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Teaching methods for critical thinking in health education of children up to high school: A scoping review [1]
['Anna Prokop-Dorner', 'Department Of Medical Sociology', 'Chair Of Epidemiology', 'Preventive Medicine', 'Jagiellonian University Medical College', 'Kraków', 'Aleksandra Piłat-Kobla', 'Magdalena Ślusarczyk', 'Institute Of Sociology', 'Jagiellonian University']
Date: 2024-08
A total of 15919 records of 15909 studies were initially identified. After removing duplicates, 15150 studies were screened on the basis of the title and abstract. This yielded 1056 potentially relevant studies, which were screened based on full texts. Of the 1056 studies, 243 (25.5%) were excluded because they did not concern the development of critical thinking. Other studies were excluded because they were only theoretical (n = 174), did not concern the population of interest (n = 171), did not address health literacy (n = 132), did not provide information about the teaching methods used (n = 99), or for other reasons (n = 116). The list of the excluded studies, along with reasons for exclusion, is available on the project website in the OSF Registries [17]. We identified 118 eligible studies, of which 3 were still ongoing [43–45]. Finally, we included 115 completed studies (Fig 1).
The included studies met the eligibility criteria and described the teaching methods used, but most of them (80%) did not examine the effectiveness of these teaching methods but interventions used in the study. Below we present the findings first referring to the quantitative and then to qualitative analysis.
Finally, research conducted in Australia concerned such health topics as psychoactive substance use [ 70 – 72 , 81 ], lifestyle [ 16 , 17 ], as well as public [ 23 , 102 ] and mental health [ 23 ], while an educational intervention conducted in South America covered the topic of SRH [ 20 ].
Most studies conducted in Asia addressed sexual health [ 14 , 56 , 119 , 132 , 136 , 141 ], including AIDS and HIV prevention [ 56 , 116 , 119 , 133 , 136 ]. Mental health was addressed by three studies [ 64 , 112 , 141 ], psychoactive substance use by two [ 74 , 84 ]; and somatic health by one study [ 121 ]. In the last three years, studies have emerged whose educational interventions focused on lifestyle [ 27 , 110 ]. Among African studies reporting on educational interventions, there were six articles that focused on SRH [ 10 , 55 , 62 , 118 , 124 , 132 ], and one intervention that was dedicated to health claims [ 130 ].
Most studies conducted in Europe concerned lifestyle, including both nutrition and/or physical activity interventions [ 7 , 9 , 11 , 22 , 24 , 46 , 91 , 97 , 103 , 106 , 109 , 126 , 134 ], public health [ 8 , 12 , 13 , 29 , 47 , 88 , 101 , 105 , 139 ], and psychoactive substance use [ 7 , 15 , 48 , 51 , 84 , 114 , 122 ]. Four papers concerned somatic health [ 22 , 30 , 97 , 125 ] and five–mental health [ 68 , 97 , 99 , 109 , 113 ]. Only two educational intervention addressed sexual health [ 28 , 115 ].
Educational interventions conducted in North America covered a broad range of topics and addressed psychoactive substance use [ 21 , 26 , 50 , 52 , 53 , 58 , 61 , 65 , 67 , 75 , 80 , 83 , 85 , 92 , 95 , 117 , 140 ], lifestyle (including nutrition, physical activity) [ 57 , 60 , 63 , 77 , 87 , 89 , 96 , 100 , 135 ], sexual and reproductive health (SRH) [ 19 , 49 , 82 , 94 , 98 , 108 , 120 , 127 , 128 ] (including AIDS and HIV prevention [ 21 , 59 , 73 , 86 , 93 ]), public health [ 18 , 31 , 66 , 69 , 78 , 79 , 87 , 90 , 111 ], and somatic health [ 25 , 87 , 123 , 131 , 140 ]. The topic of mental health has only emerged in publications from the last three years [ 100 , 104 , 138 ].
A total of 115 studies were included in this scoping review, including 65 studies reporting quantitative methods [ 46 – 113 ], 25 studies reporting mixed methods [ 114 – 140 ], and 25 studies reporting qualitative methods [ 7 – 32 ] (See S3 Table ). Some educational interventions were described in more than one article. In such cases, the records were merged and assessed as one study [ 16 , 17 , 56 , 70 – 72 , 119 ]. The most common study design was cluster randomized (25 articles, 22%) and quasi-experimental (20 articles, 17%). The dates of article publication covered nearly 40 years. More than a half of the eligible articles were published after 2010 (74 articles, 64%) and only 12 studies were published before 2000 (10%). The included studies were conducted in various cultural contexts, but mostly in the Western societies of North America (52 articles, 45%) and Europe (34 articles, 30%). Only 14 studies were conducted in Asia (12%); 8, in Africa (7%); 5, in Australia (4%); and 2, in South America (2%). In one article, there was no information on the country [ 137 ].
