Effects of the Informed Health Choices podcast on the ability of parents of primary school children in Uganda to assess claims about treatment effects: a randomised controlled trial

Prioritising Key Concepts for informed health choices in cancer: An evidence-based online educational programme

Objective

The overabundance of health misinformation has undermined people's capacity to make evidence-based, informed choices about their health. Using the Informed Health Choices (IHC) Key Concepts (KCs), we are developing a two-stage education programme, Informed Health Choices-Cancer (IHC-C), to provide those impacted by cancer with the knowledge and skills necessary to think critically about the reliability of health information and claims and make well-informed choices. Stage 1 seeks to prioritise the most relevant Key Concepts.

Methods

A project group and a patient and carer participation group completed a two-round prioritisation process. The process involved disseminating pre-reading materials, training sessions, and a structured judgement form to evaluate concepts for inclusion. Data from each round were analysed to reach a consensus on the concepts to include.

Results

Fourteen participants were recruited and completed the first-round prioritisation. Fifteen participants undertook the second-round prioritisation. Nine Key Concepts were selected for the programme across five training sessions and two consensus meetings.

Conclusion

The prioritised concepts identified represent the most pertinent aspects of cancer-related information for those impacted by the disease. By incorporating these concepts into educational materials and communication strategies, healthcare providers and organisations can potentially help cancer patients, survivors, and their loved ones to recognise and combat cancer-related misinformation more effectively.

Innovation

This study introduces a participatory prioritisation process, which integrates the expertise of healthcare professionals with the insights of patients and carers, thereby enhancing the programme's relevance and applicability.

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.

The Use of Podcasts as Patient Preparation for Hospital Visits-An Interview Study Exploring Patients' Experiences

INTRODUCTION

Podcasts have emerged as a promising tool in patient preparation for hospital visits. However, the nuanced experiences of patients who engage with this medium remain underexplored.

OBJECTIVES

This study explored patients' experiences of receiving information by way of podcasts prior to their hospital visits.

METHODS

Semi-structured interviews were conducted with patients with suspected chronic obstructive pulmonary disease (COPD), lung cancer, or sleep apnea. The method of data analysis chosen was thematic analysis.

RESULTS

Based on data from 24 interviews, five key themes were identified: technical challenges in utilization of podcasts; individual preferences for information prior to hospital visits; building trust and reducing anxiety through podcasts; the role of podcasts as an accessible and convenient source of information; and enhancement of engagement and empowerment through podcasts. Additionally, the study highlighted the critical importance of tailoring podcasts' content to individual preferences to optimize the delivery of healthcare information.

CONCLUSIONS

Podcasts can serve as a meaningful supplement to traditional information sources for patients. However, it is important to recognize that not all patients may be able to engage with this medium effectively due to technical challenges or personal preferences.

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.

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.

Strategies for communicating scientific evidence on healthcare to managers and the population: a scoping review

BACKGROUND

Health evidence needs to be communicated and disseminated in a manner that is clearly understood by decision-makers. As an inherent component of health knowledge translation, communicating results of scientific studies, effects of interventions and health risk estimates, in addition to understanding key concepts of clinical epidemiology and interpreting evidence, represent a set of essential instruments to reduce the gap between science and practice. The advancement of digital and social media has reshaped the concept of health communication, introducing new, direct and powerful communication platforms and gateways between researchers and the public. The objective of this scoping review was to identify strategies for communicating scientific evidence in healthcare to managers and/or population.

METHODS

We searched Cochrane Library, Embase®, MEDLINE® and other six electronic databases, in addition to grey literature, relevant websites from related organizations for studies, documents or reports published from 2000, addressing any strategy for communicating scientific evidence on healthcare to managers and/or population.

RESULTS

Our search identified 24 598 unique records, of which 80 met the inclusion criteria and addressed 78 strategies. Most strategies focused on risk and benefit communication in health, were presented by textual format and had been implemented and somehow evaluated. Among the strategies evaluated and appearing to yield some benefit are (i) risk/benefit communication: natural frequencies instead of percentages, absolute risk instead relative risk and number needed to treat, numerical instead nominal communication, mortality instead survival; negative or loss content appear to be more effective than positive or gain content; (ii) evidence synthesis: plain languages summaries to communicate the results of Cochrane reviews to the community were perceived as more reliable, easier to find and understand, and better to support decisions than the original summaries; (iii) teaching/learning: the Informed Health Choices resources seem to be effective for improving critical thinking skills.

