Mental Health: Global Challenges Journal

https://www.sciendo.com/journal/MHGCJ

ISSN 2612-2138

Harvard Medical School Global Mental Health:

Trauma and Recovery Course: What is the Global

Impact? Three Year’s Results

Richard F. Mollica1, 2, Giovanni Muscettola3, Eugene F. Augusterfer1, Qiuyuan Qin4, Fanny Y. Cai1

1Massachusetts General Hospital, Boston, Massachusetts, USA

2Harvard Medical School, Boston, Massachusetts, USA

3University Medical School “Federico II,” Naples, Italy

4University of Rochester, Rochester, New York

Abstract

Purpose: This paper describes and documents an innovative blended learning Global Mental

Health: Trauma and Recovery certificate training course. This course combines a two-week

face-to-face training in Orvieto, Italy with a five-month follow-up online vir

tual training as a

learning experience for global health care practitioners. Continuing medical education (CME)

accreditation is offered upon completion. This course utilized an innovative blended learning

model with a community of practice approach, a combination of lectures and discussions, and

online in-depth group case study discussions.

Methodology: Data was collected by self-

reported anonymous evaluation by participants of

three continuous years of the CME Global Mental Health: Trauma and Recovery certificate

training course sponsored by Harvard Medical School. One hundred fifty-five participants (n= 39

in 2011; n = 57 in 2012; n=59 in 2013) underwent a pre- and post-

course evaluation to

determine sustained confidence in performing medical and psychiatric care to traumatized

patients and communities, as well as to determine their learning of the Global Mental Health

Action Plan (GMHAP).

Results: Over the course of three independent years, a total of 155 participants were evaluated.

There was evidence for significant improvement in their confidence levels in all clinical areas

(diagnosis; treatment of trauma; use of psychotropic medication) when comparing baseline to

completion of the six-

month course. All ten dimensions of the GMHAP and nine medical and

psychiatric aspects of treatment revealed significant improvement in confidence levels.

Regression an

alysis also indicated similar results after the adjustment of demographic

covariates. Physicians and participants with mental health and social work background had

significantly higher confidence. Participants who were MD’s or psychiatrists had higher

confidence in most of the categories of confidence except for self-care, understanding culture,

collaboration, and policy and financing. The model showed no difference in learning based

upon gender and level of development of country of origin.

Conclusion: The

evaluation of this blended learning CME program provides evidence of

significant enhancement of clinical practice and planning skills in health care practitioners

working with highly traumatized patients and communities worldwide. This successful training

over the past 18 years has gone far to achieve the health and mental health capacity building

as requested by the Ministers of Health from post-conflict societies in the historic Rome meeting

in 2004.

Keywords

Mental Health, psychiatry, medical education, trauma, recovery, training, international

Mental Health: Global Challenges Journal

https://www.sciendo.com/journal/MHGCJ

ISSN 2612-2138

Address for correspondence:

Richard F. Mollica, Harvard Program in Refugee Trauma, 2 Castle Drive,

Wilmington, MA 01887

E-mail: RMOLLICA@partners.org

This work is licensed under a Creative Commons Attribution-Non-Commercial 4.0 International

License (CC BY-NC 4.0).

©Copyright: Mollica, 2024

Publisher: Sciendo (De Gruyter)

DOI: https://doi.org/10.56508/mhgcj.v7i1.186

Submitted for publication: 04

January 2024

Revised: 27 February 2024

Accepted for publication: 04

March 2024

Introduction

Ministers of Health (MOHs) from the world’s

post-conflict affected countries met in Rome,

Italy in December 2004, for the first time to

endorse a science-based Global Mental Health

Action Plan (GMHAP) and a Global Mental Health

Textbook of Best Practices (GMHTBP) to be

implemented and disseminated worldwide. This

first-ever meeting was called Project One Billion

(POB) for the more than one billion persons world-

wide affected by violence from war, ethnic

conflict, torture, and terrorism (Mollica &

McDonald, 2003). Participants from the Ministries

of Health came from thirty-five countries (n=35)

including post-conflict societies such as

Afghanistan, Uganda, Peru, Lebanon, Liberia,

and Rwanda. A full list of MOH participants is

available (Mollica, 2012). POB was sponsored by

the Harvard Program in Refugee Trauma (HPRT),

Caritas Rome, Istituto Superiore di Sanitá (ISS,

Italian National Institute of Health), US Fulbright

New Century Scholars Program, and the World

Bank, with the support of the World Health

Organization (WHO) and the Italian Ministry of

Health and Foreign Affairs.

