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

Ronald Ssenyonga; Simon Lewin; Esther Nakyejwe; Faith Chelagat; Michael Mugisha; Matt Oxman; Allen Nsangi; Daniel Semakula; Sarah E. Rosenbaum; Jenny Moberg; Andrew D. Oxman; Heather Munthe-Kaas; Christine Holst; Margaret Kaseje; Laetitia Nyirazinyoye; Nelson Sewankambo

doi:10.9745/GHSP-D-23-00484

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FIGURE
Teacher’s Feelings of Being Prepared and Confident to Teach the Informed Health Choices Lessons, Uganda

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TABLE 1.

Characteristics of Participants in Informed Health Choices Intervention Process Evaluation, Uganda

	Data Collection Method (No.)	Total, No.	Sex, No. females	Age, Years, Median (IQR)	No. From Public Schools
Students	FGD (10)	103	66	16 (15–17)	49
Teachers	KII (10)	10	6	32 (29–35)	5
Head teachers	KII (4)	4	2	49 (42–58)	2
Parent/guardian	FGD (1), KII (3)	11	7	43 (33–51)	9
Policymakers (curriculum developers, examinations director, national and district education officers)	KII (9)	9	1		N/A

Abbreviations: FGD, focus group discussion; KII, key informant interview; IQR, interquartile range; N/A, not applicable.

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TABLE 2.

Logic Model Linking Information Health Choices Intervention Process Evaluation Findings to Randomized Control Trial Findings, Uganda

Intervention Characteristics	Effect Modifiers	Short-Term Impacts	Medium-Term Impacts
Accessibility and adaptability of lessons: Teachers found the IHC resources easy to access and adaptable (similar teaching strategies to those in the new curriculum, lesson structure easy to follow). (high confidence)	Teacher training: Teacher training improved understanding, motivation, and confidence among teachers to deliver the IHC lessons. (high confidence)	Understanding of key concepts: Most students were able to understand and apply the key concepts. Several students gave illustrations of how they applied them to think critically about health. This was mainly for concepts about claims and less for concepts about research. (high confidence)	This will be explored in the 1-year follow-up study.
Value of the lessons: All the students, teachers, head teachers, and policy makers interviewed valued the lessons and recognized their importance. (high confidence)	Student motivation: Most students found the lessons enjoyable, understandable (simple English, familiar examples) and related to the health issues that the lessons addressed. (high confidence)	Interest in STEM subjects and health: Several students expressed increased interest in STEM subjects and the health profession. Teachers also noticed this interest among some of their students. (moderate confidence)
Lesson delivery: Nearly all planned IHC lessons were taught. Recommended teaching strategies and anticipated time for preparation (30 minutes) were used. However, few lessons were delivered as scheduled (once a week, during normal class time and within 40 minutes). Most lessons were taught in students’ private reading time, and all took longer than 40 minutes to deliver. (high confidence)	National curriculum and examinations: Because the IHC lessons were not in the curriculum and not nationally examined, teachers’ preparation for lessons, students’ attendance, and head teachers’ prioritization of the lessons were limited. (high confidence)	Perceived benefit to students: Students felt they were getting skills they would use now and even after school. (high confidence)
Resource credibility: Credibility of the institution that developed the resources may have impacted effective delivery. Some student and teachers mentioned that they viewed material from Makerere University as important to learn. Other teachers mentioned the presence of curriculum developers at the teacher training workshop improved their trust of the resources. (high confidence)	The content was not assessed in the national examinations, yet the examinations remain a key motivator for use of additional learning resources in schools. Head teachers must decide what can be taught that contributes to the students’ scores. Teachers are often acknowledged based on their students’ performance on national examinations. Students take additional learning materials that are not examinable less seriously. (high confidence)	Perceived benefit to teachers: Teachers reported to have used the taught IHC concepts to access health information and make choices in their own lives. (high confidence)
Lack of time: Finding time to teach IHC lessons impeded delivery as intended and may also affect scale-up of the intervention. (high confidence)
Need for printed materials: Some policymakers and teachers expressed the need to have printed materials alongside the digital materials, particularly if the intervention was to be scaled up. For some, this was due to ICT challenges and how printed materials are used in the new curriculum. For others, this was to give students easy access to the material. (moderate confidence)

Abbreviations: ICT, information communication technology; IHC, Informed Health Choices; STEM, science, technology, engineering, and math.

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TABLE 3.

Informed Health Choices Lessons Taught, Time Spent, and Student’s Attendance, Uganda

Lesson	Schools, No.	Time Spent, Minutes, Mean (SD)		Students Attended IHC Lessons, Mean (SD)
Lesson	Schools, No.	Preparation	Teaching	Students Attended IHC Lessons, Mean (SD)
1: Health actions	40	31 (12)	67 (22)	71 (21)
2: Health claims	40	32 (8)	69 (14)	73 (23)
3: Unreliable claims	40	34 (11)	74 (12)	78 (20)
4: Reliable claims	40	34 (16)	71 (14)	74 (25)
5: Using what we learned	40	29 (11)	66 (16)	74 (26)
6: Randomly created groups	39	36 (11)	72 (17)	68 (23)
7: Large enough groups	39	32 (14)	69 (17)	68 (26)
8: Personal choices	39	30 (15)	67 (13)	73 (23)
9: Community choices	39	32 (12)	70 (14)	76 (35)
10: Using what we learned (2)	39	30 (14)	69 (18)	73 (27)
Overall		32 (12)	69 (16)	73 (25)

Abbreviation: SD, standard deviation.
Source of data: Teachers lesson evaluation forms.

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TABLE 4.

Observations of Teachers’ Delivery of Informed Health Choices Lessons, Uganda

Did teachers facilitate lesson delivery as intended?	Lesson Section and Corresponding Desired Delivery, No. (%) (N=67)
	Introduction		Activity	Wrap-up
	Teacher reviewed key messages from previous lesson	Teacher explained answers from review questions	Most students had opportunity to participate in activities	Teacher repeated key messages and asked students to take notes
Yes	48 (71.6)	66 (98.5)	0 (0.0)	62 (92.5)
Yes, for the most part	17 (26.4)	0 (0.0)	58 (86.6)	0 (0.0)
Yes, to some degree	2 (3.0)	0 (0.0)	0 (0.0)	0 (0.0)
No	0 (0.0)	1 (1.5)	9 (13.4)	5 (7.5)