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 teachers and other stakeholders. 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 prioritised 29 concepts. Based on feedback from teachers, students, curriculum developers, and other members of the research team, two concepts were dropped. A second panel of nine judges prioritised 17 of the 27 concepts. Due to the Covid-19 pandemic and school closures, we have only been able to develop one set of resources instead of two, as originally planned. 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.

Introduction 58 Dewey noted the importance of teaching concepts over a century ago. 1  . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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Comparisons
Studies should make fair comparisons, designed to minimize the risk of systematic errors (biases) and random errors (the play of chance).

Choices
What to do depends on judgements about a problem, the relevance of the evidence available, and the balance of expected benefits, harms, and costs.
1.1 It should not be assumed that treatments are safe or effective -or that they are not.

a)
Treatments can cause harms as well as benefits. b) Large, dramatic effects are rare. c) It is rarely possible to be certain about the effects of treatments.

Seemingly logical assumptions are not a sufficient basis for claims.
a) Treatment may not be needed. b) Beliefs alone about how treatments work are not reliable predictors of the presence or size of effects. c) Assumptions that fair comparisons of treatments in research are not applicable in practice can be misleading. d) An outcome may be associated with a treatment but not caused by it. e) More data is not necessarily better data. f) Identifying effects of treatments depends on making comparisons. g) The results of one study considered in isolation can be misleading. h) Widely used treatments or those that have been used for decades are not necessarily beneficial or safe. i) Treatments that are new or technologically impressive may not be better than available alternatives. j) Increasing the amount of a treatment does not necessarily increase its benefits and may cause harm. k) Earlier detection of 'disease' is not necessarily better. l) It is rarely possible to know in advance who will benefit, who will not, and who will be harmed by using a treatment.

Trust in a source alone is not a sufficient basis for believing a claim.
a) Your existing beliefs may be wrong. b) Competing interests may result in misleading claims. c) Personal experiences or anecdotes alone are an unreliable basis for most claims. d) Opinions alone are not a reliable basis for claims. e) Peer review and publication by a journal do not guarantee that comparisons have been fair.

Comparisons of treatments should be fair.
a) Comparison groups should be as similar as possible. b) Indirect comparisons of treatments across different studies can be misleading. c) The people being compared should be cared for similarly apart from the treatments being studied. d) If possible, people should not know which of the treatments being compared they are receiving. e) Outcomes should be assessed in the same way in all the groups being compared. f) Outcomes should be assessed using methods that have been shown to be reliable. g) It is important to assess outcomes in all (or nearly all) the people in a study. h) People's outcomes should be counted in the group to which they were allocated.

Syntheses of studies need to be reliable.
a) Reviews of studies comparing treatments should use systematic methods. b) Failure to consider unpublished results of fair comparisons may result in estimates of effects that are misleading. c) Treatment claims based on models may be sensitive to underlying assumptions.

Descriptions should clearly reflect the size of effects and the risk of being misled by the play of chance.
a) Verbal descriptions of the size of effects alone can be misleading. b) Relative effects of treatments alone can be misleading. c) Average differences between treatments can be misleading. d) Small studies may be misleading. e) Results for a selected group of people within a study can be misleading. f) The use of p-values may be misleading; confidence intervals are more informative. g) Deeming results to be "statistically significant" or "nonsignificant" can be misleading. h) Lack of evidence of a difference is not the same as evidence of "no difference".

Evidence should be relevant.
a) Attention should focus on all important effects of treatments, and not surrogate outcomes. b) Fair comparisons of treatments in animals or highly selected groups of people may not be relevant. c) The treatments compared should be similar to those of interest. d) There should not be important differences between the circumstances in which the treatments were compared and those of interest.

Expected advantages should outweigh expected disadvantages.
a) Weigh the benefits and savings against the harms and costs of acting or not.
b) Consider the baseline risk or the severity of the symptoms when estimating the size of expected effects. c) Consider how important each advantage and disadvantage is when weighing the pros and cons. d) Consider how certain you can be about each advantage and disadvantage. e) Important uncertainties about the effects of treatments should be addressed in further fair comparisons.

