Educating medical and

nursing students to provide

mental health, neurological
and substance use care
A practical guide for pre-service education
Educating medical and
nursing students to provide
mental health, neurological
and substance use care
A practical guide for pre-service education
Educating medical and nursing students to provide mental health, neurological and substance use care:
a practical guide for pre-service education

ISBN 978-92-4-010412-9 (electronic version)

ISBN 978-92-4-010413-6 (print version)

© World Health Organization 2025

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Contents
Preface......................................................................................................... v
Acknowledgements.................................................................................... vi
Glossary of terms ........................................................................................ x

Executive summary.............................. xiii

1. Introduction....................................... 1
1.1 Background............................................................................................ 2
1.2 About this guide..................................................................................... 8

2. Prepare and plan for change................ 11

2.1 Pick a curriculum review committee .................................................. 12
2.2 Do a situation analysis......................................................................... 16
2.3 Advocate for and secure endorsement .............................................. 20
2.4 Develop a work plan and budget........................................................ 23

3. Define competencies.......................... 25
3.1 Use a competency-based approach................................................... 26
3.2 Identify MNS care tasks for doctors and nurses................................. 27
3.3 Identify competencies required.......................................................... 29

iii
4. Enhance the curriculum...................... 39
4.1 Set learning objectives........................................................................ 40
4.2 Structure learning content.................................................................. 42
4.3 Plan learning experiences and teaching methods............................. 50
4.4 Select methods of assessment........................................................... 57
4.5 Train educators.................................................................................... 61
4.6 How to apply the competency framework: two examples................ 62

5. Implement the curriculum.................. 67

5.1 Decide on an implementation approach............................................ 68
5.2 Address barriers to implementation .................................................. 73
5.3 Monitor and evaluate........................................................................... 78

6. Conclusion........................................ 85
References........................................... 87
Annex: tools and resources..................... 90

iv
Preface
Severe shortages in the mental health workforce how to assess student outcomes and monitor
cause an enormous gap in care for people with and evaluate educational programmes. The guide
mental health, neurological and substance is meant to be used flexibly, to either enhance
use (MNS) conditions. As outlined in WHO’s existing curricula or to develop new curricula
Comprehensive Mental Health Action Plan where education on MNS care is absent. The guide
2013–2030, pre-service education (PSE) in MNS also provides strategies for engaging stakeholders,
care for future doctors and nurses can support mobilizing resources and implementing
long-term sustainability of MNS services and curriculum changes in diverse contexts.
systems by building a competent national and
The need for competent health professionals
local MNS workforce.
who can provide quality MNS care has never been
This guide aims to strengthen competency-based greater. This guide can offer a practical pathway
education in providing MNS care by focusing on to transform medical and nursing education,
enhancing first-degree educational curricula contributing to improving the lives of people
for future doctors and nurses. The guide was who face MNS conditions. By working together to
informed by extensive literature reviews, educate doctors and nurses to implement these
documentation of best practice examples and evidence-based approaches, we can build a health
consultations with experts globally, including care workforce that is not only technically skilled,
people with lived experience of MNS conditions. but also compassionate and rights-based in their
It defines 12 core competencies for MNS care care. By strengthening pre-service education in
relevant to the roles of doctors and nurses in MNS care, we have an unprecedented opportunity
most countries and offers practical advice on how to create meaningful and lasting change for
to embed these into undergraduate curricula, generations to come.
including suggestions for teaching methods, and

Dévora Kestel
Director
Department of Mental Health, Brain Health and Substance Use
World Health Organization

v
Acknowledgements
The development of this document was Philadelphia, USA), Ricardo Leon Borquez (World
coordinated by the mental health unit (Brandon Federation of Medical Education, Zapopan,
Gray and Mark van Ommeren) under the overall Mexico), Niall Boyce (Wellcome Trust, London,
direction of Dévora Kestel (Director, Department United Kingdom of Great Britain and Northern
of Mental Health, Brain Health and Substance Ireland), Genquen Philip Carado (Association of
Use, WHO). It was written by Sherianne Kramer, Philippine Medical Colleges - Student Network,
Sian Lewis, Brandon Gray, Shekhar Saxena, and Manila, Philippines), Odile Chang (Fiji National
Mark van Ommeren. University, Suva, Fiji), Shubao Chen (Sun Yat-Sen
University, Guangzhou, China), Sophie Chung
(Wellcome Trust, London, United Kingdom),
WHO contributors and reviewers
Carmel Clancy (International Nurses Society on
WHO Headquarters staff and consultants:
Addictions, London, United Kingdom), Devina
Ben Adams, Piumee Bandara, Elaine Brohan,
Dabholkar (All India Institute of Medical Sciences,
Georgina Campbell, Kenneth Carswell, Neerja
New Delhi, India), Christopher Dowrick (World
Chowdhary, Siobhan Fitzpatrick, Alexandra
Organization of Family Doctors, Liverpool,
Fleischmann, Michelle Funk, Dzmitry Krupchanka,
United Kingdom), Angel Belle Cheng Dy (Ateneo
Katherina Molek, Sandersan Onie, Vladimir
de Manila University School of Medicine and
Poznyak, Alison Schafer, Katrin Seeher, Chiara
Public Health, Manila, Philippines), Ragnhild
Servili, James Underhill and Inka Weissbecker.
Dybdahl (Africa Centres for Disease Control and
WHO staff in regions and countries: Prevention, Langesund, Norway), Mohamed Eissa
Kedar Marahatta (WHO Country Office for (International Federation of Medical Students
Nepal), Carmen Martinez and Renato Oliveira e Association, Cairo, Egypt), Isabel Elicer (UC
Souza (WHO Regional Office for the Americas), CHRISTUS, Santiago, Chile), Erin Ferenchick
and Khalid Saeed (WHO Regional Office for the (United for Global Mental Health, New York,
Eastern Mediterranean). USA), Sandra Ferreria (Global Mental Health
Peer Network, Johannesburg, South Africa),
Valerie Ferri (The Philadelphia Mental Health
External contributors and reviewers
Care Corporation, Philadelphia, USA), Kosha Gala
Tarek Abdelgawad (Cairo University, Cairo, Egypt),
(International Federation of Medical Students
Atalay Alem (Addis Ababa University, Addis
Association, Pune, India), Charlene Gamaldo
Ababa, Ethiopia), Samar Almouazen (Damascus
(John Hopkins University School of Medicine,
University, Damascus, Syrian Arab Republic),
USA), David Gordon (World Federation of Medical
Silvana Virginia Sarabia Arce (Universidad Peruana
Education, Manchester, United Kingdom), Ana
Cayetano Heredia, San Martín de Porres District,
Carolina Paris Guerrero (Universidad de Ciencias
Peru), Arushi Arushi, (All India Institute of Medical
Médicas, San José, Costa Rica), Sandhya Gupta
Sciences, New Delhi, India), Melody Tunsubilege
(All India Institute of Medical Sciences, New Delhi,
Asukile (University Teaching Hospital, Lusaka,
India), Charlotte Hanlon (King’s College London,
Zambia), José Luis Ayuso-Mateos (Universidad
London, United Kingdom), Halah Ibrahim Hassen
Autónoma de Madrid, Madrid, Spain), Christina
(Khalifa University of Science and Technology,
Babusci (University of Pittsburgh, Pittsburgh,
Abu Dhabi, United Arab Emirates), Helen Herrman
United States of America (USA)), Gavin Bart
(University of Melbourne, Melbourne, Australia),
(University of Minnesota, Minneapolis, USA),
Zeinab Hijazi (United Nations Children’s Fund,
Emily Becker-Haimes (University of Pennsylvania,

vi
New York, USA), Simone Honikman (University Enmore, Guyana), Roger Ng (World Psychiatric
of Cape Town, Cape Town, South Africa), Xiaona Association, Hunan, China), Victor Ng (World
Huang (United Nations Children’s Fund, Beijing, Organization of Family Doctors, Ontario, Canada),
China), Peter Hughes (International Committee Kelvin Ngoma (Regional Psychosocial Support
of the Red Cross, London, United Kingdom), Initiative, Lusaka, Zambia), Ma Ning (South China
Mohamed Ibrahim (University of British Columbia, Normal University, Guangzhou, China), Olayinka
Vancouver, Canada), Hamdi Issa (United for Omigbodun (University of Ibadan, Ibadan, Nigeria),
Global Mental Health, Hargeisa, Somalia), Helen Uta Ouali (University of Tunis El Manar Medical
Jack (University of Washington, Washington, School, Tunis, Tunisia), Clare Pain (Universities of
USA), Afzal Javed (World Psychiatric Association, Toronto, Toronto, Canada), Lajja Patel (All India
Birmingham, United Kingdom), Dutsadee Institute of Medical Sciences, New Delhi, India),
Juengsiragulwit (Department of Mental Health, Kamilla Pedersen (Aarhus University, Aarhus,
Bangkok, Thailand), Adelard Kakunze (Africa Denmark), David Ponka (World Organization of
Centres for Disease Control and Prevention, Family Doctors, Ontario, Canada), Richard Rawson
Addis Ababa, Ethiopia), Beatrice Kathungu (University of California, Los Angeles, USA), Espen
(Kenyatta University, Nairobi, Kenya), Salman Gade Rolland (International Council of Nurses,
Khan (International Federation of Medical Viken, Norway), Fiamma Rupp (United Nations
Students Association, Mumbai, India), Sarah Kline Children’s Fund, New York, USA), Leandro Salazar
(United for Global Mental Health, London, United (Department of Health, Manila, Philippines),
Kingdom), Kristiana Siste Kurniasanti (Universitas Deanna Saylor (John Hopkins University School
Indonesia, Jakarta, Indonesia), Joanna Lai of Medicine, Maryland, USA), Thomas Schulze
(United Nations Children’s Fund, New York, (World Psychiatric Association, New York, USA),
USA), Saul Levin (World Psychiatric Association, Soraya Seedat (Africa Centres for Disease Control
Washington, USA), Michał Lew-Starowicz (Medical and Prevention, Stellenbosch, South Africa), Li
Center for Postgraduate Education, Warsaw, Shao (Shanghai Jiao Tong University, Shanghai,
Poland), Jean Rya Lim (Association of Philippine China), Pratap Sharan (All India Institute of
Medical Colleges - Student Network, Manila, Medical Sciences, New Delhi, India), Rannia
Philippines), Kathryn Lombardo (International Shehrish (International Federation of Medical
Association of Medical Regulatory Authorities, Students Association, Dhaka, Bangladesh), Laura
Minnesota, USA), Jiang Long (Shanghai Mental ShieldsZeeman (Trimbos, Utrecht, Kingdom of the
Health Center, Shanghai, China), Crick Lund Netherlands), Ali Shirazi (United Nations Children’s
(King’s College London, London, United Kingdom), Fund, Beijing, China), Norbert Skokauskas (World
Debra Machando (African Mental Health Research Psychiatric Association, Torgarden, Norway),
Initiative, Harare, Zimbabwe), Walter Mangezi Armen Soghoyan (World Psychiatric Association,
(University of Zimbabwe, Harare, Zimbabwe), Yerevan, Armenia), Katherine Sorsdahl (University
Suzana Guerrero Martínez (Universidad of Cape Town, Cape Town, South Africa), Alfreda
Iberoamericanal, Dominican Republic), Juliana Stadlin (Ajman University, Ajman, United Arab
Mayhew (American Psychological Association, Emirates), David Stewart (International Council of
Maryland, USA), Kevin Mulvey (International Nurses, Queensland, Australia), Eli-Claire Suarez
Consortium of Universities for Drug Demand (University of the Philippines College of Medicine,
Reduction, Maryland, USA), Dana Murphy-Parker Manila, Philippines), Graham Thornicroft (King’s
(International Nurses Society on Addictions, College London, London, United Kingdom),
Colorado, United States), Dinah Palmera Nadera Trung Lam Tu (Dong A University, Da Nang,
(Philippines Open University, Laguna, Philippines), Viet Nam), Pichet Udomratn (Prince of Songkla
Nichole Nedd-Jerrick (Enmore Polyclinic, University, Hat Yai, Thailand), Jose Javier Mendoza

vii
Velasquez (Coordination of National Strategies Declarations of interest were requested from
and Commission of Mental Health and Addictions, all external reviewers and contributors. An
Mexico City, Mexico), Musa Abba Wakil (Africa email was sent to all potential reviewers and
Centres for Disease Control and Prevention, contributors requesting them to complete a
Maiduguri, Nigeria), Danuta Wasserman (World declaration of interests form. The coordination
Psychiatric Association, Solna, Sweden), Winter team reviewed the declarations of interest along
Williams (University of Alabama, Alabama, USA), with additional information (obtained through
Dawit Wondimagegn (Addis Ababa University, internet and bibliographic database searches) and
Addis Ababa, Ethiopia), Esther Wong (Ministry of assessed them to determine whether there were
Health, Putrajaya, Malaysia), Yifeng Xu (Shanghai any conflicts of interest and, if so, whether this
Mental Health Center, Shanghai, China), Tuohong necessitated a management plan. No significant
Zhang (Peking University, Beijing, China), Min conflicts were identified throughout the process.
Zhao (Shanghai Mental Health Center, Shanghai,
This project was made possible with the financial
China), Na Zhong (Shanghai Mental Health Center,
support of WHO Assessed Contributions and
Shanghai, China), Yves Miel Zuniga (United for
the UHC Partnership (Belgium, European Union,
Global Mental Health, Manila, Philippines).
France, Ireland, Japan, Luxembourg, United
Kingdom and WHO).

viii Photo credit (next page): health care workers in a rural setting. ©Freepik
Glossary of terms
Brain health. The state of brain functioning across Enhanced curriculum. A course curriculum
cognitive, sensory, social-emotional, behavioural for medical and nursing students that has
and motor domains, allowing a person to realize been enriched to include greater emphasis on
their full potential over the life course, irrespective developing students’ competencies for providing
of the presence or absence of disorders. care to people with mental health, neurological
and substance use conditions (either by adapting
Community-based mental health care. Any
an existing curriculum or by developing a
mental health care that is provided outside of
new curriculum).
a psychiatric hospital.1 This includes services
available through primary health care, specific Integrated care. Health services that are
health programmes (for example HIV clinics), managed and delivered so that people receive
district or regional general hospitals, community a continuum of health promotion, disease
mental health teams, relevant social services and prevention, diagnosis, treatment, disease
services in other outpatient settings. management, rehabilitation and palliative care
services, coordinated across the different levels
Competence. A person’s proficiency in
and sites of care within and beyond the health
applying competencies to tasks according to a
sector, and according to their needs throughout
pre-defined standard. Competence is contextual,
the life course.
multidimensional and dynamic; it changes with
time, experience and setting. Medical doctors (including family and primary
care doctors).3 Health professionals who
Competency.2 A person’s ability to integrate
diagnose, treat and prevent illness, disease, injury,
specific attitudes, knowledge and skills when
and other physical and mental impairments and
performing tasks. Competencies are durable,
maintain general health. Medical doctors plan,
trainable and, through the expression of
supervise and evaluate the implementation of care
behaviours, measurable.
and treatment plans by other health care workers.
Curriculum. A set of organized educational They do not limit their practice to certain types of
activities and environments designed to achieve disease or methods of treatment, and they may
specific learning goals. The curriculum comprises: assume responsibility for providing continuing
the learning content and how it is organized and comprehensive medical care to individuals,
and sequenced; teaching methods and learning families and communities.
experiences; assessment formats and programme
evaluation; and quality improvement strategies.

1
As conceptualized in: World mental health report: transforming mental health for all. Geneva: World Health Organization;
2022 (https://iris.who.int/handle/10665/356119, accessed 16 September 2024).
2
As defined in: Mills J-A, Middleton JW, Schafer A, Fitzpatrick S, Short S, Cieza A. Proposing a re-conceptualisation of
competency framework terminology for health: a scoping review. Hum Resources Health. 2020;18(1):15. doi:10.1186/
s12960-019-0443-8. See also: Global competency and outcomes framework for universal health coverage. Geneva: World
Health Organization; 2022 (https://iris.who.int/handle/10665/352711, accessed 16 September 2024).
3
In this document, the term “doctors” refers to medical doctors.

x
Mental health.4 A state of mental well-being that sclerosis), neuroinfections, brain tumours or
enables people to cope with the stresses of life, traumatic injuries.
to realize their abilities, to learn well and work • Substance use conditions include disorders
well, and to contribute to their communities. due to psychoactive substance use, as well
Mental health is an integral component of health as hazardous and harmful use of alcohol,
and well-being and is more than the absence of psychoactive drugs or other substances.
mental disorder.
MNS care. In the context of this guide,
mhGAP priority conditions. A subset of mental
“MNS care” is used to mean services that
health, neurological and substance use conditions
provide psychosocial, psychological and/
with a high burden in terms of mortality,
or pharmacological care (e.g. assessment,
morbidity, disability, economic cost, or human
management, and referral) for people
rights violations.
experiencing MNS conditions.
Mental health, neurological and substance use
MNS care tasks. The tasks that doctors and
(MNS) conditions. A collective term for health
nurses are expected to carry out to provide
conditions and disorders that compromise mental
services for people with MNS conditions.
or brain health and functioning and may lead to
cognitive, intellectual, psychosocial or physical Nurse.6 A health care professional who
impairment, or self-harm or suicide. This includes provides autonomous and collaborative care
mental, behavioural and neurodevelopmental of individuals of all ages, families, groups and
disorders and diseases of the nervous system that communities, sick or well and in all settings.
are defined in WHO’s International Classification of Nurses promote health, help prevent illness, and
Diseases, 11th Revision (ICD-11).5 care for ill, disabled and dying people.

• Mental health conditions include diagnosable Person-centred care. Care that is organized
disorders such as psychosis and depression, around the health needs and expectations of
and also other mental and behaviourial people, not diseases. Person-centred care engages
states associated with significant distress individuals, families and communities as active
and impairment in functioning, including participants in, rather than passive recipients
self-harm or suicide. of, care. It consciously adopts people’s own
• In this guide, neurological conditions perspectives and priorities and responds to these
include neurodevelopmental disorders in humane and holistic ways. Person-centred
(such as autism spectrum disorder), but not care seeks to understand and respect people’s
neurological disorders (such as stroke, epilepsy, cultural understandings of mental health, and to
headache disorders, dementia and Parkinson ensure that mental health care workers engage
disease), neuromuscular disorders (such as in meaningful conversations about people’s
peripheral neuropathy), neuroimmunological needs and concerns.
disorders (such as meningitis and multiple

4
As defined in: World mental health report: transforming mental health for all. Geneva: World Health Organization; 2022
(https://iris.who.int/handle/10665/356119, accessed 16 September 2024.
5
See: Clinical descriptions and diagnostic requirements for ICD-11 mental, behavioural and neurodevelopmental disorders
(CDDR). Geneva: World Health Organization; 2024 (https://iris.who.int/handle/10665/375767, accessed 16 September 2024).
6
For more detailed definitions of nurses and nursing see: Current nursing definitions. In: ICN/Resources [website]. Geneva:
International Council of Nurses; 2024 (https://www.icn.ch/resources/nursing-definitions/current-nursing-definitions, accessed
16 September 2024).

xi
Pre-service education (PSE). The learning that Rights-based care. Care provided by mental
takes place in preparation for a future role as health and social services that respects
a health care worker. PSE provides pre-clinical people’s human rights and dignity, including
training and takes place in universities, by promoting autonomy, legal capacity,
colleges and professional schools, as well as non-coercion, confidentiality, participation and
other educational settings, such as health community inclusion.
institutes, clinical facilities and community
Specialists. Health professionals with advanced
organizations. In the context of this guide, PSE
training in specific diseases or treatments, who
refers specifically to the learning of medical and
use specialized methods to diagnose, treat
nursing students taking a first degree course
and prevent illness, injury or other physical
in a university setting. In many countries this is
and mental impairments. Specialists may also
undergraduate education that requires no prior
teach or do research. In this guide, specialists
courses or knowledge.
often refer to psychiatrists and other mental
Recovery-oriented care. Recovery-oriented care health professionals.
supports people in their unique recovery journey
Substance use. The use of psychoactive
and empowers them to have control of their own
substances, including alcohol, drugs and nicotine,
lives. It involves supporting people to: identify
that affect mental processes such as perception,
and work towards their goals and aspirations in
consciousness, cognition or mood and emotions.
order to lead fulfilling and meaningful lives; make
decisions about all areas of their lives including Universal health coverage (UHC). All people have
treatment, care and support; and choose their access to the full range of quality health services
own way of understanding their distress. they need, when and where they need them,
without financial hardship.

xii
Executive
summary
PSE-MNS guide

Chapter 1. Introduction
In all countries, mental health, neurological and professional development) is a useful and
substance use (MNS) conditions are widespread evidence-based approach for upskilling doctors
and cause significant suffering and early death. and nurses to manage MNS conditions. Another
Despite effective interventions, many people go complementary approach is to strengthen
untreated due to inaccessible, unaffordable, or pre-service education (PSE) in mental health care
poor-quality services, or because of stigma. for medical and nursing students before they enter
the workforce by embedding core competencies for
The shortage of trained MNS health care
MNS care throughout their undergraduate curricula
workers everywhere worsens the treatment gap.
(not just in psychiatry or neurology courses).
Expanding the specialist workforce is important
This approach is recommended by the WHO
to improve access to care, especially for people
Comprehensive mental health action plan, 2013–2030.
with moderate to severe disorders. But achieving
universal health coverage (UHC) requires other Existing PSE in MNS care varies widely in how it is
strategies, including integrating prevention and provided. It is often brief and theoretical, lacking
care for mild to moderate MNS conditions into the in practical learning for real-world tasks. There is
roles of doctors and nurses. an urgent need to enhance PSE for medical and
nursing students worldwide so that graduates are
In-service training (including postgraduate
adequately equipped to manage MNS conditions.
education, on-the-job training and continuous

