Impact statement
The contextualization and adaptation of the Child and Adolescent Mental and Behavioural Disorders module is a critical step in addressing the treatment gap for child and adolescent mental health (CAMH) in the unique contexts of Nairobi and Kilifi counties in Kenya. The process ensures cultural relevance, local applicability and sustainability of the intervention. By identifying health system barriers, such as resource shortages and workforce limitations, this study not only tailors evidence-based training and guidelines but also advocates for policy changes to improve access to CAMH services. The study findings contribute to a growing body of knowledge on contextualizing global mental health programmes, highlighting the importance of culturally sensitive and locally adaptable solutions in addressing global health disparities. This work sets the foundation for scaling up CAMH interventions in Kenya and offers a model for similar adaptations to other resource-limited settings worldwide.
Introduction
Access to mental healthcare services for children and adolescents poses a significant challenge in low- and middle-income countries (LMICs), necessitating innovative solutions. The World Health Organization (WHO) published its first Mental Health Gap Action Programme-Intervention Guide (mhGAP-IG) in 2010, revised in 2016, and updated in 2023 (World Health Organization, 2010, 2016, 2023). The mhGAP-IG provides algorithms to assess and manage priority mental, neurological and substance use (MNS) conditions for healthcare workers (HCWs) in non-specialist healthcare settings.
The mhGAP-IG includes (i) an introduction section; (ii) an Essential Care and Practice (ECP) module; and (iii) assessment, management (psychosocial and pharmacological interventions), referral and follow-up for priority MNS conditions (World Health Organization, 2016). The Child and Adolescent Mental Behavioural Disorders (CMH) module is among the modules for priority MNS conditions included in the mhGAP-IG (World Health Organization, 2016). The CMH module outlines the assessment and management of developmental, behavioural and emotional disorders. For adolescents, assessment and management of emotional disorders are linked to other priority MNS conditions, such as self-harm/suicide and substance use.
The mhGAP-IG requires contextualization and adaptation to ensure its relevance for use in non-specialist healthcare settings (World Health Organization, 2018; Faregh et al., Reference Faregh, Lencucha, Ventevogel, Dubale and Kirmayer2019; Gómez-Carrillo et al., Reference Gómez-Carrillo, Lencucha, Faregh, Veissière and Kirmayer2020; Searle et al., Reference Searle, Blashki, Kakuma, Yang, Lu, Li, Xiao and Minas2022). Contextualization refers to the addition of specific elements to existing guidelines or training materials to suit local needs, such as those of a particular country (Dizon et al., Reference Dizon, Machingaidze and Grimmer2016). Adaptation is the process of modifying existing guidelines or training materials to cater to local needs and conditions; for example, changing language to ensure cultural relevance (Fervers et al., Reference Fervers, Burgers, Haugh, Latreille, Mlika-Cabanne, Paquet, Coulombe, Poirier and Burnand2006). Adaptation has been shown to foster a sense of ownership among local HCWs and stakeholders (Mutiso et al., Reference Mutiso, Gitonga, Musau, Musyimi, Nandoya, Rebello, Pike and Ndetei2018; Bitta et al., Reference Bitta, Kariuki, Kiambu, Nasoro, Newton, Njeri, Omar and Ongeri2020), which is vital for the successful and sustainable implementation of the mhGAP-IG (Doherty et al., Reference Doherty, Dass, Edward, Manolova and Solomon2020).
With over 90 countries using the mhGAP-IG since its initial publication, there are only a few documented studies on its contextual adaptation, including Nigeria (Abdulmalik et al., Reference Abdulmalik, Kola, Fadahunsi, Adebayo, Yasamy, Musa and Gureje2013), Sri Lanka (Doherty et al., Reference Doherty, Dass, Edward, Manolova and Solomon2020), China (Zheng et al., Reference Zheng, Zhang, Chen, Chen, Kong, Xie, Li, Hall, Renzaho, J-h, D-m, Zou, X-y, Q-m and Chen2025) and Pakistan (Khan et al., Reference Khan, Hameed and Avan2023), where adaptations led to improved training outcomes. In Kenya, mhGAP-IG version 1.0, which was published in 2010, was contextualized for clinical use in Makueni County and was found to be feasible, effective and well-received, supporting its scale-up (Mutiso et al., Reference Mutiso, Gitonga, Musau, Musyimi, Nandoya, Rebello, Pike and Ndetei2018, Reference Mutiso, Pike, Musyimi, Gitonga, Tele, Rebello, Thornicroft and Ndetei2019). The mhGAP-IG version 2.0 was later contextualized and pilot-tested in Kilifi, coastal Kenya, and reported a significant improvement in trained HCWs’ knowledge (66.3–76.6%, p < 0.001; Bitta et al., Reference Bitta, Kariuki, Kiambu, Nasoro, Newton, Njeri, Omar and Ongeri2020). However, the CMH module was excluded because the child and adolescent mental health (CAMH) disorders were not considered priority MNS conditions in Kilifi (Bitta et al., Reference Bitta, Kariuki, Kiambu, Nasoro, Newton, Njeri, Omar and Ongeri2020). This lack of recognition likely reflects limited knowledge rather than a low disease burden, as 13% of children in Kilifi were found to have behavioural and emotional problems (Kariuki et al., Reference Kariuki, Abubakar, Kombe, Kazungu, Odhiambo, Stein and Newton2017; Bitta et al., Reference Bitta, Kariuki, Kiambu, Nasoro, Newton, Njeri, Omar and Ongeri2020). Although informative, these studies did not include the CMH module, a gap with policy implications in Kenya, given the rising burden of CAMH disorders (Mutiso et al., Reference Mutiso, Gitonga, Musau, Musyimi, Nandoya, Rebello, Pike and Ndetei2018; Bitta et al., Reference Bitta, Kariuki, Kiambu, Nasoro, Newton, Njeri, Omar and Ongeri2020). Building on these efforts, the current study aimed to contextualize and adapt the mhGAP-IG CMH module and its training materials for use in Nairobi and Kilifi counties, involving key stakeholders.
