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

Effects of the Informed Health Choices secondary school intervention on the ability of lower secondary students in Kenya to think critically about health choices: 1-year follow-up of a cluster-randomized trial

INTRODUCTION

The Informed Health Choices (IHC) secondary school intervention aimed to teach students to assess claims about treatments. This follow-up of a cluster randomized trial assessed the retention of knowledge and the application of the nine prioritized IHC key concepts 1 year after the intervention.

METHODS

We conducted a random assignment of 80 secondary schools in Western Kenya into either the intervention (n = 40) or control (n = 40) group. Both groups adhered to the standard curriculum. Teachers from the intervention group were invited to participate in a 2-day training workshop and were granted access to "Be Smart About Your Health" digital resources, comprising 10 lessons. These lessons, focused on nine prioritized IHC concepts, delivered over a single school term from May to August 2022. The digital resources were accessible online via smartphones or computers and could also be downloaded for offline use. The primary outcome measure, assessed at the end of the school term and again after 1 year, was the percentage of students achieving a passing score (defined as ≥ 9 out of 18 correct answers) on the "Critical Thinking about Health" test.

RESULTS

Out of the total 3360 students involved in the trial, 2446 (72.8%) completed the test after 1 year. Within the intervention group, 728 out of 1369 students (53.2%) achieved a passing score after 1 year, compared to 61.7% immediately post-intervention. In contrast, in the control group, 347 out of 1077 students (32.2%) had a passing score after 1 year. The adjusted difference in passing rates between the intervention and control groups after 1 year was 20.8% (with a 95% confidence interval of 13.6 to 28.0%), compared to 27.3% (with a 95% confidence interval of 19.6 to 34.9%) immediately after the intervention.

CONCLUSION

This study demonstrates that students were able to retain knowledge and the ability to apply the IHC key concepts, 1 year after the intervention. But fewer students in the intervention group had a passing score after 1 year compared to just after the intervention. Highlighting follow-up training is likely necessary to reinforce these skills over time.

TRIAL REGISTRATION

Pan African Clinical Trial Registry, trial identifier: PACTR202204883917313. Registered on 05/04/2022.

The People's Review protocol: planning an innovative study powered by the public

BACKGROUND

Systematic reviews provide the best quality evidence about the effectiveness of health treatments. However, systematic reviews and the important role they play in healthcare are not well understood beyond the walls of academia and healthcare. Systematic reviews can help the public make more informed health choices, based on the best available evidence. The People's Review aims to provide an opportunity to members of the public to plan and complete a full systematic review online in a supportive and engaging manner. It will be a learning-by-doing experience to support the public's understanding of what reviews are, how they are done, why they matter, and how they can be used to support everyday health decisions.

METHODS

In The People's Review the public will conduct a full systematic review, deciding the review question, planning the review, working on the parts of the review, and deciding how to share the review findings, in a 'learning by doing' process. The review will be conducted online in eight stages using Cochrane Crowd, an existing citizen science platform. The team working behind-the-scenes of The People's Review will design, produce, and share learning material to support the public's understanding at each stage of the review.

DISCUSSION

Involving the public in a systematic review online will enable members of the public to understand and use systematic reviews in everyday health choices. It provides the public with a unique 'learning by doing' opportunity to get to grips with what systematic reviews are and how they are produced. This article describes how we plan to involve the public in The People's Review. It is not a protocol for the systematic review itself - this will be published separately once the project has commenced, and the public have decided the review question.

One-year follow-up effects of the informed health choices secondary school intervention on students' ability to think critically about health in Uganda: a cluster randomized trial

INTRODUCTION

We assessed the effects of the Informed Health Choices (IHC) secondary school intervention on students' ability to think critically about choices 1 year after the intervention.

METHODS

We randomized eighty secondary schools to the intervention or control (usual curriculum). The schools were randomly selected from the central region of Uganda and included rural and urban, government, and privately-owned schools. One randomly selected class of year-2 students (ages 14-17) from each school participated in the trial. The intervention included a 2-day teacher training workshop, 10 lessons accessed online by teachers and delivered in classrooms during one school term (May-August 2022). The lessons addressed nine prioritized IHC concepts. We used two multiple-choice questions for each concept to evaluate the students' ability to think critically about choices at both the end of the school term and again after 1 year. The primary outcome was the proportion of students with a passing score (≥ 9 of 18 questions answered correctly) on the "Critical Thinking about Health" (CTH) test.

