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Informed health choices intervention to teach primary school children in low-income countries to assess claims about treatment effects: process evaluation
  1. Allen Nsangi1,2,
  2. Daniel Semakula1,2,
  3. Claire Glenton3,
  4. Simon Lewin3,4,
  5. Andrew D Oxman2,3,
  6. Matt Oxman3,
  7. Sarah Rosenbaum3,
  8. Astrid Dahlgren5,
  9. Laetitia Nyirazinyoye6,
  10. Margaret Kaseje7,
  11. Christopher James Rose3,
  12. Atle Fretheim2,3,
  13. Nelson K Sewankambo1
  1. 1Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
  2. 2Institute of Health and Society, University of Oslo Faculty of Medicine, Oslo, Norway
  3. 3Centre for Informed Health Choices, Norwegian Institute of Public Health, Oslo, Norway
  4. 4Health Systems Research Unit, South African Medical Research Council, Tygerberg, South Africa
  5. 5Regional Centre for Child and Adolescent Mental Health (Eastern and Southern Norway), Oslo, Norway
  6. 6Department of Public Health, University of Rwanda, Butare, Rwanda
  7. 7Tropical Institute of Community Health and Development, Kisumu, Kenya
  1. Correspondence to Dr Andrew D Oxman; oxman{at}


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.

  • process evaluation
  • critical thinking
  • critical appraisal
  • scaling up
  • teaching
  • education

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  • Contributors AN and DS were responsible for data collection in Uganda. AN, DS, ADO, CG and SL participated in the analyses of the qualitative data. AN, DS, ADO, CG and SL drafted the first draft of the manuscript. All the other authors (MO, SR, AD, LN, MK, AF and NKS) except for CJR reviewed the protocol, provided input on the manuscript, and agreed on the final version. CJR performed the statistical analyses. ADO, NKS and AF had the primary responsibility for overseeing the study.

  • Funding The Research Council of Norway, project number 220603/H10, funded the study. The Norwegian Institute of Public Health, recipient of the grant from the Research Council of Norway, is the coordinating centre for the Informed Health Choices project. This work was also partially supported by a Career Development Award from the DELTAS Africa Initiative grant # DEL-15-011 to THRiVE-2. The DELTAS Africa Initiative is an independent funding scheme of the African Academy of Sciences (AAS)’s Alliance for Accelerating Excellence in Science in Africa (AESA) and supported by the New Partnership for Africa’s Development Planning and Coordinating Agency (NEPAD Agency) with funding from the Wellcome Trust grant # 107742/Z/15/Z and the UK government.

  • Disclaimer The views expressed in this publication are those of the author(s) and not necessarily those of AAS, NEPAD Agency, Wellcome Trust or the UK government.

  • Competing interests None declared.

  • Patient consent for publication Obtained.

  • Ethics approval The study was approved by Makerere University Institutional Review Board and the Uganda National Council of Science and Technology as part of the Supporting Informed Healthcare Choices in Low-income Countries Project (grant no. ES498037).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request.

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