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Background Primary care physicians (PCPs) working in mental health care in Tunisia often lack knowledge and skills needed to adequately address mental health-related issues. To address these lacunas, a training based on the Mental Health Gap Action Programme (mhGAP) Intervention Guide (IG) was offered to PCPs working in the Greater Tunis area between February and April 2016. While the mhGAP-IG has been used extensively in low- and middle-income countries (LMICs) to help build non-specialists’ mental health capacity, little research has focused on how contextual factors interact with the implemented training program to influence its expected outcomes. This paper’s objective is to fill that lack. Methods We conducted a case study with a purposeful sample of 18 trained PCPs. Data was collected by semi-structured interviews between March and April 2016. Qualitative data was analyzed using thematic analysis. Results Participants identified more barriers than facilitators when describing contextual factors influencing the mhGAP-based training’s expected outcomes. Barriers were regrouped into five categories: structural factors (e.g., policies, social context, local workforce development, and physical aspects of the environment), organizational factors (e.g., logistical issues for the provision of care and collaboration within and across healthcare organizations), provider factors (e.g., previous mental health experience and personal characteristics), patient factors (e.g., beliefs about the health system and healthcare professionals, and motivation to seek care), and innovation factors (e.g., training characteristics). These contextual factors interacted with the implemented training to influence knowledge about pharmacological treatments and symptoms of mental illness, confidence in providing treatment, negative beliefs about certain mental health conditions, and the understanding of the role of PCPs in mental health care delivery. In addition, post-training, participants still felt uncomfortable with certain aspects of treatment and the management of some mental health conditions. Conclusions Findings highlight the complexity of implementing a mhGAP-based training given its interaction with contextual factors to influence the attainment of expected outcomes. Results may be used to tailor structural, organizational, provider, patient, and innovation factors prior to future implementations of the mhGAP-based training in Tunisia. Findings may also be used by decision-makers interested in implementing the mhGAP-IG training in other LMICs. Electronic supplementary material The online version of this article (10.1186/s12889-018-6261-4) contains supplementary material, which is available to authorized users.

To address the rise in mental health conditions in Tunisia, a training based on the Mental Health Gap Action Programme (mhGAP) Intervention Guide (IG) was offered to primary care physicians (PCPs) working in the Greater Tunis area. Non-specialists (such as PCPs)’ training is an internationally supported way to target untreated mental health symptoms. We aimed to evaluate the programme’s impact on PCPs’ mental health knowledge, attitudes, self-efficacy and self-reported practice, immediately following and 18 months after training. We conducted an exploratory trial with a combination of designs: a pretest–posttest control group design and a one-group pretest–posttest design were used to assess the training’s short-term impact; and a repeated measures design was used to assess the training’s long-term impact. The former relied on a delayed-intervention strategy: participants assigned to the control group (Group 2) received the training after the intervention group (Group 1). The intervention consisted of a weekly mhGAP-based training session (totalling 6 weeks), comprising lectures, discussions, role plays and a support session offered by trainers. Data were collected at baseline, following Group 1’s training, following Group 2’s training and 18 months after training. Descriptive, bivariate and ANOVA analyses were conducted. Overall, 112 PCPs were randomized to either Group 1 (n = 52) or Group 2 (n = 60). The training had a statistically significant short-term impact on mental health knowledge, attitudes and self-efficacy scores but not on self-reported practice. When comparing pre-training results and results 18 months after training, these changes were maintained. PCPs reported a decrease in referral rates to specialized services 18 months after training in comparison to pre-training. The mhGAP-based training might be useful to increase mental health knowledge and self-efficacy, and decrease reported referral rates and negative mental health attitudes among PCPs in Tunisia and other low- and middle-income countries. Future studies should examine relationships among these outcome variables.

