Cite as: Oxman AD, Chalmers I, Dahlgren A (2022). Key Concepts for Informed Health Choices: 1.1 Assumptions that treatments are safe or effective can be misleading. James Lind Library (www.jameslindlibrary.org).

© Andy Oxman, Centre for Epidemic Interventions Research, Norwegian Institute of Public Health, Norway. Email: oxman@online.no

In the previous 10 essays in this series, we explained key concepts that can help you avoid being misled by claims about treatments that have an untrustworthy basis, consider whether evidence from treatment comparisons is trustworthy, and make well informed treatment choices (Table 1). These concepts are central to critical thinking and evidence-based practice [Albarqouni 2018, Chalmers 2018, Sharples 2017], both of which have broader scopes than the key concepts explained in these essays [Oxman 2020]. There are other important concepts, for example, that can help you formulate answerable questions, find answers to those questions, appraise, interpret, and apply evidence about diagnostic accuracy, prognosis, and people’s experiences, and improve the quality of care.

Why focus on these concepts?

There are several reasons for drawing attention to the specific concepts explained in these essays. First, frameworks with a broader scope than the “Informed Health Choices (IHC) Key Concepts do not provide an adequate basis (i.e., necessary concepts) for thinking critically about claims about effects and decisions about what to do. Second, the IHC Key Concepts are applicable to a great variety of claims about the effects of interventions, not just health interventions [Aronson 2019], and they are essential points of reference for deciding which claims to believe and what to do. Third, many people do not understand and apply the IHC Key Concepts [Dahlgren 2021]. Fourth, there is a substantial body of evidence supporting these concepts [Oxman 2022a].

Some of the IHC Key Concepts are already being taught to health professionals and the public. However, there are still major gaps in the extent to which these concepts are understood and used. For example, a survey in the UK found that only about one third of the public trust evidence from medical research, while about two thirds trust the experiences of friends and family [Academy of Medical Sciences 2017]. A survey of Norwegian adults found that less than 20% of respondents understood that lung cancer can be associated with drinking alcohol but not necessarily caused by it [Oxman 2017]. A more recent survey of Norwegian adults found that less than 20% of Norwegian adults understood and applied six IHC Key Concepts [Dahlgren 2021], including:

• Do not assume that a plausible explanation is sufficient.
• Do not assume that a single study is sufficient.
• Consider whether the people being compared were similar.
• Be cautious of p-values.

There is also evidence that many journalists do not understand and use the IHC Key Concepts and, as a result, frequently report untrustworthy claims about treatment effects and fail to adequately report information about treatments [Oxman 2022b]. There is also a tremendous amount of misinformation about treatment effects in social media, as well as trustworthy information [Pian 2021]. Believing and acting on untrustworthy claims and not believing and acting on trustworthy claims can lead to unnecessary suffering and wasted resources [Berwick 2012, Brownlee 2017, Ernst 2000, Frass 2012, Glasziou 2017, Jones 2003, Pierce 2016, Shrank 2019, Starr 2015].

Table 1. Key concepts for informed health choices [Oxman 2022a]

Why should the IHC Key Concepts be taught to children?

Many of the IHC Key Concepts can be taught to children as young as 10 years-old [Nsangi 2017], and perhaps even younger [Sandoval 2014]. A randomized trial of an educational intervention to teach 12 IHC Key Concepts to primary school children (age 10-12) in Uganda found that the intervention led to a large improvement in the ability of children to assess claims about treatment effects [Nsangi 2017], and that the children retained what they learned for at least one year [Nsangi 2020b]. A priority setting process with teachers and curriculum developers in East Africa suggests that at least 29 of the IHC Key Concepts (more than half) should probably be included in lower secondary school education [Agaba 2022].

Both critical thinking skills and health are included in many primary and secondary school curricula [Care 2016, Erstad 2018, Larson 2018, Voogt 2012] . However, critical thinking about health may not be included [Chesire 2022b, Lund 2018, Mugisha 2021, Ssenyonga 2022b]. Although the IHC Key Concepts are relevant to learning goals such as understanding scientific enquiry [Chalmers 2018], they are not being taught in countries where this has been examined [Chesire 2022b, Cusack 2017, Lund 2018, Mugisha 2021, Nordheim 2016, Nordheim 2019, Ssenyonga 2022b].