Interventions tested in the included articles were typically taught in class (50%), most often in an interdisciplinary form as part of multiple school subjects, such as health education or sexual health education, math, family life education, social sciences, media literacy, language, philosophy, home economy, science, and, less typically, during a single subject such as health education (23 articles), biology (3 articles), science (3 articles), sexual health education (3 articles), language (2 articles), critical thinking (1 article), social sciences (1 article), math (1 article), home economics (1 article), and physical education (1 article). Almost all of the 115 interventions were described as having “positive results”. However, in all those cases, the evaluation concerned the entire intervention rather than single teaching methods.
Interventions reported in 94 articles (82%) were initiated by external bodies, such as universities, and were tested in several schools in a selected region ( Table 2 ). Nearly half (51) of the studies tested regionally based interventions. In 31 studies, the interventions were tested locally, typically in one or in several schools. The remaining interventions were evaluated in bigger samples, either on a national (16 articles) or international level (5 articles). Nine of the interventions were pilot interventions. Moreover, the studied interventions varied in terms of the level of education. Most of them were tested in high schools/secondary schools (60, 52%); 30, in primary/elementary schools (26%); 24, in middle schools (21%); and only 1 intervention was tested in preschools. Interventions were conducted by schoolteachers, peer educators, or both. Half of the studied interventions were preceded by teachers’ training (57 articles, 50%) and/or peer leaders training (13 articles, 11%). Only every third intervention provided pupils with additional materials, such as booklets [ 22 , 32 , 74 , 77 , 102 , 124 ], handouts [ 49 , 78 , 117 ], audiovisual materials [ 20 , 74 , 90 , 99 , 107 , 115 ], textbooks [ 84 , 85 , 130 ], recipes [ 57 ] newsletters [ 28 , 46 ], exercise book [ 129 ], and student guide [ 111 ].
Specific somatic health issues such as cancer, cardiovascular system, diabetes, eye or oral health were discussed in 11% of the articles [ 22 , 25 , 30 , 64 , 87 , 97 , 112 , 121 , 125 , 131 ]. Even fewer articles reported interventions on mental health issues, such as emotional regulation [ 64 , 89 , 97 ], resilience [ 23 ] and healthy relationships [ 23 , 111 , 119 ]. Nearly every third tested intervention covered more than one health issue [ 7 , 16 , 17 , 21 – 23 , 50 , 55 , 64 , 77 , 78 , 82 , 86 , 87 , 89 , 97 , 109 , 111 , 112 , 119 , 124 – 127 , 135 , 136 , 140 , 141 ]. Topics such as epidemic or pandemic were discussed only in a few articles, mainly with regards to HIV and AIDS [ 73 , 116 , 133 ] or social inequality during the COVID-19 pandemic [ 31 ]. Vaccinations were discussed in interventions generally linked to infectious disease [ 66 ] or aimed at increasing the uptake of specific vaccination, i.e. HPV [ 102 ].
Slightly less studies (27; 23,5%) tested an intervention on nutrition (23,5%) [ 8 , 11 , 16 , 17 , 22 , 23 , 46 , 57 , 60 , 77 , 87 , 89 , 91 , 96 , 97 , 103 , 109 , 110 , 112 , 123 , 125 , 126 , 135 , 140 – 142 ]. Public health problems, such as health care [ 21 ], violence [ 13 , 18 , 78 ], global health [ 8 ], organ donation [ 88 ], anti-microbial resistance [ 107 ], zoonosis [ 101 ], use of medicine [ 12 ], and bioethical dilemmas linked to health [ 47 ], social inequalities [ 31 ] were taught in 25% of reported interventions. Various forms of physical activity were promoted in every tenth intervention (11%) [ 7 , 9 , 16 , 17 , 63 , 77 , 87 , 89 , 97 , 135 , 142 ].
Almost one in three studies published over the last 40 years tested substance use interventions (27%). Half of them discussed nicotine [ 50 , 51 , 53 , 58 , 61 , 67 , 70 , 74 , 75 , 80 , 83 , 85 , 95 , 114 ] and drugs [ 21 , 26 , 52 , 53 , 65 , 70 – 72 , 74 , 76 , 81 , 84 , 85 , 87 , 140 ] and four in ten concerned alcohol [ 15 , 48 , 53 , 71 , 72 , 83 , 85 , 92 , 117 , 122 , 137 ].
Interventions reported in the included articles addressed a broad range of health issues, and the thematic focus of the interventions had changed over time ( Table 1 ). Until 2000, the prevailing topics in health education were substance use and SRH, in the following decades also nutrition, issues connected with public health, physical activity, as well as somatic and mental health gained interested of teachers and stakeholders in the field.
