Key Concepts for assessing claims about treatment effects and making well-informed treatment choices

Key concepts for informed health choices: Where's the evidence?

Background

The Informed Health Choices (IHC) Key Concepts is a framework that provides a basis for developing educational resources and evaluating people's ability to think critically about health actions. We developed the original Key Concepts framework by reviewing texts and checklists for the public, journalists, and health professionals and collecting structured feedback from an international advisory group. We revised the original 2015 framework yearly from 2016 to 2018 based on feedback and experience using the framework. The objectives of this paper are to describe the development of the framework since 2018 and summarise their basis.

Methods

For the 2019 version, we responded to feedback on the 2018 version. For the current 2022 version, in addition to responding to feedback on the 2019 version, we reviewed the evidence base for each of the concepts. Whenever possible, we referenced systematic reviews that provide a basis for a concept. We screened all Cochrane methodology reviews and searched Epistemonikos, PubMed, and Google Scholar for methodology reviews and meta-epidemiological studies.

Results

The original framework included 32 concepts in six groups. The 2019 version and the current 2022 version include 49 concepts in the same three main groups that we have used since 2016. There are now 10 subgroups or higher-level concepts. For each concept, there is an explanation including one or more examples, the basis for the concept, and implications. Over 600 references are cited that support the concepts, and over half of the references are systematic reviews.

Conclusions

There is a large body of evidence that supports the IHC key concepts and we have received few suggestions for changes since 2019.

Contextualizing critical thinking about health using digital technology in secondary schools in Kenya: a qualitative analysis

Background

Good health decisions depend on one’s ability to think critically about health claims and make informed health choices. Young people can learn these skills through school-based interventions, but learning resources need to be low-cost and built around lessons that can fit into existing curricula. As a first step to developing and evaluating digital learning resources that are feasible to use in Kenyan secondary schools, we conducted a context analysis to explore interest in critical thinking for health, map where critical thinking about health best fits in the curriculum, explore conditions for introducing new learning resources, and describe the information and communication technology (ICT) infrastructure available for teaching and learning.

Methods

We employed a qualitative descriptive approach. We interviewed 15 key informants, carried out two focus group discussions, observed ICT conditions in five secondary schools, reviewed seven documents, and conducted an online catalog of ICT infrastructure in all schools (n=250) in Kisumu County. Participants included national curriculum developers, national ICT officers, teachers, and national examiners. We used a framework analysis approach to analyze data and report findings.

Findings

Although critical thinking is a core competence in the curriculum, critical thinking about health is not currently taught in Kenyan secondary schools. Teachers, health officials, and curriculum developers recognized the importance of teaching critical thinking about health in secondary schools. Stakeholders agreed that Informed Health Choices learning resources could be embedded in nine subjects. The National Institute of Curriculum Development regulates resources for learning; the development of new resources requires collaboration and approval from this body. Most schools do not use ICT for teaching, and for those few that do, the use is limited. Implementation of Kenya’s ICT policy framework for schools faces several challenges which include inadequate ICT infrastructure, poor internet connectivity, and teachers’ lack of training and experience.

Conclusion

Teaching critical thinking about health is possible within the current Kenyan lower secondary school curriculum, but the learning resources will need to be designed for inclusion in and across existing subjects. The National ICT Plan and Vision for 2030 provides an opportunity for scale-up and integration of technology in teaching and learning environments, which can enable future use of digital resources in schools. However, given the current ICT condition in schools in the country, digital learning resources should be designed to function with limited ICT infrastructure, unstable Internet access, and for use by teachers with low levels of experience using digital technology.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01183-0.

The People's Trial: supporting the public's understanding of randomised trials

Background

Randomised trials are considered the gold standard in providing robust evidence on the effectiveness of interventions. However, there are relatively few initiatives to help increase public understanding of what randomised trials are and why they are important. This limits the overall acceptance of and public participation in clinical trials. The People’s Trial aims to help the public learn about randomised trials, to understand why they matter, and to be better equipped to think critically about health claims by actively involving them in all aspects of trial design. This was done by involving the public in the design, conduct, and dissemination of a randomised trial.

