Simulated patient training to improve youth engagement in HIV care in Kenya: a stepped wedge cluster randomized controlled trial
Open accessAbstract
Youth living with HIV (YLHIV) report that negative interactions with health care workers (HCWs) affects willingness to return to care. This stepped wedge randomized trial evaluated effectiveness of a standardized patient actor (SP) HCW training intervention on adolescent engagement in care in Kenya. HCWs caring for YLHIV at 24 clinics received training on adolescent care, values clarification, communication, and motivational interviewing, with 7 SP encounters followed by facilitated feedback of videotaped interactions. Facilities were randomized to timing of the intervention. The primary outcome was defined as return within 3 months after first visit (engagement) among YLHIV who were either newly enrolled or who returned to care after >3 months out of care. Visit data was abstracted from electronic medical records. Generalized linear mixed models adjusted for time, being newly enrolled, and clustering by facility. YLHIV were surveyed regarding satisfaction with care. Overall, 139 HCWs were trained, and medical records were abstracted for 4,595 YLHIV. Median YLHIV age was 21 (IQR 19–23); 82% were female, 77% were newly enrolled in care, and 75% returned within 3 months. Half (54%) of trained HCWs remained at their clinics 9 months post-training. YLHIV engagement improved over time (global Wald test, p = 0.10). In adjusted models, the intervention showed no significant effect on engagement [adjusted Prevalence Ratio (aPR) = 0.95, 95% Confidence Interval (CI): 0.88–1.02]. Newly enrolled YLHIV had significantly higher engagement than those with prior lapses in care (aPR = 1.18, 95%CI: 1.05–1.33). Continuous satisfaction with care scores were significantly higher by wave 3 compared to baseline (coefficient = 0.38, 95%CI: 0.19–0.58). Despite provider skill improvement, there was no effect of SP training on YLHIV engagement in care. This may be due to temporal improvements or turnover of trained HCWs. Strategies to retain SP-training benefits need to address HCW turnover. YLHIV with prior gaps in care may need more intensive support. Registration CT #: NCT02928900. https://clinicaltrials.gov/ct2/show/NCT02928900.
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The stepped-wedge design in Kohler et al. allows for phased implementation, which was logistically feasible given the constraints of the training program. It also enabled the evaluation of the intervention while ensuring that all clusters eventually received the potentially beneficial training.
“Allows for phased implementation, which was logistically feasible given the constraints of the training program. It also enabled the evaluation of the intervention while ensuring that all clusters eventually received the potentially beneficial training”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [88]
The randomization in Kohler et al. was done using a stratified randomization method based on region and facility size (high volume vs. medium volume).
“The randomization was done using a stratified randomization method based on region and facility size (high volume vs. medium volume)”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [88]
The study in Kohler et al. was designed with 80% power to detect a 15% difference between control and intervention periods, assuming a coefficient of variation of 0.25. It was estimated that a minimum of 5 adolescents per clinic per time point were needed.
“The study was designed with 80% power to detect a 15% difference between control and intervention periods, assuming a coefficient of variation of 0.25. It was estimated that a minimum of 5 adolescents per clinic per time point were needed.”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [88]
Facilities in Kohler et al. were randomized to the timing of the intervention in waves, ensuring each facility eventually received the training intervention.
“Facilities were randomized to the timing of the intervention in waves, ensuring each facility eventually received the training intervention.”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [88]
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- Authors
- Kohler, P. K., Mugo, C., Wilson, K. S., Moraa, H., Onyango, A., Tapia, K., Pike, K., Mburu, C., Nduati, M., Guthrie, B., Richardson, B. A., Owens, T., Bukusi, D., Inwani, I., John-Stewart, G., & Wamalwa, D.
- Affiliations
- University of Washington (US)
- University of Nairobi (KE)
- Howard University (US)
- Kenyatta National Hospital (KE)
- Corresponding author
- Kohler, Pamela K.
- ORCID
- Venue
- PLOS Global Public Health
- Publisher
- Public Library of Science (PLoS)
- Published
- 2023-04-19
- Volume
- 3
- Issue
- 4
- Pages
- e0001765
- ISSN
- 2767-3375 (ISSN-L)
- PMC
- PMC10115282
- OpenAlex
- W4366350998
- Cited by
- 5
- References
- 50
- Citations by year
- 2026: 2 · 2025: 2 · 2024: 1
- FWCI
- 1.03
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- PLOS Global Public Health (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Greater South Information System
- Funders
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (R01 HD085807)
- National Institute of Allergy and Infectious Diseases (P30 AI027757)
- Topics
- Health Sciences › Medicine › Infectious Diseases › HIV/AIDS Research and Interventions
- Health Sciences › Health Professions › Speech and Hearing › Adolescent and Pediatric Healthcare
- Health Sciences › Medicine › Physiology › Simulation-Based Education in Healthcare
- Keywords
- youth living with HIV, standardized patient training, health care worker training, patient-provider communication, motivational interviewing, values clarification, return to care, retention in care, patient satisfaction, health worker turnover, Kenya, HIV care gaps, stepped-wedge cluster randomized trial
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