Running head: TEACH BACK TOOL FOR HEADACHE PROGRAM

Using Teach Back to Evaluate the Efficacy of a Pediatric
Headache Program: A DNP Project
Melissa A. Two
Arizona State University

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TEACH BACK TOOL FOR HEADACHE PROGRAM
Abstract

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Background: Only 40%-80% of health information is retained during an office visit due to
ineffective communication. Caregivers, and patients, are unable to remember how to manage
their health care needs. Teach back is an effective tool that encourages a conversation between
the caregiver/patient and provider. The purpose of this project is to increase knowledge retention
and self-management behaviors using a headache teach back tool.
Methods: The quality department at a large children’s hospital in the southwestern United States
approved the project as a practice change and parent consent was not required. The project
design was a randomized controlled group: pretest-posttest design, quality improvement method.
Participants were chosen by convenience sample. Required diagnoses were headache or
migraine. Each group had 18 participants, for a total of 36 participants. Ages ranged from four to
18 years of age, with legal guardians present for the intervention group only. New and follow-up
patients were included in the project. Demographics for each group were statistically similar.
Questionnaires were used to assess knowledge pre and post implementation of teach back tool.
Self-management was measured by a follow-up phone call after their appointment to inquire
regarding implementation of the headache diary. Charts were reviewed for both groups regarding
the number and type of phone calls received by the office.
Outcomes: Paired sample t-test was used to evaluate mean differences in knowledge from pre
and post questions of teach back tool. Data analysis concluded a statistical increase in knowledge
of triggers and prevention techniques. Cohen’s d for triggers was 2.21 and 1.87 for prevention.
Self-management of behavior was measured by use of headache diary and determined by a
percentage. Sixty-seven individuals started to use the headache diary. Independent t-test was
used to compare number of phone calls from each group. Data concluded a decrease in phone
calls. However, due to a small sample size, statistical significance could not be established.
Conclusion: Teach back encourages caregiver/patient and provider interaction, which increases
health literacy retention and increases self-management behaviors. Future research should focus
on patients with headaches with unknown triggers for their headaches.
Keywords: Teach back, Health Literacy, Self-management, headache, migraine

TEACH BACK TOOL FOR HEADACHE PROGRAM
Using Teach Back to Evaluate the Efficacy of a Pediatric Headache Program: A DNP Project

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Caregivers only remember 40%-80% of information provided during an office visit, and
more than one-half of that information is remembered incorrectly (Agency for Healthcare
Research and Quality [AHRQ], 2017). In 2014, only 68.8% of individuals reported their provider
gave instructions that they were able to understand (Healthy People 2020, 2014). Ineffective
communication, including low health literacy, during an office visit leads to the caregiver’s
inability to manage their child’s health care needs (Lambert & Keogh, 2014).
Communication between the health care professional and patient/caregiver regarding the
care of children with headaches should encourage shared decision-making and assist the
caregiver to assume responsibility of the child’s health (Lambert & Keogh, 2014). To improve
communication and increase self-management of care, the integrative technique of teach back
can be used to initiate a conversation and correct misunderstandings during the office visit
(Slater, Hauang, & Dalawari, 2017). Teach back is a teaching method that asks the individual to
recall information in their own words.
Background and Significance
Poor communication and low health literacy have been linked to decreased health
maintenance, an increase in hospitalizations, and infrequent use of preventative services (Nouri
& Rudd, 2015). Communication is defined as the exchange of information, whether verbal or
nonverbal, between individuals (Plainlanguage.gov, n.d.a). Communication requires the use of
plain language. Plain language is communication, which is organized and concise
(Plainlanguage.gov, n.d.c). Teach back uses plain language during the conversation for the
patient/caregiver to understand the information given.

TEACH BACK TOOL FOR HEADACHE PROGRAM
Health literacy is defined as an individual’s ability to understand the information made

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available by their health care provider to make informed decisions regarding their health care
(Health.gov, 2018). Health literacy has taken a dominant role in health care and has become one
of the foremost national priorities in public health (Shone, 2012). Patients, and caregivers of
children diagnosed with headaches, are responsible for understanding and coordinating complex
medical care, requiring the ability to process health information. Low health literacy can lead to
treatment failure and unwanted complications that could be avoided with appropriate
interventions (Thomas, Edwards, & McArdle, 2017). Literature supports the need for increasing
effective communication and health literacy between the health care professional and the
individual to create better health outcomes. Teach back is the key to improving this
communication.
Because children with chronic illnesses, such as headaches, depend on their caregivers to
assist with management of their health care, health literacy is highly encouraged for positive
health outcomes in this population (Lambert & Keogh, 2014). The provider-caregiver
interaction, either through verbal communication or written handouts, directly impacts their
child’s health (Cutilli, Simko, Colbert, & Bennett, 2018). Patient Information Leaflets (PIF) are
used to increase caregiver’s health literacy and encourage caregivers to collaborate in their
child’s health care, though reading comprehension of PIFs remains a struggle for much of the
adult population (Nouri & Rudd, 2015). Over 50 million U.S. adults are reading at a junior high
reading level (Boles, Liu, & November-Rider, 2016). Patient educational materials are created
for an audience with proficient health literacy (Brega et al., 2015). In 2003, the National Center
for Education Statistics surveyed adult Americans and discovered that only 12% of the
population has proficient health literacy (Boles et al., 2016). Though health literacy affects

