This study employed a mixed methods design, combining quantitative and qualitative approaches to evaluate the impact of structured mental health training on nonspecialist HCPs. The quantitative component followed a pre- and post-test design with a comparison group to assess changes in mental health–related knowledge and attitudes. The qualitative component involved in-depth interviews with nonspecialist HCPs from group 1 (nonspecialist HCPs from the intervention sites of the parent cluster randomized trial, domestic violence intervention [DeVI]) to explore their experiences with the training and their perceived changes in knowledge, confidence, and psychosocial support skills.

According to the Nepal Demographic and Health Survey, more than 1 in 5 women and 1 in 10 men aged 15 to 49 years report symptoms of anxiety [20]. In Madhesh Province of Nepal, approximately 27% of health facilities report offering some form of mental health services. However, only 35 of 246 health facilities have essential psychotropic medicines available, and most services are delivered through private providers [29]. Given these constraints, the training targeted nonspecialist HCPs working in government primary health care centers (PHCCs) and public hospitals across 8 districts of Madhesh Province. Although public hospitals are not part of the first-contact primary care tier, they remain central to the public health care system and routinely serve women seeking maternal and reproductive health care. Because the intervention focused on supporting women affected by IPV, including nonspecialist HCPs from public hospitals was considered appropriate.

This study was a nested substudy within the broader DeVI trial, a cluster randomized controlled trial designed to reduce IPV and related psychological distress among women. Details of the trial design are described elsewhere [30]. The training was conducted before the implementation of the main DeVI. A total of 24 public health facilities were randomly selected and assigned to either the intervention or control arms of the DeVI trial [30]. Nonspecialist HCPs working at intervention sites formed group 1 and received the comprehensive training, whereas those at control sites (group 2) received a shorter training.

The training targeted 46 nonspecialist HCPs, including nurses and auxiliary nurse midwives (ANMs). One additional female participant serving in the role of psychosocial counselor also took part in the training and was included in the analysis.

Nurses and ANMs were selected because they are the primary providers of maternal and reproductive health services in Nepal and are often the first point of contact for women experiencing violence or mental health concerns. Furthermore, evidence suggests that women are more likely to disclose sensitive issues such as IPV to female care providers. Group 1 included 24 participants from intervention facilities, and group 2 included 22 participants from control sites.

This study forms part of a larger trial evaluating a multicomponent intervention to reduce IPV and psychological distress among women in Nepal [30]. The larger trial was registered with ClinicalTrials.gov (NCT05426863). Ethical approval was obtained from the Nepal Health Research Council (852/2019). All procedures adhered to the 2019 National Ethical Guidelines for Health Research in Nepal [31] and to the principles of the 1964 Helsinki Declaration and its subsequent amendments.

Written informed consent was obtained from all participating HCPs for both training participation and in-depth interviews. Consent included approval for audio recording and use of deidentified data. All data were stored securely on password-protected devices accessible only to the research team. Quantitative findings were reported in aggregated form to prevent participant identification. Audio files were deleted after transcription. Personal identifiers were removed from transcripts to maintain confidentiality. Verbatims used in this manuscript are labeled with nonidentifying labels.

HCPs received a daily allowance of either 1200 or 1600 Nepalese rupees for participation in the training, in accordance with the Nepalese government’s daily subsistence allowance rates, which vary based on the participant’s official ranking or position. Photographs of training sessions were taken only after obtaining written informed consent from participants, who explicitly indicated no objection to the use of images in study outputs. To protect privacy, faces of training participants shown in this paper were blurred.

Training was conducted from May 26 to June 4, 2022, in Bardibas, Mahottari District, Madhesh Province. Nonspecialist HCPs in group 1 received a comprehensive 10-day training, whereas group 2 participants attended a 3-day training. Each training day comprised approximately 8 hours of instruction.

The training was grounded in the WHO’s Problem Management Plus framework [32], a brief psychological intervention designed for individuals experiencing distress in adversity-affected settings. Problem Management Plus has been demonstrated to be effective in LMIC contexts, including Nepal [33-35]. The intervention was further adapted to include modules on safety planning [36]. Details of the training content are provided in Textbox 1 . Nonspecialist HCPs at both sites were trained on different mental health–related topics, such as an introduction to mental health and common mental health problems, consequences of mental health problems on women, their family, and the community, and stigma associated with mental health problems. They were further trained on the role of nonspecialist HCPs in managing mental health problems and referring patients to higher health facilities, psychiatrists, or psychologists for further management. Nonspecialist HCPs were also trained in administering data collection tools. Furthermore, nonspecialist HCPs in group 1 were trained to identify patients with mental health problems, implement stress management techniques such as slow breathing exercises, apply problem identification and solving techniques, develop safety plans against IPV/DV, and manage challenging/difficult patients.