CONCLUSION

Our findings contribute to both the knowledge translation process by identifying communication strategies with potential for immediate implementation and to future research by recognizing the need to evaluate the clinical and social impact of other strategies to support evidence-informed policies. Trial registration protocol is prospectively available in MedArxiv (doi.org/10.1101/2021.11.04.21265922).

Prioritisation of Informed Health Choices (IHC) key concepts to be included in lower secondary school resources: A consensus study

BACKGROUND

The Informed Health Choices Key Concepts are principles for thinking critically about healthcare claims and deciding what to do. The Key Concepts provide a framework for designing curricula, learning resources, and evaluation tools.

OBJECTIVES

To prioritise which of the 49 Key Concepts to include in resources for lower secondary schools in East Africa.

METHODS

Twelve judges used an iterative process to reach a consensus. The judges were curriculum specialists, teachers, and researchers from Kenya, Uganda, and Rwanda. After familiarising themselves with the concepts, they pilot-tested draft criteria for selecting and ordering the concepts. After agreeing on the criteria, nine judges independently assessed all 49 concepts and reached an initial consensus. We sought feedback on the draft consensus from other stakeholders, including teachers. After considering the feedback, nine judges independently reassessed the prioritised concepts and reached a consensus. The final set of concepts was determined after user-testing prototypes and pilot-testing the resources.

RESULTS

The first panel of judges prioritised 29 concepts. Based on feedback from teachers, students, curriculum specialists, and members of the research team, two concepts were dropped. A second panel of nine judges prioritised 17 of the 27 concepts that emerged from the initial prioritisation and feedback. Based on feedback on prototypes of lessons and pilot-testing a set of 10 lessons, we determined that it was possible to introduce nine concepts in 10 single-period (40-minute) lessons. We included eight of the 17 prioritised concepts and one additional concept.

CONCLUSION

Using an iterative process with explicit criteria, we prioritised nine concepts as a starting point for students to learn to think critically about healthcare claims and choices.

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.

Validation of an Australian parenting health literacy skills instrument: The parenting plus skills index

OBJECTIVE

Existing instruments for assessing health literacy skills in parents have limited scope to inform the design and evaluation of health literacy interventions. In this study we aimed to develop and validate a new performance-based measure of health literacy for Australian parents, the Parenting Plus Skills Index (PPSI). The instrument aimed to assess functional, communicative and critical health literacy skills.

METHODS

The PPSI was developed in three phases: 1) Modified Delphi Expert Panel to provide feedback on 34 initial items; 2) Evaluation of psychometric properties of each item using a multidimensional item response theory model in a sample of Australian adults of parenting age (20-44 years) (N = 500); 3) Assessment of subset of items in an independent sample (N = 500).

RESULTS

Following the three phases, 13 items were included in the final instrument. Participants scored on average 8.9/13 (69 %). The instrument demonstrated acceptable reliability (r = 0.70) and was significantly correlated with other performance-based health literacy instruments.

CONCLUSIONS

The PPSI is a validated 13-item performance-based instrument that assesses health literacy skills for parents in an Australian setting.

PRACTICE IMPLICATIONS

The PPSI fills an important gap in available health literacy instruments that may be useful for facilitating development and evaluation of health literacy interventions.

Development of the informed health choices resources in four countries to teach primary school children to assess claims about treatment effects: a qualitative study employing a user-centred approach

Background

People of all ages are flooded with health claims about treatment effects (benefits and harms of treatments). Many of these are not reliable, and many people lack skills to assess their reliability. Primary school is the ideal time to begin to teach these skills, to lay a foundation for continued learning and enable children to make well-informed health choices, as they grow older. However, these skills are rarely being taught and yet there are no rigorously developed and evaluated resources for teaching these skills.

Objectives

To develop the Informed Health Choices (IHC) resources (for learning and teaching people to assess claims about the effects of treatments) for primary school children and teachers.

Methods

We prototyped, piloted, and user-tested resources in four settings that included Uganda, Kenya, Rwanda, and Norway. We employed a user-centred approach to designing IHC resources which entailed multiple iterative cycles of development (determining content scope, generating ideas, prototyping, testing, analysing and refining) based on continuous close collaboration with teachers and children.

Results

We identified 24 Key Concepts that are important for children to learn. We developed a comic book and a separate exercise book to introduce and explain the Key Concepts to the children, combining lessons with exercises and classroom activities. We developed a teachers' guide to supplement the resources for children.