RESULTS

After 1-year, 71% (1749/2477) of the students in the intervention schools and 71% (1684/2376) of the students in the control schools completed the CTH test. In the intervention schools, 53% (934/1749) of students who completed the test had a passing score compared to 33% (557/1684) of students in the control schools (adjusted difference 22%, 95% CI 16-28).

CONCLUSIONS

The effect of the IHC secondary school intervention on students' ability to assess health-related claims was largely sustained for at least 1 year.

TRIAL REGISTRATION

Pan African Clinical Trial Registry PACTR202204861458660. Registered on 4 April 2022.

Experiences Using Media Health Claims to Teach Evidence-Based Practice to Healthcare Students: A Mixed Methods Study

Background

A multifaceted and interactive teaching approach is recommended for achieving proficiency in evidence-based practice, with critical thinking considered vital for connecting theory and practice. In this context, we advocate the strategic use of health claims in media to promote critical thinking and provide an accessible entry point to evidence-based practice for early-stage university healthcare students.

Method

We conducted a convergent mixed methods study, including a cross-sectional survey with structured and open-ended questions as well as focus group interviews, at the Faculty of Health Sciences, Oslo Metropolitan University, during the 2020-2021 academic year. Participants were bachelor's students in bioengineering, physiotherapy, social education, and occupational therapy. We employed a blended learning approach, combining digital learning resources, teaching in critical assessment of health claims and evidence-based practice, and a concurrent group exam assignment centered around health news. The outcome measures included students' experiences integrating health claims into evidence-based practice teaching and their experiences with teaching approaches, including the group exam.

Results

Out of 446 participants, 136 (30.5%) responded to the structured questions in the survey. In response to the open-ended questions within the survey, 109 (80.1%) of the respondents shared positive experiences about the course, while 98 (72%) suggested improvements. Additionally, 25 students participated in focus group interviews. Synthesizing the results, we found that students viewed the inclusion of health claim assessment as a useful entry point for learning evidence-based practice. In addition, both the blended learning design and the group exam were identified as contributors to a positive perception of learning outcomes from the course.

Conclusions

Integrating critical reflection on media health claims into evidence-based practice education, alongside a blended learning approach and a group exam, may be beneficial for educating bachelor's healthcare students. However, further rigorous study designs are needed to assess the effect of the course on learning outcomes.

Registration

DOI 10.5281/zenodo.6985449.

Critical thinking about health and treatments in the United States: a cross-sectional assessment of parents and undergraduate college students

BACKGROUND

There is an urgent need to study and increase the public's ability to think critically about health and treatments. Unfortunately, we do not currently have a clear, in-depth understanding of critical thinking about health in the United States, especially its rates among parents and college students, two particularly important groups. This study assessed and characterized critical thinking about health with U. S. parents and college students. We also explored whether critical thinking about health varied as a function of sociodemographic determinants.

METHODS

Parents (N = 142) and college students (N = 145) in the U. S. completed an online test of critical thinking about health, and answered questions about their background.

RESULTS

Both parents and college students in the U. S. struggled to think critically about health and treatments based on various science literacy and evidence-based practice principles. Parents with higher educational attainment had lower critical thinking about health, and college students who reported a liberal political affiliation had higher critical thinking scores.

CONCLUSIONS

This investigation demonstrates a need to increase critical thinking about health among U. S. parents and college students so they can be empowered to make informed health choices.

Teaching critical thinking about health information and choices in secondary schools: human-centred design of digital resources

Background

Learning to thinking critically about health information and choices can protect people from unnecessary suffering, harm, and resource waste. Earlier work revealed that children can learn these skills, but printing costs and curricula compatibility remain important barriers to school implementation. We aimed to develop a set of digital learning resources for students to think critically about health that were suitable for use in Kenyan, Rwandan, and Ugandan secondary schools.

Methods

We conducted work in two phases collaborating with teachers, students, schools, and national curriculum development offices using a human-centred design approach. First, we conducted context analyses and an overview of teaching strategies, prioritised content and collected examples. Next, we developed lessons and guidance iteratively, informed by data from user-testing, individual and group interviews, and school pilots.

