Evaluation of mhGAP-HIG training outcomes across multiple domains among primary care physicians in three humanitarian contexts in Pakistan: A mixed-methods study

Abstract Background Humanitarian settings in Pakistan face major gaps in mental health service delivery, with limited specialist resources and a high burden of untreated conditions. The WHO mhGAP-Humanitarian Intervention Guidelines (mhGAP-HIG) aim to strengthen the capacity of primary care physicians (PCPs) to identify and manage common mental health conditions in humanitarian contexts. However, the evidence for multidimensional training outcomes remains limited. This study evaluated the effectiveness of mhGAP-HIG training to improve outcomes in terms of knowledge, skills, attitudes and confidence among PCPs across different humanitarian contexts in Pakistan. Methods As part of implementing an evidence-based digital MHPSS service model, seven mhGAP-HIG workshops were held between September and November 2025 across two provinces and a federal area facing humanitarian contexts. We conducted a quasi-experimental, mixed-methods evaluation where a total of 149 PCPs completed standardized assessments of knowledge (mhGAP-HIG), therapeutic skills (ENACT), attitudes (MICA-4), and confidence. Paired sample t-tests and ANCOVA were used to assess within-group and between-group changes, respectively. Quantitative feedback on training quality was obtained and qualitative reflections on learning experiences were evaluated using thematic analysis. Results A modest improvement in attitude and significant improvements across all other domains were observed. The participants from KP showed greater gains in knowledge, while participants from GB showed greater gains in skills, as compared to other provinces. Participants expressed a high level of satisfaction in all workshops, and reported improvements in knowledge, confidence, and ability to identify, manage and refer people with common mental health conditions. Conclusion Systematic efforts to adapt and implement mhGAP-HIG may lead to significant improvements across multidimensional competencies of PCPs, including their knowledge, skills, attitudes and confidence.