Process Evaluation of Teaching Critical Thinking About Health Using the Informed Health Choices Intervention in Rwanda: A Mixed Methods Study

Michael Mugisha; Andrew D. Oxman; Laetitia Nyirazinyoye; Anne Marie Uwitonze; Clarisse Marie Claudine Simbi; Faith Chesire; Ronald Ssenyonga; Matt Oxman; Allen Nsangi; Daniel Semakula; Margaret Kaseje; Nelson K. Sewankambo; Sarah Rosenbaum; Simon Lewin

doi:10.9745/GHSP-D-23-00483

Key Findings

Few randomized trials have evaluated the effects of educational interventions that teach critical thinking about health. This study assessed the implementation process, impact, and scale-up of the Informed Health Choices secondary school intervention in Rwanda.
The intervention improved students’ ability to recognize claims, assess them, and weigh the benefits and harms of interventions and helped students to use what they learned.
The resources were compatible with the curriculum, but competing priorities and insufficient time affected the implementation and impact of the intervention and would likely affect scaling it up.

Key Implications

Teacher training is essential for effective implementation of the Informed Health Choices secondary school intervention.
Additional time for the lessons and integrating them into the curriculum would likely increase the impact and facilitate scaling up the intervention.

ABSTRACT

Introduction:

We evaluated the Informed Health Choices secondary school intervention in a cluster randomized trial in Rwanda. The intervention was effective in helping students to think critically about health. In parallel to the trial, we conducted a process evaluation to assess factors affecting the implementation, impacts, and scale-up of the intervention.

Methods:

We used a mixed methods approach that included quantitative and qualitative methods. We collected quantitative data from teachers to evaluate the teacher training and each lesson. We conducted focus group discussions with students (n=10) and their parents/guardians (n=5). We conducted lesson observations (n=16) and key informant interviews with teachers (n=10) and school administrators (n=10) from intervention schools and policymakers (n=2). We analyzed the quantitative data using descriptive statistics. We used framework analysis and thematic content analysis to analyze the qualitative data.

Results:

Teachers noted that the teacher training supported their delivery of the intervention and that they made only small adaptations to fit student, teacher, or contextual needs. Students reported obtaining important skills, including recognizing health claims, understanding the need for research, and “thinking twice” before deciding. Participants saw the design of the intervention, students’ and teachers’ motivation, and school and home support as key facilitators for the implementation and impact of the intervention. Implementation barriers identified included the content of the lessons not being included in national examinations, competing priorities, and time constraints. Participants identified several factors that could facilitate intervention scale-up, including the need for the skills taught in the lessons and compatibility of the intervention with the national curriculum.

Conclusion:

We found that it was feasible to implement the intervention in Rwandan secondary schools and that students benefited from the intervention. Scaling up the intervention will likely require addressing the barriers identified in this study.

Received: November 16, 2023.
Accepted: November 5, 2024.
Published: December 20, 2024.

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