Original Research

Use and Effectiveness of the Teach-Back Method in Patient Education and Health Outcomes

Fed Pract. 2019 June;36(6):284-289

References

1. Zavala S, Shaffer C. Do patients understand discharge instruction? J Emerg Nurs. 2011;37(2):138-140.

2. Engel KG, Heisler M, Smith DM, Robinson CH, Forman JH, Ubel PA. Patient comprehension of emergency department care and instructions: are patients aware of when they do not understand? Ann Emerg Med. 2009;53(4):454-461.

3. Kessels RP. Patients’ memory for medical information. J R Soc Med. 2003;96(5):219-222.

4. Coulter A. Patient engagement—what works? J Ambul Care Manage. 2012;35(2):80-89.

5. Rees S, Williams A. Promoting and supporting self-management for adults living in the community with physical chronic illness: a systematic review of the effectiveness and meaningfulness of the patient–practitioner encounter. JBI Libr Syst Rev. 2009;7(13):492-582.

6. Somers SA, Mahadevan R. Health Literacy Implications of the Affordable Care Act. https://www.chcs.org/media/Health_Literacy_Implications_of_the_Affordable_Care_Act.pdf. Published November 2010. Accessed May 9, 2019.

7. US Department of Health and Human Services, Office of Disease Prevention and Health Promotion. America’s Health Literacy: Why We Need Accessible Health Information [issue brief]. https://health.gov/communication/literacy/issuebrief. Published 2008. Accessed May 9, 2019.

8. Hersh L, Salzman B, Snyderman D. Health literacy in primary care practice. Am Fam Physician. 2015;92(2):118-124.

9. Always Use Teach-back! [training toolkit]. http://www.teachbacktraining.org. Accessed May 9, 2019.

10. Taylor SG, Renpenning K. Self-Care Science, Nursing Theory and Evidence Based Practice. New York, NY: Springer; 2011.

11. Boyde M, Peters R, New N, Hwang R, Ha T, Korczyk D. Self-care educational intervention to reduce hospitalisations in heart failure: a randomised controlled trial. Eur J Cardiovasc Nurs. 2018;17(2):178-185.

12. Goeman D, Conway S, Norman R, et al. Optimising health literacy and access of service provision to community dwelling older people with diabetes receiving home nursing support. J Diabetes Res. 2016;2016:2483263.

13. Ahmadidarrehsima S, Rahnama M, Afshari M, Asadi Bidmeshki E. Effectiveness of teach-back self-management training program on happiness of breast cancer patients. Asian Pac J Cancer Prev. 2016;17(10):4555-4561.

14. Ghiasvand F, Riazi H, Hajian S, Kazemi E, Firoozi A. The effect of a self-care program based on the teach back method on the postpartum quality of life. Electron Physician. 2017;9(4):4180-4189.

15. Ahrens SL, Wirges AM. Using evidence to improve satisfaction with medication side-effects education on a neuro-medical surgical unit. J Neurosci Nurs. 2013;45(5):281-287.

16. Bates OL, O’Connor N, Dunn D, Hasenau SM. Applying STAAR interventions in incremental bundles: improving post-CABG surgical patient care. Worldviews Evid Based Nurs. 2014;11(2):89-97.

17. Gillam SW, Gillam AR, Casler TL, Curcio K. Education for medications and side effects: a two part mechanism for improving the patient experience. Appl Nurs Res. 2016;31:72-78.

18. Green UR, Dearmon V, Taggart H. Improving transition of care for veterans after total joint replacement. Orthop Nurs. 2015;34(2):79-86.

19. Kelly AM, Putney L. Teach back technique improves patient satisfaction in heart failure patients. Heart Lung. 2015;44(6):556-557.

20. Peter D, Robinson P, Jordan M, Lawrence S, Casey K, Salas-Lopez D. Reducing readmissions using teach-back: enhancing patient and family education. J Nurs Adm. 2015;45(1):35-42.

21. Price KA. Teach-Back Effect on Self-Reported Understanding of Health Management After Discharge. Minneapolis, MN: Walden University; 2014.

