Reliability of goniometric measurements in patients with Duchenne muscular dystrophy

Previous studies of reliability of goniometric measurements have produced varied findings suggesting the need to document further the reliability of measuring range of motion in different patient groups. The purpose of this study was to determine the intratester and intertester reliability of goniometric measurements of seven common upper and lower extremity joint limitations in children with Duchenne muscular dystrophy. Five physical therapists participated in the study. The procedure and order of measurements were standardized. Results showed that intratester reliability for all measurements was high (ICC = .81 to .94), but intertester reliability showed a wide variation (ICC = .25 to .91). The results of this study indicate the need to use the same examiner for long-term follow-up and for assessing results of specific treatment interventions.

Disseminated herpes zoster in the immunocompromised host: a comparative trial of acyclovir and vidarabine. The NIAID Collaborative Antiviral Study Group

Seventy-three immunocompromised patients with disseminated herpes zoster were evaluated in a double-blind controlled trial of acyclovir (n = 37) versus vidarabine (n = 36) therapy. Acyclovir was administered at 30 mg/kg/day at 8-h intervals and vidarabine was given as a continuous 12-h infusion at 10 mg/kg/day for 7 days (longer if resolution of cutaneous or visceral disease was incomplete). No demographic differences existed between treatment groups. No deaths attributable to varicella-zoster virus infection occurred within 1 month of treatment. Neither rates of cutaneous healing, resolution of acute neuritis, and frequency of postherpetic neuralgia nor adverse clinical and laboratory events differed between treatment groups. Acyclovir recipients were discharged from the hospital more promptly than vidarabine recipients (P = .04, log rank test). These data indicate that disseminated herpes zoster is amenable to therapy with either acyclovir or vidarabine; resultant mortality is low.

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.

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

BACKGROUND

As part of the Informed Health Choices project, we developed a podcast called The Health Choices Programme to help improve the ability of people to assess claims about the benefits and harms of treatments. We aimed to evaluate the effects of the podcast on the ability of parents of primary school children in Uganda to assess claims about the effects of treatments.

METHODS

We did this randomised controlled trial in central Uganda. We recruited parents of children aged 10-12 years who were in their fifth year of school at 35 schools that were participating in a linked trial of the Informed Health Choices primary school resources. The parents were randomly allocated (1:1), via a web-based random number generator with block sizes of four and six, to listen to either the Informed Health Choices podcast (intervention group) or typical public service announcements about health issues (control group). Randomisation was stratified by parents' highest level of formal education attained (primary school, secondary school, or tertiary education) and the allocation of their children's school in the trial of the primary school resources (intervention vs control). The primary outcome, measured after listening to the entire podcast, was the mean score and the proportion of parents with passing scores on a test with two multiple choice questions for each of nine key concepts essential to assessing claims about treatments (18 questions in total). We did intention-to-treat analyses. This trial is registered with the Pan African Clinical Trial Registry, number PACTR201606001676150.

FINDINGS

We recruited parents between July 21, 2016, and Oct 7, 2016. We randomly assigned 675 parents to the podcast group (n=334) or the public service announcement group (n=341); 561 (83%) participants completed follow-up. The mean score for parents in the podcast group was 67·8% (SD 19·6) compared with 52·4% (17·6) in the control group (adjusted mean difference 15·5%, 95% CI 12·5-18·6; p<0·0001). In the podcast group, 203 (71%) of 288 parents had a predetermined passing score (≥11 of 18 correct answers) compared with 103 (38%) of 273 parents in the control group (adjusted difference 34%, 95% CI 26-41; p<0·0001). No adverse events were reported.

INTERPRETATION

Listening to the Informed Health Choices podcast led to a large improvement in the ability of parents to assess claims about the effects of treatments. Future studies should assess the long-term effects of use of the podcast, the effects on actual health choices and outcomes, and how transferable our findings are to other countries.

FUNDING

Research Council of Norway.

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.

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.

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.

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.