Methods

Using a reflexive approach, we describe the processes of development, conduct, and dissemination of The People’s Trial.

Results

Over 3000 members of the public, from 72 countries, participated in The People’s Trial. Through a series of online surveys, the public designed a trial called The Reading Trial. They chose the question the trial would try to answer and decided the components of the trial question. In December 2019, 991 participants were recruited to a trial to answer the question identified and prioritised by the public, i.e. ‘Does reading a book in bed make a difference to sleep in comparison with not reading a book in bed?’ We report the processes of The People’s Trial in seven phases, paralleling the steps of a randomised trial, i.e. question identification and prioritisation, recruitment, randomisation, trial conduct, data analysis, and sharing of findings. We describe the decisions we made, the processes we used, the challenges we encountered, and the lessons we learned.

Conclusion

The People’s Trial involved the public successfully in the design, conduct, and dissemination of a randomised trial demonstrating the potential for such initiatives to help the public learn about randomised trials, to understand why they matter, and to be better equipped to think critically about health claims.

Trial registration

ClinicalTrials.govNCT04185818. Registered on 4 December 2019

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05984-1.

Teaching and learning how to make informed health choices: Protocol for a context analysis in Spanish primary schools

Introduction The Informed Health Choices (IHC) project developed learning resources to teach primary school children (10 to 12-year-olds) to assess treatment claims and make informed health choices. The aim of our study is to explore the educational context for teaching and learning critical thinking about health in Spanish primary schools. Methods During the 2020-2021 school year, we will conduct 1) a systematic assessment of educational documents and resources, and 2) semi-structured interviews with key education and health stakeholders. In the systematic assessment of educational documents and resources, we will include state and autonomous communities' curriculums, school educational projects, and commonly used textbooks and other health teaching materials. In the semi-structured interviews, we will involve education and health policy makers, developers of learning resources, developers of health promotion and educational interventions, head teachers, teachers, families, and paediatric primary care providers. We will design and pilot a data extraction form and a semi-structured interview guide to collect the data. We will perform a quantitative and a qualitative analysis of the data to explore how critical thinking about health is being taught and learned in Spanish primary schools. Conclusion We will identify opportunities for and barriers to teaching and learning critical thinking about health in Spanish primary schools. We will formulate recommendations-for both practice and research purposes-on how to use, adapt (if needed), and implement the IHC resources in this context.

A cross-sectional study on adaptation and initial validation of a test to evaluate health claims among high school students: Croatian version

OBJECTIVES

We validated the Croatian version of the test using multiple-choice questions (MCQs) from the Claim Evaluation Tools item bank of the Informed Health Choices project, and measured the ability of high school students to appraise health claims.

SETTING

16 high schools from the urban agglomeration of the city of Split, Croatia.

PARTICIPANTS

Final year high school students of at least 18 years of age.

INTERVENTIONS

18 MCQs from the item bank considered relevant for high school students were translated. After face-validity testing, the questionnaire was piloted and sent to a convenient sample of 302 high school students.

PRIMARY AND SECONDARY OUTCOME MEASURES

Difficulty and discrimination indices were calculated for each MCQ to determine the validity of translation and the weight of MCQs. We assessed basic metric characteristics and performed initial validation of the test. Two tests were created, the full (18 MCQs) and the short version (12 MCQs). We analysed differences in test score according to gender and school.

RESULTS

The response rate was 96% (75% female respondents). Metric characteristics of both tests were satisfactory (Cronbach's α=0.71 for the full and α=0.73 for the short version). The mean score (±SD) for the full version was 11.15±3.43 and 8.13±2.76 for the short version. There were 6 easy and 12 moderately difficult questions. Questions concerning effectiveness and dissimilar comparison groups were answered correctly by fewer than 40% of students. Female students and those from grammar and health schools scored higher on both tests.

CONCLUSIONS

Both tests showed good metric characteristics and may be used for quick and reliable assessments of adolescents' ability to appraise health claims. They may be used to identify needs and inform development of educational activities to foster critical thinking about health among adolescents.