22. LeBreton M. Implementation of a Validated Health Literacy Tool With Teach-Back Education in a Super Utilizer Patient Population. Chester, PA: Widener University; 2015.

23. Silva LA. Teach-Back Effects on Self-Reported Understanding of Medication Management After Discharge. Minneapolis, MN: Walden University; 2014.

24. Slater BA, Huang Y, Dalawari P. The impact of teach-back method on retention of key domains of emergency department discharge instructions. J Emerg Med. 2017;53(5):e59-e65.

25. Betts V. Implementing a Discharge Process Change Using the Teach-Back Method for COPD Patients. Jersey City, NJ: Saint Peter’s University; 2014.

26. Centrella-Nigro AM, Alexander C. Using the teach-back method in patient education to improve patient satisfaction. J Contin Educ Nurs. 2017;48(1):47-52.

27. Hyrkas K, Wiggins M. A comparison of usual care, a patient-centred education intervention and motivational interviewing to improve medication adherence and readmissions of adults in an acute-care setting. J Nurs Manag. 2014;22(3):350-361.

28. Kandula NR, Malli T, Zei CP, Larsen E, Baker DW. Literacy and retention of information after a multimedia diabetes education program and teach-back. J Health Commun. 2011;16(suppl 3):89-102.

29. Griffey RT, Shin N, Jones S, et al. The impact of teach-back on comprehension of discharge instructions and satisfaction among emergency patients with limited health literacy: a randomized, controlled study. J Commun Healthc. 2015;8(1):10-21.

30. Negarandeh R, Mahmoodi H, Noktehdan H, Heshmat R, Shakibazadeh E. Teach back and pictorial image educational strategies on knowledge about diabetes and medication/dietary adherence among low health literate patients with type 2 diabetes. Prim Care Diabetes. 2013;7(2):111-118.

31. Press VG, Arora VM, Shah LM, et al. Teaching the use of respiratory inhalers to hospitalized patients with asthma or COPD: a randomized trial. J Gen Intern Med. 2012;27(10):1317-1325.

32. White M, Garbez R, Carroll M, Brinker E, Howie-Esquivel J. Is “teach-back” associated with knowledge retention and hospital readmission in hospitalized heart failure patients? J Cardiovasc Nurs. 2013;28(2):137-146.

33. Grice GR, Tiemeier A, Hurd P, et al. Student use of health literacy tools to improve patient understanding and medication adherence. Consult Pharm. 2014;29(4):240-253.

34. Samuels-Kalow M, Hardy E, Rhodes K, Mollen C. “Like a dialogue”: Teach-back in the emergency department. Patient Educ Couns. 2016;99(4):549-554.

35. Wilson FL, Mayeta-Peart A, Parada-Webster L, Nordstrom C. Using the teach-back method to increase maternal immunization literacy among low-income pregnant women in Jamaica: a pilot study. J Pediatr Nurs. 2012;27(5):451-459.

36. Swavely D, Vorderstrasse A, Maldonado E, Eid S, Etchason J. Implementation and evaluation of a low health literacy and culturally sensitive diabetes education program. J Healthc Qual. 2014;36(6):16-23.

37. Ebell MH, Siwek J, Weiss BD, et al. Strength of recommendation taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician. 2004;69(3):548-556.

Disease Knowledge and Management

Thirteen studies examined knowledge improvement after interventions that included teach-back. Study participants answered most questions correctly after receiving teach-back.^20,32,34,35 Slater and colleagues found ED patients who received discharge instructions with teach-back had significantly higher scores measuring knowledge of diagnosis (P < .001), signs and symptoms indicating a need to return to the ED (P < .001), and follow-up instructions (P = .03); scores measuring knowledge of medication were higher as well, but were not statistically different (P = .14).²⁴ In multiple studies, improvement was not always statistically significant in terms of knowledge retention.^{12,25,29-31,36} Studies that compared medication adherence found teach-back was more effective than motivational interviews (P = .56).²⁷