Quality of information in news media reports about the effects of health interventions: Systematic review and meta-analyses

Background Many studies have assessed the quality of news reports about the effects of health interventions, but there has been no systematic review of such studies or meta-analysis of their results. We aimed to fill this gap (PROSPERO ID: CRD42018095032). Methods We included studies that used at least one explicit, prespecified and generic criterion to assess the quality of news reports in print, broadcast, or online news media, and specified the sampling frame, and the selection criteria and technique. We assessed criteria individually for inclusion in the meta-analyses, excluding inappropriate criteria and criteria with inadequately reported results. We mapped and grouped criteria to facilitate evidence synthesis. Where possible, we extracted the proportion of news reports meeting the included criterion. We performed meta-analyses using a random effects model to estimate such proportions for individual criteria and some criteria groups, and to characterise heterogeneity across studies.  Results We included 44 primary studies in the qualitative summary, and 18 studies and 108 quality criteria in the meta-analyses. Many news reports gave an unbalanced and oversimplified picture of the potential consequences of interventions. A limited number mention or adequately address conflicts of interest (22%; 95% CI 7%-49%) (low certainty), alternative interventions (36%; 95% CI 26%-47%) (moderate certainty), potential harms (40%; 95% CI 23%-61%) (low certainty), or costs (18%; 95% CI 12%-28%) (moderate certainty), or quantify effects (53%; 95% CI 36%-69%) (low certainty) or report absolute effects (17%; 95% CI 4%-49%) (low certainty).  Discussion There is room for improving health news, but it is logically more important to improve the public's ability to critically appraise health information and make judgements for themselves.

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.

Can an educational podcast improve the ability of parents of primary school children to assess the reliability of claims made about the benefits and harms of treatments: study protocol for a randomised controlled trial

Background

Claims made about the effects of treatments are very common in the media and in the population more generally. The ability of individuals to understand and assess such claims can affect their decisions and health outcomes. Many people in both low- and high-income countries have inadequate aptitude to assess information about the effects of treatments. As part of the Informed Healthcare Choices project, we have prepared a series of podcast episodes to help improve people’s ability to assess claims made about treatment effects. We will evaluate the effect of the Informed Healthcare Choices podcast on people’s ability to assess claims made about the benefits and harms of treatments. Our study population will be parents of primary school children in schools with limited educational and financial resources in Uganda.

Methods

This will be a two-arm, parallel-group, individual-randomised trial. We will randomly allocate consenting participants who meet the inclusion criteria for the trial to either listen to nine episodes of the Informed Healthcare Choices podcast (intervention) or to listen to nine typical public service announcements about health issues (control). Each podcast includes a story about a treatment claim, a message about one key concept that we believe is important for people to be able to understand to assess treatment claims, an explanation of how that concept applies to the claim, and a second example illustrating the concept.

We designed the Claim Evaluation Tools to measure people’s ability to apply key concepts related to assessing claims made about the effects of treatments and making informed health care choices. The Claim Evaluation Tools that we will use include multiple-choice questions addressing each of the nine concepts covered by the podcast. Using the Claim Evaluation Tools, we will measure two primary outcomes: (1) the proportion that ‘pass’, based on an absolute standard and (2) the average score.

Discussion

As far as we are aware this is the first randomised trial to assess the use of mass media to promote understanding of the key concepts needed to judge claims made about the effects of treatments.

Trial registration

Pan African Clinical Trials Registry, PACTR201606001676150. Registered on 12 June 2016. http://www.pactr.org/ATMWeb/appmanager/atm/atmregistry?dar=true&tNo=PACTR201606001676150.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1745-y) contains supplementary material, which is available to authorized users.

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.

Learning to think critically about health using digital technology in Ugandan lower secondary schools: A contextual analysis

INTRODUCTION

The world is awash with claims about the effects of health interventions. Many of these claims are untrustworthy because the bases are unreliable. Acting on unreliable claims can lead to waste of resources and poor health outcomes. Yet, most people lack the necessary skills to appraise the reliability of health claims. The Informed Health Choices (IHC) project aims to equip young people in Ugandan lower secondary schools with skills to think critically about health claims and to make good health choices by developing and evaluating digital learning resources. To ensure that we create resources that are suitable for use in Uganda's secondary schools and can be scaled up if found effective, we conducted a context analysis. We aimed to better understand opportunities and barriers related to demand for the resources, how the learning content overlaps with existing curriculum and conditions in secondary schools for accessing and using digital resources, in order to inform resource development.

METHODS

We used a mixed methods approach and collected both qualitative and quantitative data. We conducted document analyses, key informant interviews, focus group discussions, school visits, and a telephone survey regarding information communication and technology (ICT). We used a nominal group technique to obtain consensus on the appropriate number and length of IHC lessons that should be planned in a school term. We developed and used a framework from the objectives to code the transcripts and generated summaries of query reports in Atlas.ti version 7.