Project One Billion achieved its major goals

and more. The MOHs requested that a global

training of high quality be established at Harvard

Medical School (HMS) through HPRT to build

worldwide mental health capacity. At the time of

this meeting, few if any, mental health

practitioners existed in participant countries that

could provide policy advice and consultation on

the development and implementation of

culturally effective mental health services. This

challenge by the MOHs was taken up by HPRT

through the HMS Division of Continuing Education

through its accredited continuing medical

education (CME) activities. Innovation was built

into the first CME HMS/HPRT Certificate Training

Course launched in November 2006. This course

was designed as an innovative blended learning

course combining face-to-face training with

follow-up on-line virtual training. The goal of the

Project One Billion CME course, Global Mental

Health: Trauma and Recovery, was to implement

scientifically effective, culturally valid mental

health training to healthcare practitioners and

professionals from other sectors throughout the

world. Tuition was kept at a modest level and

scholarships were offered to encourage

participation from low-income post-conflict

countries. At that time, published studies had

suggested that didactic CME did not appear to

produce effective change in physician

performance. Most CME courses were low in

interaction, especially meaningful interaction

among peers, leading to limited behavioral

change (Bloom, 2005; Davis et al, 1995; Rayburn,

Regnier, McMahon, 2020; Cervero & Gaines,

2015; Davis & McMahon, 2018; Davis et al, 1999;

Kanouse & Jacoby, 1988; Davis et al, 1995). In

contrast, the GMH Course was located for two

weeks onsite in Orvieto, Italy with intensive

interaction between course participants and

faculty; followed by weekly online learning

experience for five months. The Frederico II

Medical School and the ISS actively co-

sponsored this Harvard Medical School Course.

With the support of the Harvard Graduate

School of Education (HGSE), HPRT/HMS introduced

an innovative CME approach from the first

training in November 2006. The Global Mental

Health: Trauma and Recovery CME certificate

course was built upon four elements. First, the

course was built upon the GMHAP and GMHTBP

(Mollica, 2012) Second, the teaching model was

based upon the “community of practice” (COP)

learning perspective of Wenger and colleagues

(Wenger, McDermott, Snyder, 2002; Wenger,

1998). A COP is a “group of people who share a

concern or a passion for something they do, and

who learn how to do it better as they interact

regularly” (McMahon, Asthagiri, Khalessi, 2019).

Third, the course used a blended learning

approach with face-to-face learning with a

follow-up virtual learning model (Liu et al, 2016;

Cook et al, 2008; Shaw et al, 2011). This blended

learning model included two weeks on-site in

Orvieto, Italy followed up by five months online in

small groups which used case study discussions

and interactive dialogue and conversations.

Fourth, participation was interdisciplinary,

Mental Health: Global Challenges Journal

https://www.sciendo.com/journal/MHGCJ

ISSN 2612-2138

including participants from healthcare and

mental health backgrounds as well as

humanitarian aid workers from the United Nations

and international non-governmental

organizations (NGOs), journalists, and human

rights lawyers (Liu et al, 2016).

While each course training results were

evaluated by HMS, HPRT conducted a

comprehensive evaluation of a three-

consecutive year cohort from 2011 to 2013,

(n=155 participants). Although completion of the

GMH course has been almost universally

successful with fewer than ten participants

dropping out over thirteen years (primarily due to

illness), an extensive evaluation to determine its

impact on participants was undertaken. Mental

health knowledge including learning the major

dimensions of the GMHAP, confidence in

performing medical and psychiatric procedures

with highly traumatized patients, families and

communities, self-care, and cultural

competence were assessed. The major findings

of this evaluation are presented in this report.

By 2020, the GMH blended leaning course was in

its 14th year with over 1,000 alumni working in

over eighty-five countries, before pivoting to

virtual only programming in Spring of 2021 due to

the COVID-19 pandemic. Regardless, the present

evaluation reassures us that the request of the

World’s Ministries of Health in 2004 was met

through a six month culturally sensitive, evidence-

based accredited CME blended learning COP

model. In this study, we evaluated confidence

level change before and after the GMH course

among the 155 participants (Smith et al, 1998;

Wickstrom, Kelley, Keyserling et al, 2000;

Wickstrom, Kolar, Keyserling et al, 2000;

Henderson et al, 2008; Henderson et al, 2005;

Borba et al, 2015).

