Key concepts for informed health choices: Where’s the evidence?

Introduction

At the end of the last century, at least 28 frameworks were published describing the need for competencies and curriculum changes for primary and secondary schools in the 21^st century.¹ Since then, many countries have moved or are moving from knowledge-based to competence- or skill-based primary and secondary school curricula.² Critical thinking is one of the most often included competences.^1–3

Critical thinking is not a new idea. It dates at least to Socrates over 2,400 years ago, and the need to teach critical thinking in school has been argued for over 100 years.^4,5 There are many different definitions of critical thinking,⁵ and debate about how it should be taught.⁶ However, generally, the focus is on dispositions and competences that help people to decide what to believe or do.

A major new challenge to deciding what to believe or do is increased access to information online and in social media, and the need to evaluate that information, much of which is misinformation.⁴ A huge amount of health information can be found online, in addition to information that is disseminated through other channels of communication. This problem has been exacerbated by the COVID-19 pandemic, which has been accompanied by an ’infodemic’ – an overload of information including false or misleading information.⁷

In the context of health, the skills needed to decide what to believe or do are sometimes referred to as critical health literacy.^8,9 Although both critical thinking and health are widely included in primary and secondary school curricula, critical thinking about health or critical health literacy may not be,^10–13 and many people find it difficult to make decisions about what to believe or do regarding ’treatments’ or ’health actions’ (things that they can do to care for their health or the health of others).¹⁴

Being able to understand and apply some basic principles or concepts is essential for using reliable information appropriately and avoiding being misled by unreliable information. This includes concepts about claims, comparisons (research evidence from treatment comparisons), and choices (Table 1). As noted by Dewey,¹⁵ “it would be impossible to overestimate the educational importance of arriving at conceptions: that is, of meanings that are general because applicable in a great variety of different instances in spite of their difference; that are constant, uniform, or self-identical in what they refer to, and that are standardized, known points of reference by which to get our bearings when we are plunged into the strange and unknown.”¹⁶

The Informed Health Choices (IHC) Network has developed a framework that includes 49 key concepts as a starting point for deciding what to teach.^17,18 The framework provides a basis for developing learning and teaching resources and evaluating learners’ ability to think critically about health actions. Most of the concepts in the framework are relevant to other types of actions or interventions, including agricultural, educational, and environmental interventions.¹⁹

The concepts serve as the basis for developing learning resources to help people understand and apply the concepts when claims about the effects of health actions are made, and when they make health choices.²⁰ They are also the basis for an item bank of multiple-choice questions (the Claim Evaluation Tools item bank) that can be used for assessing people’s ability to apply the IHC Key Concepts.²

The concepts are principles for recognising when a claim about the effects of health actions has an untrustworthy basis, recognising when evidence from comparisons of health actions is trustworthy and when it is not, and making well-informed health choices. They can help anyone, not just researchers, to think critically about whether to believe a claim and what to do. The concepts are intended for people using research, not for doing research.

The concepts and the basis for the concepts tend to focus on ways in which claims and comparisons (evidence) can be misleading, and choices can be misinformed. This is not because we underestimate the tremendous gains that have been made in health care based on appropriate use of research. Our aim is to promote healthy scepticism, not excessive scepticism, and to help people decide what to believe and what to do. How sure we can be about the effects of health actions varies, as does how sure we can be about the balance between the advantages and disadvantages of health actions. When teaching, learning, or using these concepts, it is important to bear this in mind.

Although most people prefer to make medical decisions together with a health professional, some people prefer to delegate decisions to a health professional.²¹ Unfortunately, health professionals’ perceptions of their patients’ desire to be involved in decisions are often inaccurate.²² They may be more likely to underestimate the extent to which patients prefer to be involved in decisions. Regardless of who decides, decisions should be consistent with a patient’s values. Decision aids can help patients to clarify their values and may help them to make choices that are more consistent with their values compared to choices made without decision aids.²³ There is some evidence that patients choose more conservative approaches when they become better informed.²⁴

Even people who prefer to delegate medical decisions to a health professional are confronted with an over-abundance of information about things they can do for their health, much of which is unreliable.^7,25–30 Although much of this information can simply be ignored, to avoid being misled by claims with an untrustworthy basis, people need to be able to recognise claims about the effects of health actions, question the basis for those claims, and recognise when a claim is relevant and important, and warrants reflection.