Dimensions of teaching methods used in health education
We noted a vast diversity of approaches to teaching critical thinking in health education that were tested in the included studies. To comprehensively describe this variety, we identified six dimensions that differentiated the methods based on their important characteristics listed in Fig 2.
The level of pupils’ activity and central educator. The tested teaching methods differed in terms of the level of pupils’ activity. Most methods were based on the active participation of pupils and included a number of individual activities (e.g., reflection on values, goal setting, self-monitoring [87, 137]) or group activities (e.g., scenario writing [133], analyzing case and proposing a solution [29, 115]). On the other hand, in relatively few interventions, pupils were to remain passive (e.g., listening to a lecture, watching a video [25, 57, 74]). Some interventions were based on both of these forms of involvement [21, 28, 30, 46, 66, 69, 90, 98, 101, 103, 107, 111, 112, 120, 135, 136, 139, 142]. Peers play a crucial role in shaping the health behaviors of children and teenagers: they offer mutual support and serve as a role model and a trusted source of information [127]. This social dynamic was used in educational interventions across countries for over 40 years. A peer-to-peer approach was applied in 54 tested interventions [8, 10, 14–17, 21–23, 26, 28, 29, 31, 32, 46, 48, 55, 57, 58, 61, 62, 80, 81, 85, 86, 90, 92, 93, 95, 98, 99, 102, 106, 110, 112–114, 117, 119, 127, 128, 131, 133, 136, 137, 139, 140], either as a main or complementary teaching strategy. With peer-to-peer method as the main strategy, selected pupils typically participated in training for peer leaders and offered workshops, prepared presentations, or moderated discussions with other pupils [15–17, 31, 55, 57, 58, 62, 80, 81, 93, 95, 114, 117, 127, 136]. As a complementary strategy, the peer-to-peer approach was typically used at the end of the intervention. After going through the educational process, pupils created educational materials and presented them to their younger colleagues [10, 14, 21–23, 26, 46, 56, 61, 85, 90, 92, 119, 133, 137]. In 43 interventions, the teacher’s role was central to the teaching process. Teachers structured the lessons, introduced content, proposed tasks, and distributed homework assignments, often according to detailed instructions [12, 13, 18–20, 22–24, 28, 29, 46, 49, 51–53, 60, 65, 67, 68, 77, 78, 80, 82, 85, 88, 90, 92, 97, 98, 101, 102, 104, 106, 112, 117, 120, 124, 125, 128, 130–134]. In every fourth intervention, teacher-centered and peer-to-peer methods were combined [12, 13, 19, 20, 22–24, 46, 53, 65, 67, 80, 85, 90, 92, 96, 117, 120, 125, 128, 131, 133]. Data on the central educator were missing in almost 37 articles.
Educational materials. To facilitate the learning process, every fourth of the interventions provided educational materials [7–9, 21, 22, 25, 27, 30, 32, 46, 49, 62, 69, 74, 76, 77, 81, 83, 84, 91, 93, 97, 104, 105, 107, 111, 115, 122, 132, 135, 140, 141], such as student activity books, brochures, fact sheets, activity sheets, handouts. In a number of interventions, audiovisual materials created specifically to support the teaching objectives were provided [20, 74, 90, 115]. In 30% of the interventions, the learning process resulted in pupils creating some artefacts. Some of those creative works served as a souvenir and were supposed to remind pupils of the health issue they were taught about [125, 137]. Other works had additional educational purposes, such as a poster exhibition [23, 28, 29, 31, 32, 47, 73, 77, 83, 86, 107], creating a cartoon about the rational use of medicines [12], shooting a video about the process of making reusable sanitary cloth pads [14], developing an educational website on cancer prevention for children that was posted on the website of the Yale Cancer Center [131]. In some interventions, children prepared and consumed foods with certain nutritional values (e.g., low-fat, high-fiber products [77, 87]) or foods from different cultural contexts [8]. In one in three interventions, computer, internet, or other technological tools were used to support the educational process. The application of teaching methods was typically supported by internet search [11, 13, 22, 50, 60, 66, 73, 75, 97, 100, 102, 103, 105, 108, 115, 122, 131, 132], creating presentations [20, 22, 29, 30, 46, 47, 54, 74, 111, 140], communicating or analyzing social media [7, 8, 11, 13, 17, 20, 30, 31, 108, 122], using applications, both those generally available, i.e. interactive web-based quiz and those developed for the intervention [12, 88, 91, 99, 102, 106, 110, 115, 118], or computer games [84, 103, 107, 111, 118, 134].
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