Chapter 2. Prepare and plan for change

Embedding MNS care competencies in PSE Do a situation analysis
requires clear goals, stakeholder support and
• Assess the need for and feasibility of
institutional capacity. The planning phase of
curricular changes, internally (curricula and
curricular change includes four key activities.
educator competencies) and externally
The order and depth of these activities will
(MNS service needs).
vary by context and resources. MNS-related
updates will likely need to coincide with broader
Advocate and engage stakeholders
curriculum revisions.
• Raise awareness about the need for an
Establish a curriculum review committee (CRC)
enhanced curriculum among all stakeholders.
• Include representatives from all stakeholder • Secure support from decision-makers and
groups, including people with lived experience mobilize resources for curriculum enhancement.
of MNS conditions.
• Involve university administration and Develop an implementation plan and budget
faculty from different departments to
• Identify roles, timelines and resources needed
ensure a multidisciplinary approach and
to implement the enhanced curriculum.
reduce teaching loads.
• Make a monitoring and evaluation (M&E) plan
with indicators and means of verification for
measuring success.

xiv Photo credit (previous page): duty nurses gather at Dhaka Medical Hospital in Bangladesh, 2023. © WHO / Fabeha Monir
 MNS conditions for applying skills and performing MNS
people with MNS
appropriately and care task. This includes knowledge about
conditions
in a timely manner evidence-based interventions for specific
Executive summary and collaborate MNS conditions as well as knowledge about
5 Assess for MNS with other health
conditions public mental health.
care workers in
6 Manage priority MNS their care
conditions
11 Follow-up with

Chapter 3. Define competencies

Skills
7
Provide psychosocial people with MNS Skills provide a higher level of analysis and
support as part of conditions application of knowledge in MNS care. They are
managing MNS the focus of a competency-based curriculum.
conditions
A competency-based 12 Engage
curriculum in by
is driven self-care adequately perform MNS care tasks following PSE.
learning objectives tied to real-world health needs. The attitudes, knowledge, and skills underpinning
The first step in developing one is to identify the each of these competencies is also defined.
MNS conditions relevant to the country’s health
These competencies apply to all the priority
system and associated MNS care tasks (i.e. the
conditions of WHO’s Mental Health Gap Action
tasks that doctors and nurses must perform
Programme (mhGAP)7 and are broad enough
when providing MNS care, such as administering
to likely apply to other MNS conditions. They
diagnostic tools, providing psychosocial support,
represent the minimum set of attitudes,
or referring families to community services).
knowledge and skills for MNS care, though not all
Chapter 3 of this guide defines 12 core will apply to every situation.
competencies that doctors and nurses need to

Core competencies for MNS care

1 Demonstrate foundational 5 Assess for MNS 9 Adapt MNS care for people in
helping conditions populations with special needs (e.g.
pregnant women, new mothers, young
2 Provide rights-based care 6 Manage priority people, older adults, among others)
MNS conditions
3 Promote mental and brain 10 Refer people with MNS conditions
health, prevent/reduce 7 Provide psychosocial appropriately and in a timely
harms due to substance use support as part of manner and collaborate with other
and prevent/reduce risk of managing MNS health care workers in their care
priority MNS conditionsa conditions
11 Follow-up with people with MNS
4 Provide clinical emergency 8 Support carers of conditions
care for people with MNS people with MNS
conditions conditions 12 Engage in self-care

Attitudes Knowledge Skills

Attitudes are a person’s feelings, Knowledge provides the Skills provide a higher level
values and beliefs, which influence informational basis for of analysis and application of
their behaviours and performance of applying skills and performing knowledge in MNS care. They are
tasks. If students develop the right MNS care tasks. This the focus of a competency-based
attitudes identified (e.g. genuineness, includes knowledge about curriculum.
compassion, inclusivity, warmth, evidence-based interventions
respect and non-judgement) they for specific MNS conditions
will be better able to care for people as well as knowledge about
experiencing MNS conditions. public mental health.

a
MNS stands for mental health, neurological and substance use

7
The mhGAP priority conditions are: alcohol use disorders (AUDs), generalized anxiety disorder, panic disorder and panic
attacks, child and adolescent mental and behavioural disorders, post-traumatic stress disorder, dementia, depression, drug
use disorders (DUDs), epilepsy and seizures, psychosis and bipolar disorder, self-harm and suicide, and other significant
emotional problems and bodily distress.

xv
PSE-MNS guide

Chapter 4. Enhance the curriculum

The core competencies form the foundation and computer-based modules), offer safe
for shaping the enhanced curriculum, guiding environments for practising competencies, and
learning objectives and content. Chapter 4 gives help prepare students for evolving fields such as
examples of how situation analyses inform tele-mental health.
competencies and learning objectives; and
how these competencies then guide curriculum Select competency assessments
enhancement to meet identified needs,
• Assess all levels of learning that graduates
ensuring relevance to both students and the
must demonstrate to achieve full competence
health care system.
(knows, knows how, shows and does).
Key activities in this phase include planning • Use structured role plays to measure behaviours
learning experiences to shift attitudes, building in a controlled setting; and use real-world
knowledge and fostering skills, selecting observation to assess how students deliver MNS
assessment methods and training educators. care in practice.
• Complement role plays and real-world
Plan learning experiences
observation with tests for knowledge and
• Combine active learning with classroom-based attitudes to ensure a comprehensive evaluation.
teaching for competency development.
• Exposure to different health care settings Train educators
(community, primary, secondary and tertiary)
• Training educators is important to ensure they
is essential for practical learning. Where this is
can effectively deliver the enhanced curriculum.
not feasible, structured role plays can simulate
• Training approaches include self-directed
practice environments and provide valuable
learning (for experienced educators in
learning experiences.
MNS care), train-the-trainer models, and
• Team-based learning, such as group discussion,
senior-to-junior faculty mentorship, where
across disciplines is important to foster
postgraduates teach undergraduates with
collaboration, allowing students to develop
senior oversight.
broader competencies and build relationships
• Existing initiatives such as mhGAP can also be
that support integrated care models.
leveraged to train educators.
• Digital technologies can reduce resource
demands (e.g. through pre-recorded lectures

xvi
Executive summary

Learning experiences to shape attitudes, knowledge and skills

Shifting stigmatizing attitudes Knowledge building often Skills development is
around MNS conditions is relies on traditional didactic the central focus of a
difficult. The most effective teaching methods, but active competency-based curriculum.
strategy is social contact, learning strategies, such as It requires hands-on learning
where students interact with case-based and problem-based through digital technologies
individuals with lived experience learning, improve retention. or real-life clinical practice.
of MNS conditions. Research has Students can engage in role
Participatory methods such
shown that courses co-taught plays, simulations (virtual or
as flipped classrooms, where
by people with lived experience real-life standardized patients),
students lead research,
significantly reduce stigma. case studies, and clinical
presentations and seminars,
tasks through shadowing or
Other approaches, such as myth also enhance understanding
supervised clinical placements.
busting, experiential learning, and retention, laying the
peer and mentor support and groundwork for future Clinical placements should
community engagement and skills development. reflect students’ likely future
advocacy, can also contribute to work environments, such as
attitudinal change. primary care settings, and
involve supportive supervision.

Local organizations providing

community mental health
care can also serve as valuable
placement providers.

xvii
PSE-MNS guide

Chapter 5. Implement the curriculum

How an enhanced curriculum is implemented Monitor and evaluate
will vary by country and resources available
• Design M&E to track the curriculum’s
(especially time, funds and people) but includes
effectiveness in preparing graduates to
three key activities.
provide MNS care and drive continuous
Identify barriers and solutions curriculum improvement.
• Define key indicators to cover relevance of
• Common barriers include insufficient funding,
learning content, teaching methods and
educator shortages and resistance to change.
assessments; applicability to national context;
Limited access to technology and tight donor
curriculum structure, teaching quality and
deadlines can also add pressure.
student satisfaction; and changes in student
• Enablers include political and institutional
competencies and confidence.
support, early student and faculty involvement,
• M&E data can also be used to support
peer support, and environments that promote
and inform research on field testing a
mental health for both learners and educators.
newly enhanced curriculum, investigating
• Regular consultation with professional
the impact of specific recommendations
organizations helps keep curricula aligned
(e.g. involving co-educators with lived
with the latest evidence-based practices,
experience), or analysing cost–effectiveness. In
and robust feedback mechanisms ensure
resource-constrained settings, applied research
continuous improvement.
and small-scale studies documenting feasibility
and impact may be prioritized to mobilize funds
Choose an implementation approach
for bigger changes.
• In resource-constrained contexts, start small to
demonstrate value before scaling up.

Three tips for resource-constrained settings

Rethink teaching methods by Make small changes to existing Harness community resources
replacing traditional lectures courses, such as adding by involving people with lived
with participatory formats MNS-focused case studies, MNS experience as co-educators
(e.g. flipped classrooms modules or lectures and and partnering with local
and role-playing) and using expanding clinical placements organizations as clinical
self-directed online learning to beyond psychiatric hospitals to placement providers.
reduce resource loads. also include general hospitals
and other health care settings

xviii
 1
Introduction
PSE-MNS guide 1

1.1 Background
Mental health, neurological and substance use budget line for treating substance use disorders
(MNS) conditions are highly prevalent, affecting (9). What budget there is tends to go to hospital-
people across every community and age group in rather than community-based services (10).
the world, including children and adolescents. In
The lack of trained MNS health care workers
2021, around one in eight people were living with
in countries of all income levels worsens the
MNS disorders (1) (see Fig. 1.1). A considerable
treatment gap (11). Nearly half the world’s
number of people are also affected by broader
population lives in countries with fewer than one
MNS conditions – including psychosocial as well
psychiatrist per 200 000 people (7). Neurologists
as cognitive disabilities, and other mental states
and addiction medicine specialists are even
associated with significant distress, impairment in
scarcer (12, 9). Globally, the number of mental
functioning, and suicide or self-harm (2).
health nurses – who make up 44% of the global
These conditions cause significant disability mental health workforce – fluctuates, with only
(3, 4). They can also lead to early death, often slight increases observed since 2017 (7). And
co-occurring with physical illnesses (see Fig. 1.1). everywhere, the MNS specialist workforce that
does exist is often concentrated in cities and
In addition to the direct costs of treatment,
large hospitals away from rural areas, which puts
MNS conditions have indirect societal costs
services out of reach for many people.
such as reduced productivity and high
unemployment (2). People with these conditions Expanding the specialist workforce is important
face stigma, discrimination and human rights to reduce the MNS treatment gap, especially for
violations, including isolation, incarceration people with moderate to severe disorders. But
and ill-treatment. countries cannot rely solely on MNS specialists to
achieve UHC. They must look to other strategies,
There are many effective psychosocial and
including integrating prevention and care for
pharmacological interventions to prevent and
mild to moderate MNS conditions into the
treat MNS conditions, many of which can be
responsibilities of other health care workers,
quickly and easily delivered at relatively low costs
such as doctors (i.e. general practitioners,
(5, 6). At the population level, laws and policies
paediatricians) and nurses.
can help promote mental and brain health, avoid
harms due to substance use and reduce the risks Doctors and nurses are often the first to see
associated with the onset of MNS conditions. people with MNS conditions in the health
system, making them a valuable resource for
Yet despite the existence of effective treatments,
MNS diagnosis and care. They make up a huge
most people experiencing MNS conditions go
portion of the health care workforce and work
untreated because services are inaccessible,
in diverse settings, from hospitals and urgent
unaffordable, insufficient or of poor quality, or
care centres to primary care clinics, community
because stigma stops them from getting help.
health centres, long-term care facilities, schools
Governments allocate, on average, just 2% of
and even homes. They are well placed to identify,
health budgets to mental health (7). Only 12%
treat, care and support people experiencing MNS
of countries have a separate budget line for
health conditions (13).
neurological conditions (8). Even fewer have a

2 Photo credit (previous page): doctor standing in front of a bed in a hospital in a low-resource setting. Somalia, 2022 © WHO / Ismail Taxta
Chapter 1 Introduction 1

Integrating MNS diagnosis and care into the • promotes collaborative and
responsibilities of doctors and nurses has person-centred care (2);
many benefits. It: • allows for better recognition of physical
health problems;
• expands the workforce available for MNS care;
• keeps people close to their support systems for
• increases access to care;
better recovery; and
• reduces stigma and human rights
• is more likely to deliver positive physical and
violations (14, 15);
mental health outcomes (16, 17).

FIG. 1.1
MNS disorders are widespread and are major causes of disability and early death.

Prevalence
7.5% of children 400 million
1 billion people under 5 years have a
people (7% of people over 15
globally were living with a disorder contributing
years of age) have alcohol
mental disorder in 2021.a to developmental
use disorders (AUDs).c
disability.b

More than
64 million people Nearly 57 million 24 million
had drug use disorders people had dementia
people had epilepsy
(DUDs) in 2022.d in 2021.e
in 2021.e

Early death
The harmful use of Psychoactive
More than 720 000 alcohol caused around drug use caused
people died by suicide
in 2021.f
2.6 million 0.6 million
deaths in 2019. c
deaths in 2019.c

People living with severe mental disorders die

Dementia caused nearly
10–20 years earlier, often because two million
of unrecognized and untreated comorbidities, such as
deaths in 2021.e
cardiovascular disease.g

Sources:
a
IHME, 2021 (1). d
UNODC, 2024 (19). f
WHO, 2021 (20).
b
WHO and UNICEF, 2023 (18). e
GBD 2021 Nervous System Disorders g
Chesney et al, 2014 (21); Heiberg et al,
c
WHO, 2024 (9). Collaborators, 2024 (4). 2019 (22).

3
PSE-MNS guide 1

1.1.1 A focus on pre-service They can gain the competencies they need
through PSE (see Box 1.1) and in-service
education (PSE) training (including postgraduate education,
on-the-job training and continuous professional
For integration to work, doctors and nurses must development), and experience.
be equipped with the attitudes, knowledge and
All these types of learning are closely related (see
skills to competently provide high-quality MNS
Fig. 1.2). PSE and in-service training are necessary
care to people at all stages of life.1
to secure a competent workforce for MNS care

BOX 1.1
What is PSE in MNS care (PSE-MNS)?
In the context of this guide, PSE-MNS: • encourages teaching that is aligned
with WHO’s ICD-11;
• is done by medical and nursing students
• ensures a person-centred, recovery-oriented
during their first-degree in a university setting
and human rights-based approach to care;
(typically undergraduate education);
• forms the basis for later postgraduate education
• is multidisciplinary and focused on public
and other in-service training; and
health, conditions and people;
• is endorsed by health and education authorities
• covers care for MNS conditions, including MNS
and certification and regulation bodies.
disorders and related issues, that students
are likely to encounter once they enter
Good PSE in MNS care ensures that the
clinical practice;
competencies required to support people with
• covers aspects of, but is separate
MNS conditions are consistently addressed in
from, speciality programmes on
multiple learning activities across the curriculum,
psychiatry and neurology;
rather than just in dedicated psychiatry, neurology
• includes neuropsychiatry but not all aspects of
or mental health courses.
neurology (e.g. strokes and migraines);
• uses a competency-based framework; This understanding of PSE for MNS care aligns with
• includes practical training experiences; key WHO initiatives, such as the Mental Health Gap
• is evidence-based; Action Programme (mhGAP).

1
This includes the foundational helping skills that are a universal prerequisite for delivering effective psychosocial
and psychological care (and indeed all health care), and which lie at the heart of the WHO-UNICEF Ensuring Quality in
Psychosocial and Mental Health Care (EQUIP) project to strengthen quality in psychosocial and psychological training and
service delivery (see Box 4.8).

4
Chapter 1 Introduction 1

that continuously maintains performance over Those who go on to specialize in mental health
time (23). Where a workforce is specialized, nursing through postgraduate education will
including postgraduate education to ensure develop deeper competencies to navigate the
competency is equally important. For example, complex health, psychological, biological and
because all nurses are expected to contribute to social aspects of mental health. These advanced
mental health care, all nursing undergraduate competencies will likely go beyond diagnosis,
curricula should equip students with a set of basic treatment and management of MNS
foundational competencies for mental health conditions to include advocacy, leadership,
care. Those students that go straight into research, psychopharmacology, crisis intervention
service after graduating will continue to refine and the delivery of more advanced and scalable
these competencies through in-service training. psychological interventions (24).

FIG. 1.2
A system of continuous competency-based learning to ensure quality and
effective MNS care.

PSE-MNS In-service education

Postgraduate Continuous professional

education education for MNS care
Often undergraduate Including MNS specialties Short courses,
education. (e.g. psychiatry) and others self-learning materials,
(e.g. paediatrics, observation, supervised
gynecology, oncology etc). practice
(e.g. using mhGAP-IG).

Basic attitudes, knowledge Advanced and specialized Continuous learning refines

and skills develops knowledge and skills competencies required by
competencies required by deepens competencies all practitioners to keep
all practitioners to provide required by specialists to pace with evolving practice
quality and effective MNS provide quality and effective and provide quality MNS
care in general health care. MNS care at all levels care at level of both general
including in clinical settings. and specialized care.

5
PSE-MNS guide 1

Embedding MNS care into PSE is especially valuable. that do not – in terms of service users and care
– reflect the broader primary health care and
• It encourages doctors and nurses to take
community environments where many students
responsibility for MNS care early in their careers.
will work. This can reinforce stigma and neglect
• New graduates gain confidence in providing
person-centred, rights-based care.
MNS care and can be assessed for competence.
• Graduates are better prepared to address Commonly cited barriers to PSE in MNS care include:
physical, mental and brain health and
• overloaded curricula;
substance use issues holistically.
• resistance to change (e.g. by educators,
• Graduates can use postgraduate education
universities, professional boards and
and in-service training to build on their initial
ministries, and students);
training, rather than starting from scratch.
• insufficient resources, funding
• PSE reduces stigma (25) and can promote a
and infrastructure;
common understanding of MNS care among
• stigma and low prioritization of MNS conditions;
different categories of health professionals.
few clinical sites, placements and
• It ensures that MNS conditions are valued
mentors available; and
equally with other health issues.
• lack of standard, normative or
• It is a sustainable approach, supporting
evidence-based guidance and evaluations on
long-term development of the
pre-service curricula.2
health workforce (26).

As a result, learners may not achieve the

competencies needed for effective MNS
PSE in MNS care today
care. Conditions such as depression often go
PSE varies widely in how it is provided across and
undetected or are poorly managed by general
within countries (27). In 2020, only 44% of countries
health care workers (29). Person-centred,
reported using PSE to train health professionals in
rights-based care is rare (30). Health care workers,
providing MNS services (Mental Health Atlas 2020
often unintentionally, stigmatize people with
Survey, World Health Organization, unpublished
MNS conditions, which delays help seeking and
data, 2020), and about 10% lacked education on
compromises quality of care (31, 32). Graduates
substance use disorders (9).
are rarely equipped to provide emotional and
While many universities include MNS content in practical support so people experiencing MNS
their PSE (most often in the form of psychiatry conditions, including emotional distress, suicidal
and neurology programmes), it is often brief thoughts and self-harm, and social difficulties
and theoretical, lacking practical learning for often rely on other sources to receive care, such
real-world tasks (28). For example, students as families, school systems or specialists.3 The
may learn how to deliver evidence-based demand for specialist services has increased due
pharmacological interventions but may to Covid-related issues.
be insufficiently trained in applying basic
There is an urgent need to strengthen PSE to
psychosocial support skills. Traditional clinical
qualify doctors and nurses in MNS care and
placements often focus on severe cases in highly
improve the extent and quality of care for people
specialized settings (e.g. psychiatric or forensic
with MNS conditions globally.
hospitals, eating disorder units, inpatient settings)

2
For more information on pre-service implementation barriers and how to overcome them, see section 5.2.
3
For example, see: Provider core competencies for improved mental health care of the nation. Pretoria: Academy of Science of
South Africa; 2021 (https://research.assaf.org.za/items/f5a5fb05-11bf-4fcd-9fa8-2c48e44e2831, accessed 16 September 2024).

6 Photo credit (next page): Kitatumba nursing school in DRC, 2019. © WHO / Hugh Kinsella Cunningham
PSE-MNS guide 1

1.2 About this guide

This document offers practical guidance to assistants, health assistants, midwives, general
strengthen PSE in MNS care for medical and social workers, general occupational therapists,
nursing students worldwide. and other allied health professionals, as well
as family doctors and paediatricians) and in
postgraduate programmes within and beyond
1.2.1 Purpose and use mental health, brain health and substance use.

It is not meant for students already studying

Written for health care workforce decision-makers
mental health, brain health or responses
and educators, this guide outlines key activities
to substance use, for example first-degree
and considerations for better integrating
psychology or cognitive neuroscience students
MNS care into PSE.
and postgraduate students specializing in
Using a competency-based approach, it defines psychiatry, neurology, addiction medicine,
relevant learning outcomes and offers advice for mental health nursing or mental health social
enhancing existing curricula (although it can be work. It is also not meant for training community
used to develop new curricula if needed). While health workers, volunteers or in-service staff
focused on PSE, it can also be used with other (although some content may still be useful
WHO resources to support postgraduate and for these groups).5
in-service training programmes (33).
Doctors and nurses have distinct but
complementary roles in health care and

1.2.2 Scope must understand their own and each other’s

professional principles. Differences in traditions,
laws and population needs across the world mean
This guide focuses on educational approaches
that while the roles of doctors and nurses in MNS
to develop medical and nursing students’
care vary widely, they often overlap. Task-sharing
competence in promoting mental and brain health,
further blurs these boundaries, making roles
avoiding harm from substance use, and identifying
dynamic. In this context, it is essential for
and managing MNS conditions commonly found
enhanced curricula to focus on core competencies
in general health care settings. It focuses on MNS
across the entire health system, not just specific to
conditions that are widespread, disabling, costly
each profession.
and linked to human rights violations (6).4
This document speaks of medical and nursing
It does not cover broader public health strategies,
students together and presents guidance for both
such as universal promotion and prevention or
groups. While this broad approach is beneficial in
multisectoral initiatives to address the social
supporting integrated care across general health
determinants of MNS conditions.
settings (including primary health care), the
In targeting medical and nursing students, this guidance should be adapted to fit local cultural
guide is relevant for all countries. It may also and country contexts and regulations.
inspire improvements in the PSE of other health
care workers (such as clinical officers, medical

4
See Box 2.2 in Chapter 2 for a list of the priority MNS conditions addressed by the WHO Mental Health Gap Action Programme (mhGAP).
5
For training resources for community health workers, see: CHW Central [website]: https://chwcentral.org/training-resources-search.