Background Tunisia is a lower-middle-income country located in North Africa. Since the 2010-2011 Revolution, a campaign of civil resistance to protest high levels of youth unemployment, difficult living conditions, and government corruption, a rise in mental health problems, substance use disorders, and suicide attempts/deaths has been recorded. To address untreated mental health symptoms, a mental health training program was offered to primary care physicians (PCPs) working in the Greater Tunis area of Tunisia, a collaboration between members of the Tunisian Ministry of Health, the *School of Public Health* at the *Universite de Montreal* (Quebec, Canada), the *World Health Organization* (*WHO*) office in Tunisia, and the *Montreal WHO-PAHO Collaborating Center (CC) for Research and Training in Mental Health* (Quebec, Canada). # Program description The training was based on the *Mental Health Gap Action Programme (mhGAP) Intervention Guide (IG)*, a program developed by the *WHO* to help further develop the mental health competencies of non-specialists working in non-specialized settings. Our team adapted the *mhGAP-IG* training to the primary care realities of the Greater Tunis area, offered the training program to PCPs between February and April 2016, and evaluated the program using a randomized controlled trial and implementation analysis. # Discussion The adaptation, implementation, and evaluation of the training program equipped our team with important lessons learned, supported by evidence in the field of *Global Mental Health*. First, developing partnerships helped create a feasible program that met the practical and research needs of the country. Second, benefitting from political commitment to mental health facilitated the development of partnerships, the implementation of the training program, and the training's accompanying evaluation. Third, piloting the program helped identify challenges attributed to the training program and its implementation, the mental health care system, and the research tools, information that may be used to "build back better." Last, sharing research findings collaboratively helped ensure their validity and encouraged greater knowledge uptake. # Conclusion We hope that sharing such lessons learned will aid other countries with similar profiles to develop and/or adapt, implement, and evaluate programs that target untreated mental health symptoms in primary and community-based settings and hence address priorities in *Global Mental Health*.

Examples of interview questions. (DOCX 20.5 kb)

BackgroundIn order to make mental health services more accessible, the Tunisian Ministry of Health, in collaboration with the School of Public Health at the University of Montreal, the World Health Organization office in Tunisia and the Montreal World Health Organization-Pan American Health Organization Collaborating Center for Research and Training in Mental Health, implemented a training programme based on the Mental Health Gap Action Programme (mhGAP) Intervention Guide (IG) (version 1.0), developed by the World Health Organization. This article describes the phase prior to the implementation of the training, which was offered to general practitioners working in primary care settings in the Greater Tunis area of Tunisia.MethodsThe phase prior to implementation consisted of adapting the standard mhGAP-IG (version 1.0) to the local primary healthcare context. This adaptation process, an essential step before piloting the training, involved discussions with stakeholder groups, as well as field observations.ResultsThrough the adaptation process, we were able to make changes to the standard training format and material. In addition, the process helped uncover systemic barriers to effective mental health care.ConclusionsTargeting these barriers in addition to implementing a training programme may help reduce the mental health treatment gap, and promote implementation that is successful and sustainable.

Final Code book. (DOCX 33.2 kb)

Background In order to make mental health services more accessible, the Tunisian Ministry of Health, in collaboration with the School of Public Health at the University of Montreal, the World Health Organization office in Tunisia and the Montreal World Health Organization-Pan American Health Organization Collaborating Center for Research and Training in Mental Health, implemented a training programme based on the Mental Health Gap Action Programme (mhGAP) Intervention Guide (IG) (version 1.0), developed by the World Health Organization. This article describes the phase prior to the implementation of the training, which was offered to general practitioners working in primary care settings in the Greater Tunis area of Tunisia. Methods The phase prior to implementation consisted of adapting the standard mhGAP-IG (version 1.0) to the local primary healthcare context. This adaptation process, an essential step before piloting the training, involved discussions with stakeholder groups, as well as field observations. Results Through the adaptation process, we were able to make changes to the standard training format and material. In addition, the process helped uncover systemic barriers to effective mental health care. Conclusions Targeting these barriers in addition to implementing a training programme may help reduce the mental health treatment gap, and promote implementation that is successful and sustainable.