Methods
Study design
A qualitative approach was used to adapt and contextualize the CMH module and its training materials. This process was preceded by a situational analysis to understand the CAMH systems and services in Nairobi and Kilifi (Abdulmalik et al., Reference Abdulmalik, Kola, Fadahunsi, Adebayo, Yasamy, Musa and Gureje2013; Faregh et al., Reference Faregh, Lencucha, Ventevogel, Dubale and Kirmayer2019; Bitta et al., Reference Bitta, Kariuki, Kiambu, Nasoro, Newton, Njeri, Omar and Ongeri2020). Two workshops were then held for the contextualization and adaptation process.
Study context
This study was conducted in the Kilifi and Nairobi counties. Kilifi County (population 1.45 million in 2019) is predominantly rural, with high poverty (68%) and widespread mental health misconceptions (Bitta et al., Reference Bitta, Kariuki, Kiambu, Nasoro, Newton, Njeri, Omar and Ongeri2020; City Population, 2019; Kariuki et al., Reference Kariuki, Abubakar, Kombe, Kazungu, Odhiambo, Stein and Newton2017). Nairobi County (5.54 million residents) has a stronger economy but faces overcrowding, service delivery gaps and limited CAMH care access, despite having over 1,200 healthcare facilities (Kumar et al., Reference Kumar, Nyongesa, Kagoya, Mutamba, Amugune, Krishnam, Wambua, Petersen, Gachuno and Saxena2021; Wambua et al., Reference Wambua, Falkenström, Kumar and Cuijpers2022; Mbithi et al., Reference Mbithi, Mabrouk, Sarki, Odhiambo, Namuguzi, Dzombo, Atukwatse, Kabue, Mwangi and Abubakar2023; World Population Review, 2024).
Sampling procedures
Purposive sampling and snowballing were used to identify participants for the situational analysis and adaptation workshops. The initial participants were selected based on their roles in mental health planning and service delivery in the two counties, with additional participants identified through referrals. These sampling strategies ensured the inclusion of experts and stakeholders, who provided valuable insights throughout the study.
Participants
The situational analysis involved six key informants. The first workshop had 13 participants, all of whom returned for the second workshop, except for the psychiatrist who was represented by a counselling psychologist. In the second workshop, a caregiver of a child with autism and a paediatrician were invited based on recommendations of their inclusion from delegates in the first workshop; however, the paediatrician did not attend. Of all the participants, three were involved in the situational analysis as well as both the workshops. Table 1 provides details of the participants’ characteristics.
Summary of participants
Data collection
The paragraphs below describe how data were collected for the situational analysis, the adaptation workshops and Training of Trainers and Supervisors (ToTS) conducted between January and February 2024, steps summarized in Figure 1.
Contextual adaptation process for the mhGAP-IG CMH module.
Situational analysis of the CAMH system and services in Nairobi and Kilifi counties
In-depth interviews were conducted to understand the broader mental health system context in Nairobi and Kilifi counties. CAMH service availability, resources and existing policies were also assessed. The interview guide (Supplementary Material S1) was drafted using a brief questionnaire from the WHO’s Assessment Instrument for Mental Health Systems (WHO-AIMS; World Health Organization, 2005) to ensure systematic data collection.
Preliminary review of the CMH module’s materials
In preparation for the workshops, B.M. and B.N. reviewed the CMH module and its training materials. Second, areas that required expert deliberation were identified based on the contextualization questionnaire provided in the mhGAP operations manual on page 85 (World Health Organization, 2018). Third, a final template was developed to guide discussions during workshops (Supplementary Material S2). The participants were then provided with the CMH module and training materials for review before the first workshop. The key areas identified for adaptation shaped the agenda of the first workshop.
