Accepted for/Published in: JMIR Medical Education
Date Submitted: Dec 19, 2025
Date Accepted: May 30, 2026
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Can digital training improve lay health workers’ knowledge and skills in HIV index case testing? Findings from a cluster randomized trial
ABSTRACT
Background:
Task shifting in low-resource settings requires lay health care workers (HCWs) to provide a variety of health services, such as HIV index case testing whereby sexual partners and family of people living with HIV are offered HIV testing. For this, lay HCWs require adequate specialized training. Digital technologies hold promise for training lay HCWs in low-resource settings, but their impacts on improving knowledge, attitudes, and skills are not understood.
Objective:
We evaluated the impact of digital training on lay HCWs’ knowledge, attitude, and skills to provide HIV index case testing.
Methods:
We recruited lay HCWs from 34 health facilities in Malawi. We conducted a two-arm cluster randomized controlled trial from 2022-2023, evaluating the impact of a digital training approach. Health facilities (clusters) were randomized 1:2 to the Enhanced or Standard arms. Lay HCWs in both arms received the standard in-person index case testing training. In addition, lay HCWs in the Enhanced arm received tablet-guided training. Knowledge acquisition was measured using multiple-choice questionnaires administered before and after training. Attitudinal gains were assessed through a questionnaire with Likert scale responses before and after training. Between-arm mean differences were evaluated using t-tests. Skills (fidelity to index and contact testing protocols) were measured using 15-item checklists. Fidelity scores were compared between the Enhanced and Standard arms by estimating mean differences and 95% confidence intervals (CIs) using generalized estimating equations.
Results:
We enrolled 306 lay HCWs, 125 (40.8%) in Enhanced arm and 181 (59.2%) in Standard arm. Knowledge improved 4.4% more in the Enhanced arm than in the Standard arm (p=0.005). Attitudes toward digital training improved 4.5% more in the Enhanced arm than the Standard arm (p=0.008). Fidelity to index client counseling protocols was 30.5% higher among HCWs in the Enhanced arm than the Standard arm (CI: 26.0%, 35.0%, p<0.001). Fidelity to contact client counseling protocols was 22.7% higher in the Enhanced arm than the Standard arm (CI: 19.5%, 25.9%, p<0.001).
Conclusions:
The digital training improved lay HCWs’ knowledge, attitudes and skills surrounding index case testing counseling. The findings support digital training as a useful strategy for strengthening the capacity of lay HCWs in low-resource contexts. Clinical Trial: NCT05343390
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