FINDINGS

Critical thinking is a key competency in the lower secondary school curriculum. However, the curriculum does not explicitly make provision to teach critical thinking about health, despite a need acknowledged by curriculum developers, teachers and students. Exam oriented teaching and a lack of learning resources are additional important barriers to teaching critical thinking about health. School closures and the subsequent introduction of online learning during the COVID-19 pandemic has accelerated teachers' use of digital equipment and learning resources for teaching. Although the government is committed to improving access to ICT in schools and teachers are open to using ICT, access to digital equipment, unreliable power and internet connections remain important hinderances to use of digital learning resources.

CONCLUSIONS

There is a recognized need for learning resources to teach critical thinking about health in Ugandan lower secondary schools. Digital learning resources should be designed to be usable even in schools with limited access and equipment. Teacher training on use of ICT for teaching is needed.

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.

Quality of information in news media reports about the effects of health interventions: Systematic review and meta-analyses

Background Many studies have assessed the quality of news reports about the effects of health interventions, but there has been no systematic review of such studies or meta-analysis of their results. We aimed to fill this gap (PROSPERO ID: CRD42018095032). Methods We included studies that used at least one explicit, prespecified and generic criterion to assess the quality of news reports in print, broadcast, or online news media, and specified the sampling frame, and the selection criteria and technique. We assessed criteria individually for inclusion in the meta-analyses, excluding ineligible criteria and criteria with inadequately reported results. We mapped and grouped criteria to facilitate evidence synthesis. Where possible, we extracted the proportion of news reports meeting the included criterion. We performed meta-analyses using a random effects model to estimate such proportions for individual criteria and some criteria groups, and to characterise heterogeneity across studies.  Results We included 44 primary studies in the review, and 18 studies and 108 quality criteria in the meta-analyses. Many news reports gave an unbalanced and oversimplified picture of the potential consequences of interventions. A limited number mention or adequately address conflicts of interest (22%; 95% CI 7%-49%) (low certainty), alternative interventions (36%; 95% CI 26%-47%) (moderate certainty), potential harms (40%; 95% CI 23%-61%) (low certainty), or costs (18%; 95% CI 12%-28%) (moderate certainty), or quantify effects (53%; 95% CI 36%-69%) (low certainty) or report absolute effects (17%; 95% CI 4%-49%) (low certainty).  Discussion There is room for improving health news, but it is logically more important to improve the public's ability to critically appraise health information and make judgements for themselves.

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.

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.

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.

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.

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.

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.

Effects of the informed health choices secondary school intervention after 1 year: a prospective meta-analysis using individual participant data

BACKGROUND

Critical thinking about health choices is essential to avoid being misled by unreliable information and to use reliable information appropriately. The aim of this prospective meta-analysis was to synthesize the results of 1-year follow-up data from three cluster-randomized trials of an intervention designed to teach lower secondary school students to think critically about health choices. Only one other randomized trial has evaluated a school-based intervention to teach adolescents to think critically about health choices. That trial compared two teaching strategies to teach statistical reasoning. It did not assess long-term learning-retention.

METHODS

We conducted the trials in Kenya, Rwanda, and Uganda. The intervention included providing a 2-3-day teacher training workshop and digital resources for ten lessons. The intervention focused on nine key concepts. We did not intervene in control schools. The primary outcome was a passing score on a test (≥ 9 of 18 multiple-choice questions answered correctly). We performed random effects meta-analyses to estimate the overall intervention effects. We calculated learning retention as the test results in the intervention schools after 1 year relative to just after the intervention, adjusted for chance.

RESULTS

Altogether, 244 schools (11,344 students) took part in the three trials. Follow-up data was collected for 8298 students (73%). The overall odds ratio for the primary outcome after 1 year was 3.6 (95% CI: 1.9-7.1; p = 0.0001) in favor of the intervention, whereas it was 5.5 (95% CI: 3.0-10.2) just after the intervention. This corresponds to 25.6% (95% CI: 21.1-30.0%) more students in the intervention schools passing the test after 1 year versus 33.3% (95% CI: 28.7-37.8%) just after the intervention. Overall, 2273 (52.6%) of 4324 students in intervention schools had a passing score after 1 year compared to 3397 (58.1%) of 5846 students just after the intervention, indicating 88.3% learning retention.

CONCLUSIONS

One year after the intervention, we still found a positive effect on the ability of students to think critically about health choices, but 5.5% fewer students in the intervention schools had a passing score. The certainty of the evidence was also lower due to 27% of students being lost to follow-up.

TRIAL REGISTRATION

The protocol for this prospective meta-analysis was registered with PROSPERO May 31, 2022, ID 336580. The three randomized trials were registered in the Pan African Clinical Trial Registry February 15, 2022, PACTR202203880375077; April 5, 2022, PACTR20220488391731; and April 14, 2022, PACTR202204861458660.