“We worked as a team”: Frontline providers’ experiences of a multi-cadre training initiative for early identification, care, and referral for children with developmental disabilities in Kenya

Abstract

Abstract Children with developmental disabilities remain among the most underserved globally, with significant delays in early identification and access to care. In Kenya, limited capacity in the frontline workforce further disrupts the timely recognition and management of DDs. This study evaluated the impact of a multi-cadre capacity-strengthening training intervention on the knowledge and practice of healthcare workers (HCWs) and community support workers (CSWs) (including community health promoters, teachers, and caregivers of children with disabilities) to improve early identification, assessment, care, and referral of children with DDs in Kenya. We conducted a sequential mixed-methods study and collected data between 2023 and 2025. Quantitative measures included sociodemographic surveys for all participants (CSWs and HCWs) and pre- and post-knowledge assessments using a 15-item Mental Health Gap Action Programme Intervention Guide (mhGAP-IG)-based questionnaire administered only to HCWs participating in the training. Qualitative data were obtained through focus group discussions with CSWs (n=5, 58 participants) and HCWs (n=5, 48 participants) to explore training experiences, perceived skill gains, and implementation experiences. Quantitative analysis used descriptive statistics and Wilcoxon signed-rank tests, while qualitative data were analysed thematically. A total of 321 frontline providers were trained. Ninety-seven HCWs from 25 public health facilities received DDs training based on the WHO mhGAP-IG module, while 224 CSWs received a DD-focused co-designed training on community-based early identification and referral. Among HCWs with pre-post assessments (n=70), knowledge scores improved significantly (mean change: +0.86, p < 0.001), and the proportion scoring ≥12 increased from 51% to 75%. Qualitative findings post-implementation indicated strengthened capacity in developmental milestone assessment, identification of DDs, and improved referral across the community, facility and other related sectors. Both cadres reported improved confidence in addressing myths and misconceptions related to DDs, coordinated teamwork, and improved caregiver engagement during assessment, and referrals driven by improved provider confidence and more supportive communication following the training. Increased workload, limited time for assessments, and limited resources were reported as challenges. This evaluation of a multi-cadre training model demonstrated improved knowledge, skills, and confidence among CSWs and HCWs, improving early identification, care, and referral practices for children with DDs. Sustaining these gains will require ongoing supervision, integration into routine workflows, strengthened referral systems, and continued investment in frontline workforce development within primary care settings.