The Norwegian public's ability to assess treatment claims: results of a cross-sectional study of critical health literacy

Background: Few studies have evaluated the ability of the general public to assess the trustworthiness of claims about the effects of healthcare. For the most part, those studies have used self-reported measures of critical health literacy. Methods: We mailed 4500 invitations to Norwegian adults. Respondents were randomly assigned to one of four online questionnaires that included multiple-choice questions that test understanding of Key Concepts people need to understand to assess healthcare claims. They also included questions about intended behaviours and self-efficacy. One of the four questionnaires was identical to one previously used in two randomised trials of educational interventions in Uganda, facilitating comparisons to Ugandan children, parents, and teachers. We adjusted the results using demographic data to reflect the population. Results: A total of 771 people responded. The adjusted proportion of Norwegian adults who answered correctly was < 50% for 17 of the 30 Key Concepts. On the other hand, less than half answered correctly for 13 concepts. The results for Norwegian adults were better than the results for Ugandan children in the intervention arm of the trial and parents, and similar to those of Ugandan teachers in the intervention arm of the trial. Based on self-report, most Norwegians are likely to find out the basis of treatment claims, but few consider it easy to assess whether claims are based on research and to assess the trustworthiness of research. Conclusions: Norwegian adults do not understand many concepts that are essential for assessing healthcare claims and making informed choices. Future interventions should be tailored to address Key Concepts for which there appears to be a lack of understanding.

Teaching critical thinking about health using digital technology in lower secondary schools in Rwanda: A qualitative context analysis

Introduction

Adolescents encounter misleading claims about health interventions that can affect their health. Young people need to develop critical thinking skills to enable them to verify health claims and make informed choices. Schools could teach these important life skills, but educators need access to suitable learning resources that are aligned with their curriculum. The overall objective of this context analysis was to explore conditions for teaching critical thinking about health interventions using digital technology to lower secondary school students in Rwanda.

Methods

We undertook a qualitative descriptive study using four methods: document review, key informant interviews, focus group discussions, and observations. We reviewed 29 documents related to the national curriculum and ICT conditions in secondary schools. We conducted 8 interviews and 5 focus group discussions with students, teachers, and policy makers. We observed ICT conditions and use in five schools. We analysed the data using a framework analysis approach.

Results

Two major themes found. The first was demand for teaching critical thinking about health. The current curriculum explicitly aims to develop critical thinking competences in students. Critical thinking and health topics are taught across subjects. But understanding and teaching of critical thinking varies among teachers, and critical thinking about health is not being taught. The second theme was the current and expected ICT conditions. Most public schools have computers, projectors, and internet connectivity. However, use of ICT in teaching is limited, due in part to low computer to student ratios.

Conclusions

There is a need for learning resources to develop critical thinking skills generally and critical thinking about health specifically. Such skills could be taught within the existing curriculum using available ICT technologies. Digital resources for teaching critical thinking about health should be designed so that they can be used flexibly across subjects and easily by teachers and students.

Comparison of the Informed Health Choices Key Concepts Framework to other frameworks relevant to teaching and learning how to think critically about health claims and choices: a systematic review

Background: The Informed Health Choices (IHC) Key Concepts are principles for evaluating the trustworthiness of claims about treatment effects. The Key Concepts provide a framework for developing learning-resources to help people use the concepts when treatment claims are made, and when they make health choices.

Objective: To compare the framework provided by the IHC Key Concepts to other frameworks intended to promote critical thinking about treatment (intervention) claims and choices.

Methods: We identified relevant frameworks from reviews of frameworks, searching Google Scholar, citation searches, and contact with key informants. We included frameworks intended to provide a structure for teaching or learning to think critically about the basis for claims, evidence used to support claims, or informed choices. For a framework to be included, there had to be a description of its purpose; a list of concepts, competences, or dispositions; and definitions of key terms. We made independent assessments of framework eligibility and extracted data for each included framework using standardised forms.