71
. CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 16, 2022. ;https://doi.org/10.1101https://doi.org/10. /2022  should focus on "big ideas" and "core tasks"; "A big idea is a concept, theme, or issue that gives meaning 89 and connection to discrete facts and skills," while a core task is "the most important performance demands 90 in any field". 9 Priorities should be established by building upon the big ideas and by focusing schoolwork 91 around core tasks or "transfer tasks" derived from authentic challenges. Bruner's idea of a "spiral curriculum" is based on recurring, deepening inquiries into big ideas and important 96 tasks, helping students learn in a way that is developmentally sensible and effective; "The basic ideas at the . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The copyright holder for this preprint this version posted April 16, 2022. ; https://doi.org/10.1101/2022.04.11.22273708 doi: medRxiv preprint 121 Ten judges initially prioritised the IHC Key Concepts to be included in the IHC secondary school resources 122 (Table 2). Three were curriculum specialists or teachers, one was a health promotion officer, and the other 123 six were health researchers who were members of the project team and were familiar with the IHC Key 124 Concepts. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The copyright holder for this preprint this version posted April 16, 2022. ; Following the pilot, we agreed on six revised criteria (Table 3). These included the importance of each 142 concept for the "central ideas" and the "core tasks" ( is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The copyright holder for this preprint this version posted April 16, 2022. ; https://doi.org/10.1101/2022.04.11.22273708 doi: medRxiv preprint Table 4. Central ideas and core tasks "Central ideas" and "core abilities" Central ideas are central principles* underlying what students should learn. Core abilities are essential actions that students should be able to perform. We collected informal feedback on the initial prioritisation from teacher and student networks and advisory 154 groups in each country, from our international advisory group, and from other members of our research 155 team. 14 An introductory meeting was held with a second panel of judges (

160
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The copyright holder for this preprint this version posted April 16, 2022. ; https://doi.org/10.1101/2022.04.11.22273708 doi: medRxiv preprint In addition to prioritising the concepts, the panels also made judgements about when each included concept 169 should be taught (Table 3).

171
In the initial prioritisation, the average score for including each of the 49 concepts ranged from seven (for 172 "Treatments can cause harms as well as benefits," "Your existing beliefs may be wrong," and "Personal 173 experiences or anecdotes alone are an unreliable basis for most claims.") to 1.2 (for "Failure to consider 174 unpublished results of fair comparisons may result in estimates of effects that are misleading" and 175 "Treatment claims based on models may be sensitive to underlying assumptions.") (Supporting information 176 1). Seventeen concepts had an average score greater than six. Nine concepts had an average score between 177 five and six, eight had an average score between four and five, and 15 had an average score less than four.

178
After discussing the scores, the panel agreed on prioritising 29 of the 49 concepts (Table 6).

179
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    3. It is rarely possible to be certain about the effects of treatments.
  Seemingly logical assumptions are not a sufficient basis for claims. 4. Treatment may not be needed.
  5. Beliefs alone about how treatments work are not reliable predictors of the presence or size of effects.
   6. Assumptions that fair comparisons of treatments in research are not applicable in practice can be misleading. 7. An outcome may be associated with a treatment but not caused by it.
   8. More data is not necessarily better data. 9. Identifying effects of treatments depends on making comparisons.
    10. The results of one study considered in isolation can be misleading.
  11. Widely used treatments or those that have been used for decades are not necessarily beneficial or safe.

   
12. Treatments that are new or technologically impressive may not be better than available alternatives.

   
13. Increasing the amount of a treatment does not necessarily increase its benefits and may cause harm.

  
14. Earlier detection of 'disease' is not necessarily better. 15. It is rarely possible to know in advance who will benefit, who will not, and who will be harmed by using a treatment. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted April 16, 2022.  192 and other members of the research team.: "If possible, people should not know which of the treatments 193 being compared they are receiving" and "Average differences between treatments can be misleading." 194 (Table 6).
. CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted April 16, 2022. ;https://doi.org/10.1101https://doi.org/10. /2022 The average score for the 27 concepts ranged from seven (for "Treatments can cause harms as well as 196 benefits.") to 4.3 (for "The results of one study considered in isolation can be misleading.") (Supporting 197 information 2). After discussing the scores, the panel agreed on prioritising 17 of the Key Concepts.

198
Our original plan was to develop two sets of learning resources to be used during two school terms.

199
However, due to the Covid-19 pandemic, school closures, and project delays, it was only possible to produce 200 one set of resources for a single school term. After collecting feedback on prototypes of the learning 201 resources, the second consensus panel agreed on the nine concepts included in the IHC secondary school 202 resources (Table 6).