Purpose

This evaluation study contributes to the

emerging evidence that CME activities can use

innovative interactive approaches for training

health care practitioners and humanitarian

aid/human rights workers globally in the care of

highly traumatized patients and communities.

Methodology

Study Sample

There were 155 participants in the training

program across the three years from 2011 to

2013 (N2011=39; N2012=57; N2013=59).

Evaluation Approach

The participants’ confidence levels were

evaluated by a measure of competence on

performance using the Smith, et al. approach

(Smith et al, 1998; Wickstrom, Kelley, Keyserling et

al, 2000; Wickstrom, Kolar, Keyserling et al, 2000;

Henderson et al, 2008; Henderson et al, 2005;

Borba et al, 2015). Considerations for the level of

health practitioners’ confidence is closely

correlated with their actual performance, have

been demonstrated.

Demographics (gender, age, occupation,

and specialty) and confidence level were

collected at the beginning of the training and

end of the training. (See Table 1)

First, participants’ confidence was measured

on implementing the GMHAP at the beginning of

the training (baseline) and the end of the

training(post-training). A six-point Likert scale (1 =

not confident, 2 = slightly confident, 3 =

somewhat confident, 4 = confident, 5 = very

confident, 6 = extremely confident) for each

question was used to measure their level of

confidence. We measured the confidence level

on nineteen aspects: policy/legislation, financing,

science-based mental health services,

multidisciplinary education, role of international

agencies, linkages to economic development,

human rights, research, evaluation, and ethics

(Details about each category can be found in

the Appendix)

We asked sixty-four (64) questions about their

confidence towards multiple aspects of medical

and psychiatric treatment at the beginning of the

training (baseline) and the end of the training

(post-training). Similar to the above, a six-point

Likert scale for each question was used to

measure their level of confidence. The 64

confidence questions were summarized into 9

different categories: treating trauma (N = 15),

psychiatric diagnosis (N = 6), assist patient care

and social issue (N = 11), prescribe psychotropic

med (N = 1), self-care (N = 3), understanding

culture impact (N = 8), collaboration (N = 1),

policy financing (N = 1), and teaching research

evaluation (N = 11). Each category of

confidence was measured by a set of questions

from the questionnaire. We calculated the score

of each category by summing the scores of

questions in the category. Because the number

of questions in different categories of confidence

is not the same, the total confidence scores of

the nine categories are different. The details

about which questions are included in each

category are in the Appendix. The total score for

each category equals to six times the number of

questions in the category.

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ISSN 2612-2138

Statistical analysis

The data from participants responses across 3

years were combined, and the summary statistics

for the nine confidence categories was

calculated. Table 2 includes the number of

questions and total score for each category. The

average score, standard deviation, standard

error, average difference, and percentage of

improvement of each confidence category at

baseline and post-training was calculated,

including the t-test statistics and p-value to

compare the differences in average confidence

score of each category at baseline and post-

training.

Table 1. Descriptive table combined 3 years (2011-2013)

Demography

N (%) mean (SD)

Age

42.9 (11.8)

Gender

33 (21.3%) Male

122 (78.7%) Female

Location of work

20 (11.2%) Africa

17 (9.5%) Asia

11 (6.1%) Australia

5 (2.8%) Caribbean

17 (9.5%) Europe

21 (11.7%) Middle East

84 (46.9%) North America

4 (2.2%) South America

Workplace

47 (30.3%) University

12 (7.7%) Field clinic

34 (21.9%) Hospital

49 (31.6%) NGO

20 (12.9%) Government

13 (8.4%) Inter-governmental agency

37 (23.9%) Private sector

16 (10.3%) Public sector

Professional

Specialty

44 (28.4%) Clinic

85 (54.8%) Mental health

73 (47.1%) Social work

55 (35.5%) Consulting

20 (12.9%) MD (not psychiatrist)

20 (12.9%) Psychiatrist

Multiple

specialty

(52.9%) Yes

(47.1%) No

Paired T-test

To compare the nine categories of

confidence score of participants before and after

the training program, we applied paired t-test on

confidence score at baseline and post training

for same participant. The null hypothesis assumes

the difference in average confidence score μ_d

is 0. The test statistic formula used is in the

Appendix.