8
Chapter 1 Introduction 1

1.2.3 Structure and overview do and defining the core competencies required
(see Chapter 3).
• Enhance the curriculum by specifying the
The remaining chapters focus on key activities
learning content, learning experiences,
across four phases of action to embed MNS care
and assessment methods that will be used;
competencies in first-degree medical and nursing
and training educators where necessary
curricula (see Fig. 1.3).
(see Chapter 4).
• Prepare and plan for curricular change by • Implement the enhanced curriculum using
analysing existing contexts, building awareness a context-relevant approach and use
and appetite among stakeholders and agreeing monitoring and evaluation to drive continuous
a work plan and budget (see Chapter 2). improvement (see Chapter 5).
• Define the parameters of change by identifying
MNS care tasks that doctors and nurses need to

FIG. 1.3
Four phases of action to embed MNS care competencies in first-degree medical
and nursing curricula.

PREPARE DEFINE DEVELOP/ENHANCE IMPLEMENT

Analyse existing Identify MNS care Set learning objectives. Decide implementation
situation. tasks for general Plan learning content, approach.
Advocate to health workers. experiences, and Address barriers.
stakeholders. Define core assessment. Monitor and evaluate
Agree a work plan and competencies Train educators. for continuous
budget. required. improvement.

CONTEXTUALIZE

Adapt content and processes to local contexts.

Translate to native languages.

9
PSE-MNS guide 1

1.2.4 Development methods associations. Participants shared their

experience and expertise to define key
The content for this document, including the list of competencies, curriculum content and
core competencies for MNS care provided in Table implementation strategies.
3.1 was developed in collaboration with partners, • Desktop review. A review of peer-reviewed
using an eight-step process. articles and grey literature on
competency-based education, including
• Scoping review. A review of the literature
academic publications, existing curricula,
on PSE in MNS care, covering 12 scientific
WHO programmes and publications,6 and
publications, 12 studies of mhGAP in
various international standards and national
PSE, 13 full university curricula, and nine
professional guidelines.7
curriculum summaries.
• Competency table. WHO staff developed an
• Expert consultations. Semi-structured
initial set of 51 competencies, defined them in
interviews and focus groups with 43
terms of attitudes, knowledge and skills; and
stakeholders across all six WHO regions,
then reduced them to 12 core competencies.
including academics, researchers, ministries
• Review. Multiple reviews of core competencies
of health and education, accreditation
for technical accuracy and alignment with WHO
and licencing bodies, medical and nursing
tools and international guidelines,6 first by WHO
societies, students and people with lived
staff, then by 63 global stakeholders.
experience of MNS care.
• Second expert group meeting. An
• Expert group meeting. A two-day workshop
international meeting with 27 stakeholders to
with 35 stakeholders from universities,
validate the 12 core competencies.
government health and education
• Finalization. Refinement of core competencies
departments, and professional and student
based on feedback from reviews.

6
For example: mhGAP training manuals (https://iris.who.int/handle/10665/259161), UHC compendium (https://www.who.int/
universal-health-coverage/compendium/database), Global competency and outcomes framework for UHC (https://iris.who.
int/handle/10665/352711), and EQUIP (https://equipcompetency.org/en-gb).
7
For example: International Council of Nurses guidelines on mental health nursing (https://www.icn.ch/resources/
publications-and-reports/guidelines-mental-health-nursing), World Psychiatry Association recommendations (https://www.
wpanet.org/_files/ugd/e172f3_831da6ddcfcf43a284c2afc1a1666589.pdf) and UK General Medical Council guidelines (https://
www.gmc-uk.org/-/media/documents/outcomes-for-graduates-2020_pdf-84622587.pdf).

10
 2
Prepare and
plan for change
PSE-MNS guide 2

Embedding MNS care competencies in PSE is situation analysis may come before appointing
essentially an exercise in curricular change. a CRC, which may be formal or informal. In
Success requires a clear purpose, stakeholder resource-limited settings, curricular change may
support and institutional capacity. Key activities start with small changes, or target only a small
are establishing a curriculum review committee cohort of students. Later, any successes can be
(CRC), doing a situation analysis to assess needs, used to drive further investment and expansion.
advocating and engaging stakeholders, and
Although curricular change is urgent because of
developing an implementation plan and budget.
large treatment gaps and workforce shortages,
Importantly, there is no single order in which to its timing relies on available resources, context
do these activities, and the depth to which each and university processes. You will likely need to
is completed will vary depending on context and align MNS-related enhancements with general
resources. So, for example, in some cases the university curriculum updates.

2.1 Pick a curriculum review committee

The CRC is responsible for planning and overseeing settings it may simply be an informal group.
the development and implementation of an enhanced Ideally, it should include representation from key
curriculum. Its diverse roles include: engaging stakeholder groups such as people with lived
stakeholders, building support and securing resources experience of MNS conditions, students and
(see section 2.3), planning and overseeing the process graduates, educators, policy-makers, health care
of curricular change (see section 2.4), and overseeing workers, and professional organizations such
monitoring and evaluation (see section 5.3). as nursing and medical associations. Different
stakeholders have different roles in supporting
The CRC may be established at national or
curricular change (see Table 2.1).
institutional levels. In resource-constrained

TABLE 2.1
Stakeholder roles in curricular change.

Stakeholder group Role in curricular change

Accrediting, licensing, Medical and nursing • Set accreditation criteria and guidelines for an
professional and boards, licensing boards, enhanced curriculum.
regulatory bodies ministries of health and/ • Use a competency-based approach and include MNS
or education, professional content in national board exams (or equivalent).
associations and societies.
• Align accreditation and licensing requirements.
• Audit the enhanced curriculum.

University Senates, faculty deans • Guide and approve curricular changes.

administration and councils, any • Promote change to university staff and students.
other staff responsible
• Oversee the process of curricular change.
for managing and
apprwoving curricula. • Liaise with accrediting bodies to get the enhanced
curriculum accredited and audited.

12 Photo credit (previous page): nurses doing paperwork at a health centre. Tajikistan, 2023 ©WHO / Mukhsin Abidzhanov
Chapter 2 Prepare and plan for change 2

TABLE 2.1 (continued)

Stakeholder group Role in curricular change

People with lived Service user groups • Identify gaps in current practice.
experience of MNS and people with lived • Provide feedback on proposals for an
conditions (and experience of MNS enhanced curriculum.
non-profit and advocacy conditions, their
• Help monitor and evaluate the enhanced
groups that work with families and carers
curriculum (including by providing feedback on
these populations) (formal and informal).
graduates’ competencies that can be reported
back to university and national boards).

University staff and Teaching staff, course • Where possible, join a multidisciplinary
external consultants coordinators, supervisors team to co-develop, deliver and assess the
(including pedagogical and heads of schools/ enhanced curriculum.
consultants, departments responsible • Promote curricular change to
faculty developers, for developing and colleagues and students.
health science delivering curricula.
• Monitor and evaluate the enhanced curriculum;
education researchers)
and make changes for continuous improvement.

Clinical placement Community-based health • Host clinical placements for the

institutes and care facilities, general enhanced curriculum.
supervisors hospitals, primary health • Provide supervisors and external staff for
care bodies, regional enhanced curriculum in-clinic activities
clinics and their staff and assessments.
and administrators.
• Help monitor and evaluate (including by
participating in pilot tests and evaluating
graduates’ competencies and reporting them to
the university and national boards).

Public and private health • Help define learning outcomes and competencies
Potential employers
care services and their needed for practice.
of graduates staff and administrators. • Help monitor and evaluate (including by
participating in pilot tests and evaluating
graduates’ competencies and reporting these
back to the university and national boards).

Learners Current students, • Provide feedback on enhanced curriculum

prospective students and proposals; and co-develop content.
recent graduates. • Help monitor and evaluate (including by
participating in pilot tests and providing
feedback of experiences during and after the
enhanced curriculum).

13
Chapter 2 Prepare and plan for change 2

Ideally, multiple representatives from each a multidisciplinary approach, which reduces

stakeholder group, especially people with teaching loads and means that students cover all
lived experience, are appointed to the CRC. aspects of MNS care (see Box 2.1). Educators may
Involving university administration and faculty need incentives to participate, for example extra
across different departments – such as general training or recognition towards recertification or
medicine and nursing, neurology, paediatrics, continuing professional development (34).
psychology and psychiatry – can help ensure

BOX 2.1
Lessons from Costa Rica: harnessing the power of a multidisciplinary CRC
In Costa Rica, at the University of Medical Sciences and assessments; and to teach the newly
(UCIMED), a multidisciplinary CRC from psychiatry, enhanced curriculum.
psychology, medicine, pharmacology, public
Sharing the teaching load across subject experts
health, and nutrition developed and delivered
reduced the resources needed for training and
an enhanced curriculum for undergraduate
ensured that students covered all aspects of MNS
medical students.
care. Each aspect of care was taught by subject
Led by the head of the psycho-pedagogy experts (for example, public health educators
department, the committee used the mhGAP covered the public health framework for MNS care,
intervention guide (mhgap-IG) as the basis for pharmacists taught the pharmacology of MNS
its work and adopted a collaborative approach care, and psychiatrists taught diagnostics etc).
to content creation. Committee members
The curriculum structure encouraged students
reviewed the guide through their area of
to see their future careers as part of an
expertise, integrating it with existing curricula
interdisciplinary MNS care team, reflecting the
and adding content. Each committee member
collaborative, multidisciplinary nature of MNS care.
was also invited to develop additional content
Source: Ana Carolina Paris de Zaidman, School of Medicine, Department of Psychopedagogy, University of Medical Sciences
(UCIMED), Costa Rica, personal communication, 26 November 2022.

Photo credit (previous page): doctors at an Ebola hospital in Nigeria, 2014. © WHO / Andrew Esiebo 15
PSE-MNS guide 2

2.1.1 Establish a shared vision • why curricular change is needed and what gaps
it will address;
• the target audience for curricular change (e.g.
A first task for the CRC is to develop a shared vision
nursing students, medical students);
that defines the purpose of curricular change to
• specific goals and objectives for an
guide the committee’s work. This vision should be
enhanced curriculum; and
developed with input from key stakeholder groups
• envisioned outcomes of an enhanced
and should specify:
curriculum (see Chapter 4).

2.2 Do a situation analysis

A situation analysis helps identify to what extent • the broader local, regional and national context
curricular change is necessary and feasible. It informs for setting and delivering these curricula, and
planning and implementation (see Table 2.2). It also the needs in health services that they should
guides the CRC in selecting competencies to be address (external situation analysis).
taught in the enhanced curriculum (see Table 3.1). It
includes gathering information about: Data for the situation analysis can be national,
regional or local (e.g. for a specific district
• existing first-degree medical and nursing
or setting). Information can be quantitative,
curricula and how they are implemented
qualitative or mixed. It should be as recent and
within the university, including educators’
specific to the context as possible.
competencies (internal situation analysis); and

TABLE 2.2
Types of information to gather in a situation analysis.

Internal situation analysis

• Learner objectives for developing MNS care competencies.
• Learning content and sources.
• Organization and sequencing (e.g. time spent on MNS care).
• Learning experiences and teaching methods.
The existing curriculum
• Assessment methods and formats (e.g. use of role plays or equivalent).
• Structure of course credits.
• Alignment with evidence-based, rights-based, person-centred care approaches.
• Any recent reports or evaluations of existing curriculum.

• Existing and potential resources for curriculum delivery (e.g. people, time,
Existing and potential funds, infrastructure).
resources within • Existing competencies of educators (to assess training needs).
the institution • Any plans to revise existing curricula.
• University guidance for curriculum reform.

• Attitudes toward MNS issues within the university (i.e. how educators and
Institutional context
students perceive people with MNS conditions and MNS care).

16
Chapter 2 Prepare and plan for change 2

TABLE 2.2 (continued)

External situation analysis

• Standards of MNS care and defined roles for doctors and nurses (e.g. policies,
strategies, legislation, prescribing privileges).

• Requirements for MNS care in first-degree medical and nursing curricula.

• Any recent reports or evaluations of medical and nursing curricula.

Standards, policies
and recommendations • Relevant legislation (e.g. on substance use, criminalization of suicide and
self-harm; mental health laws, voluntary and involuntary admissions).

• Context-specific limitations (e.g. alignment with governmental standards and

curricula, evidence, and national priorities).

• National MNS-related plans, policies and strategic framweworks.a b c

• Epidemiology of MNS conditions across the life course.c d

• Community needs for accessing MNS care.

MNS needs • Discrimination and stigma against people with MNS conditions.

• Cultural considerations (e.g. cultural expressions of MNS conditions or culturally

appropriate care such as from traditional and faith healers).

• Availability, accessibility, acceptability and quality of services for

providing MNS care.b c
Existing
• Guidelines, protocols and expectations for MNS care provided by
services for MNS care
doctors and nurses.

• In-service training in MNS care for doctors and for nurses.

• Existing and potential resources for defining, developing and delivering an

Existing and enhanced curriculum (e.g. clinical placement provider organizations, champions
potential resources for change, funding).
outside the university • Available and relevant training materials that could be adapted for the
enhanced curriculum.

Notes:
a
WHO MiNDbank provides an online database of national and regional policies, strategies, laws and service standards on
mental health, substance abuse, disability, general health, NCDs, human rights, development, children and youth, and older
persons. See: https://extranet.who.int/mindbank/.
b
The WHO Mental Health Atlas tracks progress in implementing WHO’s Comprehensive Mental Health Action Plan 2013–2030,
with information on mental health policies, resources and services. See: https://iris.who.int/handle/10665/345946.
c
The Global Information System on Alcohol and Health (GISAH) is a tool for assessing and monitoring the health situation,
trends and policy responses related to alcohol consumption and alcohol-related harm. See: https://www.who.int/data/gho/
data/themes/global-information-system-on-alcohol-and-health.
d
If there are no national epidemiology studies available, then modelled data are available from the Institute for Health Metrics
and Evaluation at: https://ghdx.healthdata.org.

17
PSE-MNS guide 2

2.2.1 Identify targets for 2.2.2 Tailor to context

improvement The external situation analysis helps prioritize and
tailor curricular change to context.
Embedding MNS competencies into PSE for doctors
and nurses typically involves enhancing an existing In all countries, this guide proposes that medical
curriculum, rather than building a new one. Only and nursing students be trained to competently
in some cases, for example the establishment of a care for the priority conditions in WHO’s mhGAP
new medical school, or a complete absence of MNS (see Box 2.2). It also suggests students should
education, will a new curriculum be necessary. be able to identify and respond to a broad range
of issues that may increase the risk of MNS
Targets for improvement that might emerge from
conditions, such as child abuse or bereavement
the situation analysis include:
(see Fig. 2.1). Addressing these social issues
• updating content to better reflect current evidence; will typically require collaborating with health,
• shifting towards a more biopsychosocial legal, social or other professionals, agencies or
model that emphasizes human rights and resources as they often extend beyond the scope
person-centered care; of nursing and medical practice.
• including contextual influences and
Students should also recognize and be able to
culture-related features of MNS conditions;
refer (but not necessarily be skilled to manage)
• involving service users in curriculum delivery;
people living with a wider range of conditions,
• adding more practical components or
such as obsessive-compulsive disorder, specific
competency-based assessments to strengthen
phobias, social anxiety disorder, and cerebral
experiential learning;
palsy. Additionally, students should be aware
• increasing the use of digital technology to
of context-specific differences in the concepts
support teaching and learning processes;
of mental health, brain health, substance
• training faculty to increase their MNS knowledge; or
use and MNS care.
• refining clinical placement settings.

BOX 2.2
mhGAP priority conditions

mhGAP focuses on priority MNS conditions that panic disorder and panic attacks, child and
represent a high burden in terms of mortality, adolescent mental and behavioural disorders,
morbidity and disability; cause large economic post-traumatic stress disorder, dementia,
costs; or are associated with widespread violations depression, drug use disorders (DUDs), epilepsy
of human rights. and seizures, psychosis and bipolar disorder,
self-harm and suicide, and other significant
The mhGAP priority conditions are: alcohol use
emotional problems and bodily distress.
disorders (AUDs), generalized anxiety disorder,

18
Chapter 2 Prepare and plan for change 2

FIG. 2.1
Social issues that increase the risk of developing an MNS condition.

Relationship Social or cultural environment

• Physical, sexual or psychological abuse • Social exclusion, rejection or isolation.
(including domestic gender-based violence and • Social, economic and gender inequalities.
intimate partner violence). • Injustice, discrimination or persecution.
• Child neglect and/or abuse. • Conflict and forced displacement.
• Elder abuse. • Climate crisis, pollution or
• End of relationship. environmental degradation.
• Harassment or bullying (including online). • Myths and misconceptions
about MNS conditions.
• Social norms that favour substance use.
Absence, loss or death of others • Easy access and advertisement of
• Bereavement. psychoactive substances.
• Disappearance or death of family • Cultural beliefs and practices that affect
member/close friend. health-seeking behaviour.
• Terminal diagnosis of family member.

Work
Family circumstances • Unemployment.
• Separation or divorce. • Discrimination in accessing or carrying
• Pregnancy, infertility, fetal exposure to out work.
psychoactive substance use, maternal • Poor working conditions.
reproductive and postpartum health
• Chronic workplace stress.
or new parenthood.
• Inadequate family support.
• Caregiver stress.
Health behaviours
• Financial pressures. • Hazardous alcohol and/or drug use.
• Adverse childhood experiences. • Hazardous gambling and/or gaming.
• Problems with diet, physical activity, hygiene
and/or oral health.
Exposure to potentially traumatic events • Poor health and help-seeking behaviours.
• Exposure to disaster, conflict or violence.
• Victim of (violent) crime or terrorism.
• Serious accident. Other
• Interpersonal or collective • Initiating opioid or other addictive painkillers
gender-based violence. as a response to acute or chronic disease.
• Sexual exploitation. • Dealing with difficult diagnoses.
• Irrational or inappropriate practices for
prescribing and dispensing medicines.
Education • Diversion of medicines with psychoactive
• Problems associated with low-level literacy. and dependence-producing properties
• Limited or interrupted education. to nonmedical use.
• Poor learning environments. • Problems with criminal justice.

Sources: WHO, 2024 (35); WHO, 2022 (2).

19
PSE-MNS guide 2

2.2.3 Find sources of This involves assessing their knowledge of MNS

conditions and care, position on change, interest,
support power, and leadership potential. Mapping
stakeholders onto a power–interest grid can guide
A key part of the situation analysis is evaluating their engagement (37).
resources to address capacity gaps, including
Understanding the perspectives of national
identifying funding for curricular change.
decision-makers, and university staff and
For example, the analysis may show that general management is especially important as these
nursing and medical faculty need training to stakeholders can make or break an enhanced
effectively deliver MNS-related content (see curriculum. If accrediting, licensing and regulating
section 4.5). Or it may point to other disciplines, bodies support stronger MNS care in first-degree
departments or external organizations skilled in curricula, it will ease the process. Similarly,
MNS care that can help co-develop and co-deliver university administrations that prioritize mental
an enhanced curriculum (see Box 2.1). and brain health and substance use prevention are
more likely to mobilize resources.

2.2.4 Understand your Engaging students is key to understanding

their mental health needs and priorities,
stakeholders identifying potential curriculum issues that
might lead to overload and excessive stress,
Part of the situation analysis should focus on and assessing the availability of mental health
learning about stakeholders to better understand services and resources for support. Involving
how curricular change might impact them, people with lived experience is also valuable for
gauge their support or resistance, identify curriculum development as well as for advocacy
conflicts of interest and determine how they and endorsement.
might contribute (36).

2.3 Advocate for and

secure endorsement
Achieving curricular change relies on ongoing • achieve widespread acceptance and meaningful
advocacy and engagement from diverse participation of those affected (including
stakeholders. Advocacy efforts aim to: students, people with lived experience of MNS
conditions and health care workers).
• raise awareness and understanding of the
need for an enhanced curriculum focused on
Advocacy goals and the level of endorsement
MNS competencies;
needed will vary by context and stakeholder group.
• secure support, consensus and endorsement
among key decision-makers;
• mobilize resources for curriculum development
and delivery; and

20
Chapter 2 Prepare and plan for change 2

2.3.1 Focus on levers for stories, they can help people better understand
MNS conditions and their economic, social and
change individual impacts and so build support for an
enhanced curriculum (39).
Building an investment case for promoting mental
Students and educators can also drive change by
and brain health, preventing substance use harms,
raising awareness of MNS conditions and lobbying
and supporting curricular change is often a critical
for stronger integration of MNS care into existing
first step in advocacy. This forms the foundation
curricula (see Box 2.3). Demand for curricular
for effectively engaging with stakeholders.
change can be built top-down, for example
Findings from the situation analysis may point to by influencing exam boards to include more
useful entry points or levers for change. content on MNS care in exit exams. Or they can
be built bottom-up through student and faculty
• Use national or regional policies or regulations
initiatives, such as by:
to argue for greater emphasis on MNS or
clinical practice. For example, the June 2018 • promoting self-care and MNS awareness
mental health law in the Philippines mandates on campus;
psychiatry and neurology as required subjects in • hosting events in universities and communities
all medical and allied health courses (38). to profile mental health, brain health and the
• Leverage mhGAP in countries where it is prevention of substance use harms;
well known and used for in-service training to • strengthening student associations’ capacity
disseminate information. Emphasize integrating to voice the need for MNS care to be integrated
MNS care into primary health care and other into the curriculum;
services and build buy-in for enhanced curricula • supporting university clubs related to mental
among health care workers and educators health, brain health and substance use; and
(including potentially through training, • increasing the weight of MNS components in
see section 4.5). formal student performance evaluations.
• Look for windows of opportunity provided
by favourable contexts or key events that Global experiences in integrating mental and brain
can provide the momentum for change. For health and substance use responses into PSE
example, emergencies, natural disasters and highlight the importance of engaging university
conflict, while tragic, can also represent an staff (40). Involving specialists, such as teaching
opportunity to capitalize on increased public psychiatrists, neurologists and advanced mental
and political attention to develop appetite health nurse practitioners, ensures content
for mental, brain and behavioral health and accuracy and encourages specialist community
workforce development. support (26). Non-specialist educators will
• Use institutional curriculum review need training to teach and assess an enhanced
cycles as a framework for reform and formal curriculum (see section 4.5).
opportunities to push for significant revisions.
Early engagement can help educators take
ownership of any new learning content,
Effective advocacy is a collective task. Champions
reducing the need for extensive preparation and
and collaborators, respected by their peers
endorsement later. Eventually, having a strong
and enthusiastic about MNS care, should be
curriculum on MNS care will boost institutional
recruited across stakeholder groups. People
reputation, which in turn will attract new faculty
with lived experience of MNS conditions can be
and students and generate funds for further
particularly valuable champions. By sharing their
investment in PSE.