First consultative workshop to contextualize and adapt the CMH module and training materials
The first workshop was conducted on January 18, 2024. Written informed consent was obtained from all participants. Then, an overview of the study and the CMH module was provided. Subsequently, guided small group discussions were conducted. Each group comprised four to five participants assigned to review the content of their professional expertise, and one study team member. For instance, participants with clinical experience examined sections such as the common presentations of CMH disorders. Their input into specific sections of the CMH module and training materials ensured that the adaptations were relevant to the local context. Finally, each group presented key points to the larger group, which was moderated by B.M., and the session was audio-recorded.
After the first workshop, content analysis to summarize the key findings from the discussions and deliberations was consolidated by B.M. and V.A. The emerging themes informed the planning and agenda of the second adaptation workshop. This initial analysis provided timely feedback that supported iterative adaptation. The full thematic analysis was conducted retrospectively using the approach by Braun and Clarke (Reference Braun and Clarke2006), owing to time and resource constraints.
Second consultative workshop to contextualize and adapt the CMH module and training materials
The second workshop was held on February 13, 2024, to discuss the changes suggested in the previous workshop and reach consensus on the study team’s interpretation of the feedback from the previous workshop. Consent was obtained from the two participants who were not present at the initial workshop. The outputs from the first workshop were then discussed by the entire group, and each suggested change was debated, with the final adaptations reflecting the agreement of the larger group. Whenever there were disagreements, participants were encouraged to share their perspectives until a compromise was reached. Consensus was achieved through facilitated discussions, in which all views were welcomed. Although no formal consensus-building techniques (e.g., Delphi or nominal group methods; McMillan et al., Reference McMillan, King and Tully2016) were used, differing opinions were discussed and documented to ensure that minority voices were considered and bias was minimized. This participatory approach ensured that the final adaptations reflected the views of a broad range of stakeholders. B.M. facilitated the discussions, which were audio-recorded.
Further adaptations during the training of trainers and supervisors training
Discussions from the workshops were shared with the WHO CAMH international trainer, L.P., a child and adolescent psychiatrist, to obtain expert feedback on how best to integrate stakeholder input into the mhGAP-IG guidelines and training content. Building on this, adaptations made during the workshops were revisited during the ToTS sessions held from February 19–23, 2024, which included seven of the same mental health experts and stakeholders in the earlier contextualization workshops. Additional suggestions emerged during the ToTS sessions, including inputs from L.P., who drew on experiences from other CMH module implementation contexts. These proposals were deliberated collectively with local stakeholders during the ToTS sessions, ensuring alignment with the contextual priorities. Final adaptations were agreed upon by consensus, paving the way for subsequent training of HCWs.
Data management
All qualitative data were audio-recorded, with written informed consent obtained from the participants. Audio recordings were transcribed verbatim, and all identifying information was removed. Transcribed data and audio recordings were securely stored on a password-protected laptop that was accessible only to the research team. The data were anonymized by assigning each participant a unique identifier.
Data analysis
Guided by Braun and Clarke (Reference Braun and Clarke2006), thematic analysis was conducted using the original transcripts to extract emergent, recurring themes, using the NVivo-Lumivero© 15 software. A line-by-line reading of a subset of transcripts (two in-depth interviews and one workshop) was conducted to identify emerging codes and develop the codebook. This involved B.M., B.N. and J.M. Systematic coding in NVivo was done by B.M., and the preliminary categories and themes developed were reviewed and discussed with V.A. All other researchers participated in reviewing the results and interpretations. This collaborative process ensured credibility and coherence of the findings.
Results
The subsequent sections highlight the key findings of the situational analysis and adaptations made to the CMH module and the training materials.
Situational analysis of the CAMH services in Kilifi and Nairobi
Findings on the CAMH system and services are organized according to the six domains outlined in the WHO-AIMs tool, presented below and summarized in Table 2.
Key sub-themes from the situational analysis of the child and adolescent mental health in Nairobi and Kilifi
Policy and legislative framework
Since the 2013 devolution in Kenya, the County Health Departments have been responsible for managing healthcare services. In mental health, the mandate is guided by national frameworks, such as the Mental Health Policy 2015–2030 (Ministry of Health, 2015), Mental Health Action Plan 2021–2025 (Ministry of Health, 2021) and the amended Mental Health Act of 1989, revised in 2023 (Republic of Kenya, 2023).