Linear Regression

To evaluate the impact of the training

program on participants’ confidence, linear

regression analysis was used on the nine aspects

of medical and psychiatric treatment as

outcomes and adjusted demographics and work

background information about participants which

includes age, gender, work locations, and work

specialties. The outcomes were standardized due

to different scales of outcomes. Age was

included as a continuous variable, gender and

work location were as categorical variables.

Indicators were added about their specialty

including mental health, clinical work, social work,

consulting into the model, Also, indicators were

added about whether they are MD not

psychiatrist or psychiatrist. The indicators were

added for each category because those were

not mutually exclusive. To further examine

whether demographics or work backgrounds of

participants would impact their learning

outcomes, the same regression model was

applied with additional interaction terms of post-

training and each covariatel.

Mental Health: Global Challenges Journal

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ISSN 2612-2138

Results

The overall characteristics of the participants

are described in table 1. Most of the participants

were female (78.7%), the mean age was 42.9

(SD: 11.8). Most of them worked in North America

(46.9%), some of them worked in Asia (9.5%),

Africa (11.2%), and the Middle East (11.7%). They

worked in diverse fields, including universities

(30.3%), hospitals (21.9%), non-governmental

organizations (NGOs) (31.6%). More than half of

the participants had a professional specialty in

mental health (54.8%), and many of them had a

professional specialty in social work (47.1%),

consulting (35.5%) and clinics (28.4%). Around

54% of participants have more than one

professional specialty.

Figure 1 shows average confidence scores of

the overall 10 Global Mental Health Action Plan

(GMHAP) questions before and after the training.

Figure 1 reveals statistically significant

improvements in all of the questions after the

training program. The average improvement

score is about 0.7, which means on average,

participants move to a higher confidence level in

GMHAP after training. Participants generally had

the largest improvement in “Linkage to economic

development.” Participants had relatively low

average confidence scores in “Financing” before

and after the training, they had relatively high

average confidence scores in “Science-based

mental health services” and “Evaluation” before

and after the training.

Figure 1. Average confidence score of the overall 10 Mental Health Action Plan questions

Table 2 provides a summary of confidence

scores for the nine categories of clinical

outcomes. We measured confidence scores at

baseline and post training and used paired t-test

to compare confidence scores. Overall, there

was a significant improvement in participants’

confidence in all categories of confidence

significant (p<0.001). The average improvements

in confidence scores were all more than 14%.

The largest improvement was in policy and

financing (51.6%). There are also large

improvements in treating trauma (27.3%),

teaching research evaluation (27.1%),

understanding culture impact (21.0%), and self-

care (20.5%).

Table 3 shows the regression results of the nine

regression models with the nine medical and

psychiatric aspects of treatment. Generally, the

coefficient of post-training indicator in the

adjusted models showed participants’

confidence was significantly improved in the nine

outcomes. From the results, participants with

specialty in mental health or social work have

higher confidence scores in most of the

categories compared to people without specialty

at mental health or social work. For example,

compared to people who did not have specialty

in mental health, people specialized in mental

health had 0.37 standard deviation higher

confidence score in treating trauma. Also,

participants who are MDs or psychiatrists had

higher confidence scores in most of the

categories of confidence. For example, people

who were psychiatrists had 1.02 standard

deviation higher confidence score in prescribing

psychotropic medication. Age was positively

correlated with psychiatric diagnosis (Est: 0.02,

p<0.001), self-care (Est: 0.02, p<0.001), and

collaboration (Est:0.01, P = 0.003), and it is

negatively correlated with policy financing (Est: -

0.01, p = 0.012). Participants with specialty in

consulting have higher confidence in policy

financing (Est :0.32, P = 0.005) and have lower

confidence in psychiatric diagnosis (Est: -0.36,

P<0.001) and prescribe psychotropic medicine

(Est: -0.35, P<0.001).

Mental Health: Global Challenges Journal

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Additionally, the model showed no significant

difference in the change in confidence level

before and after training based upon gender,

level of development of country of origin, and

work specialties. Participants with older age had

less increase in confidence in assisting with

patient care, social issues, and self-care.

Detailed results are in the Appendix.