Results: Twenty-two frameworks met our inclusion criteria. The purpose of the IHC Framework is similar to that of two frameworks for critical thinking and somewhat similar to that of a framework for evidence-based practice. Those frameworks have broader scopes than the IHC Framework. An important limitation of broad frameworks is that they do not provide an adequate basis (concepts) for deciding which claims to believe and what to do. There was at most some overlap between the concepts, competences, and dispositions in each of the 22 included frameworks and those in the IHC Framework.

Conclusions: The IHC Key Concepts Framework appears to be unique.  Our review has shown how it and other frameworks can be improved by taking account of the ways in which other related frameworks have been developed, evaluated, and made useful.

Protocol for assessing stakeholder engagement in the development and evaluation of the Informed Health Choices resources teaching secondary school students to think critically about health claims and choices

Background

As part of a five year plan (2019–2023), the Informed Health Choices Project, is developing and evaluating resources for helping secondary school students learn to think critically about health claims and choices. We will bring together key stakeholders; such as secondary school teachers and students, our main target for the IHC secondary school resources, school administrators, policy makers, curriculum development specialists and parents, to enable us gain insight about the context.

Objectives

To ensure that stakeholders are effectively and appropriately engaged in the design, evaluation and dissemination of the learning resources.

To evaluate the extent to which stakeholders were successfully engaged.

Methods

Using a multi-stage stratified sampling method, we will identify a representative sample of secondary schools with varied characteristics that might modify the effects of the learning resources such as, the school location (rural, semi-urban or urban), ownership (private, public) and ICT facilities (under resourced, highly resourced). A sample of schools will be randomly selected from the schools in each stratum. We will aim to recruit a diverse sample of students and secondary school teachers from those schools. Other stakeholders will be purposively selected to ensure a diverse range of experience and expertise.

Results

Together with the teacher and student networks and the advisory panels, we will establish measurable success criteria that reflect the objectives of engaging stakeholders at the start of the project and evaluate the extent to which those criteria were met at the end of the project.

Conclusion

We aim for an increase in research uptake, improve quality and appropriateness of research results, accountability and social justice.

Learning to make informed health choices: Protocol for a pilot study in schools in Barcelona

Introduction: The Informed Health Choices (IHC) project has developed learning resources to teach primary school children (10 to 12-year-olds) to assess treatment claims and make informed health choices. The aim of our study is to explore both the students' and teachers' experience when using these resources in the context of Barcelona (Spain). Methods: During the 2019-2020 school year, we will conduct a pilot study with 4 th and 5 th-year primary school students (9 to 11-year-olds) from three schools in Barcelona. The intervention in the schools will include: 1) a workshop with the teachers, and 2) lessons to the students. The data collection will include: 1) initial assessment of the resources by the teachers, 2) non-participatory observations during the lessons, 3) semi-structured interviews with the students after a lesson, 4) assessment of the lessons by the teachers, 5) treatment claim assessment by the students, and 6) final assessment of the resources by the teachers. We will use ad hoc questionnaires and guides to register the data. We will perform a quantitative and qualitative analysis of the data to explore understandability, desirability, suitability, usefulness, facilitators and barriers of the resources. The most relevant results will be discussed and some recommendations on how to use, how to adapt (if needed), and how to implement the IHC resources to this context will be agreed. We will publish the study results in a peer-reviewed journal and in several Internet resources (web pages, electronic bulletins, and social media), and we will present them to the different users of interest in conferences, workshops, and meetings. Ethical considerations: The study protocol has obtained an approval exemption from the Ethics Committee of the Hospital de la Santa Creu i Sant Pau (Barcelona, Spain).

