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Background We designed the “Be smart about your health” digital resources to teach lower secondary school students how to assess the trustworthiness of claims about the effects of treatments. We shall evaluate effects of using these resources in a randomised trial in Uganda. This paper describes the process evaluation that will be conducted alongside this trial. The aim is to identify factors affecting the implementation, fidelity, effects, and scaling up use of the Be smart about your health teaching resources in Uganda and potential adverse and beneficial effects of the intervention. Methods Forty teachers from 40 schools in the intervention arm of the trial will complete a lesson evaluation questionnaire after each of the 10 lessons and at the end of the term. We will conduct structured classroom observations at all 40 schools. We will purposively select eight schools where we will conduct focus group discussions with teachers and students. We also will conduct key informant interviews among education officers (that visit the schools to monitor the implementation), teachers, head teachers, learners, and their parents. We will use a framework analysis approach to analyse the data. Expected results We anticipate that the findings from this evaluation will provide insights into factors that may impact the effectiveness of using the Be smart about your health resources, factors that can inhibit or facilitate scaling up use of the resources, and potential effects that were not measured quantitatively after the intervention, including transfer of what was learned to other contexts and adverse effects.

Background: People frequently make decisions about what can improve their health. They do this based on large amounts of information that they get from different sources, which include claims about what harms or improves health. People therefore need skills to assess the trustworthiness of health claims. The Informed Health Choices (IHC) Key Concepts framework was used to develop the ‘Be Smart about your Health’ secondary school resources to help students in lower secondary to assess health claims about the effects of treatments. We are evaluating these resources in a cluster randomized trial in 80 lower secondary schools in Kenya. This protocol is for a process evaluation that will be conducted alongside the trial. The objective of this evaluation is to explore the extent to which the intervention was delivered as planned; understand factors that facilitated or hindered the delivery and impact of the resources; and antici-pated and unanticipated effects. Study design: We will employ a mixed-methods design using quantitative and qualita-tive data. We will collect quantitative data from all schools (n=40) allocated to the in-tervention arm using lesson evaluation forms. Our qualitative data collection will in-clude: (a) structured classroom observations in all schools (n=40), with at least one lesson observed in each school. In a sample of eight schools, we shall observe more than one lesson. (b) We will conduct focus group discussions (with students (n=4), teachers (n=1) and parents (n=4). (c) Key informant interviews with policymakers in education (n=5), teachers (n=8), and with school principals (n=8)). We will purposively select these schools based on location (urban and rural) and ownership (private and public). Data analysis: We will use framework analysis to analyze qualitative data and descrip-tive analysis to analyze quantitative data. We will summarize and appraise the confi-dence of the key findings from the qualitative data using a modified version of the GRADE-CERQual approach.

Background: Young people are exposed to many claims about the effects of things they can do to protect or improve health. To make good health choices, they need the ability to assess the reliability of those claims critically. Critical thinking is a core competence in the Rwandan secondary school curriculum and in many countries. However, critical thinking about health is rarely taught in Rwanda. Digital secondary school resources for critical thinking about health can potentially address this gap and if published be widely disseminated at low cost. The objective of the planned study is to evaluate the effects of using digital secondary school resources to help students learn to think critically about health. Methods: We will conduct a two-arm cluster-randomized trial. We will randomly select 84 lower secondary schools from 10 districts representing all five provinces of Rwanda. Using stratified random allocation, we will assign 84 schools to the intervention or control arm. Schools in the intervention arm will teach 10-lessons after teacher training on the content of the secondary school resources. Schools in the control arm will not receive any training and resources. They will carry on with teaching the national curriculum. The primary outcome will be the proportion of students with a predetermined passing score on a test with multiple-choice questions from the Claim Evaluation Tools item bank. The questions measure the ability to apply key concepts related to assessing health claims and making informed health choices. The test will include two questions addressing each of the nine concepts covered by the secondary school resources. Discussion: This is one of three randomized trials to assess the effects of the Informed Health Choices secondary school resources in Rwanda, Kenya, and Uganda. The findings will inform decisions about how to promote critical thinking about health. Trial registration: Pan African Clinical Trial Registry, trial identifier: PACTR202203880375077, Registered on 15th February 2022.

Background: There is an overabundance of claims about the advantages and disadvantages of health interventions. Many people are unable to assess the reliability of these claims. Acting on unreliable health claims or failing to act on reliable advice can lead to waste of resources and unnecessary suffering. There is a global focus on teaching critical thinking, including in the new Kenyan curriculum, however, critical thinking about health is not taught in Kenyan schools. The study planned for in this protocol is an evaluation of the effects of the Informed Health Choices secondary school intervention on the ability of lower secondary school students in Kenya to think critically about health information and choices. The intervention consists of providing teachers with digital teaching resources and training them to deliver the intervention to students. The intervention covers 10 lessons that address nine key concepts. Methods: This study is a cluster-randomized trial. We will stratify lower secondary schools by ownership and geographical location, and randomly select 80 of them. We will randomly allocate the schools to either the intervention or control group. The intervention schools will teach the 10 lessons in one academic term alongside the Kenya national secondary school curriculum. The control schools will continue teaching the national secondary school curriculum. The primary outcome measure will be a test with multiple-choice questions from the Claim Evaluations Tools item bank. The test will include two items for each of the nine concepts covered by the teaching resources. The primary outcome will be the proportion of students attaining a predetermined passing score. Trial registration: Pan African Clinical Trial Registry, trial identifier: PACTR202204883917313. Registered on 05/04/2022.

Background To make well-informed choices, people must possess skills to assess the trustworthiness of health-related claims. It is important that young people learn to assess the reliability of claims to inform decisions, both when making their own choices and as citizens participating in a democracy. This trial aims to evaluate the effect of the Informed Health Choices (IHC) teaching resources on secondary school students’ ability to assess health-related claims and make informed choices. Methods This will be a two-arm cluster-randomised trial. We will randomise 80 lower secondary schools to evaluate the IHC secondary school digital teaching resources. The resources for teachers include 10 lessons to be delivered in a single school term, using lesson plans developed for classrooms equipped with only a blackboard or with a projector. Teachers in the intervention arm will be invited to a three-day teacher training workshop. Teachers in the control schools will continue teaching the national curriculum. Uganda’s National Curriculum Development Centre introduced a new competence-based curriculum in 2020. This curriculum has critical thinking as one of seven generic skills to be taught across all subjects. The curriculum does not explicitly include critical thinking about health. The IHC lessons address nine prioritised key concepts. We will use multiple choice questions – two for each key concept - to evaluate the student’s ability to assess claims and make informed choices. We will measure the proportion of students with a passing score at the end of the school term, and again after one year to assess retention of what was learned. Expected results Based on previous work done in Ugandan primary schools, we anticipate that the use of the teaching resources will lead to a large improvement in the lower secondary school students’ ability to assess claims and make informed health choices.

Additional file 1. Interview guides.

Additional file 3. ICT observation checklist.

Additional file 5. COREQ checklist.

This work was implemented under four main objectives. The first was to develop a mass media intervention to improve the ability of parents of primary school children in Uganda to critically appraise the trustworthiness of claims about the effects of treatments. The second and third were to evaluate the effects of this intervention immediately and a year after implementation, respectively. The last one was to investigate factors that might influence the impact, implementation and scaling up of the intervention, and any other effects., Daniel Semakula defended this thesis for the degree of PhD (Philosophiae Doctor) December 2, 2020 at Institute of Health and Society, University of Oslo.