Discussion

The MOHs from post-conflict countries (e.g.,

Afghanistan, Bosnia and Herzegovina, Haiti, etc.)

were convened for the first time in Rome, Italy in

December 2004, in order to generate together a

Global Mental Health Action Plan. This was

achieved. Unfortunately, at that time, most post-

conflict countries did not have the trained mental

health personnel in their country who could assist

in developing mental health policies for their

civilian populations (Mollica et al, 2004). Thus, a

request was made to the Harvard Program in

Refugee Trauma (HPRT) to develop a training

program to train healthcare providers in best

practices for treating survivors of mass violence,

such as, armed conflict. In response to this

request, HPRT developed the Global Mental

Health: Trauma and Recovery Course to address

the gap in training as identified by the MOH in the

Rome meeting. A curriculum was developed,

and mental health experts were recruited

worldwide to participate in HPRT’s six-month

training program through Harvard Medical

School. Global trainees were assembled for two

weeks of face-to-face intensive training on-site in

Orvieto, Italy; followed by five months of

continued training online with didactic lectures

combined with supervised small groups (n=10)

discussions of the lectures and intense case study

discussion learning. The small groups were led by

two faculty members; clinical cases and

psychosocial projects were addressed. The

global participants had an opportunity for a two-

week intensive in-depth discussion with each

faculty member on their original on-site lectures in

Italy. A healing environment exercise also took

place in which each participant was taught how

to design and implement a healing environment

video. This video was presented and discussed

within their small groups. In addition, an

innovative blended learning model (two weeks

onsite; five months online), and a Community of

Practice (COP) model formed the foundation of

the course.

A COP is a group of people or professionals

who share a common interest and a desire to

learn from and contribute to their communities

with their variety of experiences and expertise.

These people are intentionally committed to

learning new skills, information, and knowledge

within a model of dialogue and discussion.

•COP groups have a shared empathic

horizon that aims to achieve support among

groups members who share new ideas, policies,

and plans in a professional environment.

•The ultimate aim is to foster greater

goodness, beauty, and justice in the workplace,

and the world.

•COP groups are focused on mutual

learning through case-based discussions.

Specifically, this model is based upon co-

constructed learning – where everyone has

something to share, and everyone has something

to teach.

•The group process relies on the group

members’ willingness to reflect and exchange

ideas. This process has demonstrated that new

ideas and strategies emerge, as close

relationships develop among participants.

An initial evaluation revealed the value of this

innovative approach (Johnson, 2009) We found

that the COP model was greatly appreciated by

participants since all participants were highly

competent clinicians, despite their limited

knowledge and skills in caring for highly

traumatized patients and communities. In

addition, they were a vast reservoir of the cultural

knowledge necessary to care for the patients

within their local communities.

Seven years later, this evaluation of the GMH

course revealed the significant improvement in

GMH participants in learning the GMHAP and

confidence in diagnosing and treating highly

traumatized patients in culturally sensitive and

scientifically valid ways.

Demonstrated results of the GMH course

included:

1. Participants in this study worked at

different locations all over the world, and they

had diverse working backgrounds, many of them

working in multiple fields. People also had various

specialties, we had participants with specialty in

mental health, also had participants with

specialty in social work and consulting.

2. Participants had significant improvements

in confidence level across all nine aspects of

medical and psychiatric care, ranging from

psychiatric diagnosis to policy and financing.

3. Participants had significant improvements

in confidence level of all ten dimensions of the

GMHAP.

There was no significant difference in learning

across differences in gender, level of

development of country of origin, and work

specialties. Although older participants had less

improvement in assisting with patient care, social

issues, and self-care.

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Table 2. Confidence comparing baseline to post-training.