People have the right to participate collectively as well as individually in the planning and implementation of their health care.³¹ In addition to being a democratic right, public participation in deliberative and decision-making processes has the potential to improve the quality of the judgements and decisions that are made, build trust, improve adherence, and help to ensure transparency and accountability.³² However, the extent to which potential benefits of public participation are achieved (and potential harms are avoided) depends, among other things, on the ability of citizens to think critically about collective decisions as well as personal choices.

People often disagree about the effects of health actions, including experts. Who makes a claim, how likable they are, or how much experience and expertise they have do not provide a reliable basis for assessing how reliable their claim is. This does not mean that conflicting opinions should be given equal weight – or that the existence of conflicting opinions means that no conclusion can be reached. It also does not mean that all sources of information are equally reliable. How much weight to give an opinion should be based on the strength of the evidence supporting it. How much trust to place in a source of information about health actions should be based on whether it provides information about the effects of health actions based on systematic reviews.²⁵

The objective of this paper is to describe the development of the IHC Key Concepts from 2019 to 2022 and to summarise the development of the framework over the past decade, its basis, and how it has been used.

Methods

The following invitation was included in the 2018 and 2019 versions: Please send any comments or suggestions to: contact@informedhealthchoices.org. In addition, we asked people to provide feedback at workshops where we presented the Key Concepts. Seven individuals provided feedback on the 2018 version and four provided feedback on the 2019 version. The suggestions came from members of the IHC Network and other researchers.

For the 2019 version, we reviewed and responded to feedback on the 2018 version. For the current, 2022 version, in addition to reviewing and responding to feedback on the 2019 version,^17,63 we reviewed the evidence base for each of the concepts. For each concept, we have provided one or more examples to illustrate the explanation, and the basis for the concept. The examples, for the most part, were taken from relevant methodological research. Due to the nature of the research, most of the examples are medical. We selected examples that clearly illustrate the concept and that can easily be understood with little explanation by a wide audience without a medical background.

Whenever possible, we have referenced systematic reviews that provide a basis for a concept. We started with reviews with which we were familiar, including some that we had co-authored. Additional systematic reviews were identified by searching and screening the following sources:

We did not restrict searches or exclude reviews based on language or the date of publication.

In addition, we searched Epistemonikos, PubMed, and Google Scholar for systematic reviews that support the explanation for each concept using key terms or phrases from the explanation or related terms. These searches were conducted and screened by one of the authors (ADO). The searches varied for each concept. For example, when our initial searches did not find a recent systematic review, we used citation searches in Google Scholar to search for a recent review or more recent research. We did not record the searches that were conducted for each concept. The purpose of these searches was to summarise the evidence supporting each concept, in addition to the logical explanations.

We included systematic reviews of methodological studies and overviews of reviews, such as Cochrane methodology reviews, methodological studies based on a systematic review of research (“meta-epidemiological” studies), and systematic reviews of treatment effects. We categorised as systematic reviews any review of research that included a methods section that described the search strategy for finding studies and selection criteria.

Results

The 2019 version of the framework included 49 concepts.⁶³ We added five new concepts in response to feedback:

We organised the concepts in the same way as in the 2018 version of the framework, under three higher-level concepts in each of the three main groups (Table 2).

In response to feedback,⁶⁹ we also edited the list of concepts in the 2019 version of the framework to make their descriptions more consistent, and we edited some of the explanations. We also clarified our goal (Table 3), increased the list of competences needed to achieve that goal from 10 to 20, and increased the list of dispositions from 10 to 15.