TEACH BACK TOOL FOR HEADACHE PROGRAM
caregivers of different education levels and socioeconomic status, caregiver’s self-efficacy

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determines their ability to increase their health literacy (Rajah, Ahmad, Jou, & Murugiah, 2017).
Poorly written materials can lead to caregiver confusion and can cause disruption in illness
management, leading to negative health outcomes (Protheroe, Estacio, & Saidy-Khan, 2105).
Teach back initiates a conversation between the individual and the health care
professional. The method uses a patient-centered approach that encourages patients to interact
with the health care professional (Truong, Nguyen, Armor, & Farley, 2017). It involves a
conversation using plain language and requires the individual to repeat back the information they
have learned. Teach back assesses the true transfer of knowledge and misinformation can be
corrected before the individual leaves the office. Regardless of education or age, teach back
increases retention of health information (Slater, Huang, & Dalawari, 2017).
Healthy People 2020 is a national program that sets goals and objectives for the nation’s
health. One Healthy People 2020 objective (HC/HIT-2.2) delineates the need to increase the
number of individuals who report that their health care professional gave easy to understand
instructions (Office of Disease Prevention and Health Promotion [ODPHP], 2014). Other
Healthy People 2020 objectives, HC/HIT 1.1 and HC/HIT 1.2, discuss the need to increase the
proportion of individuals who can repeat back care instructions directed by the health care
professional, and increase the proportion of individuals who self-management their care
(ODPHP, 2014).
Another government agency that supports increasing communication between patients
and health care professional is The National Action Plan to Improve Health Literacy. This
agency promotes effective communication with the goal of improving caregivers’ ability to make
informed decisions and improve their child’s quality of life (U.S. Department of Health and

TEACH BACK TOOL FOR HEADACHE PROGRAM
Human Services, 2010). The Plain Writing Act of 2010 is a law requiring federal agencies to

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write in plain language, and mandates that information is understood the first time it is read or
spoken (Plainlanguage.gov, n.d.b). National programs, such as Healthy People 2020, The Plain
Language Act of 2010, and the National Action Plan to Improve Health Literacy have
recognized the health literacy disparities in the United States and are striving to increase
awareness and provide solutions for improvement.
Problem Statement and PICO(T)
At a children’s neurology clinic, affiliated with a large children’s hospital in the
southwest United States, specializing in pediatric headaches, the evaluation of provider-caregiver
communication was accomplished by the using a short caregiver health literacy questionnaire.
The questionnaires used were written in plain language and distributed at the end of each office
visit. The clinic’s goal was to evaluate the effectiveness of their health care provider’s
communication. At the time of initial evaluation, no formal tracking system was in place to
monitor the results of questionnaires. The office manager also reported a large number of phone
calls from caregivers regarding headache prevention. The office used a headache handout,
written in plain language, which was developed in collaboration with the provider and the
hospital education center. Teach back was included at the end of the handout that reviewed
triggers and prevention techniques for headaches. The handout also included a headache diary,
which promoted self-management of care. Prior to initiation of this project teach back and the
headache diary were not being reviewed with the patient/caregiver.
Review of the evidence-based literature supported an appropriate intervention to increase
health literacy and health outcomes. This inquiry led to the clinically relevant PICOT question
“For patient, or caregivers of children, diagnosed with headache/migraine (P), how does teach

TEACH BACK TOOL FOR HEADACHE PROGRAM
back (I), compared to no teach back (O), increase individual’s health literacy and self-

