Sarah Rosenbaum

Background: Vaping among adolescents is an emerging public health concern, driven by increasing uptake and potential health risks. In Norway, e-cigarette use among young teenagers persists despite regulatory measures. Public service announcements (PSAs) are widely used to prevent vaping; however, evidence on how young adolescents perceive and engage with such messages remains limited. This study explores how Norwegian teenagers experience and evaluate anti-vaping PSAs, with particular attention to source of credibility, emotional resonance, and perceived effectiveness. Methods: We conducted a qualitative study using semi-structured interviews with six adolescents aged 13–14 years from three schools in Tromsø, Norway. Participants were recruited through purposive convenience sampling. Each participant viewed four anti-vaping PSAs representing different communication strategies. Data were analyzed using reflexive thematic analysis, informed by the Perceived Effectiveness (PE) framework and the Think-before-you-talk (TENK) ethical framework to guide data interpretation of credibility, emotional engagement, and message reception. Results: Participants identified peer messengers as more credible and relatable than adults or authority figures. PSAs that evoked emotional responses—such as fear, empathy, or discomfort—were perceived as more engaging and memorable than those emphasizing factual information alone. However, participants also expressed a need for clear, concrete explanations of vaping-related health risks. Emotional impact influenced both perceived effectiveness and willingness to share content, with social sharing framed as an important component of message diffusion among peers. Conclusions: The findings suggest that anti-vaping PSAs targeting young adolescents may prioritize emotionally engaging content, incorporate peer-based messaging, and provide clear, accessible health information. Recognizing adolescents as both recipients and active disseminators of health messages may enhance the reach and impact of public health campaigns.

Summary: The journey of guidelines being informed by evidence is less than 50 years old, but it has seen notable advances documented in various publication series and led by key organizations. Although Evidence‐to‐Decision (EtD) frameworks were officially born in 2016, since the early 2000s, groups like GRADE had begun to formulate key determinants of the recommendation‐formulation process. The EtD frameworks started with criteria such as the balance between desirable and undesirable outcomes, values and preferences, and resource use. Nowadays, they are extended to cover criteria like planetary health, human rights, and socio‐cultural acceptability. Experiences with the use of EtD frameworks are generally positive; they are flexible, facilitate multidisciplinary discussions, and bring rigor and transparency to the guidelines. More guidance is required on how to use EtD frameworks, as well as more research to understand how they can lead to better guidelines, and more recently, how artificial intelligence can responsibly help navigate this path.

Young people are increasingly exposed to health misinformation, especially in social media. They often lack the skills necessary to think critically about misleading claims they encounter and decisions they make. The Informed Health Choices framework provides principles for critical health literacy. These can be taught using resources shown to have positive impact on student's abilities to think critically about health claims and make informed decisions. We explored the potential for school nurses in Norway to use a tailored set of teaching resources to support young people's resilience to health misinformation harm. We conducted this qualitative context analysis for the purpose of informing resource development. We identified key issues related to school nurses' capability, opportunity, and motivation to teach a set of critical health literacy principles and their needs regarding resource design. We conducted interviews, a focus group discussion, and co-design workshop and applied framework analysis to synthesize findings. School nurses in Norway seem keenly aware of young people's vulnerability to harms posed by misinformation and likely motivated to expand their teaching role to include teaching critical health literacy. However, critical health literacy knowledge varies among school nurses. Teaching opportunities are limited, largely due to many mandated tasks. Therefore, content needs to be clearly aligned with their nurses' existing responsibilities and school curricula, and resources should be designed to support school nurses with limited time and critical health literacy skills, adaptable to emerging topics, be engaging to students, and facilitate school collaboration.

Objectives The aims of this study were (1) to develop and validate the interactive CLAIM Test (iCLAIM Test) to measure children’s ability to assess claims about treatment effects and make informed health choices and (2) to measure this ability in Spanish primary school children using the developed test. Design We followed a multistep process including (1) definition of the test scope, (2) selection of the questions, (3) translation process, (4) design and development of the online test, (5) external review with experts, (6) user-test with children and (7) cross-sectional validation study with Rasch analysis. Setting Spanish primary schools. Participants Twelve experts (75% women) participated in the review, 11 children (45% girls) participated in the user-test and 480 Spanish primary school children (46.5% girls) from fourth to sixth grades (9–12 years old) participated in the cross-sectional validation study. Results The iCLAIM Test is an online, interactive and user-friendly test in Spanish that measures children’s ability to understand and apply key concepts of the informed health choices (IHC) Project when assessing claims about treatment effects and making IHCs. The test includes 30 questions: six demographic questions and 24 questions from the Claim Evaluation Tools item bank. Less than 40% of the students who participated in the cross-sectional validation study showed basic knowledge of the IHC Key Concepts and how to apply them, and less than 4% showed a clear knowledge. The test showed a good fit to the Rasch model and was acceptable to the target audience. Conclusions The iCLAIM Test is the first instrument validated for measuring children’s ability to assess treatment claims in Spain. In the future, we can tailor IHC education interventions and improve critical thinking skills about the health of Spanish children.