21
PSE-MNS guide 2

BOX 2.3
Lessons from the Philippines: engaging student champions

In the Philippines, the Association of Philippine Sessions were well received by medical students
Medical Colleges – Student Network (APMCSN) across the Philippines. The APMCSN used their
was instrumental in improving MNS care training success to advocate for MNS care training at a
for medical students. In collaboration with the national event with deans from all 62 medical
Philippine Educational Theatre Association schools and faculties in the country. The network
(PETA) and faculty at the Ateneo School of then continued to lobby universities to include
Medicine and Public Health, APMCSN started the MNS-related content in medical curricula. Many
Semicolon Project, a series of workshops about students used the lobbying as a platform to speak
MNS conditions. out about their own mental health struggles.

These workshops combined informational The students’ efforts worked: one university
sessions with standardized role plays and practical developed a module on mental health; others
exercises where students could apply what they included mental health talks and seminars in
learned in a peer-to-peer context. Sessions went their curricula. One school set up a mental health
beyond MNS conditions to cover a broad array of wellness team and another launched a mental
psychologically distressing issues. The Semicolon health workshop. These changes were driven
Project sessions adapted to online formats during by student advocacy, but would not have been
the COVID-19 pandemic and several typhoons. possible without the support and collaboration of
university administrators and various stakeholders.
Source: Jean Rya Lim and Leandro Salazar, Association of Philippine Medical Colleges - Student Network; Fatima Barateta,
Philippines Student Organizations Coordinating Council; and Genquen Philip Carado, Philippine General Hospital Interns’
Council. Focus group discussion: the Philippines; 26 November 2022.

22
Chapter 2 Prepare and plan for change 2

2.4 Develop a work plan and budget

The situation analysis findings should be used to develop a work plan and budget that identifies the who,
what, where, how and when of implementing an enhanced curriculum (see Fig. 2.2).

FIG. 2.2
Typical components of a work plan for curricular change.

Target Budget Team

Competencies Contributors
Objectives Roles
Outcomes Responsibilities
Indicators

PREPARE DEFINE DEVELOP IMPLEMENT

Develop a work plan and budget

Planning Appoint a Mobilize available resources

Internal and external
multistakeholder CRC
situation analyses
with a shared vision

Secure endorsement through advocacy activities

Advocacy Identify stakeholders
Secure funding Stakeholders promote
PSE-MNS

Identify MNS care Set learning objectives

tasks and priority CONTEXTUALIZATION
Adapt to local contexts

conditions Develop learning

Enhancing the curriculum content, teaching
Develop list of methods and
competencies assessments

Pre-implementation Train the trainers Decide approach

Staggered roll out to

implementation deliver enhanced
curriculum

Monitor and evaluate

Maintenance enhanced curriculum

Timeline

23
PSE-MNS guide 2

International principles for educational (re)design Where teaching, funding, and time constraints exist,
recommend that work plans be (41, 23): the work plan for enhancing the curriculum might
comprise just a few quick changes (see Box 2.4).
• targeted, with clear and realistic objectives for
curricular change; The CRC should be responsible for developing,
• inclusive, developed with the meaningful monitoring and, where necessary, revising the
involvement and support of stakeholders, work plan and draft budget. To that end, the
including people with lived experience of MNS group will need to:
conditions and students;
• define the specific goals and objectives of
• informed by evidence and information about
curricular change;
MNS conditions and care in the local context (i.e.
• identify possible barriers and mobilize available
based on findings from the situation analysis);
resources (see section 5.2 and Table 5.1);
• competency-based, with all activities working
• list activities, inputs and deliverables across all
toward the achievement of attitudes, knowledge
phases of implementation;
and skills needed for professional roles;
• decide who will lead each activity;
• comprehensive in listing activities throughout
• cost activities and inputs;
implementation;
• identify and secure reliable funding;
• specific in defining roles, responsibilities and
• establish implementation indicators for the plan
realistic timelines for action; and
and track the status of each activity; and
• resourced based on realistic costings.
• create a monitoring and evaluation plan to
assess the curriculum’s success after launch
(see Chapter 5).

BOX 2.4
Practical tips for working in resource-constrained settings
In resource-limited settings, consider these tips • Integrate MNS-related content into
for quick curriculum enhancements. existing courses without waiting for formal
curriculum renewals.
• Focus on just a few core competencies (or
• Work with other faculties and schools to
underpinning knowledge, attitudes and skills)
maximize teaching resources.
rather than all of them (see Table 3.1).
• Partner with local organizations and
• Reorganize curriculum hours
stakeholders (consultants, people with lived
instead of adding more.
experience, clinical placement providers) to
• Make small changes to existing courses, such
deliver curriculum content.
as replacing case studies with those based
on MNS conditions.
For more information on implementing an
• Replace didactic teaching with self-learning
enhanced curriculum and practical tips for
or technologically supported methods to save
delivery in resource-constrained settings,
time in the curriculum.
see section 5.2.

24
 3
Define
competencies
PSE-MNS guide 3

3.1 Use a competency-based approach

In a competency-based approach, the curriculum medical errors, and increased patient safety
is driven by learning objectives that are informed (44, 45, 46). Compared with other educational
by real-world, context-specific health needs models, competency-based education promotes
and expectations (42, 43). These objectives better learner engagement and preparedness
are competencies linked to the MNS care for practice (47). By focusing on educational
tasks that medical and nursing students must outcomes, it provides greater transparency and
master by the time they graduate and join the accountability to learners, policy-makers, and
workforce (see Box 3.1). other stakeholders (48).

Competency-based education has long been A competency-based approach affects how

a focus of educational reform for health an enhanced curriculum is structured and
professionals (42, 43, 23). Implemented well, implemented. A defining characteristic is that
it can increase the quality of MNS and other the curriculum is learner centred. Students
health services and support students to develop learn by “doing”; and they are encouraged to
essential skills. Achieving and sustaining show what they have learned and mastered in a
competencies is associated with lower workforce variety of ways (49).
turnover rates, higher job satisfaction, reduced

BOX 3.1
Defining MNS care tasks and competencies
MNS care tasks are the tasks that doctors and performance of MNS care tasks (50). Competencies
nurses are expected to carry out to provide are durable, trainable and, through the expression
services for people with MNS conditions during of behaviours, observable and measurable. To tell
routine delivery of health care, including managing if someone is competent (proficient in applying
the issues in Fig. 2.1. competencies to tasks according to a pre-defined
standard), their behaviour must be observed and
MNS competencies are the abilities of medical
assessed while they carry out tasks. Competence
and nursing students and graduates to
is contextual, multidimensional and dynamic,
integrate attitudes, knowledge and skills in their
changing with time, experience and setting.

26 Photo credit (previous page): malaria vaccination campaign in Binava and Toumad. Côte d'Ivoire, 2024 © WHO / Amani, ADIDJ
Chapter 3 Define competencies 3

In practice, a competency-based approach to • Identify MNS care tasks. Determine the MNS
developing an enhanced curriculum for MNS care care tasks doctors and nurses need to perform
comprises four main activities. based on these conditions (see section 3.2).
• Select competencies. Choose the competencies
• Define MNS conditions. Identify the MNS
(and associated attitudes, knowledge and skills)
conditions (disorders, psychosocial issues, etc)
required for students to adequately perform
relevant to the country’s health system.8
these tasks (see section 3.3).
This is accomplished through the situation
• Tailor the curriculum. Design content, learning
analysis (see section 2.2).
experiences and assessments to help students
to achieve those competencies (see Chapter 4).

3.2 Identify MNS care tasks for

doctors and nurses
Doctors and nurses need to perform various tasks covered during later in-service training including
when supporting people with MNS conditions. These postgraduate education.
will vary by context and should integrate mental,
physical and social health care. Examples include:

• gathering information through assessments to

3.2.1 Consider your context
understand support needs;
Many MNS care tasks apply to both doctors and
• administering screening and diagnostic tools;
nurses but might vary in types of responsibility (for
• developing and adjusting treatment
example, a doctor may have to do more detailed
and recovery plans;
assessments). The specific MNS care tasks will
• providing medicines and monitoring
depend on local regulations, needs, resources and
their side effects;
available health services.
• providing psychosocial support;
• responding to crises; and The availability of specialists also influences
• referring families to specialist care or community task distribution. In contexts where doctors and
supports and services, as appropriate. nurses are supported by MNS specialists, or work
in teams for collaborative care, MNS care tasks
Some MNS care tasks are condition-specific, for become multidisciplinary activities with shared
example assessing for depression, or educating responsibility. By contrast, in contexts with limited
a person and their family about epilepsy. Others access to specialists, especially in rural or private
are cross-cutting, for example explaining health care settings, doctors and nurses often
confidentiality, encouraging self-care, providing taken on most MNS care tasks.
outreach, or addressing life-course needs, like
Interviews with educators, MNS specialists and other
those of children or older adults. Combatting
stakeholders highlight the diverse MNS care tasks
stigma is a universal task (39, 51). In first-degree
expected across different contexts (see Fig. 3.1).
medical and nursing curricula, MNS tasks should
be foundational, with more specialized tasks

8
Remember to consider all mhGAP priority conditions as well as any other nationally relevant MNS conditions (including
disorders and related issues).

27
PSE-MNS guide 3

FIG. 3.1
Examples of locally relevant MNS care tasks for doctors and nurses, as prioritized
by country stakeholders.

Detect depression, self-harm and suicide among children and

adolescents.
Support individuals experiencing psychological distress related to
GUYANA HIV or diabetes.
Do home visits to support people with AUDs.
Community outreach.

Identify clinically significant distress, substance use and self-harm.

Provide perinatal, child and adolescent mental health care and support.
Engage communities to promote and protect mental and brain health
and avoid harms due to substance use.
INDIA
Integrate traditional medicines and methods of care in mental health
care plans.
Link people to social insurance schemes.
Participate in monitoring activities to collect data.

Accurately detect mental health conditions.

Prescribe medicines.
ETHIOPIA Refer to specialists.
Communicate with individuals and families.
Reduce stigma through mental health advocacy.

Provide mental health care for children and youth.

Raise awareness of MNS conditions.
Administer culturally appropriate screening.
ZAMBIA
Deliver interventions for alcohol and substance use related conditions.
Deliver suicide prevention interventions.
Deliver remote support.

Sources: Ethiopia: Atalay Alem, Department of Psychiatry, University of Addis Ababa, Co-director of a WHO Collaborating
Centre, interviewed on 11 July 2022. Guyana: Nicole Nedd-Jerrick, Enmore Polyclinic, Georgetown Guyana, Head of Clinic
and Medical Practitioner, interviewed on 19 October 2022. India: Pratap Sharan, All Institute of Medical Sciences, Professor,
interviewed on 28 July 2022. Zambia: Kelvin Ngoma, REPSSI, Country director, interviewed on 5 August 2022.

The findings from the situation analysis can government policy. It will also identify existing
help identify relevant MNS care tasks, including resources for MNS services in the health system.
those that might be mandated or prioritized in

28
Chapter 3 Define competencies 3

3.3 Identify competencies required

To provide quality and effective care for people performing MNS care tasks (see Fig. 3.2).
with MNS conditions, doctors and nurses must Competencies are expressed as behaviours
be competent, i.e. they must be able to integrate that can be observed and measured when
relevant knowledge, skills and attitudes when performing MNS care tasks.

FIG. 3.2
Competencies comprise attitudes, knowledge, and skills integrated in the
performance of MNS care tasks.

Attitudes Knowledge Skills

COMPETENCIES

Observable behaviours

MNS CARE TASKS

The sections that follow define 12 core While curricula should ideally cover all 12 core
competencies that doctors and nurses need to competencies, some may require only minimal
adequately perform MNS care tasks following PSE enhancements or may focus on specific skills
(see Table 3.1). The attitudes, knowledge and skills (e.g. a course on psychological assessment). In
underpinning each competency are also defined. some cases, additional competencies may be
necessary for locally relevant MNS conditions,
These competencies apply to all mhGAP priority
such as conditions related to regionally specific
conditions (see Box 2.2) and are broad enough to
psychoactive substances (e.g. khat in Somalia,
likely also apply to other MNS conditions. They
tramadol in Northwest Syria, or heroin in
represent the minimum set of attitudes, knowledge
Afghanistan). Competency selection will be guided
and skills for MNS tasks in any clinical encounter,
by the situation analysis (see section 2.2).
though not all will be relevant in every situation.

29
30
TABLE 3.1
Core competencies required by doctors and nurses to effectively care for people with priority MNS conditions
across settings and tasks.
PSE-MNS guide

Competencies Attitudesa Knowledge Skills

1. Demonstrate Cross-cutting • What foundational helping skills are and • Use non-verbal communication and active listening.
foundational helpingb foundational why they matter. • Use verbal communication.
(applies to every clinical attitudes that apply to • Local cultural differences in communication, • Explain and promote confidentiality.
encounter) all competencies: help-seeking and expectations of care.
• Genuine. • Build rapport and support self-disclosure.
• Legal provisions on confidentiality and consent.
• Compassionate. • Explore and normalize feelings.
• Risk and protective factors for suicide.
• Warm. • Demonstrate empathy, warmth and genuineness.
• Psychoeducation topics for MNS conditions.
• Optimistic/hopeful. • Assess risk of harm to self and harm to or from
others and develop a collaborative response plan.
• Inclusive.
• Connect to social functioning and impact on life.
• Respectful.
• Explore the explanation of the problem from
• Non-judgmental.
the perspective of the person and their social
• Collaborative. support network.
• Involve family members and others appropriately.
• Collaboratively set goals and address
expectations (with the person, their caregivers
and other health care workers).
• Promote realistic hope for change.
3

• Incorporate coping mechanisms and solutions

that worked in the past.
• Provide psychoeducation and use local terminology.
• Get feedback when providing advice, suggestions
and recommendations.

Notes.
a
The definition of foundational helping is based on the Enhancing Assessment of Common Therapeutic (ENACT) competencies. See: https://equipcompetency.org/sites/default/
files/downloads/2022-07/ENACT_inperson_published_220321.pdf.
b
Attitudes are defined as a person’s feelings, values and beliefs, which influence their behaviours and performance of tasks. See: Mills J-A, Middleton JW, Schafer A, Fitzpatrick S,
Short S, Cieza A. Proposing a re-conceptualisation of competency framework terminology for health: a scoping review. Hum Resour Health. 2020;18(1):15. https://doi.org/10.1186/
s12960-019-0443-8.
 TABLE 3.1 (continued)

Competencies Attitudes Knowledge Skills

2. Provide rights-based • Foundational • What is involved in person-centred, • Promote respect, dignity and non-coercive practice.
carec attitudes (see above recovery-oriented rights-based care. • Promote the rights of people with MNS conditions
(applies to every clinical row 1). • Health care workers’ roles promoting and (including inclusion and participation in society)
encounter) • Non-coercive. protecting rights and preventing coercion, on an equal basis with others.
• Empowering. violence and abuse. • Address MNS-related stigma and discrimination,
Chapter 3 Define competencies

• Non-stigmatizing. • International and national human rights including by supporting people with MNS
standards and principles as applied conditions to overcome discrimination.
• Respect for rights of
to MNS conditions. • Respect the will and preference of and promote
individuals and their
families. • Legal limits of confidentiality. supported decision-making, access, recovery
• National legislation that protects the rights of and advance planning in the care of people
people living with MNS conditions and reporting with MNS conditions.
mechanisms for violations. • Identify ongoing or immediate risks of human
• Legal context related to MNS conditions rights violations against people with MNS
(e.g. illegal drug use and consequences; conditions and protect them from coercion,
criminalization of suicide). violence and abuse.
• Ethical approaches to health care and health care • Educate people with MNS conditions on
workers’ roles in promoting and protecting rights their rights and ensure informed consent for
and preventing coercion, violence and abuse. treatment plans.
• Educate families and any social care providers
on how to protect and promote human rights of
family members with MNS conditions.
3

• Assess the person’s capacity to understand,

endorse, retain, evaluate, and communicate
decisions relating to their care.
• Respect the person’s culture and their
endorsement of other potential health care options
(such as religious, faith or traditional healers).

c
The definition of rights-based care is based on QualityRights training materials. See: https://www.who.int/publications/i/item/who-qualityrights-guidance-and-training-tools

31
and https://www.who.int/teams/mental-health-and-substance-use/policy-law-rights/qr-e-training.
32
TABLE 3.1 (continued)

Competencies Attitudes Knowledge Skills

PSE-MNS guide

3. Promote mental • Foundational • Evidence-based strategies and interventions • Promote mental and brain health and prevent/
and brain health, attitudes (see above in prevention or reduction of harms due reduce harms due to substance use during
prevent/reduce harms row 1). to substance use, mental and brain health routine clinical care.
due to substance use • Proactive. promotion and MNS condition prevention that • Educate people with MNS conditions and their
and prevent/reduce can be offered during clinical care. families on healthy choices around diet, physical
risk of priority MNS • Risk factors (particularly reversible ones) and activity, sleep, and on risks associated with
conditions determinants of MNS conditions. alcohol and drug use.
• Other health-related problems associated with • Educate people with MNS conditions and
MNS conditions, e.g. sleep problems, obesity, their families on mental health, brain health
social isolation or withdrawal and substance use. and substance use and early warning signs of
• Suicide prevention strategies and interventions. priority MNS conditions.
• Other health conditions that can lead to increased • Educate people with MNS conditions and their
rates of different MNS conditions. families on suicide prevention strategies and
early warning signs of suicidal behaviour.
• Early childhood development and
socio-emotional skills learning. • Promote social connection and activation of
social networks.
• Community outreach and awareness raising
strategies and opportunities. • Promote early childhood development and
socio-emotional skills learning among children
and adolescents.
3

4. Provide clinical • Foundational • Emergency protocols and best practice (e.g. • Assess and manage emergency presentations
emergency care for attitudes (see above related to suicidal behaviour, self-harm, common in priority MNS conditions (e.g.
people with MNS row 1). aggression, convulsions, substance use), those related to self-harm, suicidal behaviour,
conditions • Solution-focused. covering both non-pharmacological and aggression, convulsions, substance use),
pharmacological interventions. covering both non-pharmacological and
• Calm and composed.
• National standards, legislation and regulations pharmacological interventions.
for emergency response.
 TABLE 3.1 (continued)

Competencies Attitudes Knowledge Skills

5. Assess for MNS • Foundational • The steps of MNS assessment. • Obtain presenting complaints.
conditions attitudes (see above • Mental status and neurological examinations. • Assess physical health (history, physical
row 1). examination, laboratory tests).
• Common presentations of MNS conditions.
• Deliberate. • Conduct mental status and
• Clinical assessment techniques (e.g. clinical
• Determined. interviewing, laboratory testing) and specific neurological examinations.
Chapter 3 Define competencies

clinical assessments (e.g. assessment of • Assess for physical symptoms of MNS conditions
cognitive decline and behavioural/psychological (and vice versa).
symptoms for dementia). • Assess personal and family history
• Local idioms and concepts of distress, local of MNS conditions.
help-seeking behaviours and local explanatory • Conduct psychosocial assessment (e.g. of
models for priority MNS conditions. stressors, psychological and environmental
• Methods for psychosocial assessment. resources, social, material and relational support
• Diagnostic criteria for priority MNS conditions needs, and social, structural and economic
and differential diagnoses (including symptoms, barriers/determinants impacting people with
syndromes, threshold and sub-threshold, acute MNS conditions).
and chronic presentations).d • Conduct specific clinical assessments, as
indicated (e.g. assessment of cognitive
decline and behavioural/psychological
symptoms for dementia).
• Conduct and interpret results of screening for
3

substance use related health risks.

• Identify the problem and/or priority MNS
condition and make differential diagnosis.d

33
Local law will vary on what nurses and doctors are licensed to do.
34
TABLE 3.1 (continued)

Competencies Attitudes Knowledge Skills

PSE-MNS guide

6. Manage priority MNS • Foundational • Non-pharmacological techniques for specific • Collaboratively plan treatment and recovery
conditions attitudes (see above priority MNS conditions. (with the person, their caregivers and other
row 1). • Essential medicine prescription and ongoing health care workers).
• Considered. management (education on benefits, harms, • Manage physical health comorbidities and risk
• Determined. duration and adherence; laboratory monitoring of factors in people with MNS conditions.
specific medicines). • Provide (psycho)education to individuals and
• Recovery-oriented.
• Guidelines for managing symptoms that may caregivers for priority MNS conditions.
• Critical attitude to
be associated with MNS conditions, e.g. sleep • Provide psychosocial support (see row 7 below).
consider the value
problems, pain, obesity, enuresis.
and limitations of • Provide non-pharmacological techniques for
different psychosocial • Guidelines for managing side effects of medicines. specific priority MNS conditions (e.g. individually
and pharmacological • How to start and end care. tailored brief interventions for substance use
interventions. conditions, brief problem-solving techniques,
advice on behavioural activation for depression;
cognitive stimulation for dementia; counselling
on physical activity for depression).
• Offer essential medicines for priority MNS
conditions if indicated.d
• Depending on local regulations and scope of
practice, rationally prescribe any medicines
with psychoactive and dependence
producing properties.d
3

• Manage symptoms that may be associated

with MNS conditions, e.g. sleep problems, pain,
obesity, enuresis.
• Manage any side effects of medicines.d
• Keep clinical records of assessment,
management, referral, and follow-up
throughout care.

d
Local law will vary on what nurses and doctors are licensed to do.
 TABLE 3.1 (continued)

Competencies Attitudes Knowledge Skills

7. Provide psychosocial • Foundational • Social resources in the community. • Identify and explore social stressors, difficulties,
support as part attitudes (see above • Problem solving counselling techniques. impact of social determinants, and support
of managing MNS row 1). needs (e.g. relationship problems, employment/
• Professional and legal responsibilities related to
conditions • Values psychosocial livelihood issues, housing, bereavement,
maltreatment, abuse and neglect.
support. receiving a difficult diagnosis, education,
• Biopsychosocial impact of stress. social welfare).
Chapter 3 Define competencies

• Recovery-oriented.
• Guided self-help materials and techniques. • Collaboratively identify ways to address social
• Solution-focused.
• Specific stress management techniques. difficulties and link to relevant social resources
(with the person, their caregivers and other
health care workers).
• Where appropriate, accommodate or collaborate
with traditional or faith healers.
• Assess and manage situations of maltreatment,
abuse and neglect.
• Offer guided self-help or refer to
mutual support groups.
• Teach stress management.
• Strengthen social (interpersonal) supports.

