this, we specifically designed refresher training to focus on skill-building through role-play in areas flagged by the PHCWs.

Evaluation of training

In the assessment of knowledge, pre-training test scores showed notable knowledge gaps on the modules on general principles of care, PTSD, suicide, harmful use of alcohol and drugs, and epilepsy. Significant knowledge gaps regarding suicide and the harmful use of alcohol and drugs were also found in other studies, and particularly in humanitarian settings. ^{Reference Momotaz, Ahmed, Jalal Uddin, Karim, Khan and Al-Amin35,Reference Ahrens, Kokota, Mafuta, Konyani, Chasweka and Mwale38,Reference Greene, Haddad, Busse, Ezard, Ventevogel and Demis39} According to the United Nations Office on Drugs and Crime report, ⁴⁰ 10.7% of the population of Khyber Pakhtunkhwa ‘abused harder narcotics’, which was nearly double the national average at that time. Since then, there has been an alarming rise in the use of illicit substances, but health professionals are not equipped to respond with basic psychosocial interventions. ⁴¹ This gap is steadily being filled by commercial and sometimes unscientific detoxification services. Hence, we also made additional efforts to educate the PHCWs to protect the rights of people with substance use disorder by identifying it as a disorder and to prevent the common malpractice of forced hospital admission and unsafe practices. ^{Reference Lassi42}

The pre-training test also revealed consistent misconceptions about the statements that ‘People with mental disorders cannot make decisions about their treatment’ and ‘Asking about suicide increases the likelihood of suicide’. These misconceptions highlighted deep-rooted stigma and misinformation related to mental illness and people with mental disorders in our cultural context. Mental illness is often misattributed to weak faith, demonic possession or moral transgression, and individuals experiencing it are perceived as dangerous, ‘crazy’ and incapable of friendship. Such perceptions contribute to their social exclusion, denial of human rights and reluctance to seek professional help. ^{Reference Mansoor and Warsi43,Reference Javed, Ahsan, Khattak and Afzal44} Alarmingly, this stigma is not limited to the general community; it also seeps among medical students and healthcare professionals, highlighting the need for stronger emphasis on psychiatric education in pre-service training. ^{Reference Husain, Zehra, Umer, Kiran, Husain and Soomro45} Despite being an alarming public health issue, suicide remains misunderstood owing to cultural and religious prohibitions. It is framed as a source of familial shame or an unforgivable sin, which prevents people from seeking help. A recent review on the need to address stigma for suicide prevention in Pakistan calls for the incorporation of mental health education into school curricula and community-based initiatives and the establishment of accessible mental health services. ^{Reference Mashhood, Saeed and Sami46}

The reflective process also revealed commonly held misconceptions and systemic gaps in medical practice. For instance, we know that limited recognition of somatic manifestations of mental disorders in primary care, frequent misdiagnoses and repetitive laboratory investigations act as a barrier to timely initiation of appropriate treatment. ^{Reference Wazir, Kakakhel, Gul, Awan, Khattak and Yousaf47} Similarly, the prevailing disease-centred approach and the malpractice of prescribing benzodiazepines without being aware of their harmful consequences or addiction potential had to be emphasised during the training sessions. ^{Reference Naqvi, Sabzwari, Hussain, Islam and Zaman48}

The PCPs acknowledged a gap in their understanding of commonly neglected issues associated with children, such as bedwetting. Role-play was found to be effective in practising the technique of psychoeducation in this scenario. The skill to support the parents of children with intellectual disability was another crucial gap. In Pakistan, high rates of depression and anxiety were found among such parents. ^{Reference Azeem, Dogar, Shah, Cheema, Asmat and Akbar49} The cumulative social, emotional and financial burden placed on these families highlights the necessity of equipping PHCWs with the skills to educate and support the families.

Evaluation of post-training knowledge

The results of the post-training evaluations were encouraging, with a significant increase in knowledge shown at the end of training and after 8 months – a trend reported in other countries. ^{Reference Keynejad, Spagnolo and Thornicroft27,Reference Tarannum, Elshazly, Harlass and Ventevogel28} The refresher training confirmed retention of knowledge among PHCWs over this period. We were able to confirm long-term knowledge retention in only half of our original cohort because of logistical and budgetary constraints. However, based on the similarities in our demographic analysis and post-training scores of all districts, we believe that knowledge retention is likely to be consistent in the other districts as well.

Limitations of the study

We acknowledge specific limitations of our work. First, the grouping of districts was based primarily on logistical considerations rather than contextual variables. In future studies, district grouping could be refined using more relevant criteria – such as urban–rural classification, or service accessibility – to relate to the contextual relevance. Second, our pre- and post-training evaluations of PHCWs’ existing capacity might have been more robust by using additional measures to assess skills, attitudes and confidence. Third, for sustainable outcomes we consider it vital to engage the trainers formally, preferably through financial or career incentives. Fourth, we need to make greater efforts to work with healthcare authorities to carefully recruit PHCWs based on their clinical experience and interest. Last, we believe that either the training time needs to be increased or fewer modules need to be prioritised, so that critical skills are adequately demonstrated and practised during the training.

Future directions

Mental health must be identified as a public health priority at the provincial level. A sustainable coordinating mechanism is needed between the health department, humanitarian agencies and development partners. Currently, many projects are undertaken in silos, with blurred and short-term outcomes. A clear direction needs to be set, with focused objectives to optimise resource utilisation.

An average district in Khyber Pakhtunkhwa has at least 100 doctors working at the primary care level, who are a huge potential resource for providing MHPSS services. ^{Reference Raviola, Naslund, Smith and Patel34} Our work demonstrates a way forward to scale up capacity-building initiatives and develop a multidisciplinary PHCW workforce across the province. For this reason, regular posts for clinical psychologists should be created in primary healthcare facilities. Additionally, we recommend incorporating the mhGAP-HIG-PK into pre-service medical training, as the successful implementation of the mhGAP guidelines in undergraduate and postgraduate programmes for medical and allied specialties is well-documented. ^{Reference Iversen, Ogallo, Belfer, Fung, Hoven and Carswell50}