Conclusion

By employing a user-centred approach to designing resources to teach primary children to think critically about treatment claims and choices, we developed learning resources that end users experienced as useful, easy to use and well-suited to use in diverse classroom settings.

Effects of the Informed Health Choices podcast on the ability of parents of primary school children in Uganda to assess the trustworthiness of claims about treatment effects: one-year follow up of a randomised trial

INTRODUCTION

Earlier, we designed and evaluated an educational mass media intervention for improving people's ability to think more critically and to assess the trustworthiness of claims (assertions) about the benefits and harms (effects) of treatments. The overall aims of this follow-up study were to evaluate the impact of our intervention 1 year after it was administered, and to assess retention of learning and behaviour regarding claims about treatments.

METHODS

We randomly allocated consenting parents to listen to either the Informed Health Choices podcast (intervention) or typical public service announcements about health issues (control) over 7-10 weeks. Each intervention episode explained how the trustworthiness of treatment claims can be assessed by using relevant key concepts of evidence-informed decision-making. Participants listened to two episodes per week, delivered by research assistants. We evaluated outcomes immediately, and a year after the intervention. Primary outcomes were mean score and the proportion with a score indicating a basic ability to apply the key concepts (> 11 out of 18 correct answers) on a tool measuring people's ability to critically appraise the trustworthiness of treatment claims. Skills decay/retention was estimated by calculating the relative difference between the follow-up and initial results in the intervention group, adjusting for chance. Statistical analyses were performed using R (R Core Team, Vienna, Austria; version 3.4.3).

RESULTS

After 1 year, the mean score for parents in the intervention group was 58.9% correct answers, compared to 52.6% in the control (adjusted mean difference of 6.7% (95% CI 3.3% to 10.1%)). In the intervention group, 47.2% of 267 parents had a score indicating a basic ability to assess treatment claims compared to 39.5% of 256 parents in the control (adjusted difference of 9.8% more parents (95% CI 0.9% to 18.9%). These represent relative reductions of 29% in the mean scores and 33% in the proportion of parents with a score indicating a basic ability to assess the trustworthiness of claims about treatment effects.

CONCLUSIONS

Although listening to the Informed Health Choices podcast initially led to a large improvement in the ability of parents to assess claims about the effects of treatments, our findings show that these skills decreased substantially over 1 year. More active practice could address the substantial skills decay observed over 1 year.

TRIAL REGISTRATION

Pan African Clinical Trial Registry (www.pactr.org), PACTR201606001676150. Registered on 12 June 2016.

Effects of the Informed Health Choices primary school intervention on the ability of children in Uganda to assess the reliability of claims about treatment effects, 1-year follow-up: a cluster-randomised trial

INTRODUCTION

We evaluated an intervention designed to teach 10- to 12-year-old primary school children to assess claims about the effects of treatments (any action intended to maintain or improve health). We report outcomes measured 1 year after the intervention.

METHODS

In this cluster-randomised trial, we included primary schools in the central region of Uganda that taught year 5 children (aged 10 to 12 years). We randomly allocated a representative sample of eligible schools to either an intervention or control group. Intervention schools received the Informed Health Choices primary school resources (textbooks, exercise books and a teachers' guide). The primary outcomes, measured at the end of the school term and again after 1 year, were the mean score on a test with two multiple-choice questions for each of the 12 concepts and the proportion of children with passing scores.

RESULTS

We assessed 2960 schools for eligibility; 2029 were eligible, and a random sample of 170 were invited to recruitment meetings. After recruitment meetings, 120 eligible schools consented and were randomly assigned to either the intervention group (n = 60 schools; 76 teachers and 6383 children) or the control group (n = 60 schools; 67 teachers and 4430 children). After 1 year, the mean score in the multiple-choice test for the intervention schools was 68.7% compared with 53.0% for the control schools (adjusted mean difference 16.7%; 95% CI, 13.9 to 19.5; P < 0.00001). In the intervention schools, 3160 (80.1%) of 3943 children who completed the test after 1 year achieved a predetermined passing score (≥ 13 of 24 correct answers) compared with 1464 (51.5%) of 2844 children in the control schools (adjusted difference, 39.5%; 95% CI, 29.9 to 47.5).

CONCLUSION

Use of the learning resources led to a large improvement in the ability of children to assess claims, which was sustained for at least 1 year.

TRIAL REGISTRATION

Pan African Clinical Trial Registry (www.pactr.org), PACTR201606001679337. Registered on 13 June 2016.