8. Support carers • Foundational • Role of carers in supporting people • Provide psychosocial support to carers
3

of people with MNS attitudes (see above with MNS conditions. (see row 7 above).
conditions row 1). • Impact of priority MNS conditions on caregivers. • Provide (psycho)education on MNS conditions
• Values carers’ • Where to refer to for resources for carer to carers, including self-care and when to seek
contributions and training and support. additional care.
needs. • Refer carers with MNS conditions,
• Carer support resources and methods for
selected conditions (e.g. for dementia, where appropriate.
developmental disabilities). • Empower and engage carers in
decision-making as appropriate.

35
36
TABLE 3.1 (continued)

Competencies Attitudes Knowledge Skills

PSE-MNS guide

9. Adapt MNS care for • Foundational • Risks and special considerations in caring for • Apply specific protocols for deciding on
people in populations attitudes (see above populations with special needs. medicines for populations with special needs.
with special needs row 1). • Medicine interactions and contra-indications in • Provide indicated management for populations
(e.g. pregnant women, • Non-discriminatory. populations with special needs. with special needs.
new mothers, young
• Principles and approaches for child-, youth- and • Apply principles of child- family- and older
people, older adults,
family-centred care. adult-centred care.
among others)e

10. Refer people • Foundational • Available MNS specialists and their roles. • Refer to other health care workers where needed.
with MNS conditions attitudes (see above • Referral procedures and options for MNS • Refer for indicated psychological interventions
appropriately and in row 1). specialist care, psychological interventions and (e.g. brief, manualized, evidence-based
a timely manner and support from community resources (e.g. social interventions based on approaches or specialist
collaborate with other services, employment support, harm reduction delivered cognitive behavioural therapy (CBT)).
health care workers in services, legal aid, mutual help groups). • Refer for indicated specialist care, including
their care
• Barriers to accessing care and help-seeking (e.g. pharmacological interventions if necessary
lack of privacy, limited opening hours, lack of (e.g. opioid agonists maintenance treatment,
youth-friendly services). uncontrolled seizures).
• Refer for support and resources in the community
(e.g. social care services or harm reduction
services for people using drugs).
3

• Collaborate with other health and social care

workers in providing care, the person with an
MNS condition and their caregivers.

e
Populations with special needs may include, for example: children and adolescents; older adults; pregnant women and new mothers; people with learning, intellectual and
other disabilities; neurodiverse people; people who identify as LGBTIQ+; people exposed to intimate partner violence and sexual violence; migrants and/or refugees; people living
with HIV or other comorbid conditions, people in contact with the criminal justice sector, people experiencing homelessness, people who identify as ethnic minorities, etc.
 TABLE 3.1 (continued)

Competencies Attitudes Knowledge Skills

11. Follow-up with • Foundational • Importance of follow-up. • Monitor and assess for change in symptoms
people with MNS attitudes (see above • Frequency of follow-up for different and functioning.
conditions row 1). interventions/clinical scenarios. • Monitor and assess for change in physical health.
• Proactive. • Barriers and facilitators to MNS • Monitor and assess for change in environmental
• Realistic. treatment adherence. or social circumstances and support needs.
Chapter 3 Define competencies

• Flexible. • Monitor management of priority MNS conditions.

• Monitor, assess and support adherence to
treatment and recovery plan.
• Collaborate with people with MNS conditions,
and, based on their will and preference, other
relevant health care workers, family members
and/or caregivers to continue with treatment and
recovery plan or adapt it.

12. Engage in self-care • Proactive. • Signs and symptoms of excessive stress. • Engage in healthy choices around diet, physical
• Self-compassionate. • Techniques and approaches for self-care and activity, alcohol and drug use, and sleep.
• Insightful. stress management. • Engage in self-reflection to identify personal
• When and where to seek additional support for impacts of stress.
• Warm.
stress or other challenges at work. • Practice self-care and stress
• Genuine.
management techniques.
3

• Respectful.
• Maintain professional boundaries between work
• Non-juudgement. and personal life.
• Optimistic/hopeful. • Seek social and other support, including MNS
care, where necessary.

37
PSE-MNS guide 3

Just as the care tasks expected of doctors and communicate a provisional diagnosis and then
nurses may differ, the required competencies for either provide care or arrange for a referral – all
each group can vary based on local or national while supporting the person’s rights. This requires
scope of practice. Even where knowledge and multiple competencies.
skills overlap, they may be taught differently in
Other competencies such as decision-making,
each curriculum (see Chapter 4).
teamwork, and commitment to lifelong learning
Competencies often interrelate. Any one clinical are also important for MNS services, even if
encounter may involve several MNS care tasks, they are not included in Table 3.1. WHO’s Global
which in turn will require several competencies. competency and outcomes framework for UHC (23)
offers a complementary reference for shaping
For example, in a single interaction, the same
curriculum content. Leadership and advanced
doctor or nurse may have to build rapport,
collaboration competencies are likely covered in
gather information, assess, interpret results,
postgraduate courses.

38
 4
Enhance
the curriculum
PSE-MNS guide 4

In this chapter, we provide the building blocks for 117 outcomes related to MNS care (52). The 12 core
curricular development or enhancement using competencies in this guide can be matched to these
the core competencies set out in Table 3.1. Each predefined topics and outcomes, which include the
competency describes a broad learning objective doctor–patient relationship, mental health, alcohol
(e.g. providing rights-based care, assessing for MNS and substance use, and psychiatric emergencies.
conditions, or supporting carers of people with MNS
Where learning objectives are not externally set,
conditions). These objectives guide the attitudes,
curriculum development or enhancement can be
knowledge and skills that form the basis for learning
more flexible. Competencies can be selectively
content. Together, the 12 core competencies
integrated to strengthen individual courses or
represent the minimum set of learning objectives
programmes. For example, an undergraduate
that are likely to be relevant across most countries.
nursing course may already cover all the knowledge
In some countries, national guidelines dictate components of core MNS competencies and may
learning objectives to standardize outcomes for only need new content to develop attitudes and
medical and nursing graduates. In these cases, the skills. Meanwhile, a paediatrics course might
core competencies can be aligned with national focus only on child mental health competencies.
requirements. For example, the Medical Council of A comprehensive review of medical and nursing
India has introduced competency-based education curricula (see Chapter 2) will guide decisions on
for medical students, outlining 19 learning topics and which competencies to integrate and where.

4.1 Set learning objectives

Table 4.1 gives examples of how needs identified
in the situation analysis inform competencies and
broad learning objectives.

TABLE 4.1
Examples of how needs identified in the situation analysis inform competencies
and learning objectives.
Example (adapted) competencies
Need identified in MNS care tasks required to required to perform MNS care
situation analysis meet need tasks = broad learning objectives

Depression is Identify depression symptoms (and any 1. Demonstrate foundational helping.

common but not related somatic symptoms).
2. Provide rights-based care.
always identified
in health services Use psychosocial and clinical assessment 5. Assess for MNS conditions (depression
tools to identify people with depression. in this example).
Recognise contributing factors and 6. Manage depression.
social determinants of depression during
7. Provide psychosocial support as part
clinical formulation.
of managing MNS conditions (depression
Make a diagnosis. in this example).

Community outreach to encourage

help-seeking behaviour.

40 Photo credit (previous page): medical students in a lecture hall. Zimbabwe, 2011 ©Africa University
Chapter 4 Enhance the curriculum 4

TABLE 4.1 (continued)

Example (adapted) competencies
Need identified in MNS care tasks required to required to perform MNS care
situation analysis meet need tasks = broad learning objectives

Substance use Take physical and history examinations, 1. Demonstrate foundational helping.
is a pervasive social perform screening for substance
2. Provide rights-based care.
issue that leads use-related health risks.
to high rates of 3. Promote mental and brain health,
substance use Identify and explore social stressors, prevent/reduce substance use harms
disorder difficulties, impact of social determinants and prevent/reduce risk of priority
and support needs. MNS conditions (hazardous use of
substances or substance use disorders
Educate individuals about risks in this example).
associated with substance use. 5. Assess for MNS conditions (hazardous
use of substances or substance use
Provide individually tailored brief disorders in this example).
interventions for people with substance
7. Provide psychosocial support and
use conditions and arrange access to
pharmacological treatment as part of
further treatment for those in need.
managing MNS conditions (substance
use disorders in this example) or arrange
Refer to other services such as social referral to specialized care.
services, housing etc.

Follow up to reduce substance use harms.

People with MNS Educate individual about medicines. 1. Demonstrate foundational helping.
conditions do not
2. Provide rights-based care.
always adhere to Offer prescriptions with clear instructions
their prescribed and educate on side effects. Ensure 6. Manage priority MNS conditions.
medications informed consent. 8. Support carers of people
with MNS conditions.
Collaborate with carers.
11. Follow-up with people
with MNS conditions.
Follow up to encourage adherence.

People with Refer to appropriate specialists or 1. Demonstrate foundational helping.

MNS conditions community services and supports.
2. Provide rights-based care.
sometimes get lost
on referral pathways Collaborate and communicate with other 10. Refer people with MNS conditions.
in community health care workers. appropriately and in a timely manner.
settings and do not 11. Follow-up with people
always receive the Follow up with other health workers. with MNS conditions.
care that they need
Collaborate with carers.

41
PSE-MNS guide 4

After setting broad learning objectives, more economic interventions and community
specific objectives can be developed based on the supports, including their purpose and access
attitudes, knowledge and skills needed for each points (knowledge);
competency (see Table 3.1). These components • recognize when referral is needed, refer people
guide the curriculum’s content, learning for psychological interventions, specialist
experiences and assessments. care or community supports as indicated, and
promote collaboration between health and
For example, if the broad learning objective is
social care workers (skills).
to ensure professionals can refer people with
MNS conditions appropriately and promptly,
Assessing learners’ competencies may include
the specific learning objectives (and so
evaluating component attitudes, knowledge and skills
learning content and experiences) will focus on
as well as overall competence as expressed through
supporting students to:
behaviours when practising MNS tasks. In the example
• be genuine, compassionate, warm, optimistic, above, assessments would involve observing and
inclusive, respectful, non-judgemental and measuring students’ behaviours as they refer people
collaborative (attitudes); with MNS conditions, either in structured role plays or
• understand available specialist services in supervised real-world settings (see section 4.4).
and lifestyle, psychological, social and

4.2 Structure learning content

An enhanced curriculum can be structured using In most cases, adapting existing modules or
horizontal integration across disciplines, vertical adding new ones may be necessary to ensure the
integration across time, spiral integration across both, curriculum is competency-based.
or a combination of these approaches (see Box 4.1) (53).
Enhanced curriculum modules can be organized
It is common and advisable to choose an approach by related competencies (e.g. assessment and
that breaks content down into manageable chunks management) across all priority MNS conditions
– for example, modules – that make it easier for (see Fig. 4.2) or by individual MNS conditions, with
students to navigate the content and achieve each module covering all relevant competencies
competencies (54). for each condition (see Box 4.2).

The existing curriculum for medical and nursing Each module would consist of several learning
students may already be structured into modules sessions, each with their own learning content
that can easily incorporate MNS care content. based on the subset of competencies that need
Some content – especially the knowledge to be achieved and the attitudes, knowledge and
components – may even already be covered. skills underpinning them (see Table 3.1).

42
Chapter 4 Enhance the curriculum 4

BOX 4.1
Lessons from India: integrating medical education at AIIMS

Since 2019, the National Medical Council (NMC) medicines, while afternoons cover clinical
of India has emphasized integrating disciplines knowledge and skills. This fusion is expected to
in undergraduate medical education to promote enhance students’ understanding, retention and
holistic, person-centred care. At the All India application of knowledge.
Institute of Medical Sciences (AIIMS) in New
Now AIIMS is looking to strengthen its efforts
Delhi, psychiatry is integrated both vertically and
through: horizontal integration across community
horizontally into medical education.
medicine and psychiatry (on issues ranging from
Even before NMC’s recommendation, AIIMS had burden of disease to disaster management);
begun integrating practical psychiatric teaching and vertical integration, embedding psychiatric
into undergraduate courses. Second-year training in the teaching of attitudes, ethics and
medical students take two courses that blend communication in areas associated with stress (e.g.
pharmacology and psychiatry: the management end of life issues and palliative care), stigma (e.g.
of psychotic and manic disorders; and the HIV-AIDS and other sexually transmitted infections)
management of anxiety and depression. Mornings and managing complex conversations (e.g. difficult
focus on the pharmacology of psychotropic diagnoses or hostile or uncooperative individuals).
Sources: Pratap Sharan and Nishtha Chawla, All India Institute of Medical Sciences, personal communication, 19 April 2024;
Sood and Sharan, 2011 (55).

43
PSE-MNS guide 4

FIG. 4.2
Modules can be organized by competency.
MODULES

Screening, Managing Promotion

Referral and
Introduction assessment MNS and
follow up
and diagnosis conditions prevention

1. Demonstrate foundational helping

2. Provide rights-based care

4. Provide clinical emergency care for people with MNS conditions

12. Engage in self-care

COMPETENCIES

8. Support carers and caregivers of people with MNS conditions

5. Assess for 7. Provide psychosocial support as part of managing MNS

MNS conditions conditions

6. Manage 10. Refer 3. Promote

priority MNS appropriately mental and
conditions and in a timely brain health,
way. prevent/reduce
harms due
9. Adapt MNS to substance
care for people 11. Follow-up use and
in populations with people prevent/reduce
with special with MNS risk of priority
needs conditions MNS conditions
CONDITIONS

AUDs, anxiety, child and adolescent mental disorders, conditions related to stress,
dementia, depression, DUDs, epilepsy and seizures, psychosis and bipolar disorder,
self-harm and suicide, other significant emotional and medically unexplained
somatic complaints.

44
Chapter 4 Enhance the curriculum 4

BOX 4.2
Lessons from integrating mhGAP-IG into university curricula

In 2018, WHO hosted three consultative the four countries, these enhanced curricula were
meetings and later a three-day workshop introduced for undergraduate and postgraduate
on enhancing pre-service curricula using the medical and nursing students. In Kyrgyz Republic,
mhGAP intervention guide (mhGAP-IG) for legislative changes and support were needed
decision-makers and clinical educators from before mhGAP-IG modules could be introduced.
medical universities in Armenia, Georgia, Kyrgyz Lecture plans were adjusted, reducing didactic
Republic and Ukraine. Participants discussed how sessions while maintaining or increasing practical
best to incorporate mhGAP-IG, with a focus on sessions, group activities and self-study.
the module on child and adolescent mental and
Evaluations of the enhanced curricula one
behavioural disorders.
year after they were implemented showed that
Following the workshop, each university adapted the mhGAP-IG modules were well received by
its curriculum, integrating different mhGAP-IG students and contributed to increased mental
modules based on their specific needs. Across health awareness.
Source: Pinchuk I et al, 2021 (56).

Learning content in an enhanced curriculum will interventions can be used to manage AUDs and
generally apply across all priority MNS conditions. DUDs and understand which public policies
For example, self-help interventions that doctors are effective in preventing them. By the end
and nurses can deliver are relevant to multiple of the curriculum, students will need to show
conditions, including depression, anxiety and they can provide appropriate brief psychosocial
AUDs and DUDs (57). interventions and medicines, refer for other
treatment if necessary, monitor treatment and
Some condition-specific content is also necessary,
promote mental and brain health and avoid harms
including evidence-based interventions for each
due to substance use to prevent relapse.
priority MNS condition. For example, part of
learning to assess for substance use conditions Table 4.2 offers examples of WHO-recommended
includes learning how to screen and deliver evidence-based interventions for each mhGAP
brief interventions for harmful and hazardous priority condition, with a broader list available
substance use (e.g. the Alcohol, Smoking and in the mhGAP evidence resource centre (59). All
Substance Involvement Screening Test (ASSIST)) doctors and nurses should at least be aware of
(58). That means students need to understand these interventions to apply them within their
the health risks of psychoactive substances, practice or make appropriate referrals. Note that
know how to assess patterns of use and tailor while stigma or other local factors may lead to an
interventions to the level of risk. They should emphasis on certain conditions, WHO suggests
also know which medicines and psychosocial covering all priority MNS conditions in PSE.

45
PSE-MNS guide 4

TABLE 4.2
Examples of evidence-based interventions recommended by WHO for mhGAP
priority conditions.

Priority MNS condition WHO-recommended evidence-based interventionsa

Alcohol and/or drug use • Screening and brief interventions for harmful and hazardous substance use
disorders (AUDs and (e.g. Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) and
DUDs) Alcohol Use Disorders Identification Test (AUDIT)).
• Structured and standardized psychosocial interventions for substance use
disorders (e.g. CBT, contingency management, motivational interviewing and
motivational enhancement interventions, community reinforcement and
family-oriented approaches, mutual-help groups).
• Medicines for substance use disorders (benzodiazepines to manage alcohol
withdrawal; thiamine to prevent Wernicke’s encephalopathy; baclofen,
naltrexone, acamprosate and disulfiram to treat AUDs; opioid agonists
(methadone, buprenorphine) and antagonists (naltrexone) to manage opioid
dependence; naloxone to prevent opioid overdose).
• Harm reduction services for people using drugs, including needle and syringe
programmes, testing and counselling for infectious diseases, low-threshold
community outreach.

Anxiety • Structured physical exercise.

• Stress management techniques, including relaxation and mindfulness training.
• Brief, structured psychological interventions, including those based
on CBT principles.
• Antidepressants for adults, including selective serotonin reuptake inhibitors.

Child and adolescent • Interventions to manage maternal depression.

mental disorders • Interventions for children with intellectual disabilities, such as
beginning-to-read interventions.
• CBT and interpersonal psychotherapy for children and adolescents with
emotional disorders, and caregiver skills training for their caregivers.
• Caregiver skills training for caregivers of children and adolescents with
developmental, behavioural or emotional disorders.
• Referral to or consultation with a specialist to explore initiation of fluoxetine in
combination with psychological treatments in adolescents (13–17 years) with
moderate to severe depression when psychosocial interventions alone have
proven ineffective.
• Structured physical exercise to improve motor skills and executive functioning,
and to reduce anxiety and problem behaviours in children and adolescents with
attention deficit hyperactivity disorder (ADHD).

Notes.
a
Evidence profiles and further recommendations can be found in WHO’s mhGAP evidence resource centre at https://www.who.
int/teams/mental-health-and-substance-use/treatment-care/mental-health-gap-action-programme/evidence-centre.

46
Chapter 4 Enhance the curriculum 4

TABLE 4.2 (continued)

Priority MNS condition WHO-recommended evidence-based interventions

Conditions related to • Stress management training, including relaxation training.

stress • Psychological interventions, including CBT with a trauma focus and eye
movement desensitization and reprocessing.
• Serotonin reuptake inhibitors and tricyclic antidepressants when stress
management and psychological interventions have failed or are unavailable.

Dementia • Non-pharmacological interventions, including CBT, cognitive stimulation therapy

and cognitive training.
• Physical activity interventions (30–45 minutes of physical exercise 3–4 times per
week for more than 12 weeks).
• Psychosocial interventions for carers of people living with dementia,
including mindfulness-based interventions, multicomponent interventions,
psychoeducation and psychotherapy/counselling. Respite care
should be considered.
• Cholinesterase inhibitors for people with mild to moderate Alzheimer
disease; and memantine for those with moderate to severe Alzheimer
disease and vascular dementia (memantine should not be prescribed for
Lewy Body dementia).
• Dietary advice for people at risk of undernutrition.

Depression • Brief, structured psychological interventions, including CBT, interpersonal

therapy, behavioural activation therapy, third wave therapies, and
problem-solving treatment.
• Advice on regular physical activity.
• Antidepressants for moderate to severe depression, including serotonin reuptake
inhibitors and tricyclic antidepressants.

Epilepsy and seizures • Intravenous lorazepam or diazepam for acute convulsive seizures in adults and
children, where intravenous access is available.
• Intravenous medicines – fosphenytoin, phenytoin, levetiracetam, phenobarbital
or valproic acid (sodium valproate – except for women/girls with childbearing
potential) – with monitoring, for adults and children with established status
epilepticus, i.e. seizures persisting after two doses of benzodiazepines.
• Monotherapy with lamotrigine or levetiracetam, or valproic acid (sodium
valproate), as first-line treatment for generalized onset seizures in adults,
adolescents and children (but valproate in women/girls with childbearing
potential should be avoided). Monotherapy with lamotrigine or levetiracetam as
first-line treatment for focal onset seizures in children and adults with epilepsy.
• Psychological interventions, including relaxation therapy, psychoeducation and
treatments based on CBT principles, as adjunctive treatments.
• Information and advice on avoiding high risk activities and providing relevant
first aid, given in a culturally appropriate and sensitive manner.

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PSE-MNS guide 4

TABLE 4.2 (continued)

Priority MNS condition WHO-recommended evidence-based interventions

Psychosis and bipolar • Oral or long-lasting injection antipsychotics, such as haloperidol, paliperidone
disorder and risperidone.
• Mood stabilizers, e.g. lithium and valproic acid (except in women/girls with
childbearing potential) for bipolar mania.
• Psychosocial interventions for individuals and their families or carers, including
psychoeducation, medicine adherence therapy and life or social skills training.
• Psychological interventions, including CBT.
• Recovery-oriented strategies to enhance community and economic inclusion,
such as assisted living or supported employment.

