Adaptation and psychometric evaluation of the ENhancing Assessment of Common Therapeutic factors (ENACT) tool to build the capacity of primary care physicians in low-resource settings

Overview

This study addresses the gap in evidence regarding adaptation and implementation of the ENhancing Assessment of Common Therapeutic factors (ENACT) tool for evaluating non-specialist competencies in delivering psychosocial interventions within resource-constrained primary care settings. The research is situated within task-sharing frameworks designed to address mental health service delivery gaps, with emphasis on feasibility and scalability for low-resource contexts.

Methods and approach

A sequential mixed-methods approach was employed to adapt and pilot test the ENACT tool for non-specialists trained through mhGAP programs. The adaptation process comprised three phases: competency selection via literature review and focus group discussion, test strategy design including case vignette development with iterative refinement and scoring framework adaptation, and feasibility testing within mhGAP workshop settings. Role-play assessments were video-recorded and evaluated by trained raters using a four-point ordinal scale.

Results

Eight competencies were retained following relevance, comprehensibility, and feasibility evaluation. The four-point scoring framework ranged from level 1 (no skill) to level 4 (advanced skills). Good inter-rater reliability was demonstrated, with significant correlations observed between competency domains. The adapted tool was feasible to implement within mhGAP workshop contexts with resource constraints.

Implications

The ENACT tool demonstrates utility for assessing therapeutic skills of non-specialists but requires paired structured rater training and contextual adaptation to function effectively. The study's resource-conscious design addresses implementation challenges through manageability constraints, supporting scalability within low-resource settings. This approach establishes mechanisms for quality improvement in training delivery and supervision systems.
Findings can inform mhGAP curriculum design by facilitating shifts from biomedical-centered training toward patient-centered approaches. The tool enables identification of priority skill areas requiring refresher training and supports refinement of training protocols. Results also provide evidentiary support for policy decisions regarding integration of foundational competencies into large-scale training and supervision systems across resource-limited contexts.