Oxman, MattChesire, FaithMugisha, MichaelSsenyonga, RonaldNsangi, AllenOxman, Andrew DFretheim, AtleRosenbaum, SarahKaseje, MargaretSewankambo, NelsonMelby-Lervåg, MonicaLewin, Simon2026-06-152026-06-152025-09-29Oxman, M., Chesire, F., Mugisha, M., Ssenyonga, R., Nsangi, A., Oxman, A. D., ... & Lewin, S. (2025). Participants’ experiences of potential adverse effects of an intervention to improve critical thinking about health choices: a qualitative cross-trial process evaluation in Kenya, Rwanda and Uganda. BMJ open, 15(10), e104236.2044-6055https://dir.muni.ac.ug/handle/20.500.12260/993The present study contributes to SDG 3 (Good Health and Well-being), Target 3.4, by enhancing health literacy and supporting informed health choices among young people. It further advances SDG 4 (Quality Education), Target 4.7, by fostering critical thinking, evidence-based learning, and lifelong learning skills. In addition, the study supports SDG 16 (Peace, Justice and Strong Institutions), Target 16.7, by promoting informed and inclusive decision-making. This research aligns with Uganda’s National Development Plan IV (NDP IV), particularly the Human Capital Development Program, which seeks to improve the quality of education, learners' skills, and health awareness. By examining potential negative effects of critical thinking interventions, including anxiety, inequity, conflict, and cognitive dissonance, the study provides evidence to inform the development of more effective and student-centered educational programs. The findings may inform policies and teaching methods that cultivate critical thinking while safeguarding student well-being. This approach supports human capital development, evidence-based decision-making, and the formation of informed, resilient citizens capable of addressing complex health and social challenges.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.enAdverse effectsCritical thinkingHealth choicesProcess evaluationQualitative researchUgandaArticle