Development of mass media resources to improve the ability of parents of primary school children in Uganda to assess the trustworthiness of claims about the effects of treatments: a human-centred design approach

BACKGROUND

Claims about what we need to do to improve our health are everywhere. Most interventions simply tell people what to do, and do not empower them to critically assess health information. Our objective was to design mass media resources to enable the public to critically appraise the trustworthiness of claims about the benefits and harms of treatments and make informed health choices.

METHODS

Research was conducted between 2013 and 2016 across multiple iterative phases. Participants included researchers, journalists, parents, other members of the public. First, we developed a list of 32 key concepts that people need to understand to be able to assess the trustworthiness of claims about treatment effects. Next, we used a human-centred design approach, to generate ideas for resources for teaching the key concepts, and developed and user-tested prototypes through qualitative interviews. We addressed identified problems and repeated this process until we had a product that was deemed relevant and desirable by our target audience, and feasible to implement.

RESULTS

We generated over 160 ideas, mostly radio-based. After prototyping some of these, we found that a podcast produced collaboratively by health researchers and journalists was the most promising approach. We developed eight episodes of the Informed Health Choices podcast, a song on critical thinking about treatments and a reminder checklist. Early versions of the podcast were reportedly too long, boring and confusing. We shortened the episodes, included one key concept per episode, and changed to story-telling with skits. The final version of the podcast was found to be useful, understandable, credible and desirable.

CONCLUSION

We found many problems with various prototypes of mass media resources. Using a human-centred design approach, we overcame those problems. We have developed a guide to help others prepare similar podcasts.

Informed Health Choices media intervention for improving people's ability to critically appraise the trustworthiness of claims about treatment effects: a mixed-methods process evaluation of a randomised trial in Uganda

We developed the Informed Health Choices podcast to improve people's ability to assess claims about the effects of treatments. We evaluated the effects of the podcast in a randomised trial.

OBJECTIVES

We conducted this process evaluation to assess the fidelity of the intervention, identify factors that affected the implementation and impact of the intervention and could affect scaling up, and identify potential adverse and beneficial effects.

SETTING

The study was conducted in central Uganda in rural, periurban and urban settings.

PARTICIPANTS

We collected data on parents who were in the intervention arm of the Informed Health Choices study that evaluated an intervention to improve parents' ability to assess treatment effects.

PROCEDURES

We conducted 84 semistructured interviews during the intervention, 19 in-depth interviews shortly after, two focus group discussions with parents, one focus group discussion with research assistants and two in-depth interviews with the principal investigators. We used framework analysis to manage qualitative data, assessed the certainty of the findings using the GRADE-CERQual (Grading of Recommendations, Assessment, Development and Evaluations-Confidence in the Evidence from Reviews of Qualitative Research) approach, and organised findings in a logic model.

OUTCOMES

Proportion of participants listening to all episodes; factors influencing the implementation of the podcast; ways to scale up and any adverse and beneficial effects.

RESULTS

All participants who completed the study listened to the podcast as intended, perhaps because of the explanatory design and recruitment of parents with a positive attitude. This was also likely facilitated by the podcast being delivered by research assistants, and providing the participants with MP3 players. The podcast was reportedly clear, understandable, credible and entertaining, which motivated them to listen and eased implementation. No additional adverse effects were reported.

CONCLUSIONS

Participants experienced the podcast positively and were motivated to engage with it. These findings help to explain the short-term effectiveness of the intervention, but not the decrease in effectiveness over the following year.

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).

Reducing research waste by promoting informed responses to invitations to participate in clinical trials

Poor recruitment to, and retention in, clinical trials is a source of research waste that could be reduced by more informed choices about participation. Barriers to effective recruitment and retention can be wide-ranging but relevance of the questions being addressed by trials and the outcomes that they are assessing are key for potential participants. Decisions about trial participation should be informed by general and trial-specific information and by considering broader assessments of 'informedness' and how they impact on both recruitment and retention. We suggest that more informed decisions about trial participation should encourage personally appropriate decisions, increase recruitment and retention, and reduce research waste and increase its value.

Informed health choices intervention to teach primary school children in low-income countries to assess claims about treatment effects: process evaluation

BACKGROUND

We developed the informed health choices (IHC) primary school resources to teach children how to assess the trustworthiness of claims about the effects of treatments. We evaluated these resources in a randomised trial in Uganda. This paper describes the process evaluation that we conducted alongside this trial.

OBJECTIVES

To identify factors affecting the implementation, impact and scaling up of the intervention; and potential adverse and beneficial effects of the intervention.