Nonspecialist HCPs were provided with brochures containing referral sites for women with mental health problems and a training manual, in line with the WHO’s recommendations for conducting intervention research on violence against women [37].

Training methods included didactic lectures, interactive group discussions, case vignettes, role plays, demonstrations, and brainstorming sessions (Figure 1). Activities were designed to maintain engagement and facilitate experiential learning. Recreational activities were incorporated to reduce fatigue during long training sessions.

Sessions were delivered in Nepali by a multidisciplinary team, including mental health professionals, public health experts, and members of the study team.

Participants demonstrated active engagement during training sessions. Role-play exercises using different scenarios were integrated into the training sessions (Figure 1). Experts demonstrated how interventions should be delivered. Nonspecialist HCPs also put forward different situations that could arise during the implementation of the intervention, which were addressed by experts via role plays. Role plays were evaluated by trainers based on predefined criteria, including confidentiality, nonjudgmental listening, and appropriate application of stress management and problem-solving techniques.

Quantitative data were collected using a self-administered questionnaire that included demographic information and 3 validated instruments.

Mental health knowledge schedule (MAKS) [38]: A 12-item tool scored on a 5-point Likert scale. The first 6 items in the scale measure the stigma-related mental health knowledge areas while the other 6 measure the knowledge on mental health problems. For positive statements, “strongly agree” is scored the highest 5 points whereas “strongly disagree” is scored 1. The points are reversed for the negative statements. Total scores are obtained by adding the scores of 12 items and higher score indicates higher participant’s knowledge in mental health.

Social Distance Scale (SDS) [39]: A 7-item scale assessing attitudes toward individuals with mental illness. Responses are rated on a 0 to 3 scale, with higher scores indicating a greater desire to distance one from the people with mental health problems. An example of an item is, “How would you feel about renting a room in your home to a person with serious mental illness?”

Perceived Dangerousness Scale [40]: An 8-item tool assessing participants’ beliefs about the dangerousness of individuals with mental health problems. Each item is scored from 0 to 5, with higher scores indicating greater perceived threat.

Although a more detailed version of SDS is available, we aimed at maintaining brevity while ensuring content validity for use in training evaluation context. All tools underwent cultural and linguistic adaptation following standard translation and back-translation procedures. A panel of Nepali mental health and public health experts reviewed the instruments for content and cultural appropriateness before finalization. It was then reviewed by a Nepali language expert to confirm cultural appropriateness and clarity. Lastly, the tools were finalized after consensus within the study team.

Qualitative data were collected using an interview guide focused on participants’ perceptions of the training, changes in knowledge, confidence, and self-reported skills. In-depth interviews were conducted only with group 1 participants due to the comprehensive nature of their training.

The pretest, post-test, and follow-up questionnaires were self-administered questionnaires in Nepali language and took on average 15 to 20 minutes for completion. The pretest assessment was conducted prior to the training, while the post-test assessment was conducted after completion of the training. The follow-up questionnaire was completed after 3 months of training. In-depth interviews were conducted face-to-face and were audio-recorded with written consent from nonspecialist HCPs after completion of the training.

Quantitative data were self-administered by participants. In contrast, qualitative data were collected through interviews conducted by a mix of health workers, some of whom were involved in implementing the training sessions and others who were not. This approach was employed to capture detailed and diverse perspectives on participants’ experiences.

Table 1 presents the sociodemographic characteristics of the 46 nonspecialist HCPs included in this study. The mean age of participants was 34.2 (SD 6.96) years, ranging from 21 to 50 years. Participants aged 21 to 30 years accounted for 39% of the sample (18/46), those aged 31 to 40 years also accounted for 39% (18/46), and participants aged 41 to 50 years constituted 22% (10/46). The majority of participants were married (38/46, 83%). More than half of participants were ANMs and senior ANMs combined (30/46, 65%), one-third were nurses (15/46, 33%), and 1 participant was a psychosocial counselor (1/46, 2%).