Learning to make informed health choices: Protocol for a pilot study in schools in Barcelona

Introduction: The Informed Health Choices (IHC) project has developed learning resources to teach primary school children (10 to 12-year-olds) to assess treatment claims and make informed health choices. The aim of our study is to explore both the students' and teachers' experience when using these resources in the context of Barcelona (Spain). Methods: During the 2019-2020 school year, we will conduct a pilot study with 4 th and 5 th-year primary school students (9 to 11-year-olds) from three schools in Barcelona. The intervention in the schools will include: 1) assessment of the IHC resources by the teachers before the lessons, 2) non-participatory observations during the lessons, 3) semi-structured interviews with the students after a lesson, 4) assessment of the lessons by the teachers after a lesson, 5) treatment claim assessment by the students at the end of the lessons, and 6) assessment of the IHC resources by the teachers at the end of the lessons. We will use ad hoc questionnaires and guides to register the data. We will perform a quantitative and qualitative analysis of the data to explore understandability, desirability, suitability, usefulness, facilitators and barriers of the resources. The most relevant results will be discussed and some recommendations on how to use, how to adapt (if needed), and how to implement the IHC resources to this context will be agreed. The findings of the contextualization activities could inform the design of a cluster-randomised trial, to determine the effectiveness of the IHC resources in this context prior to scaling-up its use. Ethical considerations: The study protocol has obtained an approval exemption from the Ethics Committee of the Hospital de la Santa Creu i Sant Pau (Barcelona, Spain).

Learning to make informed health choices: Protocol for a pilot study in schools in Barcelona

Introduction: The Informed Health Choices (IHC) project has developed learning resources to teach primary school children (10 to 12-year-olds) to assess treatment claims and make informed health choices. The aim of our study is to explore both the students' and teachers' experience when using these resources in the context of Barcelona (Spain). Methods: During the 2019-2020 school year, we will conduct a pilot study with 4 th and 5 th-year primary school students (9 to 11-year-olds) from three schools in Barcelona. The intervention in the schools will include: 1) a workshop with the teachers, and 2) lessons to the students. The data collection will include: 1) assessment of the IHC resources by the teachers before the lessons, 2) non-participatory observations during the lessons, 3) semi-structured interviews with the students after a lesson, 4) assessment of the lessons by the teachers after a lesson, 5) treatment claim assessment by the students at the end of the lessons, and 6) assessment of the IHC resources by the teachers at the end of the lessons. We will use ad hoc questionnaires and guides to register the data. We will perform a quantitative and qualitative analysis of the data to explore understandability, desirability, suitability, usefulness, facilitators and barriers of the resources. The most relevant results will be discussed and some recommendations on how to use, how to adapt (if needed), and how to implement the IHC resources to this context will be agreed. The findings of the contextualization activities could inform the design of a cluster-randomised trial, to determine the effectiveness of the IHC resources in this context prior to scaling-up its use. Ethical considerations: The study protocol has obtained an approval exemption from the Ethics Committee of the Hospital de la Santa Creu i Sant Pau (Barcelona, Spain).

The James Lind Initiative: books, websites and databases to promote critical thinking about treatment claims, 2003 to 2018

BACKGROUND

The James Lind Initiative (JLI) was a work programme inaugurated by Iain Chalmers and Patricia Atkinson to press for better research for better health care. It ran between 2003 and 2018, when Iain Chalmers retired. During the 15 years of its existence, the JLI developed three strands of work in collaboration with the authors of this paper, and with others.

WORK THEMES

The first work strand involved developing a process for use by patients, carers and clinicians to identify shared priorities for research - the James Lind Alliance. The second strand was a series of articles, meetings, prizes and other developments to raise awareness of the massive amounts of avoidable waste in research, and of ways of reducing it. The third strand involved using a variety of approaches to promote better public and professional understanding of the importance of research in clinical practice and public health. JLI work on the first two themes has been addressed in previously published reports. This paper summarises JLI involvement during the 15 years of its existence in giving talks, convening workshops, writing books, and creating websites and databases to promote critical thinking about treatment claims.

CONCLUSION

During its 15-year life, the James Lind Initiative worked collaboratively with others to create free teaching and learning resources to help children and adults learn how to recognise untrustworthy claims about the effects of treatments. These resources have been translated in more than twenty languages, but much more could be done to support their uptake and wider use.