METHODS

All 85 teachers in the 60 schools in the intervention arm of the trial completed a questionnaire after each lesson and at the end of the term. We conducted structured classroom observations at all 60 schools. For interviews and focus groups, we purposively selected six schools. We interviewed district education officers, teachers, head teachers, children and their parents. We used a framework analysis approach to analyse the data.

RESULTS

Most of the participants liked the IHC resources and felt that the content was important. This motivated the teachers and contributed to positive attitudes. Although some teachers started out lacking confidence, many found that the children's enthusiasm for the lessons made them more confident. Nearly everyone interviewed thought that the children learnt something important and many thought that it improved their decision-making. The main barrier to scaling up use of the IHC resources that participants identified was the need to incorporate the lessons into the national curriculum.

CONCLUSION

The mostly positive findings reflect the trial results, which showed large effects on the children's and the teachers' critical appraisal skills. The main limitations of this evaluation are that the investigators were responsible for both developing and evaluating the intervention.

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.

Educational interventions to improve people's understanding of key concepts in assessing the effects of health interventions: a systematic review

BACKGROUND

Health information is readily accessible but is of variable quality. General knowledge about how to assess whether claims about health interventions are trustworthy is not common, so people's health decisions can be ill-informed, unnecessarily costly and even unsafe. This review aims to identify and evaluate studies of educational interventions designed to improve people's understanding of key concepts for evaluating claims about the effects of health interventions.

METHODS/DESIGN

We searched multiple electronic databases and sources of grey literature. Inclusion criteria included all study types that included a comparison, any participants (except health professionals or health professional students) and educational interventions aimed at improving people's understanding of one or more of the key concepts considered necessary for assessing health intervention claims. Knowledge and/or understanding of concepts or skills relevant to evaluating health information were our primary outcome measures. Secondary outcomes included behaviour, confidence, attitude and satisfaction with the educational interventions. Two authors independently screened search results, assessed study eligibility and risk of bias and extracted data. Results were summarised using descriptive synthesis.

RESULTS

Among 24 eligible studies, 14 were randomised trials and 10 used other study designs. There was heterogeneity across study participants, settings and educational intervention type, content and delivery. The risk of bias was high in at least one domain for all randomised studies. Most studies measured outcomes immediately after the educational intervention, with few measuring later. In most of the comparisons, measures of knowledge and skills were better among those who had received educational interventions than among controls, and some of these differences were statistically significant. The effects on secondary outcomes were inconsistent.

CONCLUSIONS

Educational interventions to improve people's understanding of key concepts for evaluating health intervention claims can improve people's knowledge and skills, at least in the short term. Effects on confidence, attitude and behaviour are uncertain. Many of the studies were at moderate or greater risk of bias. Improvements in study quality, consistency of outcome measures and measures of longer-term effects are needed to improve confidence in estimates of the effects of educational interventions to improve people's understanding of key concepts for evaluating health intervention claims.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016033103.

Key Concepts for Informed Health Choices: a framework for helping people learn how to assess treatment claims and make informed choices

Many claims about the effects of treatments, though well intentioned, are wrong. Indeed, they are sometimes deliberately misleading to serve interests other than the well-being of patients and the public. People need to know how to spot unreliable treatment claims so that they can protect themselves and others from harm. The ability to assess the trustworthiness of treatment claims is often lacking. Acquiring this ability depends on being familiar with, and correctly applying, some key concepts, for example, that' association is not the same as causation.' The Informed Health Choices (IHC) Project has identified 36 such concepts and shown that people can be taught to use them in decision making. A randomised trial in Uganda, for example, showed that primary school children with poor reading skills could be taught to apply 12 of the IHC Key Concepts. The list of IHC Key Concepts has proven to be effective in providing a framework for developing and evaluating IHC resources to help children to think critically about treatment claims. The list also provides a framework for retrieving, coding and organising other teaching and learning materials for learners of any age. It should help teachers, researchers, clinicians, and patients to structure critical thinking about the trustworthiness of claims about treatment effects.

Establishing a library of resources to help people understand key concepts in assessing treatment claims-The "Critical thinking and Appraisal Resource Library" (CARL)

BACKGROUND

People are frequently confronted with untrustworthy claims about the effects of treatments. Uncritical acceptance of these claims can lead to poor, and sometimes dangerous, treatment decisions, and wasted time and money. Resources to help people learn to think critically about treatment claims are scarce, and they are widely scattered. Furthermore, very few learning-resources have been assessed to see if they improve knowledge and behavior.

