Do studies of interventions to improve laypeople's critical thinking about health choices assess potential harms? A systematic review.

Clinical Snapshot

Key Findings

• P Value: Not applicable for descriptive analysis

• Effect Size: 1 of 35 studies (2.9%) assessed potential adverse effects

• Primary Outcome: Assessment of potential adverse effects in critical thinking intervention studies

• Nnt Or Sensitivity: 97.1% of studies failed to assess potential harms

• Confidence Interval: Not applicable for descriptive systematic review

Clinical Application

Highly feasible to implement harm assessment in future intervention studies with minimal additional cost Relevant to Australian health literacy initiatives, medical education programs, and public health policy development under NHMRC guidelines Researchers designing educational interventions, policymakers implementing critical thinking programs, educators in health literacy

Abstract

OBJECTIVES: To make informed health choices, and avoid waste and unnecessary suffering, people need critical thinking skills. However, like health interventions, educational interventions can have adverse effects. In this systematic review, the objective was to assess the extent to which researchers have included potential adverse effects in studies of interventions intended to improve the critical thinking of laypeople about health choices. DESIGN: This study was a systematic review, in which we updated the search for an earlier systematic review of intended effects of relevant interventions. The earlier review did not address potential adverse effects. We did not update the analysis of intended effects. DATA SOURCES: We searched Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Epistemonikos, Medical Literature Analysis and Retrieval System Online (MEDLINE), Education Resources Information Center (ERIC) and Web of Science up to March 2025. In addition to studies from the original review and updated search, we included any additional studies included in a similar, even earlier review. Our unit of analysis was study report (eg, journal article). ELIGIBILITY CRITERIA: We included all studies from the original review. We applied the same inclusion criteria to the results of the updated search: the study included a comparison, the population was laypeople and the intervention was intended to improve understanding of ≥1 key concept for informed health choices. DATA EXTRACTION AND SYNTHESIS: We extracted data about study design (randomised trial or other), participants (children, adolescents or adults), study setting (countries), main intervention (resources delivered to participants) and comparator (usual/no intervention or other). For the analysis, we extracted verbatim text describing any assessment of a potential adverse effect of the intervention. We conducted a narrative synthesis of the extracted data. RESULTS: We included 35 reports of quantitative studies (including multi-method and mixed-methods studies). Most often, the study was a randomised trial, the setting was a high-income country, the population included adults (including university students) and the intervention was school-based (including university). In one of the 35 reports, authors described assessing a potential adverse effect. CONCLUSION: To our knowledge, this is the first systematic review assessing the extent to which researchers have assessed adverse effects of any category of educational interventions. Our review shows that researchers generally have not assessed potential adverse effects of interventions to improve critical thinking about health choices. Researchers should pay more attention to such effects, while policymakers and educators making decisions about implementing relevant interventions should consider the lack of evidence. The findings of this study suggest a need for research that facilitates assessing potential adverse effects of interventions to improve critical thinking about health choices.

References

1. 1.Oxman, M., Cusack, L., Verdugo-Paiva, F., Ávila, C., Peña, J., Novillo, F., Oxman, A. D., Fretheim, A., Melby-Lervåg, M., & Nordheim, L. (2026). Do studies of interventions to improve laypeople's critical thinking about health choices assess potential harms? A systematic review. BMJ Open, 16(4), e108268. https://doi.org/10.1136/bmjopen-2025-108268