While Kilifi has a costed Mental Health and Disability Action Plan 2022–2026 (Kilifi County, 2022) and Nairobi recently launched its Mental Health and Strategic Action Plan 2025–2030 (Nairobi City County, 2025), both counties lacked a CAMH-specific policy or action plan. They rely on the National Mental Health Policy and Action Plan (Ministry of Health, 2015, 2021). One participant highlighted:
“…we do not have an existing policy for child and adolescent mental health…as a county we have the action plan we narrowed down from the national one…” (KII02_County Health Manager)
A limited CAMH policy focus leads to inadequate funding, with CAMH often deprioritized compared to other health programmes. A respondent reported:
“…One of the challenges is inadequate resources towards mental health services specifically focusing on adolescents and children…” (KII01_County Health Manager)
Mental health services
Access to quality CAMH services in the two counties was limited, with care offered through outpatient clinics and few inpatient options. In Nairobi, referrals for severe presentations of mental disorders are directed to national-level facilities, such as the Mathari National Teaching and Referral Hospital and private facilities. In Kilifi, the absence of a local inpatient facility necessitates referrals to Mombasa County’s mental health unit, which is more than 90 km away. One respondent reported:
“…we do not have any [county] inpatient services…we refer to private clinics… Mathari [Hospital] does not admit those who are under eighteen [years]…that is the major challenge…especially when we get [adolescents] who have attempted suicide…self-harm…experiencing psychosis…” (KII03_Clinical Psychologist)
Second, frequent stockouts of essential psychotropic medications lead to delayed treatment and poor adherence, especially for those facing financial constraints. One participant pointed out the following:
“…Even the most desired antidepressant fluoxetine [for adolescent depression], I have never seen the government supply….” (KII04_Psychiatric Nurse)
Third, the participants pointed out the lack of dedicated clinical space for mental healthcare services. Often, clinic spaces are shared, compromising privacy and care quality. Additionally, stigma and dismissive behaviour from HCWs have been reported.
“…there’s a lot of stigma and discrimination…I wish we could sensitize staff (HCWs) to treat mental health [disorders] like any other disease…” (KII03_Clinical Psychologist)
Mental health in primary healthcare settings
Participants highlighted improvements in mental healthcare in Primary Healthcare (PHC) settings, such as hiring counsellors and psychologists, establishing new clinics and service integration. For example, psychotherapy services for children and adolescents are offered at a child-friendly outpatient clinic in a health centre in Nairobi. Additionally, community health promoters (CHPs), who are recognized by the Ministry of Health as service providers at the community level, were seen as playing a critical role in the early identification of CAMH disorders and referral to PHC facilities. One participant noted:
“… I have received so many of them (children/adolescents with CAMH disorders) through the CHPs…” (KII04_Pschiatric Nurse)
However, key gaps remain. Capacity-building initiatives, such as mhGAP-IG trainings, often exclude the CMH module and minimize HCWs’ preparedness at the PHC level to manage CAMH disorders.
“…For child and adolescent… we have not received training on that…” (KII02_Clinical Psychologist)
Further, specialist mental health services, such as speech and occupational therapy, remain concentrated at higher-level facilities, limiting access at the PHC level.
“…occupational therapy, speech therapy is offered not in health centres and dispensaries, it would be level 4 and above…” (KII03_Clinical Psychologist)
Human resources
A lack of human resources, especially mental health specialists, was reported in both counties. Facilities often rely on volunteers, interns or temporary support from Non-Governmental Organizations (NGOs) because of chronic staffing shortages.
“…We are understaffed… I am the mental health specialist for the entire sub-county…” (KII05_Psychiatric Clinical Officer)
“…I work alone, but I have volunteers….and every three months we get interns…I train them…” (KII03_Clinical Psychologist)
Despite ongoing capacity-building efforts, such as psychiatry training for medical doctors, neither county has employed a child and adolescent psychiatrist. The scarcity of specialists results in overwhelming workloads. A participant reported:
“…We are so much overwhelmed. Seeing 40 patients alone leads to significant burnout…” (KII04_Psychiatric Nurse)
These staffing constraints were further compounded by budgetary restrictions that limited recruitment.
“…The biggest challenge with staffing is the budget…you can only do a maximum of 35% for personnel to the recurrent budget…recruitment is limited….” (KII01_County Health Manager)
Public education and links with other sectors
Respondents noted that stigma and harmful cultural beliefs hindered access to CAMH services, and mental health was often considered a taboo topic. A participant stated:
“…Some parents say they observed certain behaviours for quite a long time but were afraid to seek help…their children may be labelled with mental issues or fear of community gossip…” (KII04_Psychiatric Nurse)
Consequently, families often turn to traditional healers or religious leaders before seeking formal healthcare, which can delay treatment and worsen their outcomes. Participants noted limited community awareness of CAMH, which hinders early identification and care.
Participants noted the valuable role that NGOs and private sector stakeholders play in strengthening mental health service gaps by providing scholarships, antipsychotics and psychotherapy. One participant explained:
“…the [mentions organisation] NGO is supporting mental health in terms of a scholarship for a higher diploma in mental health…” (KII04_Psychiatric Nurse)
Monitoring and research
Participants highlighted the absence of mental health monitoring tools and CAMH-specific indicators in PHC facility registers and reports, which limits the visibility and strategic planning for CAMH.
“…Whenever we are doing the general report, it won’t show that you’ve seen a child who has anxiety, depression… we don’t have that indicator…” (KII03_Clinical Psychologist)
This lack of disaggregated data weakens advocacy for CAMH funding and programme development.
“… you need that disaggregated data for planning and intervention programmes.” (KII0_County Health Manager)
Summary of mhGAP CMH module and training materials adaptations considered
Adaptations aimed to improve clarity, contextual fit and usability for non-specialist HCWs in PHC, covering (1) training materials and (2) the CMH module content.
Adaptations to the CMH module training materials
Several adaptations were made to enhance the delivery of the training and support the application of knowledge and skills into practice. A summary of these adaptations is presented in Table 3.