Key Concepts for assessing claims about treatment effects and making well-informed treatment choices

Background: The Informed Health Choices (IHC) Key Concepts are standards for judgement, or principles for evaluating the trustworthiness of treatment claims and treatment comparisons (evidence) used to support claims, and for making treatment choices. The list of concepts provides a framework, or starting point, for teachers, journalists and other intermediaries for identifying and developing resources (such as longer explanations, examples, games and interactive applications) to help people to understand and apply the concepts. The first version of the list was published in 2015 and has been updated yearly since then. We report here the changes that have been made from when the list was first published up to the current (2018) version. Methods: We developed the IHC Key Concepts by searching the literature and checklists written for the public, journalists, and health professionals; and by considering concepts related to assessing the certainty of evidence about the effects of treatments. We have revised the Key Concepts yearly, based on feedback and suggestions; and learning from using the IHC Key Concepts, other relevant frameworks, and adaptation of the IHC Key Concepts to other types of interventions besides treatments. Results: We have made many changes since the Key Concepts were first published in 2015. There are now 44 Key Concepts compared to the original 32; the concepts have been reorganised from six to three groups; we have added higher-level concepts in each of those groups; we have added short titles; and we have made changes to many of the concepts. Conclusions: We will continue to revise the IHC Key Concepts in response to feedback. Although we and others have found them helpful since they were first published, we anticipate that there are still ways in which they can be further improved. We welcome suggestions for how to do this.

Key Concepts for assessing claims about treatment effects and making well-informed treatment choices

Background: The Informed Health Choices (IHC) Key Concepts are standards for judgement, or principles for evaluating the trustworthiness of treatment claims and treatment comparisons (evidence) used to support claims, and for making treatment choices. The list of concepts provides a framework, or starting point, for teachers, journalists and other intermediaries for identifying and developing resources (such as longer explanations, examples, games and interactive applications) to help people to understand and apply the concepts. The first version of the list was published in 2015 and has been updated yearly since then. We report here the changes that have been made from when the list was first published up to the current (2018) version. Methods: We developed the IHC Key Concepts by searching the literature and checklists written for the public, journalists, and health professionals; and by considering concepts related to assessing the certainty of evidence about the effects of treatments. We have revised the Key Concepts yearly, based on feedback and suggestions; and learning from using the IHC Key Concepts, other relevant frameworks, and adaptation of the IHC Key Concepts to other types of interventions besides treatments. Results: We have made many changes since the Key Concepts were first published in 2015. There are now 44 Key Concepts compared to the original 32; the concepts have been reorganised from six to three groups; we have added higher-level concepts in each of those groups; we have added short titles; and we have made changes to many of the concepts. Conclusions: The IHC Key Concepts have proven useful in designing learning resources, evaluating them, and organising them. We will continue to revise the IHC Key Concepts in response to feedback. We welcome suggestions for how to do this.

Key Concepts for assessing claims about treatment effects and making well-informed treatment choices

Background: The Informed Health Choices (IHC) Key Concepts are standards for judgement, or principles for evaluating the trustworthiness of treatment claims and treatment comparisons (evidence) used to support claims, and for making treatment choices. The list of concepts provides a framework, or starting point, for teachers, journalists and other intermediaries for identifying and developing resources (such as longer explanations, examples, games and interactive applications) to help people to understand and apply the concepts. The first version of the list was published in 2015 and has been updated yearly since then. We report here the changes that have been made from when the list was first published up to the current (2018) version. Methods: We developed the IHC Key Concepts by searching the literature and checklists written for the public, journalists, and health professionals; and by considering concepts related to assessing the certainty of evidence about the effects of treatments. We have revised the Key Concepts yearly, based on feedback and suggestions; and learning from using the IHC Key Concepts, other relevant frameworks, and adaptation of the IHC Key Concepts to other types of interventions besides treatments. Results: We have made many changes since the Key Concepts were first published in 2015. There are now 44 Key Concepts compared to the original 32; the concepts have been reorganised from six to three groups; we have added higher-level concepts in each of those groups; we have added short titles; and we have made changes to many of the concepts. Conclusions: The IHC Key Concepts have proven useful in designing learning resources, evaluating them, and organising them. We will continue to revise the IHC Key Concepts in response to feedback. We welcome suggestions for how to do this.