Implementation of a School-based Risk Management Protocol within a Task-shifted Mental Healthcare Model

Adolescent mental health problems are prevalent in low- and middle-income countries, like Kenya where access to care remains severely limited. Task-shifted, school-based interventions offer scalable solutions but often lack structured protocols for managing elevated risk, such as suicidality or abuse. The Shamiri Risk Management Protocol (Shamiri-RMP) was developed to address this gap through a tiered system for screening, classifying, and responding to student risk within a stepped-care mental health model. We conducted a mixed-methods implementation study across 149 public high schools in Kenya. Caseworker fidelity and risk classification accuracy were evaluated through a clinical review of 222 student cases. The Consolidated Framework for Implementation Research guided qualitative analysis of caseworker surveys to identify implementation barriers and facilitators. Of 76,855 students enrolled in the broader Shamiri program, 977 (1.27%) were referred for risk assessment, and 222 (0.28%) were enrolled in the Shamiri-RMP. Among these, risk classifications were 42.71% were low-risk, 35.68% moderate-risk, and 21.61% high-risk. Risk reductions occurred in 60.47% of high-risk, 56.34% of moderate-risk, and 51.76% of low-risk cases. Implementation facilitators included supervisory support (50.88% of caseworkers) and protocol clarity (80.70%), while key barriers included referral gaps (5.26%) and confidentiality concerns (54.39%). Findings support the feasibility and scalability of the Shamiri-RMP in low resource school settings.