Contextual adaptations to CMH training materials
The Training of Healthcare Providers (ToHP) was extended from the mhGAP-IG’s recommended 5.8 h minimum to a 5-day schedule, allowing for videos, group discussions and role plays to promote active learning. The revised schedule, drafted by L.P. and reviewed by B.M. and V.A., incorporated inputs from the WHO technical staff based on prior training experience and local stakeholders. The extended training duration also allowed for the inclusion of the ECP module, which equips HCWs with skills for respectful, culturally responsive communication and assessment, enabling them to engage with traditional beliefs and explanatory models without reinforcing stigma. Additional mhGAP content on mania, suicide/self-harm and substance use further broadened the coverage to address the CAMH specialist shortage and limited prior training.
Training presentation slides were also revised to improve structure and trainee engagement, and instructions for small group activities and discussions, previously in the trainer’s manual, were added directly to the slides to ensure clarity and smooth facilitation. In addition, the slide sequence was reorganized by the disorder category: developmental, behavioural and emotional disorders, with each discussed sequentially from assessment to follow-up protocols. This replaced the previous flow, which grouped all assessments, all management and all follow-up steps across conditions. The revised structure supported deeper learning and improved familiarity with the CMH protocols, making it easier for non-specialist HCWs to apply them in practice.
Supporting training materials, such as roleplays and personal stories, were also adapted. For example, role-play four was revised during ToTS in consultation with L.P. and stakeholders to reinforce the mhGAP-IG recommendation of interviewing adolescents alone during assessment. In addition, the developmental milestones checklist from the mhGAP was replaced with that found in Kenya’s Ministry of Health Maternal and Child Health booklet, ensuring alignment with national tools already in use at the PHC level.
Together, these adaptations aimed to improve the contextual fit, acceptability and practical utility of the mhGAP training for HCWs in resource-limited and high-need settings, such as Kilifi and Nairobi.
Changes made to the CMH module of the mhGAP-IG
This section outlines key modifications to the terminology, differential diagnosis, psychosocial and pharmacological interventions and referral pathways in the CMH module. Details of the CMH adaptations are in Table 4.
Contextual adaptations to the mhGAP-IG CMH module
The situational analysis identified stigma as a major barrier to the early identification of CAMH disorders. In response, some stigmatizing terms, as noted by the stakeholders, were rephrased to support more respectful and culturally sensitive communication. For example, in the “Common Presentations” section (p. 71) of the CMH, “failure to thrive” was rephrased to “sub-optimal growth”. Participants articulated the following:
“…Failure is a bit harsh…” (P8_Counselling Psychologist)
“…some of these words (failure to thrive) can perpetuate stigma…” (P1_Mental Health Coordinator at a Local Organization)
A suggestion by stakeholders during the ToTS was to create a “CMH Overview” (mhGAP-IG, p. 70) poster outlining steps for assessment, management and follow-up in the CMH module. Consequently, to enhance the usability of the poster at PHC facilities, L.P. recommended adding page numbers for quick referencing and slight rephrasing adjustments. For example, “Assess for developmental disorders” became “Assess development and functioning.” These changes helped HCWs better understand specialized terms. An adapted CMH Overview page is provided in Supplementary Material S3.
The differential diagnosis sections in the CMH module were updated to help non-specialist HCWs ensure diagnostic accuracy. For example, diabetes was added to the conditions to rule out when assessing emotional disorders because it resembles or exacerbates emotional disorders. These changes support comprehensive care amid limited CAMH care services.
The psychosocial interventions in the CMH module were retained, even for those that were expected to become available in the future. Stakeholders emphasized the need for practical alternatives to physical discipline, reflecting a common challenge in the community. They suggested that ToHP should reinforce strategies that caregivers can realistically apply at home. One participant said:
“…one parent asked me ‘if you don’t want me to cane my child then what exactly should I do to help rectify the behaviour?’… you need to give them options to practice when they get back home…’.” (P1_Mental Health Coordinator at a Local Organisation)
Stress-reduction techniques already in the CMH module, such as breathing techniques and progressive muscle relaxation, were recommended for children, caregivers and HCWs, given the risk of burnout and emotional fatigue from staff shortages noted in the situational analysis. A psychologist said:
“…I just found out that this [breathing] technique works wonders for adolescents and even adults…” (P8_Counselling Psychologist)
A new recommendation was added to the “Simple Tips” section (p. 89) of the CMH module, advising teachers to closely supervise paired students. This builds on the existing guidance to support learners with classroom difficulties through peer pairing and volunteer involvement.