Over half of the nonspecialist HCPs had worked at their current health facility for 1 to 5 years (25/46, 54%), and more than one-third over 5 years of service (18/46, 39%). Just over half of the participants reported attending to 50 or fewer patients per week (25/46, 54%).

Although nonspecialist HCPs often receive in-service training, the majority (40/46, 87%) reported that this was their first exposure to training focused on mental health. Only 6 out of 46 nonspecialist HCPs (13%) stated that they had earlier received training on mental health, particularly on psychosocial counseling. None of the participants from group 2 or from primary health care facilities in group 1 had previously received training on mental health (Table 1).

The in-depth interviews highlighted the importance of mental health–related training.

In-depth interviews conducted with group 1 participants revealed a range of positive changes in knowledge, confidence, and skills following the training.

Participants shared that the training enhanced their understanding of the interrelationship between mental health and IPV, equipping them to better identify, assess, and support affected individuals.

Participants reported that the training changed their understanding of mental health. They earlier believed that mental health problems could only be solved via clinical interventions, but now they consider it a social issue that can be managed by counseling and empathy.

Participants valued the structured nature of the training, particularly the sessions on problem management and safety planning.

Participants expressed that the training boosted their confidence in identifying and addressing mental health issues, even for those with no prior exposure.

Participants shared that the training enhanced their ability to manage mental health problems, particularly in stress management. Nonspecialist HCPs reported notable improvement in supportive skills like screening, problem identification, and active listening. Some also mentioned that they are now aware of referral sites for more advanced care.

Nonspecialist HCPs emphasized that mental health is often neglected in Nepal; this training helped to fill critical gaps in awareness, empathy, and basic support strategies. They recognized that simple interventions, such as counseling and stress management, could mitigate adverse outcomes, including depression or suicidal ideation. Overall, the training was perceived as essential in equipping nonspecialist HCPs with the necessary skills to help reduce mental health problems within their communities, marking a transformative change in their perceptions and approaches to mental health care.

Table 2 summarizes changes in outcome measures before and after the training. In group 1, MAKS scores improved significantly from pretest to post-test (mean difference [MD] 7.41, 95% CI 4.85‐9.98) and remained elevated at 3-month follow-up (MD 7.08, 95% CI 4.28‐9.87). Group 2 also showed modest improvements at post-test (MD 3.82, 95% CI 0.01‐7.63) and at follow-up (MD 3.09, 95% CI 0.46‐5.71). Attitudes, as measured by the Perceived Dangerousness Scale, declined post-training in both groups (Table 2). Group 1 showed reductions at post-test (MD 2.30, 95% CI 0.27‐4.30) and 3 months follow-up (MD 4.67, 95% CI 2.33‐6.99). Group 2 also improved, with reductions at post-test (MD 4.77, 95% CI 2.60‐6.93) and 3 months follow-up (MD 6.91, 95% CI 4.17‐9.63).

SDS scores decreased in both groups post-training. Group 1 reported reduced scores at post-test (MD 1.87, 95% CI 0.02‐3.77) and follow-up (MD 2.87, 95% CI 0.75‐4.99). Group 2 demonstrated similar reductions at post-test (MD 3.50, 95% CI 0.82‐6.17) and follow-up (MD 2.45, 95% CI 0.11‐5.02) (Table 2).

One-way ANOVA showed no significant pretest differences in MAKS scores between groups. However, post-test and follow-up scores were significantly higher in group 1, suggesting a stronger training effect. Similarly, for the Perceived Dangerousness Scale, significant between-group differences emerged only at the 3-month follow-up. Kruskal-Wallis tests for the SDS showed significant between-group differences post-training, but not at follow-up (Table 2).

This study found that nonspecialist HCPs had limited prior knowledge of mental health, as many were exposed to mental health–related training for the first time. This finding is consistent with previous studies indicating that individuals with mental health problems in LMICs often lack adequate care due to the limited mental health knowledge among HCPs [27,43]. Although Nepal has initiated mental health Gap Action Program-based mental health training programs through government and development partner collaborations [44], our earlier work showed that the majority of HCPs (almost 90%) had never received formal mental health training [12]. Consistent with previous research in Nepal [28] and international contexts such as Hong Kong and China [45,46], our study demonstrated an increase in mental health knowledge post-training in both groups. To help sustain knowledge gains, the study team conducted brief reviews of key training content during monthly regular monitoring visits.