Results

Final resources include online lesson plans, teachers' guide, and extra resources, with lesson plans in two modes, for use in a classroom equipped with a blackboard/flip-chart and a projector. The resources are accessible offline for use when electricity or Internet is lacking. Teachers preferred the projector mode, as it provided structure and a focal point for class attention. Feedback was largely positive, with teachers and students appreciating the learning and experiencing it as relevant. Four main challenges included time to teach lessons; incorrect comprehension; identifying suitable examples; and technical, logistical, and behavioural challenges with a student-computer mode that we piloted. We resolved challenges by simplifying and combining lessons; increasing opportunities for review and assessment; developing teacher training materials, creating a searchable set of examples; and deactivating the student-computer mode.

Conclusion

Using a human-centred design approach, we created digital resources for teaching secondary school students to think critically about health actions and for training teachers. Be smart about your health resources are open access and can be translated or adapted to other settings.

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.

Evaluating health claim assessment skills of parents with preschool children: A cross-sectional study using Informed Health Choices Claim Evaluation Tool

Background

Health literacy is a global problem and is particularly relevant when making health care decisions about small children. We analysed how parents of preschool children assess health claims and explored the predictors of their assessment skill.

Methods

We conducted a survey with questions from the Claim Evaluation Tools (CET) database, part of the Informed Health Choices (IHC) project, in ten paediatric primary care practices of the Split-Dalmatia County Health Center, Split, Croatia, from 1 February to 31 March 2023. Eligible participants were parents accompanying preschool-aged children for check-ups. We also collected data on parents' and children's demographic and health characteristics (including the presence of any chronic illness in the child), visits to paediatric emergency service, hospitalisations, vaccination status, the presence of chronic illness of parents or relatives, and whether parents had to made treatment decisions for themselves and/or their family member.

Results

Overall, 402 parents of preschool children (median age 35 years (interquartile range (IQR) = 31.0-38.3)) had a median IHC CET test score of 10.0 (IQR = 8.0-11.0) out of 12 questions. The multiple regression analysis showed that female gender, higher level of education, being employed, and having a history of a visit to paediatric emergency service were significant predictors of the test score, explaining 21.9% of the variance.

Conclusions

Parents of preschool children have a very good ability for critical assessment of health-related statements in a complex health care system and an environment of generally unsatisfactory health literacy. Further studies should explore how parents understand health claims in different geographical, socio-economic and cultural setting, and explore educational interventions to increase critical thinking abilities and informed decision-making, especially among fathers, unemployed parents and those with lower levels of education.

Effects of the Informed Health Choices secondary school intervention on the ability of students in Rwanda to think critically about health choices: A cluster-randomized trial

AIM

The aim of this trial was to evaluate the effects of the Informed Health Choices intervention on the ability of students in Rwandan to think critically and make Informed Health Choices.

METHODS

We conducted a two-arm cluster-randomized trial in 84 lower secondary schools from 10 districts representing five provinces of Rwanda. We used stratified randomization to allocate schools to the intervention or control. One class in each intervention school had ten 40-min lessons taught by a trained teacher in addition to the usual curriculum. Control schools followed the usual curriculum. The primary outcome was a passing score (≥ 9 out of 18 questions answered correctly) for students on the Critical Thinking about Health Test completed within 2 weeks after the intervention. We conducted an intention-to-treat analysis using generalized linear mixed models, accounting for the cluster design using random intercepts.

RESULTS

Between February 25 and March 29, 2022, we recruited 3,212 participants. We assigned 1,572 students and 42 teachers to the intervention arm and 1,556 students and 42 teachers to the control arm. The proportion of students who passed the test in the intervention arm was 915/1,572 (58.2%) compared to 302/1,556 (19.4%) in the control arm, adjusted odds ratio 10.6 (95% CI: 6.3-17.8), p < 0.0001, adjusted difference 37.2% (95% CI: 29.5%-45.0%).

CONCLUSIONS

The intervention is effective in helping students think critically about health choices. It was possible to improve students' ability to think critically about health in the context of a competence-based curriculum in Rwanda, despite challenging postpandemic conditions.

Use of the informed health choices educational intervention to improve secondary students' ability to think critically about health interventions in Uganda: A cluster-randomized trial

AIM

The aim was to evaluate the effect of the Informed Health Choices (IHC) educational intervention on secondary students' ability to assess health-related claims and make informed choices.

METHODS

In a cluster-randomized trial, we randomized 80 secondary schools (students aged 13-17 years) in Uganda to the intervention or control (usual curriculum). The intervention included a 2-day teacher training workshop, 10 lessons accessed online by teachers and delivered in one school term. The lesson plans were developed for classrooms equipped with a blackboard or a blackboard and projector. The lessons addressed nine prioritized concepts. We used two multiple-choice questions for each concept to evaluate the students' ability to assess claims and make informed choices. The primary outcome was the proportion of students with a passing score (≥9 of 18 questions answered correctly).