Self-harm and suicide • Assessment for self-harm or suicide.

• Interventions based on principles of safety planning.
• Regular contact and follow up.
• Problem-solving approaches.
• Where there is imminent risk or occurrence of self-harm, prioritize removing any
means of suicide and provide urgent referral to a mental health service.

Other significant • Psychological interventions based on CBT principles to manage bodily

conditions and bodily distress complaints.
distress complaints • Pharmacological interventions.
• Psychosocial interventions, such as psychoeducation.
• Self-help interventions and mutual support groups.

As well as knowing about specific interventions Students should also be competent in assessment
for managing mhGAP priority MNS conditions, and first-line management of:
graduates will also be expected to know about
• neurological conditions not covered by
other MNS conditions so that they can accurately
mhGAP or this guide, such as stroke, migraine,
identify and refer people experiencing them.
meningitis and Parkinson disease;
The list of these conditions will vary by • other physical health conditions common
country and may include eating disorders, among people with psychoactive substance
obsessive-compulsive disorder, phobias or use, such as HIV, hepatitis C, gastrointestinal
disorders due to addictive behaviours (such as diseases, cardiovascular disease and
gaming or gambling). Students should know what pulmonary disease; and
each condition is and how it typically presents, • cases where maternal health, pregnancy and
how prevalent it is and what effective treatments breastfeeding might impact MNS conditions.
are available, but not necessarily how to deliver
them. They should be skilled in recognizing these Care and support for people with these conditions
conditions and know about relevant referral are not covered in this guide but are expected to be
services (see Table 4.3). covered elsewhere in medical and nursing curricula.

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Chapter 4 Enhance the curriculum 4

Additionally, medical and nursing students should socio-economic consequences, benefits of care,
have a general understanding of public mental common misconceptions and prevailing attitudes
health, including social and biological determinants and beliefs, including stigma in both the community
of MNS conditions, their disease burden and and health care workforce (see Table 4.3).

TABLE 4.3
Knowledge requirements for medical and nursing students.

Type of knowledge Content

Knowledge of priority MNS • Basic science (including neuroscience, behavioural science, social science)
conditions (e.g. conditions of MNS conditions.
covered in mhGAP) as defined • Everything listed in the knowledge column of Table 3.1.
by WHO’s ICD-11a
To achieve core competencies

Knowledge of other MNS • Common presentations and diagnostic criteria.

conditions (e.g. conditions • Effective treatments (awareness of what these are but not necessarily how
beyond mhGAP) as defined to deliver them).
by WHO’s ICD-11a
To inform
recognition and referral

Knowledge of public health • Core concepts in mental health, brain health and substance use (e.g.
relevant to MNS conditionsb classification and diagnostic systems, mental health on a continuum,
A base for all practice relationships with physical health, life course approach, social indicators
and outcomes of mental health).
• Epidemiology of MNS conditions (prevalence, incidence, age of onset,
course, determinants, gender differences, treatment gap).
• Impact/disease burden of MNS conditions.
• Benefits of preventing and caring for MNS conditions (e.g. improved
public health, reduced human rights violations, social and
economic development).
• Stigma, discrimination and human rights.
• Policy and relevant legislation.
• Population-based prevention and promotion.
• Service models including team-based care, multidisciplinary teams and
referral and counter-referral systems.
• Roles of specialists (in service and in multidisciplinary teams).
• National guidelines on MNS care tasks for doctors and nurses.
• Evidence-based strategies and policies to promote workplace mental
health (for doctors and nursing students who become managers/leaders in
the health system).

Notes.
a
See WHO, 2024 (35).
b
Key sources of information include: WHO, 2022 (2); and Stewart et al, 2024 (24).

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PSE-MNS guide 4

4.3 Plan learning experiences and

teaching methods
There are many ways of supporting students to Good curricula combine educational approaches
develop core competencies. Learning experiences and tools to shape attitudes, build knowledge
may be face-to-face or online, facilitated or and foster skills (see Fig. 4.3). They support
self-directed, theoretical or practical. Different diverse learning styles and are culturally sensitive,
learning experiences suit different types and reflecting local backgrounds and realities. Time
levels of competency. spent on different learning experiences and
teaching methods may vary between medical and
nursing students.

FIG. 4.3
A mix of practical and didactic learning experiences to consider.

BUILDING CHANGING DEVELOPING AND

KNOWLEDGE ATTITUDES APPLYING SKILLS

Books
Awareness
and journal Shadowing
campaigns
articles

Experiential
Case studies
Statistics exercises
and
and facts
simulations

Contact
Clinical
Theory-based with people Role
The media practice
lectures with lived plays
tasks
experience

Didactic Practical

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Chapter 4 Enhance the curriculum 4

Combining active learning and practical Team-based learning, such as small group
experiences with classroom-based teaching is discussions and group work, bring multidisciplinary
important (see Box 4.3). students together to develop cross-cutting
competencies. These experiences empower
While resources such as class size may limit
students in their education. They also help build
options, in some cases it may be possible to
transferable skills and foster relationships that
expose students to different practical experiences,
support collaborative models of care. Group
for example in community, primary, secondary
work can happen in and out of the classroom.
and tertiary health care settings. Where this is not
For example, at Ajman University’s College of
feasible, innovative methods such as structured
Medicine in the United Arab Emirates, student
role plays can recreate practice environments.
psychology clubs are supported by a faculty
Simulation-based education, which involves
member but function outside the classroom. They
interacting with real or virtual scenarios, has
host discussions on MNS-related topics to deepen
been shown to enhance undergraduate medical
students’ knowledge and understanding, engage
students’ attitudes, knowledge and skills although
the university community, and organize public
it can be expensive and difficult to implement
events to raise mental health awareness (Alfreda
at scale (60, 61).
Stadlin, Ajman University College of Medicine,
personal communication, 13 March 2024).

BOX 4.3
Lessons from Norway: strengthening nursing students’ competencies in MNS care
At Lovisenberg Diaconal University College in in primary and specialist health care services.
Oslo, core competencies for mental health care Before starting, students have two weeks
are integrated into the undergraduate nursing of studies that blend theoretical knowledge
curriculum, with clear progression objectives teaching with hands-on learning, including by
for each of the three years. A mix of didactic and practising specific skills using simulations, medical
practical learning experiences build students’ equipment and interactive technology. The goal
knowledge and skills, in line with European Union is to build students’ confidence and competence
and national regulations that require at least half in mental health care before they enter more
of nursing training hours to be in clinical training, formal practice.
including in mental health and psychiatry.a
During clinical placements, students focus on
Students interact with people experiencing MNS further developing their attitudes, knowledge and
conditions throughout their studies. In their skills to provide good and compassionate care for
third year, they complete an eight-week clinical people receiving various forms of treatment and
placement in psychiatry and mental health care psychosocial support.
Notes.
a
See: Directive 2005/36/EC of the European Parliament (https://eur-lex.europa.eu/eli/dir/2005/36/oj); and Norway Ministry of
Education Regulations on national guidelines for nursing education (https://lovdata.no/dokument/LTI/forskrift/2019-03-15-412).
Source: Espen Gade Rolland, Lovisenberg Diaconal University College and Norwegian Nurses Organization, personal
communication, 22 April 2024.

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PSE-MNS guide 4

4.3.1 Harness digital • include electronic portfolios and web or mobile

applications to showcase learning over time and
technologies track progress and performance. For example,
the University of Alabama at Birmingham (UAB)
Digital technologies bridge theoretical knowledge uses a mobile tool to link bedside competencies
with practical skills, strengthening medical with overall performance (see Box 4.4); and
education and improving quality of care provided • can gather data on the effectiveness of the
after graduation (62). Different types of digital curriculum to inform adjustments (64).
technologies can be used to support an enhanced
curriculum in different ways. Digital tools are also valuable for preparing
students for the growing field of tele-mental
Basic digital technologies:
health and mobile and wireless technologies
• reduce resource loads through pre-recorded for health (mHealth). In tele-mental health, MNS
lectures, computer-based modules, online care is provided remotely via video call, phone
learning materials or assessments, and call or messaging. mHealth uses smart phones,
self-learning environments; tablets and wearable devices to similarly deliver
• facilitate communication between students remote MNS services, monitor service users, and
and supervisors through online lectures, support prevention and management of MNS
video conferencing and group discussion or conditions. The skills and knowledge required for
messaging applications; and these activities fit well into a competency-based
• may be especially useful in resource-limited curriculum (65).
settings and for self-paced learning, giving
The benefits of using digital technologies for
students better control over their time
teaching and learning are clear; but it comes with
and study content.
budget considerations. The human and financial
costs of technology and training must be assessed
Advanced digital technologies:
in terms of context, implementation process and
• enable observations of live or recorded real-life available funding.
sessions with service users;
• provide safe environments for students to
practise their competencies and explore 4.3.2 Shape attitudes
and experience real MNS-related situations
such as emergency responses and individual Attitudes are fundamental to how we learn and
interactions; and apply knowledge and skills. In general, despite
• can use augmented or virtual reality to offer cultural differences in attitudes, if students
innovative interactive learning via simulations, develop the attitudes identified in Table 3.1 (e.g.
gamifications, virtual clinical placements,9 and genuineness, compassion, inclusivity, warmth,
artificial intelligence driven role plays (63, 64). respect and non-judgement) they will be better able
to care for people experiencing MNS conditions.
Digital assessment tools:
Attitudes are potentially the hardest element of
• range from online quizzes to complex objective competency to teach; and changing stigmatizing
structured clinical examinations software; attitudes is difficult, especially in the medium
to long term (66).

9
Virtual clinic placements provide a simulated practice setting that is delivered remotely online to give students practical
experience of care.

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Chapter 4 Enhance the curriculum 4

BOX 4.4
Lessons from the USA: mobile app tracks progress in clinical training
At the UAB Heersink School of Medicine, a mobile and validated scale that scores students on their
application is used to evaluate and track third-year ability to perform skills independently.
medical students’ progress during clinical
The app has a curated list of expected
placements, including four-week psychiatry
behaviours for supervisors to observe, which
placements. This “clerkship app” was developed
helps standardize student feedback and makes
by existing personnel (without external resources)
assessments more objective and comparable
who repurposed software that the university was
across different clinical settings.
already licensed to use.
Scores are viewable on a dashboard, helping
Students log routine caregiving tasks, called
clinical placement directors monitor students’
“observable professional activities (OPAs)” on the
progress and ensure they meet curriculum
app. These include core skills, such as capturing a
requirements. The school also uses the data
focused history, conducting a physical and mental
to identify areas of the curriculum that need
status examination and doing an oral presentation.
strengthening. Students can also track their
Clinical supervisors observe and provide formative progress and focus on areas needing improvement
feedback through the app, using an evidence-based to achieve competency.
Source: Winter Williams and James Willig, University of Alabama at Birmingham Heersink School of Medicine, personal
communication, 24 April 2024.

‘Social contact’ strategies that emphasize • Engage people with lived experience of MNS
recovery and get students to interact with people care as co-educators to teach and evaluate
with lived experience of MNS conditions (and their students together with or separately from other
families) are the most effective means of shifting faculty (see Box 4.5).
attitudes and reducing stigma (67, 68, 69). They
can be implemented in different ways. Social contact between students and people with
lived experience may be done in person or online.
• Ask staff (or graduates) to talk about their
Providing space for both formal and informal
own lived experience of MNS conditions.
interactions is important. If live interactions are
• Invite individuals and families to share
not possible, social contact through photographic
their lived experience through presentations,
narratives or pre-recorded films, podcasts or
seminars and question-and-answer sessions.
social video platforms can also be useful.
• Link to local organizations such as
Alcoholics Anonymous. In all cases, people sharing their lived experience
• Use digital tools such as Moving Stories ,the in an enhanced curriculum should provide their
Dutch game-based school programme that informed consent. They should also be:
combines video gaming with social contact to
• assured of confidentiality;
reduce stigma (70).

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PSE-MNS guide 4

• paid on an equal basis with other • Faculty training to develop positive attitudes
professionals; and leads to modelling behaviours that promote
• given safeguards and boundaries for their effective MNS care (see section 4.5).
engagement. Some people may need support • Safe learning environments enable students
in preparing to tell their story and to answer to discuss MNS conditions, share personal
difficult questions, as well as support afterwards. experiences and seek support for their own
mental health, which fosters a culture of
Research on mhGAP and anti-stigma training has openness and empathy (76).
shown that attitudes are particularly sensitive to • Community engagement and advocacy
change in courses that are co-taught by people empowers students to challenge stigma and
with lived experience (71, 72). These “experience advocate for mental and brain health and
consultants” or “experts by experience”: prevention of substance use harms in their
communities (77).
• help students recognize, evaluate and change
their own stigmatizing attitudes and practices;
• reduce anxiety, increase empathy, spark
connections and deepen understanding 4.3.3 Build knowledge
of recovery (73);
• teach students how to support individuals Building students’ knowledge provides a vital
facing stigma and promote ethical awareness of basis for applying skills and performing MNS care
their own role in challenging stigma; and tasks. While students may already know about
• inspire students to explore MNS-related issues some concepts in an enhanced curriculum, their
that exacerbate stigma, such as homelessness, application in MNS care may be new. For example,
sex work and social inequalities (74). students may know how to take a family history
but not how to do so for MNS conditions. Similarly,
Beyond social contact, other approaches in and they may understand diagnostic criteria for MNS
out of the classroom can be used to shape and conditions but not know how to perform a mental
shift attitudes. status exam to accurately diagnose a condition.

• Myth busting targets unconscious biases and The depth of required knowledge varies across
corrects false beliefs through information disciplines. Medical and nursing students who will
sharing, role play (including with actors), and make clinical diagnoses or prescribe medicines in
awareness campaigns. Tools to support myth their future roles need a much firmer grasp of basic
busting in an enhanced curriculum include the sciences, differential diagnosis, and pharmacology.
WHO QualityRights e-training (see Box 4.6).
Knowledge building often relies on didactic
• Experiential learning through
learning, but active learning approaches such
community-based clinical placements provide
as case-based and problem-based learning
real-world social contact and can enhance
methodologies enhance retention (78).
students’ understanding and empathy towards
people’s varied needs and situations. Learning materials should be up to date, evidence
• Peer and mentor support facilitate role based, and relevant to the country and setting
modelling of positive attitudes and values, where the curriculum will be implemented.
guiding students in reflecting on experiences, Materials from one socioeconomic setting may
challenging stigma, and help seeking (75). need adaptation for others. All learning materials
should come from trustworthy sources.

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Chapter 4 Enhance the curriculum 4

BOX 4.5
Lessons from READ: shifting attitudes through direct social contact

READ (Responding to Experienced and Anticipated • personal recovery stories from the experts by
Discrimination) is an anti-stigma training for experience to show how recovery can mean
medical students promoted by the INDIGO different things; and
Network (https://www.indigo-group.org) and • role plays of experienced and
people with lived experience of MNS conditions anticipated discrimination.
(experts by experience). Its social contact
approach combines methods proven to improve READ aims to help medical students reduce
attitudes and understanding, such as multiple discriminatory behaviours and interact more
forms of contact with experts by experience; and a effectively with people with MNS conditions.
focus on recovery. Between 2016 and 2019, READ was implemented
in 13 medical schools across 10 countries, adapted
Key elements of READ include:
to fit local cultures and resources. Evaluations
• co-delivery of the training by an expert by showed positive changes in knowledge, attitudes
experience and a psychiatrist; and skills among medical students, with increased
empathy as a key factor in improving students’
behaviours and reducing stigma.
Sources: Deb et al 2019 (51), Potts et al 2022 (71).

BOX 4.6
WHO QualityRights: changing attitudes to improve the quality of MNS care
QualityRights (https://qualityrights.org) is a global end coercive practices like seclusion and restraint
initiative designed to improve the quality of care in and emphasize respecting individual preferences.
mental health and related services and to promote
QualityRights also offers global e-training for
the rights of people with psychosocial, intellectual
health workers, policy-makers, community
and cognitive disabilities. It works at the ground
members and people with lived experience of MNS
level to change attitudes and practices, as well as
conditions and their carers. The e-training covers
through policy to create sustainable change.
how to support a person’s own mental health and
The initiative provides capacity-building resources that of others, and how to promote human rights
to combat stigma and discrimination, and promote to help tackle stigma, discrimination, abuses and
human rights and recovery. Its training materials, coercion. A 2023 evaluation showed significant
toolkits and practical guidance help health care positive shifts in attitudes towards human rights,
workers and others build knowledge and skills to especially on issues of legal capacity, treatment
choice, and coercion.
Sources: WHO, 2019 (79); WHO, 2024 (80); Poynton-Smith et al, 2023 (81).

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PSE-MNS guide 4

Participatory methods such as flipped classrooms Developing skills is the central focus of a
– including student-led research, presentations competency-based curriculum. This requires an
and seminars – can also improve understanding emphasis on practical, hands-on learning through
and retention, aiding skills acquisition later on. digital technologies or real-life clinical practice.
Options include:

4.3.4 Foster skills • role plays and simulations (including real-life or

virtual standardized patients);
• real or mock case studies; and
Where knowledge provides the informational basis
• practising clinical tasks by shadowing
for tasks, skills represent a higher level of analysis
doctors or nurses (see Box 4.7) or through
and application of knowledge in MNS care.
clinical placements.

BOX 4.7
Lessons from the Philippines: building skills through clinical experience
At the Ateneo de Manila University School of • identify salient features and establish and
Medicine and Public Health, third year medical justify a working diagnosis for the child;
students hone their skills for MNS care, among other • outline how to appropriately manage the
medical experiences, through a series of practical child’s situation; and
learning sessions known as Clinical Experiences. • apply concepts in public health, prevention and
The Clinical Experiences comprise a series of 10–12 health care management.
sessions spaced across the year, in which groups
of four students join faculty members who are also In pairs, and supervised by the clinician, students
practising clinicians for four hours to meet people interview each child and family for an hour to get
receiving care and their family members. a history; and perform a physical examination
of the child. They then observe the clinician
Each faculty member leading a Clinical Experience
disclose a diagnosis and are coached to deliver
sets their own learning objectives and activities
any recommendations to the family, including
for their session; but all focus on practising clinical
any diagnostic tests and psychoeducation. Once
tasks and developing skills for delivering care.
the children and families have left the clinic, the
For example, for students encountering children
students come together for a case discussion on
with neurodevelopmental concerns, the Clinical
the salient features, pathophysiology, assessment
Experience typically covers two cases. Learning
and management of the children seen that day.
objectives are to:
The Clinical Experiences are designed to expose
• practise taking a child’s history and conducting
students to a diverse range of conditions before
a physical examination;
they enter their clerkship year where they join
health care teams in hospital settings.
Source: Angel Belle Dy, Ateneo de Manila University, personal communication, 30 December 2023.

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Chapter 4 Enhance the curriculum 4

Clinical placements should reflect students’ interventions, use of Friendship Bench tools,
likely future workplace (e.g. primary health care and self-care (Walter Mangezi, University
facilities) and include supportive supervision. of Zimbabwe, personal communication,
Local organizations providing community mental 16 April 2024).10
health care can also serve as clinical placement
In countries where clinical placements are
providers. For example, fourth year medical
set by national authorities, advocacy and
students at the University of Zimbabwe are
engagement with governments, universities and
placed with the nongovernmental organization
clinical placement provider organizations may
Friendship Bench, where they learn how to
be needed to change placement sites. Clinical
provide brief psychological interventions, with
placement providers and supervisors should
a focus on problem-solving therapy, for people
be involved in curricular changes and trained in
with common mental health conditions. Key
the skills required by the enhanced curriculum
topics covered include: psychoeducation,
(see section 4.5).
community mental health, psychological

4.4 Select methods of assessment

Assessment is a key part of any curriculum; and • know how to apply those attitudes,
assessing competence is critical for learners, knowledge and skills;
educators, universities, accrediting bodies, • can show how attitudes, knowledge and skills
employers and ultimately the community served. should be applied; and
Assessment can be used to guide student • actually do apply attitudes, knowledge and
learning, ensure quality control, verify that skills when performing MNS care tasks.
students have sufficient skills and knowledge
to apply in practice and evaluate whether MNS Different assessments can be used to measure
competencies are cross-cutting, inter-disciplinary these levels of learning (see Table 4.4); and
and applied widely in all care settings. Deciding various tools exist to develop them (33, 35, 80).
what to assess and what assessment methods The first two levels (‘knows’ and ‘knows how’)
to use can have a big influence on what students test cognition; the second two (‘shows how’ and
learn and how (which is why lobbying exam ‘does’) test behaviour. It is important to assess
boards to include more content on MNS care in all four levels of learning because the cognition
exit exams can be an effective top-down form of zone does not necessarily correlate with the
advocacy, see section 2.3). behaviour zone: knowing how to do something
doesn’t guarantee a learner will apply it in
In an enhanced curriculum, graduates must
practice. Comprehensive assessment ensures that
demonstrate all four levels of learning to achieve
graduates deliver quality and effective care to
full competence (82). They must show that they:
people with MNS conditions.
• possess the attitudes, knowledge and skills
underpinning core competencies;

10
See 5.2.1 Practical tips for resource-constrained settings in section 5.2 for more examples of how to harness community
resources to support skill development.

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PSE-MNS guide 4

TABLE 4.4
Assessment formats and how they can be used.

Level of learningᵃ Assessment formatᵇ Measurement ofᶜ

Attitudes

Knowledge

Skills

Behaviours
Does Supervised clinical practice.
Observed work with people with MNS
conditions in real settings.

Shows how Structured role plays.

Simulations.
Demonstrations (e.g. practice
psychometric assessment or
laboratory work).
Objective structured
clinical examinations.
Standardised encounters.

Knows how Real or simulated case studies.

Applied essays.
Applied examinations using case studies
and simulated scenarios.
Clinical problem solving.

Knows Multiple choice questions.