We received little feedback on the 2019 version (10 suggestions) and decided that revisions were not needed in 2020 and 2021.⁶⁹ The 2022 version¹⁸ includes the same concepts as the 2019 version. We now provide examples in the explanation for each concept and the basis for each concept, as well as the implications. The 2022 version includes over 600 references, over half of which are to systematic reviews.

We incorporated eight suggestions in the explanations for concepts in this version. For example, a suggestion to include the concept that harms can be irreversible was incorporated in the explanation for the concept “do not assume that treatments are safe” by adding the following to the explanation for that concept: “The harm that is caused may be minor, but treatments also sometimes cause serious, irreversible harms, including death.”⁶⁹ We also reorganised the concepts into four subgroups (high-level concepts) within each of the first two main groups (claims and comparisons) and into two subgroups within the third main group (choices) (Table 1). We did this to make the organisation of the concepts more logical and the long list of concepts in some of the subgroups less overwhelming. The 10 high-level concepts also make it easier to get the gist of the concepts and makes the list for some of the subgroups less overwhelming and easier to remember. Table 4 is an overview of the 49 concepts in the three main groups and 10 subgroups.

Discussion

We made many changes to the IHC Key Concepts after they were first published in 2015.³⁵ The original version included 32 concepts in six groups. There are now 49 concepts in three main groups and 10 subgroups. In addition, there are 20 competences and 15 dispositions. There have been few suggestions for changes to the 2019 version and we have made only minor changes to the explanations for some of the concepts. We therefore have decided that the 2022 version will be the last revision made by us.¹⁸ This does not mean that this list of concepts cannot be further improved, but we will leave any further development of the IHC Key Concepts to others.

Although we have attempted to use plain language in describing the key concepts and their basis, the list of key concepts is not intended to be a learning resource for people with no relevant research background. It is a framework, or starting point, for identifying and developing learning resources and evaluation tools. It has proven to be useful for this.^{43,48,57,71–73}

We have organised the concepts logically. Although it may sometimes make sense to organise learning resources using the same logic, the logic that is used does not reflect the difficulty of the concepts or the order in which the concepts should be learned. Moreover, the full list of concepts can be overwhelming, and it is likely to be necessary to prioritise which concepts to include in learning resources and evaluation tools.⁵¹ For example, some concepts are too difficult for primary school children to understand and use, and it may not be possible to incorporate all the concepts in secondary and primary school curricula.^41,51

Ideally, the concepts should be taught and learned using a spiral curriculum, that maps out what students should learn, where they should begin, and how they should progress.^74–76 However, there are many other demands on what to include in primary and secondary school (and other) curricula.⁷⁷ This is reflected in the findings of a process evaluation of the IHC primary school intervention in Uganda.⁴⁴ The intervention was shown to have a large effect on primary school children’s ability to think critically about health claims,⁴³ which was sustained after one year.⁴⁵ Teachers who used the primary school intervention in the trial thought the IHC Key Concepts were important. They were motivated to teach the concepts, and the children were enthusiastic about the lessons. Nonetheless, use of the resources has not been scaled up. A key barrier to scaling up use of the intervention was the need to incorporate the lessons in the national curriculum. The IHC lessons were viewed as an addition to what was already a packed primary school curriculum.

Conclusions

The IHC Key Concepts framework is central to critical thinking and evidence-based practice, both of which have broader scopes than this framework.³⁷ An important weakness of frameworks with a broader focus is that they usually do not provide an adequate basis (i.e., necessary concepts) for thinking critically about claims about effects and decisions about what to do. The IHC Key Concepts are applicable to a great variety of claims about the effects of interventions, not just health interventions,¹⁹ and they are essential points of reference for deciding which claims to believe and what to do.

There is a substantial body of evidence supporting the 49 concepts, as well as logic. Although it is possible to further improve this framework, we will leave any further development of the IHC Key Concepts to others. More importantly, there is a need to incorporate the key concepts into school curricula and to develop, evaluate, and scale up the use of effective educational interventions.

Data availability