Background People need critical thinking skills to make well-informed health choices and avoid waste and unnecessary suffering. However, educational interventions can have adverse effects, which is often overlooked. We created a framework of potential harms of interventions to improve critical thinking about health choices. The objective was to identify potential effects and articulate potential mechanisms. We intended to use the framework to inform the development and evaluation of an intervention in Kenya, Rwanda, and Uganda. Methods We created an initial framework drawing on two earlier frameworks. We surveyed external experts using Likert-scale and open-ended items, including researchers, educators, and others, in a variety of relevant fields. We emailed the survey to an international advisory network, and all other experts recommended by respondents. We analyzed the quantitative data using descriptive statistics. We conducted a thematic analysis of the qualitative data. We revised the framework based on those results. To identify any effects missing from the revised framework, we individually interviewed a convenience sample of one teacher from each of Kenya, Rwanda, and Uganda. Results We received responses from 38 of 70 external experts (54%). The quantitative survey data suggested respondents agreed with the initial framework overall. However, the qualitative data led to substantial revisions. The revised framework consists of categories of adverse outcomes; outcomes within each category; sub-outcomes; individuals, groups, and populations that might experience each adverse outcome; beneficial outcomes corresponding with adverse outcomes; and potential mechanisms of adverse effects. There are six categories: decision-making harms, psychological harms, equity harms, group and social harms, waste, and other harms. In the interviews with teachers, we did not identify any effects missing from the revised framework. Conclusions As far as we know, the framework is the first tool of its kind for education research. It can be improved upon and adapted.

Objectives To explore participants’ experiences of potential adverse effects of the Informed Health Choices secondary school intervention across three trial sites and to revise a framework of potential adverse effects of interventions to improve critical thinking about health choices. Design This was a qualitative study. We extracted and analysed relevant data from separate process evaluations in each country. Data came from surveying teachers, observing lessons and group and individual interviews with students, teachers and other stakeholders. We modified and applied framework analysis, including five stages: (1) development of an initial framework of potential adverse effects, (2) familiarisation with the data, (3) indexing, (4) abstraction and synthesis and (5) revising the framework. We applied reflexive strategies individually and as a team. Setting Lower secondary school in five randomly sampled subcounties of Kisumu County in Kenya, districts representing all five provinces in Rwanda, and six districts in the central region of Uganda, between 2022 and 2024. Participants Students and teachers in the intervention arms of the trials, parents of students in the intervention arms and administrators at intervention schools, as well as curriculum developers and policy-makers. Intervention The intervention involved providing teachers with a 2–3-day training workshop, and digital classroom resources, including lesson plans for 10 lessons to be delivered over the course of one semester. Results We generated findings about potential increases in adverse misunderstandings, anxiety related to transfer of learning, adversely experienced cognitive dissonance, work or schoolwork-related stress, inequity, conflicts and waste. The revised framework includes the same categories of potential adverse effects as our initial framework: decision-making harms, psychological harms, equity harms, group and social harms, waste and other harms. We revised other elements of the framework, including definitions of the categories and its structure. Conclusions This study provides insight into the potential adverse effects of interventions to improve critical thinking about health choices. The findings complement those of the trials and country-level process evaluations.

Background We conducted an overview of systematic reviews about the effects of teaching strategies that can be used to teach primary and secondary school students to think critically. Our objective was to inform decisions about what teaching strategies to use in resources that we developed to teach critical thinking about health in secondary schools. Methods We mapped characteristics of systematic reviews of teaching strategies and summarised findings from the most relevant reviews to teaching students to think critically about health. We included reviews that assessed the effects of teaching strategies that could potentially be used in primary or secondary schools to teach students to think critically, had a Methods section with explicit selection criteria, reported at least one outcome measure of the ability to undertake one of four basic types of cognitive tasks (memory, procedural, comprehension, or opinion), and were published after 1999. Results We included 326 systematic reviews. The reviews evaluated a wide range of teaching strategies for a variety of purposes. Important limitations of the reviews included not considering adverse effects (99% of the reviews), not assessing the risk of bias for included studies (93% of the reviews), and not assessing the credibility of subgroup effects (100% of the reviews). We summarised the findings for 37 teaching strategies that we considered most relevant. The certainty of the evidence of the effects varied from very low to moderate. We used 12 of the strategies in resources that we developed to teach secondary students to think critically about health. Conclusions A tremendous amount of work has gone into evaluating the effects of a wide range of teaching strategies. The results of this research can inform decisions about how to teach critical thinking and future research. However, well-designed, up-to-date systematic reviews are still needed for many teaching strategies.

