Enabling sustainable public engagement in improving health and health equity

Claims about what people should or should not do for their health are everywhere. To make well-informed decisions, people must be able to think critically about what claims to believe and what to do. It is important that teenagers learn to think critically about health and make informed choices. The aim of this project was to develop and evaluate digital educational resources for lower secondary school students in Kenya, Rwanda, and Uganda to help them make informed choices. The project partners were Makerere University in Uganda, the University of Rwanda, the Tropical Institute of Community Health and Development in Kenya, and Epistemonikos in Chile. We found that competence-based curricula in the three countries included critical thinking as a key competence, but no learning goals related to critical thinking about health. Teachers lacked prior knowledge and skills, and we did not identify any existing educational resources in use for teaching critical thinking about health. Many schools lacked ICT equipment. We used the Informed Health Choices Key Concepts as a framework for determining the content of the resources. The 49 concepts in the framework are principles for evaluating the trustworthiness of claims and making informed choices. A panel of curriculum specialists, teachers, and researchers prioritized 17 of the concepts to include in the resources. After testing prototypes of the resources, we decided on nine concepts to include in a set of lessons that could be taught in a single school term. To inform decisions about which teaching strategies to use in the resources, we reviewed the findings of 326 systematic reviews of teaching strategies, and we summarized the findings for 37 strategies that we considered most relevant. We tested using different strategies. In the final version of the resources, we used 12 of these teaching strategies. The final version of the resources ("Be smart about your health") includes 10 lesson plans, a teachers’ guide, and extra resources. There are two versions of each lesson plan: a blackboard version for use in classrooms equipped only with a blackboard and a projector version that includes illustrated presentations. The resources are designed so that they can be used flexibly and can be adapted to different contexts. The resources also include training materials for teachers. The educational intervention that we evaluated consisted of a 2-3-day teacher training workshop and the ten 40-minute lessons. We developed a test to measure students’ and teachers’ ability to understand and apply the nine concepts. The test includes two multiple-choice questions for each concept. We validated the test in all three countries. A panel of curriculum specialists, teachers, and researchers determined the cut-off for a passing score (at least 9 of 18 questions answered correctly). We evaluated the effects of the intervention in randomized trials in each of the countries. Altogether, 244 schools (11,344 students) took part in the three trials. Overall, 33% more students and 32% more teachers had a passing score in the intervention schools compared to the schools where we did not intervene. In total, 3397 (58%) of 5846 students and 118 (97%) of 122 teachers in the intervention schools had a passing score. Other outcomes also favored the intervention. We interviewed teachers, students, and parents from the intervention schools and collected other information about perceptions and experiences of the intervention. Factors that may have facilitated implementing the intervention and could facilitate scaling it up include the design of the resources and the perceived value of the lessons. Factors that impeded implementation of the intervention and could impede scaling it up are inadequate time to prepare for and teach the lessons, the lessons not being in the curricula or national examinations, and a lack of printed materials for students. Perceived benefits of the intervention include students and teachers understanding the concepts and using them in their daily lives. Other potential benefits include students being more confident, thoughtful, and open minded. Potential adverse effects include conflicts with parents and other students, misunderstanding the lessons, and misapplying what was learned. The educational resources can be accessed, downloaded, and used in contexts with minimal resources. The platform we developed for the resources facilitates translation and adaptation of the resources. We are working with the national curriculum offices in Kenya, Rwanda, and Uganda to scale up use of the educational resources. Together with partners and organizations in other countries, we are working to make the findings of this research accessible, to translate and adapt the educational resources for use in other contexts, and to help young people learn to cope with the massive amount of health information, much of which is misinformation, and to make informed health choices.

We have demonstrated that it is possible to teach adolescents to think critically about health in settings with minimal access to ICT and printed materials. The digital educational resources can easily be accessed using a smartphone or laptop, and they can be used offline. In this way we minimized the cost of using the resources and maximized access. We are working with educational authorities to find ways to scale up use of the resources in Kenya, Rwanda, and Uganda. We created a platform for the resources that facilitates translation and adaptation of the resources for use in other contexts. The platform also can be used to develop new lessons. We have documented the benefits of using the resources. In addition, we have illustrated the value of context analyses, the Informed Health Choices (IHC) Key Concepts framework, and using a human-centered design approach to ensure that educational interventions are experienced positively and valued by teachers, students, and other stakeholders. We also developed a framework to improve consideration of potential adverse effects of educational interventions. The IHC Key Concepts and the methods that we have developed and used are being used to develop and evaluate other resources to enable critical thinking about health. The IHC network that we coordinate now includes people from 26 counties who are developing, evaluating, or contextualizing IHC resources. The primary school resources that we developed have been translated to 13 other languages and there is interest in translating and adapting the resources developed in this project.

Background: We are bombarded with claims about what might improve or harm our health, including claims about health promotion, prevention, therapies, public health policies, and health system policies. To make well-informed choices, we must be able to assess the reliability of those claims. It is important that teenagers learn to assess claims and make informed decisions as they become responsible for making their own choices and as citizens in a democracy. Objectives: To develop and evaluate learning resources for secondary school students to help them make informed personal choices about caring for their health and to participate as scientifically literate citizens in informed debate about health policies. Methods: We will prioritise Key Concepts to be included in the resources based on consultation with teachers, students, and others. This will be informed by a systematic review of frameworks for critical thinking, and an analysis of curricula in Uganda, Kenya, and Rwanda. We will use multiple-choice questions from a database developed in a previous GLOBVAC project as the basis for evaluation tools. We will validate the tools using psychometric testing and Rasch analysis. We will develop learning-resources in collaboration with teachers and students using an iterative process of brainstorming, prototyping, user testing, and feedback from teacher and student networks and advisory groups. We will randomise half of 80 to 100 schools in the three countries to use the resources and then compare the ability of the students in those schools to assess claims and make informed choices to that of the students in the comparison schools. We will use process evaluations identify unintended consequences, and explore factors that might affect scaling-up use of the Learning-resources. Expected results: Freely available and widely disseminated learning-resources to help young people make informed decisions about their health and health policies.