Pharmacological guidance was revised to align with the national policy and prescription capacity of non-specialist HCWs. Fluoxetine was retained as a first-line antidepressant for adolescents with moderate to severe depression. A note was added to protocol 6 (p. 86) of the CAMH module, stating that fluoxetine or other antidepressants should be used only after psychological interventions fail and with specialist involvement. The stakeholders agreed that non-specialist HCWs should prescribe methylphenidate only in consultation with a mental health specialist, citing safety concerns, side effects and the need for close monitoring. One participant noted:
“…considering the side effects of methylphenidate, mhGAP trained HCWS would prescribe in consultation with a specialist…” (P3_Psychologist)
Referral pathways were clarified by specifying referral points, for example, Ear, Nose and Throat or ophthalmology for hearing or vision concerns, instead of a general instruction to “consult a specialist.” These streamlined referrals improve follow-up and support continuity of care in under-resourced settings, as is the case in the study setting.
Together, these adaptations improved the CMH module alignment with the needs and constraints of PHC settings in Kilifi and Nairobi counties.
Discussion
The study contextualized and adapted the mhGAP-IG CMH module and associated training materials for implementation in Nairobi and Kilifi counties. Key adaptations included refining the language to ensure cultural sensitivity, feasibility and contextual relevance of the CMH module for use in PHC settings. This study aligns with global efforts to tailor the mhGAP-IG to local contexts (Katchanov and Birbeck, Reference Katchanov and Birbeck2012; Humayun et al., Reference Humayun, Haq, Khan, Azad, Khan and Weissbecker2017; Mutiso et al., Reference Mutiso, Gitonga, Musau, Musyimi, Nandoya, Rebello, Pike and Ndetei2018; Bitta et al., Reference Bitta, Kariuki, Kiambu, Nasoro, Newton, Njeri, Omar and Ongeri2020; Searle et al., Reference Searle, Blashki, Kakuma, Yang, Lu, Li, Xiao and Minas2022). For example, Sri Lanka re-filmed the mhGAP training videos that aligned with their cultural norms and communication styles, while Tunisia conducted stakeholder consultations to contextualize training content and identify systemic barriers to implementation (Spagnolo et al., Reference Spagnolo, Champagne, Leduc, Melki, Guesmi, Bram, Guisset, Piat, Laporta and Charfi2018). In China, adaptations to the depression and CMH modules incorporated culturally relevant practices, including family involvement, revised referral pathways and the integration of traditional Chinese medicine in diagnostic pathways (Doherty et al., Reference Doherty, Dass, Edward, Manolova and Solomon2020; Searle et al., Reference Searle, Blashki, Kakuma, Yang, Lu, Li, Xiao and Minas2022; Zheng et al., Reference Zheng, Zhang, Chen, Chen, Kong, Xie, Li, Hall, Renzaho, J-h, D-m, Zou, X-y, Q-m and Chen2025).
Building on these international examples, the contextualization process in Nairobi and Kilifi acknowledged the significant role of traditional and spiritual beliefs in shaping help-seeking behaviour in mental health conditions. Rather than viewing these beliefs purely as barriers, the adaptation process aimed to foster respectful engagement. To this end, the ECP module was included in the training to support culturally responsive assessment and communication, enabling providers to engage families in ways that reduce stigma, while respecting local norms. This approach aligns with global evidence supporting the integration of cultural beliefs into mental healthcare. For example, Zimbabwe’s Friendship Bench study trained lay workers to deliver therapy rooted in local traditions, improving acceptability and reducing stigma (Chibanda et al., Reference Chibanda, Weiss, Verhey, Simms, Munjoma, Rusakaniko, Chingono, Munetsi, Bere, Manda, Abas and Araya2016). Culturally grounded care has been shown to enhance the acceptability, uptake and effectiveness of mental health interventions (Kohrt and Mendenhall, Reference Kohrt and Mendenhall2015; Patel et al., Reference Patel, Saxena, Lund, Thornicroft, Baingana, Bolton, Chisholm, Collins, Cooper, Eaton, Herrman, Herzallah, Huang, Jordans, Kleinman, Medina-Mora, Morgan, Niaz, Omigbodun, Prince, Rahman, Saraceno, Sarkar, De Silva, Singh, Stein, Sunkel and UnÜtzer2018). Thus, the adapted CMH module contributes to a culturally responsive, system-integrated model of care.
While cultural relevance enhances acceptability, the sustainability and practicality of mhGAP implementation also depend on alignment with systemic and resource realities. Cultural and contextual adaptation is essential for addressing barriers such as limited human resources, medication availability and organizational challenges (Faregh et al., Reference Faregh, Lencucha, Ventevogel, Dubale and Kirmayer2019). Training activities must align with local realities (Faregh et al., Reference Faregh, Lencucha, Ventevogel, Dubale and Kirmayer2019; Gómez-Carrillo et al., Reference Gómez-Carrillo, Lencucha, Faregh, Veissière and Kirmayer2020) to ensure the effective and sustainable implementation of mhGAP. The adaptation of the CMH module aligns the guidelines with the realities of the limited CAMH resources in Nairobi and Kilifi, thereby enhancing its feasibility in these settings. Practical recommendations enable HCWs to make informed treatment decisions even when resources are scarce. For example, while mhGAP permits the prescription of methylphenidate at the PHC level, it is recommended that its use be restricted to mental health specialists or done in consultation with one. This reflects the complexities of paediatric psychopharmacology in LMICs, where children require weight-based dosing, ongoing monitoring and coordination with caregivers and schools, often beyond the capacity of PHC facilities in LMICs (Patel et al., Reference Patel, Kieling, Maulik and Divan2013; Rohde, Reference Rohde2013). While task shifting helps address the shortage of mental health specialists, it raises concerns about overburdening non-specialist HCWs. Ensuring safety and effectiveness requires adequate training, supervision and support (Le et al., Reference Le, Eschliman, Grivel, Tang, Cho, Yang, Tay, Li, Bass and Yang2022).