True-false questions.
Short and long answer tests.
Theoretical essays.
Student-led seminars.

Notes.
a
Levels of learning adapted from Miller, 1990 (82).
b
For more examples of potential assessment formats see Table 4.5 in WHO, 2022 (23).
c
= inferred measurement; = explicit measurement. Explicit measurement is direct and clearly represents its object of
measurement; inferred measurement is indirectly implied through another measured object and requires some interpretation.
Source: table adapted from WHO, 2022 (23).

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Chapter 4 Enhance the curriculum 4

Structured role plays measure behaviours in a specific competencies. Unpredictable factors,

controlled environment and can evaluate a wide confidentiality issues, physical settings, and the
range of competencies, not just clinical skills. comfort of service users may limit feasibility.
A common method is the objective structured
The WHO-UNICEF initiative EQUIP (Ensuring
clinical examination, which typically uses
Quality in Psychosocial and Mental Health Care)
trained actors. But structured role plays can
provides a range of competency assessment tools
also involve course instructors, supervisors, and
that can be used with structured role plays or in
peer learners. They can assess single or multiple
real world settings, as part of various types of
competencies; and can be tailored to all types of
training, including PSE (see Box 4.8).
culturally-relevant situations, making them ideal
for systematically assessing how well learners Role plays, real-world observation and other tools
perform MNS care tasks (83). assessing skills and behaviours can and should be
complemented by knowledge and attitude tests.
Real-world observation is also important and
Common knowledge assessments include written
the best way of assessing how students deliver
or oral examinations and essays.
MNS. But it is less controlled than structured
role plays and cannot be targeted to assess

BOX 4.8
EQUIP
EQUIP is a joint WHO-UNICEF initiative to assessing individual or multiple competencies,
assess and build competencies for delivering and includes a data visualization tool to track
effective psychological support to adults and learners’ competencies over time and quickly
children. It offers a variety of competency identify potentially harmful behaviours that
assessment tools and e-learning courses that need correcting.
cover both foundational helping skills and
Field tested for in-service training of
technique-specific skills, such as behavioural
non-specialists in low- and middle-income
activation, CBT, interpersonal techniques,
countries, EQUIP resources have been proven to
motivational enhancement, problem solving, and
reduce harmful behaviours and increase trainee
stress management.
competencies compared with conventional
The EQUIP platform (https://equipcompetency. training methods. Studies are ongoing to
org/) features adaptable structured role plays for apply EQUIP in PSE.
Sources: Kohrt et al, 2020 (84); Jordans et al, 2022 (85); Alipanga and Kohrt, 2022 (86); Ndeezi et al, 2023 (87).

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PSE-MNS guide 4

Assessing attitudes is more difficult. Empathy • knowledge tests take time to develop but are
scales and questionnaires, such as the Opening easily applied once established;
Minds Scale for Health Care Workers (OMS-HC), • role plays and simulations can be resource
can measures students’ attitudes before, during intensive to both develop and run but are also
and after training (88). The OMS-HC scale has structured, can be applied consistently and,
been found to be a reliable, valid and acceptable importantly, provide a controlled environment
measure of attitudes towards mental health for assessing target competencies; and
conditions (89).11 Other measures have also • observed work in real-world settings requires
been used to evaluate attitudes in the general close supervision but is the most authentic
population, including measures of stigma against assessment method of quality.
general or specific MNS conditions, MNS services
and self-stigma (90). Self-assessment and informal The choice of method will depend on resources
peer-to-peer assessment (e.g. real-time feedback available (including number and type of assessors
from group role plays) are also valuable for and assessment developers). It is also useful
gauging attitudes. to identify the assessment methods used by
other disciplines within the same school to
Assessments can be formative or summative.
promote consistency and efficiency. In all cases,
• Formative assessments offer timely, assessments should cover all learning levels
nonconsequential feedback that is integral (knows, knows how, shows how, does).
to learning throughout the curriculum
In general, when selecting assessment
to track progress and adjust learning as
methods, you should:
needed (see Box 4.4).
• Summative assessments are typically higher • be transparent (students and educators should
stakes evaluations (e.g. graded quizzes, essays, know what is being assessed, why and how);
exams, final projects) that determine whether • cover every competency, not just those that are
students can move to the next level of training. easy to assess; and
• ideally assess each competency in multiple
Getting the right balance between the two is ways and at different times in a formative and
important: medical and nursing students are supported manner that promotes learning.
known to have high levels of stress and enhanced
curricula need to be mindful of adding to their A mix of methods is important to cover all learning
burden through assessment. objectives, support different learning styles, and
identify extra learning needs. Competency is
When selecting assessment methods , it is
often context specific, so learners may not always
important to consider their validity (does it
perform consistently from task to task. Using
measure what it claims?) and reliability (is it
multiple measures across different settings and
consistent?), as well as feasibility. For example:
times can enable all students to demonstrate their
strengths and test their full range of competence.

11
Access a downloadable tried and tested version of the OMS-HC scale at: https://static1.squarespace.com/
static/5a0df2b3692ebe9b1a7973e0/t/5c7960a4ec212de75e96bd0e/1551458469417.

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Chapter 4 Enhance the curriculum 4

4.5 Train educators

When developing the enhanced curriculum, it and assess undergraduates under senior
is important to identify and equip educators to faculty mentorship.
deliver it. Ideally, the enhanced curriculum will be • Graduate trainers. CRC members or external
taught and assessed by a multidisciplinary team experts initially serve as trainers of trainers
drawn from various university departments and but over time, graduates of the enhanced
schools. In this model, each team member teaches curriculum become candidate trainers for
and assesses content in their existing area of future students, either during their time as
expertise (see Box 2.1). postgraduates or later as university faculty.
• Leverage existing initiatives. Collaboration
Using a multidisciplinary team however is not
between WHO country offices and the ministries
always possible. In these cases, new staff may be
of health and education can help leverage other
hired to cover the additional material, or existing
initiatives – including mhGAP trainings – to train
medical and nursing faculty can be asked to take
educators. This is a good alternative to using
on this responsibility. Where funding and available
the CRC as trainers of trainers given training
staff are limited, specialists could be invited to join
requires time that is often in short supply
the faculty either as honorary staff or in part time
among CRC members.
paid positions to teach specific/additional material.
Either way, these educators will need training.
Whatever approach is being used, educators’
There are different approaches to training educators. training should be tailored to their existing
competencies and contexts. Faculty with no prior
• Self-directed training. Teaching faculty
MNS care experience will need more in-depth
independently familiarize themselves with
training. Faculty may also need training in specific
new learning materials and exercises. This is
areas, such as standardized role plays, competency
most useful for orienting educators with strong
rating, and providing actionable feedback (86, 87).
knowledge and skills in MNS care.
By the end, educators should have the same
• Cascade train-the-trainer training.
competencies expected of their students after
Credentialed CRC members might train
graduation (as well as the usual competencies for
teaching faculty using a mix of didactic and
effective teaching). Doing a baseline competency
applied approaches. Trained faculty then teach
assessment at the start of training can help ensure
students. This approach is common in in-service
that the training is pitched at the right level to
training but has also been used in PSE, for
meet educators’ needs (92, 93). It can also provide
example for teaching the mhGAP intervention
a benchmark for post-training evaluation.
guide (mhGAP-IG) (33).
• Train-the-trainer variations. For example, Training of educators must be feasible according
educators complete the full enhanced to training resources, funding and time available.
curriculum themselves before teaching Practical considerations include: scheduling,
students. This approach has the advantage location and embedding training into existing
of piloting the curriculum but it is a workplans. Incentives for participation, such
resource-heavy option as it requires multiple as accreditation or reduced workloads can
trainers and takes a long time to complete (91). encourage involvement. Collaborating with
• Senior-to-junior faculty model. Postgraduates other institutions and professional organizations
learn the enhanced curriculum and teach can provide additional support through shared
resources and expertise.

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PSE-MNS guide 4

4.6 How to apply the competency

framework: two examples
This section provides two examples of how resources (see Chapter 5 for more information on
learning objectives, experiences and assessment the broader implementation options and issues).
formats might look within specific learning
In the first example, we consider modules
sessions of an enhanced curriculum. These
organized by competency, focusing on a
examples illustrate how the competency
module on managing MNS conditions through
framework can be applied, although enhanced
psychosocial support. We illustrate the learning
curricula will vary across universities, countries,
objectives (and content), experiences and
student types (i.e. medical versus nursing),
assessments for sessions designed to develop
depending on existing curricula and available
Competency 7: provide psychosocial support as
part of managing MNS conditions (see Fig. 4.4).

FIG. 4.4
Example learning sessions on providing psychosocial support.

Modules
(grouping competencies, see Fig 4.2)

Screening,
Managing MNS Referral and Promotion
Introduction assessment
conditions follow up and prevention
and diagnosis

Overall learning objectives

(competencies)

1. 2. 4. 6.
Demonstrate Provide Provide Manage priority
foundational helping rights-based care emergency care conditions

7. 8. 9.
Provide psychosocial Support Adapt for populations with
support carers special needs

Learning content
(see details on the next page)

Attitudes Knowledge Skills

Specific Learning Assessment

learning objectives experiences methods

62
Chapter 4 Enhance the curriculum 4

FIG. 4.4 (continued)

Specific learning Knowledge Skills

objectives • Identifies social resources • Identifies and explores social
in the community. stressors and difficulties.
Attitudes
• Describes problem-solving • Collaborates with individuals
• Shows compassion, empathy and
counselling techniques. to find ways of addressing
respect for all people.
• Defines professional and legal social difficulties.
• Adopts an approach that is non-
responsibilities related to • Links people to relevant
blaming, non-judgemental and
maltreatment, abuse and neglect. social resources.
non-stigmatizing.
• Explains the biopsychosocial • Assesses, identifies and manages
• Shows empathy and
impact of stress. maltreatment, abuse or neglect.
genuine concern.
• Describes guided • Offers guided self-help.
• Values psychosocial support.
self-help techniques. • Teaches stress management.
• Is recovery-oriented and
• Identifies specific stress • Provides evidence-based
solution-focused.
management techniques. suggestions to strengthen
social supports.

Learning experiences Knowledge Skills

Attitudes • Information sharing lectures and • Role plays, simulations and case
seminars on psychosocial support studies to practice providing
• Information sharing
techniques and theories. psychosocial support targeting
lectures and seminars.
• Self-directed learning from diverse sets of MNS conditions.
• Myth-busting simulations that
textbooks, journal articles, books, • Shadowing in clinical practice.
target stigma, role plays to practice
grey literature, trusted websites. • Practising clinical tasks such as
empathic approach, case studies,
films and other media. • Group discussions and group work. exploring life stressors, teaching
• Applied and student-led research, stress management skills and
• Direct interactions with people with
presentations and seminars using identifying social resources for
lived experience to reduce stigma.
case studies to demonstrate people with MNS conditions and
psychosocial support applications. their caregivers.

Assessment methods Knowledge Skills

Attitudes • Written or oral examinations to • Real or simulated case studies to
identify knowledge of psychosocial apply support skills.
• Real or simulated case studies
support theories and techniques. • Applied essays and examinations
targeting stigma.
• Multiple choice questions. using case studies to demonstrate
• Applied essays and examinations
• Short and long answer tests. application of psychosocial
using case studies relating to
support techniques.
provider attitudes. • Theoretical essays using
case studies to demonstrate • Structured role plays to practise
• Structured role plays to
understanding of psychosocial providing patient support.
practise demonstrating
empathy and compassion. support theories and techniques. • Demonstrations of ability to identify
stressors and offer guided self-help.
• Demonstrations of
solution-focused support. • Observed structured examinations.
• Observed structured examinations. • Standardized patient encounters.
• Standardized patient encounters to • Supervised clinical practice.
practice appropriate attitudes.
• Supervised clinical practice.

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PSE-MNS guide 4

In the second example, we consider modules

organized by priority MNS condition and zoom
in on a module for AUDs and DUDs. Here, core
competencies from Table 3.1 are adapted to
focus explicitly on AUDs and DUDs, with sessions
designed to develop the adapted Competency 6:
manage AUDs and DUDs (see Fig. 4.5).

FIG. 4.5
Example learning sessions on managing AUDs and DUDs.

Modules
(organized by MNS condition)

Depression, Alcohol
Psychosis Dementia, Referral Promotion
anxiety and and drug use
Introduction and bipolar epilepsy and and
stress-related disorders
disorder and seizures follow up prevention
conditions (AUDs and DUDs)

Overall learning objectives

(competencies)

1. 4. 7. 10.
Demonstrate Provide Provide psychosocial Refer for AUDs
foundational helping emergency care support and DUDs

2. 5. 8. 11.
Provide Assess for AUDs Support Follow up AUDs
rights-based care and DUDs carers and DUDs

3. 6. 9. 12.
Promote health and Manage AUDs Adapt for populations Engage in
reduce risks of AUDs/DUDs and DUDs with special needs self-care

Learning content
(see details on the next page)

Attitudes Knowledge Skills

Specific Learning Assessment

learning objectives experiences methods

64
Chapter 4 Enhance the curriculum 4

FIG. 4.5 (continued)

Specific learning Knowledge Skills

objectives • Defines AUDs and DUDs (common • Conducts and interprets
presentations and diagnostic results of screening.
Attitudes
criteria) as well as risk factors. • Provides psychoeducation on risks
• Shows compassion, empathy and
• Describes core interventions associated with alcohol and drug use.
respect for all people.
(psychosocial and pharmacological) • Implements tailored brief
• Adopts an approach that is non- for treatment of AUDs and DUDs. interventions and arranges access to
blaming, non-judgemental and
• Explains the benefits, harms, further treatment for those in need.
non-stigmatizing.
duration and adherence • Collaborates with individuals
• Shows empathy and requirements for essential medicines. to plan treatment.
genuine concern.
• Describes how to manage acute • Identifies and manages physical
• Is deliberate, recovery- substance use-related conditions. and mental health comorbidities.
oriented and determined.
• Describes evidence-based • Offers essential medicines for AUDs
• Values both pharmacological and psychosocial interventions. and DUDs as indicated.
psychosocial interventions.
• Identifies and manages acute
substance use related conditions
and other symptoms.
• Monitors treatment.

Learning experiences Knowledge Skills

Attitudes • Information sharing lectures • Role plays, simulations and case
and seminars on diagnostics studies to practise diagnosing and
• Information sharing lectures
and treatments for AUD/DUD treating AUDs/DUDs.
and seminars on providing non-
and risk factors. • Shadowing in clinical practice.
judgemental care in the context
of AUDs and DUDs. • Self-directed learning from books, • Practising clinical tasks
articles and trusted websites. with people presenting with
• Myth-busting simulations to target
stigma, role plays using positive • Group discussions and group work. symptoms of AUD/DUD.
examples of recovery, case studies, • Student-led research, presentations
films and other media. and seminars using case studies
• Direct interactions with people with to show understanding of AUD/
lived experience. DUD diagnoses, and interventions
for particular alcohol and/
or drug use cases.

Assessment methods Knowledge Skills

Attitudes • Written or oral examinations on AUD/ • Real or simulated case studies to
DUD diagnosis and psychological diagnose AUDs/DUDs and choose
• Real or simulated case studies
and pharmacological interventions. appropriate interventions.
to show non-stigmatizing and
compassionate attitudes. • Multiple choice questions. • Applied essays and examinations to
• Short and long answer tests. show diagnostic and intervention
• Applied essays and examinations to
applications for AUDs/DUDs.
show appropriate attitudes in care • Theoretical essays to demonstrate
for people with AUDs and DUDs. understanding of AUD/DUD • Structured role plays to show
diagnoses and how and when to management of symptoms.
• Structured role plays to show
compassion and patience. apply particular interventions. • Demonstrations.
• Demonstrations. • Observed structured examinations.
• Observed structured examinations. • Standardized patient encounters.
• Standardized patient encounters. • Supervised clinical practice.
• Supervised clinical practice.

Photo credit (next page): nursing students conversing in a medical university hallway. ©Freepik 65
 5
Implement
the curriculum
PSE-MNS guide 5

Implementing an enhanced curriculum requires their part. Limited funding does not have to halt
adapting the key activities outlined in previous progress; it simply means changing the type and
chapters of this guide to fit the national and scale of activities.
institutional context.
This chapter focuses on three key activities
Securing extra time and human resources will for implementation: choosing an appropriate
be important in all contexts. Advocating and approach; identifying barriers and solutions; and
engaging university administrators and educators monitoring and evaluation, including to ensure
will help ensure they are ready and willing to play continuous improvement and inform research.

5.1 Decide on an
implementation approach
The implementation approach will largely depend documenting their feasibility and impact, and
on resources available (especially time, funds using the results to build a case for investment
and people). Fig. 5.1, Fig. 5.2 and Fig. 5.3 show that can attract more resources.
examples of different strategies for limited versus
When time, funds or people are limited, creativity
sizeable resources. In resource-constrained
is key. You might use free online surveys for
contexts, the implementation approach will
stakeholder input instead of costly focus groups
likely start small, focusing on demonstrating
or informant interviews. Or you might establish
value before scaling up. For example, it may
an informal group of collaborators instead
involve making a few key curriculum changes
of a formal CRC.
within a single institution or cohort of students,

68 Photo credit (previous page): two nurses providing a lecture on premature babies. Zambia 2024 © WHO / Stanley Makumba
Chapter 5 Implement the curriculum 5

FIG. 5.1
Example approach to implementation with limited resources.

TIMELINE Engage stakeholders again after changing curriculum ACTIVITIES

Stakeholder mapping (internal and external).

Start Engagement Information and lobbying for staff buy-in.
and advocacy
Presentation/advocacy to Dean.

University (Dean) appoints a CRC and holds regular meetings.

6 – 18 months

Examine WHO’s PSE-MNS guide.

Situation Review the curriculum for gaps.
analysis
Identify how the curriculum needs to change.

Differentiate optional/compulsory learning

Enhance objectives and content.
curriculum
Prioritize enhancements based on situation analysis.

Implement agreed enhancements.

Implement
Introduce training in ongoing faculty workshops.
curriculum
Create an M&E plan.
6 – 12 months

Collect data.
M&E
Monitor and evaluate, including cost estimation.

Prepare a report and disseminate widely

To demonstrate benefits (economic and educational).
3 years
Use multiple methods e.g. policy briefings and meetings
with all stakeholder groups.

Lobby decision
makers for
SCALE UP

Source: Pre-service education in mental brain and behavioural health: scaling up implementation and dissemination.
Workshop. WHO Collaborating Centre for Research and Training in Mental Health; Shanghai, China; 13–14 March 2024.

69
PSE-MNS guide 5

FIG. 5.2
Example approach to implementation with limited funds.

1
SITUATION
Leverage existing resources
Internal grants, hospital funding, research assistants.

ANALYSIS Use inexpensive or free methods for collecting data

Surveys (of students, faculty, hospital staff, care providers, people with lived experience).
Social media (student groups and apps).
Desk reviews (of literature and existing curricula).

Collaborate with local organizations

To study and engage stakeholders; and identify targets for improvement.

ENHANCE AND
2 Gather a collaborative, informal CRC
Faculty peers, other teaching communities, students, alumni, internal college leaders.

IMPLEMENT THE Adapt learning objectives and content

CURRICULUM Based on situation analysis; and to align with core competencies.

Be creative in enhancing the curriculum

Piggyback onto other subjects (with case studies, simulations, individual lectures).
Integrate piecemeal into courses.
Create student psychology or well-being clubs.

Create a realistic M&E plan

Using course evaluations, social media feedback surveys, faculty feedback forms.

MONITOR,
3 Implement M&E plan

EVALUATE AND
ADVOCATE Baseline Immediate feedback Semester/year end In practice

Create an evidence base supporting change

Use relevant indicators and measures.

Share evidence to advocate for change

Use many methods, e.g. internal and external, events/conferences, stakeholder
meetings, social media, university marketing and communications.

SCALE UP
with funds

Source: Pre-service education in mental, brain and behavioural health: scaling up implementation and dissemination.
Workshop. WHO Collaborating Centre for Research and Training in Mental Health; Shanghai, China; 13–14 March 2024.

70
Chapter 5 Implement the curriculum 5

FIG. 5.3
Example approach to implementation with sizeable resources.

TIMELINE ACTIVITIES KEY STAKEHOLDERS

Advocate to promote the

0 months Kick off initiative and engage
national stakeholders.
Student associations

Education and
professional bodies
Establish a national CRC to
Curriculum champion and coordinate Nongovernmental
3 months review the work, including organizations
committee mobilizing and allocating
funds for activities. People with lived experience

Use curriculum gap maps and Ministries of health and

key informant interviews to education
Situation and
understand barriers and
stakeholder
facilitators for implementation.
analyses
Create checklist based on
competency framework.

Curriculum Identify a pool of experts Medical, nursing and allied

who can support national mental health specialists
6 months enhancement
teams to make curriculum
retreat Education institutes
enhancements.

Student associations
Use national teams,
Pilot Ministries of health and
9 months supported by experts,
changes education
to deliver enhanced
curriculum. UN agencies and other
development partners

Implement
1 year
AT SCALE

Source: Pre-service education in mental, brain and behavioural health: scaling up implementation and dissemination.
Workshop. WHO Collaborating Centre for Research and Training in Mental Health; Shanghai, China; 13–14 March 2024.

71
PSE-MNS guide 5

BOX 5.1
Lessons from Mexico: strengthening undergraduate training in mental health and
substance use disorders
3. Expert engagement. Mental health
Mexico’s National Commission on Mental Health
experts were engaged to develop and lead
and Addictions (Conasama) has long emphasized
evidence-based, practical learning sessions.
the need to prepare medical and nursing students
for MNS care in community settings. Yet most 4. Practice. Role plays helped learners build
clinical training still takes place in specialized confidence in delivering mental health care.
mental health clinics or psychiatric hospitals, 5. Clinical mentors. Clinical and administrative
which are insufficiently geared to the core MNS mentors were trained to support students
competencies required in primary health care. transfer skills and knowledge into clinical
practice in community settings and ensure
Since 2023, Conasama has been working
facility readiness (e.g. setting up referral
to embed mhGAP materials, concepts and
pathways, and ensuring availability of
approaches into PSE for health workers, using a
psychotropic medicines).
seven-step approach.
6. Integration. The course was integrated into
1. Needs assessment. This step defined the various PSE programmes in Mexico and linked
attitudes, knowledge and skills needed to mental health care to local referral systems.
deliver mental health care using the mhGAP-IG
7. Monitoring and evaluation (M&E).
in primary care settings; and identified gaps in
Ongoing M&E is assessing the course’s
existing PSE.
impact on students’ attitudes, knowledge
2. Course design. An eight-module, 48-hour
and skills and the quality of mental health
course combining theoretical knowledge,
care delivery in communities.
practical skills and attitude training was
developed, informed by the needs assessment.