OBJECTIVES

Our objectives were to develop the Critical thinking and Appraisal Resource Library (CARL). This library was to be in the form of a database containing learning resources for those who are responsible for encouraging critical thinking about treatment claims, and was to be made available online. We wished to include resources for groups we identified as 'intermediaries' of knowledge, i.e. teachers of schoolchildren, undergraduates and graduates, for example those teaching evidence-based medicine, or those communicating treatment claims to the public. In selecting resources, we wished to draw particular attention to those resources that had been formally evaluated, for example, by the creators of the resource or independent research groups.

METHODS

CARL was populated with learning-resources identified from a variety of sources-two previously developed but unmaintained inventories; systematic reviews of learning-interventions; online and database searches; and recommendations by members of the project group and its advisors. The learning-resources in CARL were organised by 'Key Concepts' needed to judge the trustworthiness of treatment claims, and were made available online by the James Lind Initiative in Testing Treatments interactive (TTi) English (www.testingtreatments.org/category/learning-resources).TTi English also incorporated the database of Key Concepts and the Claim Evaluation Tools developed through the Informed Healthcare Choices (IHC) project (informedhealthchoices.org).

RESULTS

We have created a database of resources called CARL, which currently contains over 500 open-access learning-resources in a variety of formats: text, audio, video, webpages, cartoons, and lesson materials. These are aimed primarily at 'Intermediaries', that is, 'teachers', 'communicators', 'advisors', 'researchers', as well as for independent 'learners'. The resources included in CARL are currently accessible at www.testingtreatments.org/category/learning-resources.

CONCLUSIONS

We hope that ready access to CARL will help to promote the critical thinking about treatment claims, needed to help improve healthcare choices.

Effects of the Informed Health Choices primary school intervention on the ability of children in Uganda to assess the reliability of claims about treatment effects: a cluster-randomised controlled trial

BACKGROUND

Claims about what improves or harms our health are ubiquitous. People need to be able to assess the reliability of these claims. We aimed to evaluate an intervention designed to teach primary school children to assess claims about the effects of treatments (ie, any action intended to maintain or improve health).

METHODS

In this cluster-randomised controlled trial, we included primary schools in the central region of Uganda that taught year-5 children (aged 10-12 years). We excluded international schools, special needs schools for children with auditory and visual impairments, schools that had participated in user-testing and piloting of the resources, infant and nursery schools, adult education schools, and schools that were difficult for us to access in terms of travel time. We randomly allocated a representative sample of eligible schools to either an intervention or control group. Intervention schools received the Informed Health Choices primary school resources (textbooks, exercise books, and a teachers' guide). Teachers attended a 2 day introductory workshop and gave nine 80 min lessons during one school term. The lessons addressed 12 concepts essential to assessing claims about treatment effects and making informed health choices. We did not intervene in the control schools. The primary outcome, measured at the end of the school term, was the mean score on a test with two multiple-choice questions for each of the 12 concepts and the proportion of children with passing scores on the same test. This trial is registered with the Pan African Clinical Trial Registry, number PACTR201606001679337.

FINDINGS

Between April 11, 2016, and June 8, 2016, 2960 schools were assessed for eligibility; 2029 were eligible, and a random sample of 170 were invited to recruitment meetings. After recruitment meetings, 120 eligible schools consented and were randomly assigned to either the intervention group (n=60, 76 teachers and 6383 children) or control group (n=60, 67 teachers and 4430 children). The mean score in the multiple-choice test for the intervention schools was 62·4% (SD 18·8) compared with 43·1% (15·2) for the control schools (adjusted mean difference 20·0%, 95% CI 17·3-22·7; p<0·00001). In the intervention schools, 3967 (69%) of 5753 children achieved a predetermined passing score (≥13 of 24 correct answers) compared with 1186 (27%) of 4430 children in the control schools (adjusted difference 50%, 95% CI 44-55). The intervention was effective for children with different levels of reading skills, but was more effective for children with better reading skills.

INTERPRETATION

The use of the Informed Health Choices primary school learning resources, after an introductory workshop for the teachers, led to a large improvement in the ability of children to assess claims about the effects of treatments. The results show that it is possible to teach primary school children to think critically in schools with large student to teacher ratios and few resources. Future studies should address how to scale up use of the resources, long-term effects, including effects on actual health choices, transferability to other countries, and how to build on this programme with additional primary and secondary school learning resources.

FUNDING

Research Council of Norway.