Despite the limited published evidence on the adaptation of the CMH module, broader implementation research shows that tailoring the mhGAP-IG enhances its effectiveness (Spagnolo et al., Reference Spagnolo, Champagne, Leduc, Piat, Melki, Charfi, Guisset, Sabatinelli, Guesmi, Trabelsi, Bram and Laporta2016, Reference Spagnolo, Champagne, Leduc, Melki, Guesmi, Bram, Guisset, Piat, Laporta and Charfi2018; Mutiso et al., Reference Mutiso, Gitonga, Musau, Musyimi, Nandoya, Rebello, Pike and Ndetei2018; Faregh et al., Reference Faregh, Lencucha, Ventevogel, Dubale and Kirmayer2019; Bitta et al., Reference Bitta, Kariuki, Kiambu, Nasoro, Newton, Njeri, Omar and Ongeri2020). In Mexico, online mhGAP training improved knowledge and skills across diverse HCW groups (Félix Romero et al., Reference Félix Romero, Tovar, López Montoya, Flores Coronado, Ferrer Reyes, Morales Chainé and Malo Serrano2023) and a social media-delivered distance mhGAP programme significantly improved knowledge scores among PHC providers (Aldana López et al., Reference Aldana López, MdR, Páez Venegas, Chávez Sánchez, Flores Bizarro, Blanco Sierra, Jarero González and Carmona Huerta2024). In Mozambique, an adapted mhGAP-IG led to increased identification and follow-up of epilepsy cases, with over 60% of the cases involving children and adolescents (Dos Santos et al., Reference Dos Santos, Cumbe, Gouveia, de Fouchier, Teuwen and Dua2019). A scoping review of CAMH training further highlighted that non-specialist HCWs value locally adapted case discussions, role plays and clinical demonstrations (Raj et al., Reference Raj, Raykar, Robinson and Islam2022), which improve engagement and understanding (Petagna et al., Reference Petagna, Marley, Guerra, Calia and Reid2023).
This global evidence resonates with the findings from Kenya, where the effectiveness of the adapted mhGAP-IG for adult modules has been demonstrated (Bitta et al., Reference Bitta, Kariuki, Kiambu, Nasoro, Newton, Njeri, Omar and Ongeri2020; Mutiso et al., Reference Mutiso, Musyimi, Tele, Gitonga and Ndetei2021). In Kilifi, pilot testing of an adapted mhGAP-IG version 2 led to significant improvement in knowledge scores (66.3–76.6%, p < 0.001; Bitta et al., Reference Bitta, Kariuki, Kiambu, Nasoro, Newton, Njeri, Omar and Ongeri2020). In Makueni, the adapted mhGAP-IG led to reduced disability, improved seizure control and greater parental awareness of children’s mental health symptoms, narrowing the treatment gap (Mutiso et al., Reference Mutiso, Musyimi, Tele, Gitonga and Ndetei2021). These findings highlight the potential of well-adapted mhGAP materials to improve knowledge, clinical outcomes and CAMH awareness in diverse settings.
Taken together, these findings suggest that implementing mhGAP-IG interventions in sub-Saharan Africa shows promise for improving access to mental healthcare, but significant challenges remain. Sustainable integration into PHC requires capacity building, regular supervision and ongoing in-service training of HCWs (Petagna et al., Reference Petagna, Marley, Guerra, Calia and Reid2023; Mkubwa et al., Reference Mkubwa, Angwenyi, Nzioka, Newton, Sijbrandij and Abubakar2024).
Policy implications
The findings of this study highlight the need for policies that support the integration of CAMH services into PHC in Kenya and other similar settings. Aligned with task-sharing and PHC priorities, the adapted CMH module can inform updates to CAMH training curricula to strengthen early identification, diagnosis, management and referral of CAMH disorders at the PHC level. Continued investment in implementation research is essential for monitoring progress, guiding future adaptations and supporting the scale-up of CAMH services at the PHC level.
Study limitations
This study has several limitations that are common to mhGAP adaptation research. First, focusing solely on Nairobi and Kilifi, counties with distinct, unique healthcare and cultural contexts, limits generalizability across Kenya. As noted in a prior study in Kilifi, effective adaptations in one region may not be translated to others due to contextual differences (Bitta et al., Reference Bitta, Kariuki, Kiambu, Nasoro, Newton, Njeri, Omar and Ongeri2020). However, the adaptation process itself may offer a framework, even if specific content requires local tailoring. Further research in diverse settings is required to ensure broader applicability.