Teach-back has been widely used in primary care, inpatient, and ED settings. Two studies on the effect of teach-back in primary care sampled patients with DM.^28,36 Kandula and colleagues found that participants who answered questions incorrectly after watching a multimedia DM education program could significantly improve their DM knowledge by engaging in teach-back immediately after the intervention; however, knowledge retention was not improved at 2-week follow-up (phone call).²⁸ In contrast, Swavely and colleagues compared patients who completed a 13-hour DM education program with or without teach-back and found that teach-back patients demonstrated significantly improved DM knowledge and self-care activities at 3 months.³⁶

Effects of Interventions on HR-QOL

The teach-back method had been used with QOL improvement programs and other interventions. Ahmadidarrehsima and colleagues incorporated teach-back into their medical self-management program (8 to 11 sessions, each lasting 1.5 to 2 hours) for women with breast cancer and found that the mean happiness score increased to 62.9 from 37.2 (P < .001) in the intervention group, whereas the score for the usual-care group decreased from 41.4 to 29.8.¹³ Ghiasvand and colleagues compared QOL of postpartum mothers who received routine care with QOL of those who received routine care plus 2 sessions of postpartum self-care with teach-back; mean QOL scores were significantly (P < .001) higher for the teach-back group (124.73) than for the no teach-back group (115.03).¹⁴

Discussion

This review examined the use and effectiveness of the teach-back method in health education and its influence in patients’ disease self-management and health outcomes. Results showed positive effects of teach-back on patient satisfaction, patient perceptions and acknowledgments, postdischarge readmissions, disease self-management and knowledge, and HR-QOL.

The teach-back method has been widely used in inpatient, outpatient, ED, and community settings as part of health education programs and interventions. It has been paired with educational interventions ranging from short instructions to 20-hour programs. These differences reflect the broad application of the method in patient education. Many studies have found that teach-back improves disease knowledge and self-management, though their results are not always statistically significant. In an RCT of patients with low health literacy, Griffey and colleagues studied the effect of ED discharge education with and without teach-back and found teach-back did not increase post-ED comprehension of diagnoses, medical examinations, and treatments or perceived comprehension of treatment and care; however, compared with the no teach-back group, the teach-back group had significantly higher scores on comprehension of post-ED self-care (P < .02), follow-up (P < .0001), and medication (P = .054).²⁹ This finding indicates teach-back is an effective method for helping patients understand self-care and disease self-management at home.

Comprehending medical diagnoses, examinations, and treatments involves acquiring, analyzing, and comparing multiple pieces of health information. Because comprehension requires a level of abstract thinking usually present in patients with intermediate and proficient health literacy,improvements might be more difficult to see in patients with low health literacy.⁸ Press and colleagues found that asthma patients who repeated respiratory inhaler instructions with teach-back during discharge education had less misuse of (P = .01) metered-dose and Diskus (P = .05) inhalers and lower 30-day readmission rates (P = .02) compared with the misuse of patients who received only 1 set of oral and written instructions.³¹ Even though the Diskus result was not statistically significant, it demonstrated teach-back can be used to improve patient self-care and education.³¹

Most participants in the reviewed studies improved their disease knowledge with teach-back, though the evidence regarding improved health care knowledge retention was limited. For example, the 2 studies on use of teach-back in primary care clinics had contradictory knowledge retention results.^28,36 As both studies incorporated teach-back into existing interventions, these results could be associated with those interventions and not with the teach-back method.

Health literacy is achieved through a complicated process of obtaining, analyzing, choosing, and communicating health information. Even though its knowledge retention results are inconsistent, the teach-back method is recommended by the American Academy of Family Physicians at strength of recommendation taxonomy level C.⁸ Such a designation indicates that the recommendation is based on expert opinion, bench research, consensus guideline, usual practice, clinical experience, or a case series and is appropriate for assessment of patient comprehension.³⁷ Teach-back is also suggested by AHRQ and IHI for university precautions regarding health literacy and as such should remain a standard of practice. More study is needed to understand the inconsistent results of knowledge retention and the long-term effects of the teach-back method.