In addition to improving knowledge, the training positively influenced HCPs’ attitudes [27]. While mental health issues are largely associated with IPV, they are often perceived as dangerous by both the public [47] and HCPs [48]. This perception was evident in our study during the pretest but showed a positive shift following the training.

Existing literature suggests that HCPs often hold stigmatizing beliefs and maintain social distance from individuals with mental health conditions [49,50]. At baseline, nonspecialist HCPs demonstrated moderate social distance scores. After training, both groups showed a reduction in these scores, reflecting improved attitudes toward people with mental health problems. Notably, group 1 maintained this reduction at the 3-month follow-up, whereas the effect was not sustained in group 2. This may be attributed to the more comprehensive and intensive training to the group 1 and prior exposure to mental health training or psychosocial counseling among some of its participants. While social distance scores differed significantly between the groups immediately post-training, the difference was no longer significant at follow-up, indicating that initial effects were not sustained and highlighting the need for ongoing support or refresher training.

Interestingly, group 2 exhibited greater improvement than group 1 in some attitude-related measures such as the SDS. This could be due to informal exposure to mental health concepts through personal experiences or ongoing discussions within their health facilities or communities. Previous literature has shown that even limited, contextually relevant exposure to mental health topics can influence stigma-related attitudes [51].

HCPs’ desire to distance themselves from individuals with mental health problems is influenced by their attitudes [52]. The training led to improved attitudes among nonspecialist HCPs, reducing their desire to distance themselves from those with mental health conditions. Prior to the intervention, many HCPs lacked the skills to manage mental health concerns or were unfamiliar with referral systems. The training addressed this gap, enhancing their perceived ability and self-reported readiness to identify symptoms, provide psychosocial support, demonstrate stress management techniques, and make appropriate referrals. For many, this was often their first structured training related to mental health, which helped foster a more supportive and responsive attitude toward affected individuals.

A key strength of this study was the inclusion of a comparison group. To our knowledge, this is among the first studies in Madhesh Province to assess mental health knowledge and attitudes among nonspecialist HCPs at different levels of health care system. The study design captured both immediate and 3-month follow-up outcomes. The training employed interactive and practical methods, including role plays, case discussions, video demonstrations, and practice interviews, which align with established criteria for effective educational interventions [53]. The target population comprised nonspecialist HCPs at public health facilities, who are expected to apply the knowledge and skills gained from the training in their daily services, which is particularly beneficial given their long-term careers within the public health system. Moreover, the training model used in this study should be integrated into routine training within the health system, especially for health workers at district and primary health care levels, to address psychological distress and to facilitate appropriate referrals when necessary.

Nonetheless, the study has limitations. It did not assess whether changes in knowledge and attitudes led to behavioral changes in clinical practice. The small, all-female sample limits generalizability, although this is justified given the nurses and ANMs predominantly provide maternal and child health services in Nepal. The findings are therefore most relevant for similar provider groups. Moreover, the study did not adjust for potential confounders such as age or experience due to the small sample size (n=46), which may result in potential residual confounding. While no validated self-efficacy scale was used to measure confidence, this was addressed through qualitative data that provided insight into perceived changes in non-specialist HCPs’ confidence and practice.

This training could be an important intervention for managing mild to moderate psychological distress and making appropriate referrals for severe mental health problems among women experiencing IPV or DV. In the present study, both groups received training; group 1 received comprehensive 10-day training while group 2 received short 3-day training. After the training, there was improvement in mental health knowledge and a positive change in attitude of nonspecialist HCPs across both groups, although the level of improvement varied between the groups. This suggests the possibility that brief training lasting for 3 days can bring some improvement among nonspecialist HCPs regarding their mental health knowledge and perception toward people with mental health problems.

The structured training program significantly improved mental health knowledge among nonspecialist HCPs in Madhesh Province. At the end of the training, group 1 showed greater improvements post-training and at follow-up. Attitude toward mental health also shifted positively. Beyond improving knowledge and attitudes, the training helped equip HCPs with essential skills in counseling, stress management, problem-solving, and referrals. Such training is especially vital in settings with limited specialist services, where nonspecialist HCPs are often the first and only point of contact for individuals facing psychological distress and IPV.