Source: José Javier Mendoza Velásquez, Conasama, personal communication, 20 February 2024.

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Chapter 5 Implement the curriculum 5

Even with plentiful resources, or when working for family physicians. A similar stepped approach
with centralized national curricula, starting small might also work for mental health care.
can be beneficial. Such an approach can help
In Mexico, the National Commission on Mental
provide proof of concept for integrating MNS
Health and Addictions used a centralized
care into PSE and serve as a model to advocate
approach to create a national network of
for scaling up.
facilitators for the mhGAP-IG, strengthening
For example, WHO Pakistan worked with Khyber pre-service training nationwide (see Box 5.1).
Medical University Peshawar to develop and
Regardless of resources, implementing an
deliver a curriculum for a postgraduate diploma in
enhanced curriculum should be paired with
family medicine. After successful implementation
monitoring and evaluation, especially in the early
in one university, the diploma was expanded to
phases (see section 5.3).
nine more, helping to build institutional capacity

5.2 Address barriers to implementation

Many factors can either help or hinder curricular Common barriers include lack of funds,
change. Backing from political leaders and the insufficient educators and limited access to
ministries of health and education can generate learning materials or facilities. Even with sizeable
interest and resources for an enhanced curriculum. funding, there may be a shortage of human
So too can national or institutional policies that resources to call on for curricular change, and
prioritize mental and brain health and substance donor deadlines can create additional pressure.
use harm avoidance. Other enablers include In some contexts, limited access, aptitude,
involving students and faculty, peer-to-peer funding or support for technology may also pose
support, and fostering learning environments that significant challenges. Resistance to change
promote and protect the mental health of both from university administrators and faculty is
learners and educators. Regular consultation with often a major obstacle, and gaining widespread
professional organizations keeps the curriculum stakeholder buy-in can take time.
aligned with the latest evidence-based practices,
An important early step in implementation is to
and robust feedback mechanisms ensure
identify likely challenges and consider how to
continuous improvement.
overcome them (see Table 5.1).

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PSE-MNS guide 5

TABLE 5.1
Common challenges to implementation and potential solutions.

Challenge 1
Resistance to change
Examples Potential solutions

Ministry of health believes • Build a case for implementation that demonstrates the health
in-service training and economic benefits of an enhanced curriculum and showcases
alone is sufficient. successes elsewhere.
• Use this WHO guide as an advocacy tool.
Donors do not
• Find champions to advocate for the curriculum.
prioritize mental health.
• Enlist local organizations as advocacy partners.
Institutional leaders (e.g. • Invest in communications, including high-level branding and launch, for
dean) are not interested in the enhanced curriculum.
enhancing the curriculum.

Teaching faculty do not endorse, • Include faculty in curriculum enhancement activities from the outset.
or lack motivation to deliver, the • Highlight benefits of the enhanced curriculum.
enhanced curriculum.
• Offer incentives to educators (e.g. extra training opportunities or points
towards recertification or continuing professional development).
• Lobby exam boards to integrate MNS-related content into exit exams
and other assessments.
• Embed curriculum delivery in educators’ workplans.

Other departments are • Demonstrate the prevalence and impact of MNS conditions and
unwilling to collaborate. highlight the health benefits of an enhanced curriculum.
• Ensure early engagement and a multidisciplinary approach to
curriculum development.
• Use relevant institutional or national recommendations to make the
case for integration.
• Offer incentives to educators.

Students are unaware or do not • Leverage professional organizations’ student working groups.
see the point of curricular change. • Support student empowerment and advocacy initiatives.
• Lobby exam boards and accreditation bodies to add MNS-related
content to exit exams and other assessments.

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Chapter 5 Implement the curriculum 5

TABLE 5.1 (continued)

Challenge 2
Limited resources and capacity
Examples Potential solutions
Limited funds. • Adopt a phased approach that starts with small changes and gathers
evidence on their benefits to lobby for more funds.
• Look for internal grants.
• Optimize use of available resources by organizing them differently.
• Make the case for investment to relevant donors.
• Start small and build institutional reputation to build national and
international interest.

Lack of resources or information • Share information, including this guide.

to assess needs for an • Make use of free software and data (e.g. free survey tools, WHO data
enhanced curriculum. and technical support).
• Leverage existing personnel (e.g. research assistants and
postgraduate students).
• Enlist local organizations as partners and collaborators.
• Use informal, cost–effective and less time consuming data
collection techniques.

Too few educators available to • Make the most of self-directed and digital learning platforms (e.g.
deliver an enhanced curriculum; replace in-person lectures with online training modules).
or multi-disciplinary teaching is • Involve faculty from other disciplines from early stages.
difficult to coordinate.
• Engage local organizations, including of people with lived experience,
as co-educators.
• Consider using resident doctors and nurses as teachers.

Limited access to learning spaces • Use digital environments instead of physical spaces for teaching.
(classrooms and clinical suites) and • Make use of free learning resources (e.g. free online courses
materials (including digital tools). and materials).

Challenge 3
Long or unrealistic timelines
Examples Potential solutions
Implementation takes • Be prepared for delays and create mitigation plans.
longer than expected. • Develop clear plans at start.
• Build flexibility into timelines.

Poor planning and missed • Engage stakeholders at each stage for update and buy-in.
deadlines create pressure.

Funders reluctant to engage in • Adopt a phased approach to enhancing the curriculum.

lengthy project.

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PSE-MNS guide 5

TABLE 5.1 (continued)

Challenge 4
Turnover
Examples Potential solutions
Political or policy change • Align the enhanced curriculum with national priorities.
deprioritizes mental health. • Secure the engagement and buy-in of a wide variety of
national stakeholders.

Turnover in administrators • Get written agreement for the enhanced curriculum.

decreases support for • Engage champions beyond administration.
curricular change.

Turnover in teaching staff creates • Engage local organizations, including of people with lived experience,
gaps in expertise. as co-educators.
• Train postgraduate students and resident doctors and nurses
simultaneously so that they can fill gaps.

Challenge 5
Full curriculum
Examples Potential solutions
There is already too much content • See 5.2.1 Practical tips for resource-constrained settings.
in the curriculum and not enough
time to deliver it.

Other areas of medicine • Collaborate with other departments on mental health aspects of
compete for time and space in somatic illness.
the curriculum. • Demonstrate the prevalence and impact of MNS conditions and
highlight the health benefits of an enhanced curriculum.
• Show how MNS conditions are relevant in every aspect of heath
science and medicine.
• Engage other departments early on in the process of change and use a
multidisciplinary approach to curriculum enhancement.
• Use this guide as an advocacy tool.
• Use relevant institutional or national recommendations to argue for
integration, not competition.

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Chapter 5 Implement the curriculum 5

5.2.1 Practical tips for be added to other health education courses

(e.g. a lecture on maternal mental health in a
resource-constrained reproductive health course).

settings These small changes also support a more

integrated approach to medical and nursing
Ideally, the enhanced curriculum is delivered as education, promoting a more holistic
a standalone set of modules with practical and understanding of health and highlighting the
clinical placements. Yet this is not always feasible. cross-cutting relevance of MNS care. Other target
Most medical and nursing curricula already have courses for integration might include:
heavy loads of lecture, practical and learning
• psychopharmacology (to link clinical and
hours for students. Limited teaching resources
prescriptive knowledge and practice with a
and facilities can further strain this load.
pharmacological basis);
While each university’s context will differ, in this • community medicine (to link epidemiology
section we share three practical tips, drawn with the identification of common MNS
from global stakeholders, to help ease the conditions, and understanding of stigma and
burden when planning and implementing an treatment gaps);
enhanced curriculum. • oncology (to link foundational and
human-rights based care to delivery of difficult
Rethink traditional teaching methods
diagnoses, bereavement experiences and
One of the easiest changes is to adjust teaching hospice plans); and
methods instead of adding hours to the • internal medicine and surgery (to acknowledge
curriculum. Examples include replacing lectures the interconnection between physical
with participatory and peer-to-peer learning, such and mental health).
as flipped classrooms, group discussions, case
presentations, and role-playing. Increasing the Harness community resources
use of digital technologies and online self-directed
Diverse local organizations and stakeholders
learning materials can also help alleviate
can be enlisted as partners in delivering an
classroom pressure (see section 4.3).
enhanced curriculum. Involving people with lived
Make small changes to existing courses experience of MNS conditions as co-educators is
especially useful for shaping attitudes (see section
Even in courses with heavy loads for students,
4.3). Local organizations and health services
universities can make small changes to build core
can enrich clinical placements by exposing
competencies in MNS care. For example, clinical
students to community-based care. For example,
placements can be expanded beyond psychiatric
students can participate in community screening
hospitals to also include general hospitals and
programmes or work with community mental
other health care settings. Existing case studies
health organizations to observe and learn from
and structured role plays can be replaced to focus
local experts (see Box 5.2).12
on MNS conditions. For example, a dementia case
study can be used in a geriatric medicine course
or a simulation of a child with a developmental
disability in a paediatrics course. Short modules
or lectures on mental health topics can also

12
See also Foster skills in section 4.3 for more examples of harnessing community resources to implement an enhanced curriculum.

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PSE-MNS guide 5

BOX 5.2
Lessons from the University of British Columbia: immersive learning in Nairobi
At the University of British Columbia in Canada, individuals and families, supporting economic and
allied health students have opportunities vocational empowerment and tackling structural
for immersive experiential learning through barriers to care, such as stigma. Visiting students
international placements, including in Nairobi, work alongside people with lived experience
Kenya. These placements include joint lectures with to advocate for mental health, develop policies
the Kenya Medical Training College, followed by four and provide psychological support to vulnerable
weeks working with local community-based mental individuals. They focus on holistic care that
health organizations, Basic Needs Basic Rights simultaneously considers the clinical, economic
Kenya (BNBR, https://basicneedskenya.org/) and and social well-being of individuals. During their
Kamili (https://www.kamilimentalhealth.org/). time in Nairobi, students confront the practical
and ethical challenges of delivering mental health
Both BNBR and Kamili run community mental
care in low-resource settings and learn about
health programmes that are person-centred,
indigenous and local culturally and spiritually
rights-based and focused on recovery. They
appropriate psychosocial interventions.
provide vital mental health services for local
Sources: Mohamed Ibrahim, University of British Columbia, personal communication, 19 April 2024; University of British
Columbia, 2023 (94).

5.3 Monitor and evaluate

Monitoring and evaluation (M&E) are separate but consistently. M&E can help assess short-term
linked processes. Monitoring involves continuously impacts and progress towards learning objectives.
and systematically collecting and analysing They can also evaluate the curriculum’s
routine data to track the enhanced curriculum’s longer-term impact on quality of MNS care.
progress and identify challenges or areas for
improvement. Evaluation involves periodically
assessing specific information at specific times 5.3.1 Indicators and
to determine the extent to which the enhanced
curriculum has met its objectives.
measures
Both are essential for assessing the curriculum’s Indicators for M&E can be defined at multiple levels,
success in preparing competent graduates from the resources and processes used to build the
to provide effective care for people with MNS curriculum to the outcomes and broader impacts
conditions. M&E should be planned from the of its implementation (see Fig. 5.4). Some M&E
start, include baseline measurements, and used frameworks include all levels, while others may

78
Chapter 5 Implement the curriculum 5

focus on just a few. Means of verification (MoV) are or health records) or qualitative (e.g. interviews,
similarly wide ranging. They can target different open surveys or focus group discussions). A mix of
groups (e.g. educators, administrators, students, methods offers a depth of information that cannot
graduates, supervisors and people experiencing be achieved by either method alone. Given these
MNS conditions). They may be quantitative (e.g. variations, each M&E framework is unique, with its
attendance records, closed questionnaires, own structures, outcomes and indicators.
employment rates, student assessment scores

FIG. 5.4
Example indicators and means of verification for monitoring and evaluating an
enhanced curriculum.

The financial, human and

e.g. indicator: budget allocated.
Inputs material resources used to
e.g. MoV: university budget plan.
implement the curriculum.

e.g. indicator: # educators trained to

Tasks and actions that mobilize
Processes deliver the enhanced curriculum.
inputs to produce outputs.
e.g.MoV: training records.

e.g. indicator: # students completing

The direct results of the
Outputs the enhanced curriculum.
activities performed.
e.g. MoV: attendance records.

e.g. indicator: % students

The short- and medium-term
demonstrating pre-defined adequate
Outcomes changes created by implementing
level of core competencies.
the curriculum.
e.g. MoV: competency assessments.

e.g. indicator: proportion of people

The curriculum’s impact on
with MNS conditions identified and
Impacts health service provision and
treated in health facilities.
service users.
e.g. MoV: service use records.

79
PSE-MNS guide 5

The CRC is responsible for developing an M&E plan Ideally, M&E continues after graduation and
(see section 2.4). This plan should be established include not only postgraduates and health care
from the outset and define indicators and means practitioners, but also their clinical supervisors
of verification for measuring the enhanced and employers, and the people they are providing
curriculum’s success. Key aspects to cover include: care to (see Table 5.2). Post-graduation M&E
supports ongoing programme improvement.
• appropriateness and relevance of learning
Example questions to address through these
content and experiences, teaching methods
activities include:
and assessments;
• applicability of content to the national context; • How many graduates are employed in health
• curriculum structure and feasibility; care and are performing MNS care tasks?
• quality of teaching; • Are graduates competent and confident at
• student and educator engagement providing care to people with MNS conditions?
and satisfaction; • Which competencies do graduates show most
• assessment burden on students consistently (and which are shown least often)?
and educators; and • Do people in care feel they have received
• changes in student competencies, confidence appropriate and well-managed care?
and commitment.
Good M&E plans prioritize resource efficiency
Monitoring and evaluating students’ progress and only collect data that will be used. They
towards competence is crucial and can be should indicate the timing for activities (such as
achieved through pre- and post-assessments data collection, analysis, reporting) and assign
that may or may not be part of the enhanced responsibilities. The CRC should also define roles,
curriculum (see section 4.4). These assessments expectations and processes for integrating M&E
help measure shifts in attitudes, knowledge findings into the enhanced curriculum to drive
and skills, and help identify areas where the continuous improvement and sustainability.
curriculum may need improvement.

80
Chapter 5 Implement the curriculum 5

TABLE 5.2
Example activities for evaluating the enhanced curriculum’s outcomes and
impacts for different groups of people.
Outcome
or impact Audience Format Example points of evaluation

• Satisfaction.
• Engagement.
• Relevance of course content.
Curriculum evaluation
Students • Methods and burden of assessment.
questionnaire.
• Learning materials and experiences.
Reaction • Infrastructure and facilities.
• Teaching quality.

• Methods and burden of assessment.

Educators Survey or interview. • Learning materials and experiences.
• Student engagement and interest.

Curriculum evaluation • Learner readiness.

questionnaire; and pre- • Changes in knowledge, skills,
Learning Students
and post-assessments of attitudes (and so competencies),
competencies. confidence and commitment.

• Percentage of graduates
licenced and employed.
Graduates
• Perception of readiness for role
and responsibility.

• Student general readiness for practice.

Behaviour Clinical Survey or interview.
• Student confidence.
supervisors
• Student values and attitudes.

• Graduate general readiness for practice.

Employers • Graduate confidence.
• Graduate values and attitudes.

Individuals and Service data; and service • Quality of care.

Results
communities user survey. • Health outcomes.

Source: WHO, 2022 (23).

81
PSE-MNS guide 5

5.3.2 Continuous • focus on specific recommendations, such

as involving people with lived experience as
improvement co-educators, shifting clinical placements
from psychiatric hospitals to general
M&E insights should drive continuous hospitals, or focusing on a subset of
improvement of the enhanced curriculum. They competencies or students;
can suggest whether the curriculum is effective • build evidence for effective practices; or
and for whom; and indicate how it should be • analyse the cost–benefits of an enhanced
revised to better achieve its objectives. Some curriculum compared with in-service training or
things to consider include: continuous professional development.

• Are the learning objectives clear?

In practice, the size of funding available will
• Is the learning content coherent and feasible?
determine the scale of ambition for research.
• Are learning experiences and assessments
In resource-constrained settings, the emphasis
pitched appropriately?
will likely be on applied research and small-scale
• Do teaching methods and assessments align
implementation studies, starting with minor
with learning objectives?
changes based on a situation analysis,
• Do clinical placements reflect likely
documenting feasibility, evaluating impact
post-graduation workplaces?
and using results to mobilize funds for bigger
changes (see Fig. 5.5)

5.3.3 Research In settings with sizeable funds, research design

is more flexible.

M&E and research are closely linked. M&E focuses Fig. 5.6 shows an example roadmap for a three-year
on improving a specific curriculum, while research experimental study of an enhanced curriculum.
has a more global focus, aiming to contribute This example uses a randomized controlled trial
to broader knowledge in PSE for MNS care. but researchers may choose different approaches,
Both can provide data to show what is possible including observational studies (e.g. cohort studies
for an enhanced curriculum and exemplify or case-control studies), qualitative studies or
the affordability, feasibility and benefits of mixed-methods studies.
PSE in MNS care.

There are many types of research. An enhanced

curriculum developed from this guide could:

• be evaluated as a whole, for example through

field testing at universities;

82
Chapter 5 Implement the curriculum 5

FIG. 5.5
Example approach to research with limited funds.

1
What and why?

Fin d c
PLAN Adapt PSE-MNS guide to context.
Research ha
Identify needs through situation analysis. m pio ns
questions
Decide on small enhancements to implement.

Research Who?
How?
design Stakeholder Team and
Mobilize mapping and capacity
resources engagement building
When? Timeline Leverage personal networks

Coordination mechanism

2 DO
Pilot study
Consider: language, scale, sample size, personnel.
A d v c ate
o an

ge
d enga

3
A d v c ate

Continuous improvement
CHECK
o

M&E to identify an
ge

areas for Report

Optimization d enga
plan
improvement

4
A d v c ate

Follow up actions
ACT
o

Follow up with individuals, the university,

an
ge

and external stakeholders. d enga

Fundraising for
Publication further research Sustainability
or scale up

Source: Pre-service education in mental, brain and behavioural health: scaling up implementation and dissemination.
Workshop. WHO Collaborating Centre for Research and Training in Mental Health; Shanghai, China; 13–14 March 2024.

83
PSE-MNS guide 5

FIG. 5.6
Example approach to research with sizeable funds.

Study objectives
Generate evidence for advocacy and scale up.
Plot enhancements to establish a good model, and see if it works.

1
RESEARCH
Situation analysis
Desk review.
DESIGN Stakeholder needs assessment.
Identify local conditions that are most burdensome.

2 Implement curriculum changes

PILOTING
Pre- and post-training evaluations

OUTCOME
3 Stratified cluster RCT Looking at:
Knowledge and skills gained in
ASSESSMENT MNS core competencies;
Intervention Control Shift in attitudes towards MNS
conditions and specialties in
MNS care as a career choice; and
1 year
Mental heath outcomes of
students.
3 year

4 Qualitative assessment
Satisfaction of doctors, students,
Impact on individuals
Diagnosis and treatment.
IMPACT
ASSESSMENT and people with MNS conditions.

5 Share findings with stakeholders

DISSEMINATION
Disseminate through publication and presentation

Source: Pre-service education in mental, brain and behavioural health: scaling up implementation and dissemination.
Workshop. WHO Collaborating Centre for Research and Training in Mental Health; Shanghai, China; 13–14 March 2024.

84
 6
Conclusion
PSE-MNS guide 6

PSE for medical doctors and nurses is key (e.g. national associations of medical schools and
to scaling up the workforce to provide care accreditation agencies) may be more important.
for people experiencing MNS conditions Either way, change can be driven from the bottom
(including MNS disorders and related issues). up (e.g. students and faculty advocating for
A competency-based approach is crucial for reform) or from the top down (e.g. governments or
effectiveness, and this guide outlines 12 core accreditation bodies initiating change).
competencies to integrate into existing curricula,
Convincing decision-makers of the case for
regardless of resource constraints.
investment often requires evidence of what works
Even small changes can help medical and nursing where and how. This can be gathered through
students develop the attitudes, knowledge and desk reviews of existing practices and initiatives.
skills they need to provide effective MNS care.
For students completing an enhanced
You do not have to follow a rigid process. Draw
curriculum, learning does not stop after their
on all or some of the elements in this guide to fit
first degree. Postgraduate education and
your university’s context. Not all the content or
continuing professional education build on the
activities included here will be necessary for every
core competencies acquired during pre-service
institution or country.
to develop specialists – not only psychiatrists,
For many countries and universities, increasing neurologists or mental health nurses, but also
buy-in for curricular change from key stakeholders radiologists, gynaecologists, paediatricians,
will be a critical first step. In countries with geriatricians, etc. Each speciality requires its own
centralized curricula, engaging government set of specialized competencies, including for MNS
stakeholders is crucial. Elsewhere engaging care. But all can benefit from and build on the
institutional leaders or organizations that bring core competencies gained through an enhanced
together institutions and medical associations undergraduate curriculum.

86 Photo credit (previous page): nursing student holds a bag and books. ©Freepik
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Annex: tools and resources

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Tools and resources

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Health Organization; 2024 (https://www.who. • Psychological interventions implementation

int/teams/mental-health-and-substance- manual: integrating evidence-based
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• Mental health structural stigma in healthcare:

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94
For more information, please contact:
Department of Mental Health, Brain Health and Substance Use
Email: [email protected]

World Health Organization

20 Avenue Appia
1211 Geneva 27, Switzerland
https://www.who.int/teams/mental-health-and-substance-use/overview