# of

questions

Total

score

Mean

Mean ∆

%∆

CI_L

Treating

Trauma

Baseline

53.14

18.46

140

Post-

training

67.68

16.31

14.53

27.3%

13.23

140

1.17

12.23,16.84

12.48

<0.001

Psychiatric

Diagnosis

Baseline

25.74

8.29

150

Post-

training

29.69

7.40

3.75

14.6%

5.12

150

0.43

2.91, 4.59

8.82

<0.001

Assisting with

patient care

and social

issues

Baseline

47.23

12.63

144

Post-

training

54.88

10.94

7.91

16.7%

9.44

147

0.80

6.32, 9.49

9.84

<0.001

Prescribing

Psychotropic

meds

Baseline

2.90

1.90

149

Post-

training

3.45

1.89

0.49

16.9%

1.30

148

0.11

0.28, 0.71

4.53

<0.001

Self-Care

Baseline

12.30

3.45

152

Post-

training

14.72

3.05

2.52

20.5%

3.29

152

0.27

1.98, 3.05

9.35

<0.001

Understanding

cultural

impact

Baseline

33.31

8.69

147

Post-

training

40.10

7.55

6.98

21.0%

7.61

148

0.64

5.71, 8.25

10.88

<0.001

Collaboration

Baseline

4.32

1.52

154

Post-

training

5.03

1.33

0.71

16.4%

1.39

153

0.11

0.49, 0.93

6.31

<0.001

Policy

Financing

Baseline

2.73

1.56

153

Post-

training

4.10

1.45

1.41

51.6%

1.62

153

0.13

1.15, 1.67

10.72

<0.001

Teaching

Research

Evaluation

Baseline

41.79

11.39

142

Post-

training

52.37

10.21

11.32

27.1%

9.06

149

0.78

9.78, 12.85

14.57

<0.001

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Table 3. Regression analysis.

Treating Trauma

Psychiatric diagnosis

Assisting w/ Patient Care & Social

Issues

Prescribing Psychotropic

Med

Predictors

Estim

ates

Estimate

Estimates

Intercept

-1.14

-1.60 – -0.67

<0.001

-1.36

-1.79 – -0.92

<0.001

-0.91

-1.39 – -0.43

<0.001

-0.49

-0.92 – -

0.07

0.023

Post Training

0.75

0.56 – 0.94

<0.001

0.49

0.31 – 0.67

<0.001

0.62

0.43 – 0.82

<0.001

0.30

0.12 –

0.47

0.001

Work Location

(developing)

-0.20

-0.41 – 0.01

0.058

-0.24

-0.44 – -0.04

0.017

-0.37

-0.59 – -0.15

0.001

-0.42

-0.61 – -

0.22

<0.00

Age

0.01

-0.00 – 0.02

0.072

0.02

0.01 – 0.02

<0.001

0.01

-0.00 – 0.02

0.127

0.01

-0.00 –

0.01

0.104

Gender (Female)

-0.16

-0.40 – 0.08

0.181

-0.11

-0.33 – 0.11

0.333

-0.12

-0.37 – 0.12

0.314

-0.44

-0.66 – -

0.23

<0.00

Specialty Mental

Health

0.37

0.15 – 0.58

0.001

0.44

0.25 – 0.64

<0.001

0.32

0.10 – 0.54

0.005

0.42

0.23 –

0.62

<0.00

Specialty Clinic

0.03

-0.20 – 0.26

0.811

0.00

-0.21 – 0.22

0.972

-0.06

-0.30 – 0.18

0.613

0.15

-0.06 –

0.36

0.166

Specialty Social

work

0.64

0.42 – 0.87

<0.001

0.71

0.50 – 0.92

<0.001

0.62

0.39 – 0.84

<0.001

0.33

0.12 –

0.53

0.002

Specialty

Consulting

-0.14

-0.35 – 0.07

0.188

-0.36

-0.56 – -0.17

<0.001

-0.14

-0.36 – 0.08

0.201

-0.35

-0.54 – -

0.16

<0.00

MD (not

Psychiatrist)

0.60

0.29 – 0.91

<0.001

0.58

0.27 – 0.89

<0.001

0.43

0.10 – 0.77

0.012

0.80

0.51 –

1.10

<0.00

Psychiatrist

0.46

0.16 – 0.77

0.003

0.64

0.35 – 0.93

<0.001

0.36

0.04 – 0.67

0.027

1.02

0.74 –

1.30

<0.00

Observations

278

298

289

295

Mental Health: Global Challenges Journal

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ISSN 2612-2138

Self-Care

Understanding Cultural

Impact

Collaboration

Policy Financing

Teaching research

evaluation

Predictors

Estima

tes

Esti

mates

timat

Est

imat

stim

ates

Intercept

1.26

1.75 –

-0.77

<0.001

-0.77

-1.27 – -

0.27

0.003

1.15

1.65 – -

0.64

<0.001

0.17

0.66 –

0.32

0.495

0.78

1.27 –

-0.28

0.002

Post training

0.69

0.49–

0.89

<0.001

0.77

0.56 –

0.97

<0.00

0.48

0.28 –

0.69

<0.001

0.83

0.63

–1.03

<0.00

0.88

0.68 –

1.07

<0.00

Work

location(dev

eloping)