203
One concept that was not one of the 17 prioritised concepts, was included as one of the nine concepts: 204 "Small studies may be misleading." That concept had the same average score ( Ordering of the concepts 210 Based on the average score for the nine judges in the second panel, the prioritised concepts were ordered as 211 shown in Table 7. However, based on feedback on early prototypes of the lessons and pilot testing a 212 complete version of the lessons, the order in which the concepts are introduced was modified. The final 213 order in which the concepts were introduced in the 10 lessons is shown in the last column in Table 7, and an 214 overview of the 10 lessons is shown in Table 8. Because students and teachers, as well as others, frequently 215 understand "treatment" narrowly to only include medical care given to a patient, we have used "health 216 action" in the secondary school resources.

217
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The copyright holder for this preprint this version posted April 16, 2022. ;https://doi.org/10.1101https://doi.org/10. /2022  18. Small studies may be misleading. Very near the last lesson 7 219 220 . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

Lesson
Learning goals and concepts Part 1. Claims about effects that are not supported by reliable comparisons are not necessarily wrong, but there is a weak basis for believing them.
The first six concepts can help people to recognise when a claim about a health action has a weak basis. By "claim", we mean something that someone says as if it is true, but it may be false. "Claim" has more than one meaning. In these resources, it means a statement of a belief or opinion about something. The focus is on claims about the effects of doing something; specifically, claims about the effects of health actions.
By the end of this lesson, students should be able to identify health actions, and explain why it is important to think critically about health actions.

Health actions
Concept ➤ Health actions can have helpful effects, but they can also have harmful effects and be expensive.

Health claims
By the end of this lesson, students should be able to identify claims about the effects of health actions and their three main parts, and explain why it is important to think critically about such claims.

Concept
➤ Health actions can have helpful effects, but they can also have harmful effects and be expensive. People often exaggerate the benefits of treatments and ignore or downplay potential harms. However, few effective treatments are 100% safe.
By the end of this lesson, students should be able to identify claims about the effects of health actions that are only based on personal experiences, how commonly-used or for how long something has been used, or how new or expensive something is, and explain why most such claims are unreliable. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The copyright holder for this preprint this version posted April 16, 2022. ; 248 of learners trying to understand the big ideas and to perform the core tasks (Table 4). Thus, it was both   249 logical and consistent with learners' needs to group the lessons into those three parts, as shown in Table 8.  The main reason for including fewer concepts in the secondary school resources was that 10 double (80-283 minute) periods were used for the primary school resources -twice as much time as for the secondary 284 school resources. In addition, the primary school resources included printed materials for the students . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 16, 2022. ; https://doi.org/10.1101/2022.04.11.22273708 doi: medRxiv preprint 285 (including textbooks), whereas the secondary school resources are primarily digital resources for teachers, 286 with optional handouts for students. Thus, they are more dependent on teachers being well-prepared to 287 teach the lessons. The reason for using digital learning resources and limiting each lesson to a single 40-288 minute period was to increase the likelihood that use of the resources will be scaled up, if shown to be 289 effective.

290
Other educational interventions to improve people's ability to think critically about healthcare claims and 291 decide what to do, and assessment tools, have included only a handful of the key concepts, 17 and it is 292 unclear how those concepts were prioritised.

293
Strengths and limitations of this study 294 Strengths of this study include involvement of curriculum specialists, teachers, and researchers in the three 295 countries for which the IHC Key Concepts were prioritised, use of explicit criteria, independent judgements 296 by a panel of judges, and feedback from teachers and other stakeholders before finalising the priorities.

297
Changes to the priorities based on feedback on prototypes and judgements made by the research team 298 could be viewed as either a strength or a limitation. It is important to be pragmatic, and we view the changes 299 made based on user-testing prototypes and pilot-testing all 10 lessons as essential. The nine concepts were 300 not being taught in any of the three countries and teachers had no prior experience teaching the concepts.

301
An important limitation of this study is that the concepts were prioritised independently of the rest of the 302 curriculum. Ideally, IHC Key Concepts could be prioritised together with other important concepts in the 303 curriculum. Rwanda implemented a new competence-based curriculum in 2016. Uganda introduced its new 304 competence-based curriculum for lower-secondary schools in 2020, and Kenya has plans to introduce a new 305 competency-based curriculum by 2024. [18][19][20] The new curricula in all three countries include critical thinking 306 as a core competence and they include health topics. However, critical thinking about health is not explicitly 307 included in any of the curricula, and both critical thinking and health are taught across subjects. This limited 308 our ability to integrate the IHC Key Concepts into the curricula. In addition, teaching is exam-oriented in all . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 16, 2022. ;