There are several reasons why IHC Key Concepts should be taught in primary and secondary schools. First, children are capable of learning at least some of the concepts [Nsangi 2017], and to use the concepts in their daily lives [Nsangi 2019, Nsangi 2020b]. Second, by targeting school children, it is possible to reach a large segment of the population, before many leave the education system and become difficult to reach. School children are the citizens, policymakers, patients, and health professionals of tomorrow. It is important that they are empowered, as individuals and as citizens, to make well-informed decisions. Third, teaching children while they are in school can capitalise on the time they have available for learning. Adults, on the other hand, have increasing demands on their time and less time to learn. It becomes increasingly difficult to reach them and to teach them. Young people who have been explicitly taught critical thinking make better judgements than those who have not [Abrami 2015]. Teaching the IHC Key Concepts in primary and secondary school can provide an important foundation for future learning. In addition, beliefs, attitudes, and behaviours that adults developed as children can be resistant to change and impede their ability to learn.

The IHC Key Concepts are relevant to many other types of interventions, including agricultural, educational, environmental, policing, social welfare, and veterinary interventions [Aronson 2019]. Teaching children to think critically about the effects of health interventions is transferable to critical thinking about the effects of other types of interventions. Focusing on health makes learning the concepts directly relevant, since health is important to everyone. As one girl in a school that piloted the IHC primary school intervention noted: this is about “things we might actually use instead of things we might use when we are all grown up and by then we’ll forget” [Nsangi 2017].

There are, however, also several barriers to teaching children to think critically about health and other types of interventions. Most importantly, there is a need for affordable and effective educational resources and for ensuring that the IHC Key Concepts are integrated in the curriculum and not an add on [Cusack 2018, Nsangi 2019, Nsangi 2017].

The Informed Health Choices (IHC) Network: developing and evaluating educational resources

The IHC Network is an informal collaboration that is working to improve people’s ability to make informed choices about what to believe and do [Informed Health Choices Network], including:

• engaging students, teachers, and other stakeholders in designing and evaluating resources [Nsangi 2020a, Nsangi 2020c, Semakula 2019b],
• undertaking context analyses to inform the design of resources and help ensure that their use can be scaled up if they are effective [Chesire 2022b, Mugisha 2021, Ssenyonga 2022b]
• prioritising which Key Concepts to include in resources [Agaba 2022],
• using human-centred design to ensure that students and teachers experience resources as useful, easy to use, well suited to people like them [Nsangi 2020c, Rosenbaum 2010, Rosenbaum 2019, Semakula 2019b],
• evaluating the effects of using resources in randomized trials [Chesire 2022a, Mugisha 2022b, Nsangi 2017, Nsangi 2020b, Semakula 2017a, Semakula 2020, Ssenyonga 2022a],
• conducting systematic reviews of the effects of educational interventions to improve people’s understanding and use of the Key Concepts and developing a database of resources [Castle 2017, Cusack 2018],
• conducting process evaluations to explore potential adverse and beneficial effects and factors that affect the impact and scaling up use of resources [Mugisha 2022a, Nsangi 2019, Semakula 2019a],
• measuring people’s understanding of Key Concepts and their ability to apply them [Aranza 2021, Austvoll-Dahlgren 2017a, Austvoll-Dahlgren 2019, Austvoll-Dahlgren 2017b, Dahlgren 2021, Dahlgren 2022, Davies 2017, Nsangi 2022, Pérez-Gaxiola 2018, Semakula 2017b, Wang 2019],
• translating and contextualising resources for use in different settings [Alderighi 2020, Glynn 2020, Ikireza 2016, Informed Health Choices Group 2017a, Informed Health Choices Group 2017b, Informed Health Choices Network , Martínez García 2019, Ringle 2020] Semakula, and
• collaborating across fields to promote understanding and use of the concepts beyond health choices [Aronson 2019, Stewart 2022]

Conclusions

There is an enormous amount of misinformation as well as trustworthy information about the effects of treatments (actions intended to improve health) and other types of interventions. Many people are unable to assess the trustworthiness of claims about effects and make well-informed choices. There is a global need for effective resources to enable people to think critically about claims, comparisons, and choices. The IHC Key Concepts provide a starting point and a framework for designing, evaluating, and scaling-up use of effective resources. It is crucial that schoolchildren learn Key Concepts so that they can start to use them in their daily lives, build a foundation for future learning, and are able to make informed choices about what to believe and do as adults.

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