0.05

0.27 –

0.17

0.676

-0.15

-0.37 –

0.08

0.196

0.20

0.42 –

0.03

0.089

0.14

0.08 –

0.37

0.204

0.07

0.29 –

0.16

0.557

Age

0.02

0.01 –

0.03

0.001

0.00

-0.01 –

0.01

0.659

0.01

0.00 –

0.02

0.003

0.01

0.02 – -

0.00

0.012

0.00

0.01 –

0.01

0.716

Gender

(Female)

0.07

0.32 –

0.19

0.603

-0.06

-0.31 –

0.20

0.668

0.10

0.36 –

0.16

0.442

0.10

0.35 –

0.15

0.444

0.14

0.39 –

0.12

0.290

Specialty

Mental

health

0.32

0.1

0 –

0.55

0.005

0.27

0.05 –

0.50

0.019

0.41

0.18 –

0.63

0.001

0.21

0.01 –

0.43

0.065

0.35

0.12 –

0.57

0.002

Specialty

clinic

0.11

0.36 –

0.13

0.354

0.04

-0.20 –

0.29

0.729

0.14

0.11 –

0.38

0.283

0.03

0.27 –

0.22

0.828

0.26

0.02 –

0.50

0.037

Specialty

social work

0.32

0.0

9 –

0.56

0.007

0.43

0.19 –

0.66

<0.00

0.28

0.04 –

0.52

0.022

0.07

0.17 –

0.30

0.576

0.22

0.01 –

0.46

0.060

Specialty

consulting

0.13

0.36 –

0.09

0.236

-0.11

-0.34 –

0.12

0.346

0.01

0.24 –

0.22

0.944

0.32

0.10

–0.54

0.005

0.30

0.08 –

0.53

0.008

MD not

psychiatrist

0.13

0.21 –

0.47

0.453

0.26

-0.09 –

0.62

0.142

0.13

0.22 –

0.48

0.466

0.20

0.14 –

0.54

0.244

0.28

0.05 –

0.62

0.096

Psychiatrist

0.25

0.08 –

0.57

0.137

0.13

-0.20 –

0.46

0.443

0.18

0.15 –

0.51

0.292

0.05

0.27 –

0.38

0.742

0.09

0.23 –

0.42

0.582

Observations

302

293

305

304

289

Mental Health: Global Challenges Journal

https://www.sciendo.com/journal/MHGCJ

ISSN 2612-2138

Anecdotally, as a testimony to the value

participants placed in the GMH course, there was

not a single drop-out; none missed their weekly

small group sessions more than three times.

Participants were proud of completing the GMH

course and of receiving not only CMEs but also

the HPRT’s Certificate of Completion. Most have

continued as GMH alumni and have had the

opportunity to participate in one-week alumni

courses in Italy. Unfortunately, due to the

catastrophic impact of COVID-19 in Italy,

America, and worldwide, this course in 2021 had

to shift to a two-week online course with no

opportunity for live face-to-face learning. The self-

care benefits of spending two weeks in a

beautiful, nurturing environment in Orvieto, Italy

was also eliminated. In contrast to the original

GMH course, the exclusively online course

allowed for an extensive number of scholarships;

younger professionals globally were also able to

attend because of reduced tuition fees and lack

of travel costs to Italy.

The GMH course revealed in this study the

powerful efficacy of a blended learning

Community of Practice model (Johnson, 2009;

Fordis et al, 2005) From the live GMH course,

there are now over 1,600 alumni working in over

eighty-five countries. The GMH alumni have

remained committed to each other; many have

said anecdotally that the GMH course was a

transformative experience. The GMH fully- online

courses over the last three years during the

COVID-19 pandemic engaged 576 participants

worldwide. It remains to be demonstrated

whether the online courses have had a similar

impact as the blended GMH courses.