Background: Well-designed public health messages can help people make informed choices, while poorly designed messages or persuasive messages can confuse, lead to poorly informed decisions, and diminish trust in health authorities and research. Communicating uncertainties to the public about the results of health research is challenging, necessitating research on effective ways to disseminate this important aspect of randomized trials. Objective: This study aimed to evaluate people’s understanding of overall and statistical uncertainty when presented with alternative ways of expressing randomized trial results. Methods: Two parallel, web-based, individually randomized trials (3×2 factorial designs) were conducted in the United States and Norway. Participants were randomized to 1 of 6 versions of a text (summary) communicating results from a study examining the effects of wearing glasses to prevent COVID-19 infection. The summaries varied in how overall uncertainty (“Grading of Recommendations Assessment, Development and Evaluation [GRADE] language,” “plain language,” or “no explicit language”) and statistical uncertainty (whether a margin of error was shown or not) were presented. Participants completed a web-based questionnaire exploring 4 coprimary outcomes: 3 to measure understanding of overall uncertainty (benefits, harms, and sufficiency of evidence), and one to measure statistical uncertainty. Participants were adults who do not wear glasses recruited from web-based research panels in the United States and Norway. Results of the trials were analyzed separately and combined in a meta-analysis. Results: In the US and Norwegian trials, 730 and 497 individuals were randomized, respectively; data for 543 (74.4%) and 452 (90.9%) were analyzed. More participants had a correct understanding of uncertainty when presented with plain language (United States: 37/99, 37% and Norway: 40/76, 53%) than no explicit language (United States: 18/86, 21% and Norway: 34/80, 42%). Similar positive effect was seen for the GRADE language in the United States (26/79, 33%) but not in Norway (30/71, 42%). There were only small differences between groups for understanding the uncertainty of harms. Plain language improved correct understanding of evidence sufficiency (odds ratio 2.05, 95% CI 1.17-3.57), compared to no explicit language. The effect of GRADE language was inconclusive (odds ratio 1.34, 95% CI 0.79-2.28). The understanding of statistical uncertainty was improved when the participants were shown the margin of error compared to not being shown: Norway: 16/75, 21% to 24/71, 34% vs 1/71, 1% to 2/76, 3% and the United States: 21/101, 21% to 32/90, 36% vs 0/86, 0% to 3/79, 4%). Conclusions: Plain language, but not GRADE language, was better than no explicit language in helping people understand overall uncertainty of benefits and harms. Reporting margin of error improved understanding of statistical uncertainty around the effect of wearing glasses, but only for a minority of participants. Trial Registration: ClinicalTrials.gov NCT05642754; https://tinyurl.com/4mhjsm7s

Background We conducted an overview of systematic reviews about the effects of teaching strategies that can be used to teach primary and secondary school students to think critically. Our objective was to inform decisions about what teaching strategies to use in resources that we developed to teach critical thinking about health in secondary schools. Methods We mapped characteristics of systematic reviews of teaching strategies and summarised findings from the most relevant reviews to teaching students to think critically about health. We included reviews that assessed the effects of teaching strategies that could potentially be used in primary or secondary schools to teach students to think critically, had a Methods section with explicit selection criteria, reported at least one outcome measure of the ability to undertake one of four basic types of cognitive tasks (memory, procedural, comprehension, or opinion), and were published after 1999. Results We included 326 systematic reviews. The reviews evaluated a wide range of teaching strategies for a variety of purposes. Important limitations of the reviews included not considering adverse effects (99% of the reviews), not assessing the risk of bias for included studies (93% of the reviews), and not assessing the credibility of subgroup effects (100% of the reviews). We summarised the findings for 37 teaching strategies that we considered most relevant. The certainty of the evidence of the effects varied from very low to moderate. We used 12 of the strategies in resources that we developed to teach secondary students to think critically about health. Conclusions A tremendous amount of work has gone into evaluating the effects of a wide range of teaching strategies. The results of this research can inform decisions about how to teach critical thinking and future research. However, well-designed, up-to-date systematic reviews are still needed for many teaching strategies.

Background People need critical thinking skills to make well-informed health choices and avoid waste and unnecessary suffering. However, educational interventions can have adverse effects, which is often overlooked. We created a framework of potential harms of interventions to improve critical thinking about health choices. The objective was to identify potential effects and articulate potential mechanisms. We intended to use the framework to inform the development and evaluation of an intervention in Kenya, Rwanda, and Uganda. Methods We created an initial framework drawing on two earlier frameworks. We surveyed external experts using Likert-scale and open-ended items, including researchers, educators, and others, in a variety of relevant fields. We emailed the survey to an international advisory network, and all other experts recommended by respondents. We analyzed the quantitative data using descriptive statistics. We conducted a thematic analysis of the qualitative data. We revised the framework based on those results. To identify any effects missing from the revised framework, we individually interviewed a convenience sample of one teacher from each of Kenya, Rwanda, and Uganda. Results We received responses from 38 of 70 external experts (54%). The quantitative survey data suggested respondents agreed with the initial framework overall. However, the qualitative data led to substantial revisions. The revised framework consists of categories of adverse outcomes; outcomes within each category; sub-outcomes; individuals, groups, and populations that might experience each adverse outcome; beneficial outcomes corresponding with adverse outcomes; and potential mechanisms of adverse effects. There are six categories: decision-making harms, psychological harms, equity harms, group and social harms, waste, and other harms. In the interviews with teachers, we did not identify any effects missing from the revised framework. Conclusions As far as we know, the framework is the first tool of its kind for education research. It can be improved upon and adapted.