Resource and time constraints prevented the translation of the mhGAP training videos (available only in Arabic with English subtitles) into Swahili or English. Additionally, the absence of a real-time thematic analysis between the first and second adaptation workshops may have limited the integration of immediate stakeholder feedback.
While the participatory approach improved cultural relevance, it may have introduced bias, with more vocal or experienced participants influencing the outcomes. The careful selection of workshop participants and skilled moderation helped mitigate this by encouraging inclusive contributions. Finally, future adaptations could further enhance cultural relevance by directly engaging traditional and religious perspectives in the refinement of the CMH module.
Conclusion
The contextualization and adaptation of the CMH module and its training materials aligned with local cultural beliefs, health system capacities and resource realities have the potential to improve HCW knowledge, promote culturally sensitive care and enhance service delivery for CAMH disorders. The process reinforced the importance of engaging stakeholders, incorporating context-specific content and addressing systemic challenges, such as medication access, workforce limitations and supervision structures. These findings contribute to a growing body of evidence supporting the adaptation of global mental health interventions to ensure the relevance, acceptability and sustainability in LMICs. Future research should focus on piloting and evaluating the adapted module within PHC settings in Nairobi and Kilifi, including the integration of routine supervision and mentorship for trained HCWs.
Open peer review
To view the open peer review materials for this article, please visit http://doi.org/10.1017/gmh.2025.10049.
Supplementary material
The supplementary material for this article can be found at http://doi.org/10.1017/gmh.2025.10049.
Data availability statement
The qualitative data generated and analysed during this study are not publicly available to protect participant confidentiality. However, de-identified excerpts relevant to the study findings are available from the corresponding author upon reasonable request, with appropriate ethical approval.
Acknowledgements
The authors would like to thank all the stakeholders and participants who contributed to this study. Special appreciation goes to the government representatives from Nairobi and Kilifi counties for their invaluable support in facilitating access to healthcare systems and providing local expertise.
Author contribution
A.A. and C.R.N. conceptualized and obtained funding for the study. B.M., A.A., M.S., C.R.N. and V.A. provided input on the study design and methodology. B.M. and M.J. conducted the situational analysis interviews. B.M. and B.N. conducted the initial review of the CMH module and training materials before the workshop. L.P. provided further guidance on adaptation before and during the ToTS training. J.G. and N.K. provided input on the healthcare system in Nairobi and Kilifi, and contributed to the contextualization and adaptation process. M.J. transcribed audio recordings from interviews and workshops. B.M. analysed the findings of the studies in NVivo while A.A., M.S. and V.A. supervised and provided guidance throughout the process. All authors contributed to the drafting and reviewing of the manuscript. B.M.’s ORCID id: 0000-0002-2058-3325.
Financial support
This research was commissioned by the National Institute for Health and Care Research (NIHR) (NIHR200842) using UK aid from the UK Government. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or Department of Health and Social Care. B.M. and A.A. also received support in part from the Science for Africa Foundation through grant number DEL-22-002, with funding from the Wellcome Trust and the UK Foreign, Commonwealth and Development Office. This support is part of the EDCTP2 programme supported by the European Union. The funders were not involved in the study design, data collection, analysis, data interpretation or development of the manuscript.
Competing interests
The authors declare none.
Ethics statements
Ethical approval was obtained from the Aga Khan University Institutional Scientific Ethics Committee (Protocol Ref:2022/ISERC-104(v3)). All participants provided written informed consent, and confidentiality was maintained throughout the study.
Open access
Comments
Mkubwa Beatrice,
The Aga Khan University
P.O. Box 30270 - 00100
Nairobi, Kenya
February 06, 2025
Editor-in-Chief
Global Mental Health Journal
Dear Editor-in-Chief,
We wish to submit our manuscript titled “Contextualization and Adaptation of the Child and Adolescent Mental and Behavioural Disorders Module of the mhGAP-IG in Kilifi and Nairobi Counties in Kenya” for consideration for publication in the Global Mental Health Journal.
Our study details the systematic approach used to adapt the module to local contexts, incorporating insights from key stakeholders, mental health experts, and frontline healthcare workers. The findings highlight critical adaptations necessary to enhance training effectiveness and improve service delivery for child and adolescent mental health (CAMH) in Nairobi and Kilifi counties. By identifying strengths and challenges within existing CAMH services, our study contributes to ongoing efforts to improve mental health interventions in resource-limited settings.
We believe that our manuscript aligns well with the scope of Global Mental Health Journal and will be of interest to your readership, particularly those engaged in global mental health, implementation science, and child and adolescent mental health policy and practice.
We confirm that this work is original and has not been published elsewhere, nor is it currently under consideration for publication elsewhere. All the authors have approved the manuscript for submission. The authors declare that they have no competing interests or conflicts of interest to disclose. Please address all correspondence concerning this manuscript to me at beatrice.mkubwa@aku.edu.
We look forward to seeing our work published in the Global Mental Health Journal.
Sincerely,
Beatrice Mkubwa.