It is not uncommon to receive the following

updates from the GMH alumni. This one was

received this year from an alum of the first

inaugural course of GMH who has sustained his

work in the conflict zone of Uganda for over

twelve years:

“I fondly remember our time together in

Orvieto, Italy. The people, the place, the

creativity, the olive oil, and the wine. It will last in

my memory for a lifetime. In fact, the ideas, and

instructions I received during the GMH course

continue to impact me and my work.” – HPRT

Alum, Uganda, 2023.

Limitations and Future Directions

The study has a few limitations. This study only

included participants of GMH education; there

were no control groups. Therefore, we could not

compare the GMH training results to other training

outcomes; we could not compare the GMH

training to no training at all. Participants were not

tracked after the training. So, no follow up data

exists to show the impact of GMH training over

time.

Conclusions

HMS through HPRT was able to respond to the

mental health training and policy needs of MOHs

in post-conflict countries. There are now more

than 1,500 trained GMH alumni worldwide

working in over eighty-five countries.

Acknowledgements

The preparation of these results was

suspended due to the COVID-19 pandemic. The

HMS HPRT GMH course had to shift from a

blended learning model to an exclusively online

virtual training program. The COVID-19 pandemic

has provided HMS and HPRT with a unique

opportunity to compare the relative success of a

blended learning course with a fully online

course.

Conflict of interest

The authors declare that they have not

conflicts of interest.

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Appendix

List of questions in each category

Treating trauma

Identify the concrete physical and mental health effects of trauma

Identify trauma related disability

Treat trauma related disability

Identify the medical problems of torture survivors

Identify the mental health problems of torture survivors

Treat the medical problems of torture survivors

Treat the mental health problems of torture survivors

Care for the psychosocial problems of torture survivors

Care for the legal problems of torture survivors

Care for the spiritual problems of torture survivors

Identify and treat adult (>18) traumatized patients/clients

Identify and treat teenage (13-18) traumatized patients/clients

Identify and treat traumatized patients/clients who are children (<13)

Refer torture survivors to appropriate providers/services

Ask about the patients’/clients’ “trauma story”

Psychiatric

diagnosis

Identify post-traumatic stress disorder (PTSD)

Identify grief reactions

Identify depression

Treat PTSD

Treat grief reactions

Treat depression

Assisting in

patient care

and social

issues

Reinforce and teach positive coping behavior for patient/clients

Recommend altruism, work, and spiritual activities to patients/clients

Reduce patient’s/client’s high-risk behaviors

Help patients/clients with disability related to financial/housing/food problems in

violence victims

Intervene with a patient/client threatening to hurt others

Intervene with a patient/client threatening to commit suicide

Involve family members in the treatment of a patient/client

Contact a psychiatrist and discuss a case

Refer a patient to a psychiatrist, social worker, nurse, or job counselor

Offer your patients/clients opportunities for work or income generation

Maintain patients’/clients’ privacy

Prescribing

psychotropic

med

Effectively use psycho-therapeutic medications

Self-care

Reduce the physical and emotional stress in your daily practice associated with

caring for torture/trauma survivors

Provide ongoing supervision and technical assistance to trainees

Prevent burnout by discussion with colleagues

Understanding

cultural impact

Go to rural areas and/or the field to treat patients/clients

Discuss health inequality issues around race, ethnicity, and diversity with trainees

Discuss ethnic, racial, and diversity issues in the doctor patient relationship

Adapt your work to different cultures and societies

Be culturally attuned to differences in meaning and interpretation of emotional upset

between cultures

Mental Health: Global Challenges Journal

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Treat a patient/client who is from a different ethnic group from your own

Work effectively with an interpreter

Understand the folk diagnosis given by the community to the patient

Collaboration

Teach skills and train other health professionals

Policy financing

Help establish a national mental health action plan in post-conflict countries

Teaching

research

evaluation

Use scientific journals as a reference for your work

Work effectively with evidence-based (i.e., scientifically proven) practices

Develop an evaluation plan

Conduct evaluation

Design and implement a research activity

Give presentations

Teach the Harvard Toolkit

Lead clinical case discussions

Write articles for journals

Conduct program evaluation of treatments(s) for torture survivors

Conduct research involving torture survivors

Paired T-test statistics

= − 

/√

Note:  is the sample mean difference.  is the standard deviation of the difference.  is the sample

size.

Regression model

=0+1+2+3+4+5 ℎℎ

+6+7 +8+9  ℎ

+10ℎ+