RESULTS

Eighty schools consented and were randomly allocated. A total of 2477 students in the 40 intervention schools and 2376 students in the 40 control schools participated in this trial. In the intervention schools, 1364 (55%) of students that completed the test had a passing score compared with 586 (25%) of students in the control schools (adjusted difference 33%, 95% CI 26%-39%).

CONCLUSIONS

The IHC secondary school intervention improved students' ability to think critically and make informed choices. Well-designed digital resources may improve access to educational material, even in schools without computers or other information and communication technology (ICT). This could facilitate scaling-up use of the resources and help to address inequities associated with limited ICT access.

Effects of the informed health choices secondary school intervention on the ability of students in Kenya to think critically about health choices: A cluster-randomized trial

AIM

There is an overabundance of claims about the advantages and disadvantages of health interventions. People need to be able to appraise the reliability of these claims. The aim of this two-arm cluster-randomized trial was to evaluate the Informed Health Choices secondary school intervention designed to teach students to assess claims about the effects of health actions and make informed decisions.

METHODS

We conducted the trial among students from 80 secondary schools in five subcounties in Kenya. We used stratified randomization to allocate schools to the intervention or control arm. The intervention included a 2-day teacher training workshop and 10 lessons that addressed nine prioritized key concepts for assessing claims about treatment effects. We did not intervene in the control schools. The primary outcome was the proportion of students with a passing score (≥ 9/18 correct answers) on the Critical Thinking about Health test, which included two multiple-choice questions for each concept.

RESULTS

Between May 11, 2022, and July 8, 2022, we recruited 3362 students and 80 teachers. We allocated 1863 students and 40 teachers to the intervention and 1499 students and 40 teachers to the control arm. In the intervention schools, 1149/1863 (61.7%) of students achieved a passing score compared to 511/1499 (34.1%) in the control schools (odds ratio 3.6 (95% CI 2.5-5.2), p < 0.0001).

CONCLUSIONS

The intervention had a large effect on students' ability to think critically about health interventions. It is possible to integrate the learning of critical thinking about health within Kenya secondary school curriculum.

Evaluating student's ability to assess treatment claims: validating a German version of the Claim Evaluation Tools

BACKGROUND

The Claim Evaluation Tools measure the ability to assess claims about treatment effects. The aim of this study was to adapt the German item sets to the target group of secondary school students (aged 11 to 16 years, grade 6 to 10) and to validate them accordingly. The scale's reliability and validity using Rasch's probabilistic test theory should be determined.

METHODS

We conducted a sequential mixed-method study comprising three stages: contextualisation and adaption of the items (stage 1), piloting of the item sets using qualitative interviews (stage 2) and a construct validation by testing the unidimensional Rasch scalability for each item set after data collection in one secondary school in Germany and two secondary schools in Austria. We explored summary and individual fit statistics and performed a distractor analysis (stage 3).

RESULTS

Secondary school students (n = 6) and their teachers (n = 5) participated in qualitative interviews in Germany. The qualitative interviews identified the need for minor modifications (e.g. reducing thematic repetitions, changing the order of the items). The data of 598 German and Austrian secondary school students were included to test for Rasch scalability. Rasch analyses showed acceptable overall model fit. Distractor analyses suggested that model fit could be improved by simplifying the text in the scenarios, removing and editing response options of some items.

CONCLUSION

After the revision of some items, the questionnaires are suitable to evaluate secondary school students' ability to assess health claims. A future goal is to increase the pool of items being translated and tested.

Health communication in and out of public health emergencies: to persuade or to inform?

Much health communication during the COVID-19 pandemic has been designed to persuade people more than to inform them. For example, messages like "masks save lives" are intended to compel people to wear face masks, not to enable them to make an informed decision about whether to wear a face mask or to understand the justification for a mask mandate. Both persuading people and informing them are reasonable goals for health communication. However, those goals can sometimes be in conflict. In this article, we discuss potential conflicts between seeking to persuade or to inform people, the use of spin to persuade people, the ethics of persuasion, and implications for health communication in the context of the pandemic and generally. Decisions to persuade people rather than enable them to make an informed choice may be justified, but the basis for those decisions should be transparent and the evidence should not be distorted. We suggest nine principles to guide decisions by health authorities about whether to try to persuade people.