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management (O)?”
Exhaustive Search
Guided by the PICOT question, a search for the literature was conducted in three
databases: PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and
PsycInfo. Keyword searches included: health literacy, health information, health outcomes,
health behaviors, health disparities, health communication ,teach back, parent, caregiver, child,
children, pediatric, chronic illness, pediatric chronic illness, chronic disease, communication,
effective communication, education, teaching, teaching health information, knowledge, increase
knowledge, internet learning, language, plain language, reading levels, ehealth, YouTube,
Facebook, Google, video-based learning, video-based messages, video learning, webinars,
patient portal, health videos, online learning, handouts, pamphlets, provider and, health care.
The Boolean connectors “AND” and “OR” were used when examining portions of the PICOT
components.
Exclusion criteria included: unpublished articles, journal entries, and publications that
were not in English. Inclusion criteria included: articles published within the last five years
(preferred), studies with evidenced-based information, studies from scholarly journals, and
preferably peer reviewed articles that addressed the other components of the PICOT question.
Search limits in PubMed were set for articles published after 2010. Search limits for PsycInfo
was set for peer-reviewed articles.
Initial search strategy in all databases used the keywords ‘health literacy’. PubMed
yielded a total of 13,117 results, CINAHL yielded 4,951 results, and PsycInfo yielded 7,779
results. To narrow down the search the terms ‘health literacy’ AND ‘parents’ AND ‘chronic

TEACH BACK TOOL FOR HEADACHE PROGRAM
illnesses were used. Final results in PubMed yielded 28 results, CINAHL yielded seven results,

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and PyscInfo yielded 11 results. Further search strategies for PubMed included keywords ‘health
literacy’ AND ‘parents’ AND ‘education’ which yielded 680 results in PubMed. To narrow the
search further, keywords ‘information technology’ and ‘internet learning’ were used for a final
result of 30 articles. Limits included randomized control trials, systematic reviews, and studies
published within the last five years. Eight articles were evaluated and critically appraised for the
evidence table. These results included three randomized controlled trials, four mixed method
studies, and one descriptive exploratory study. Further searches in CINAHL included keywords
‘internet based learning’ AND ‘health literacy’ which resulted in 14 articles and two were
critically appraised and used for the evidence table. Continued searches in PsycInfo with
keywords ‘health’ AND ‘video learning’ resulted in 1,274 articles. Further search terms included
‘internet based learning’ and limits were set to randomized control trials within the past five
years, though no articles were used for the evaluation table. Hand searches were not completed
during this search strategy.
Critical Appraisal & Synthesis
Ten studies were retained for this review, which included three randomized controlled
trials, four mixed method studies, two qualitative systematic reviews, and one descriptive
exploratory study (Appendix A). Two of the randomized controlled trials were appraised as level
two evidence, one was appraised as level three evidence, all four mixed methods studies were
appraised as level four evidence, one descriptive qualitative systemic review was appraised as
level five evidence, one qualitative systematic review was appraised as level six evidence, and
one descriptive exploratory study was appraised at level six evidence.

TEACH BACK TOOL FOR HEADACHE PROGRAM
The conceptual framework was not clearly stated for nine of the studies, but one study

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used the Conceptual Mode of Factors. Other studies appeared to follow the Self Efficacy Model,
Social Cognitive Theory, Chronic Care Model, or Stages of Change Model. Sample size was
appropriate for each study and attrition rates were accounted for during the studies (Appendix
B).
All ten studies demonstrated a degree of bias. Common biases were channeling bias,
recall bias, and author bias. Authors addressed the bias of each study in the limitation section of
the articles. The setting for each of the studies were appropriate for the type of research
conducted. All interventions contained an online learning component that could be completed in
home or at a medical office (Appendix B).
Regarding the demographics of the studies, the majority of the articles included patients
over 50 years of age. Two articles examined technology with chronic illness and three others
targeted parents. Though some articles evaluated research within the last ten years, all articles
had been published within the last five years (Appendix B).
Valid and reliable assessment tools were used in all but two studies. The Rapid Estimate
of Adult Literacy in Provider’s Office (REALM) was able to access the readability of health
information, though it did not assess if patients were able to comprehend the information. This
was the first time the Pediatric Rehabilitation Intervention Measure of Engagement for Parents
tool was used. This tool shows validity, but not reliability (Appendix B).
Homogeneity was seen throughout the ten studies regarding increasing health literacy
through an online source. Heterogeneity was observed with population age and the source of
technology intervention. Online web portals, applications, and learning programs proved to be an

TEACH BACK TOOL FOR HEADACHE PROGRAM
effective means to communicate with providers and helped patients engage in health choices

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(Appendix B).
Purpose and Rational
Children with headaches often require ongoing support for treatment and disease
management, requiring their caregivers to have increased contact with their child’s health care
provider (HCP) (Fiks, 2018). Collaboration between both the patient/caregiver and the HCP is
important to achieve and maintain an acceptable quality of life for the child (Schaffler et al.,
2018). Evidence highlights the need to increase and retain individuals’ health literacy through
effective communication techniques, such as teach back. The purpose of this project was to
increase health literacy, knowledge retention, and self-management behaviors using teach back.
Conceptual Model
The Self-Efficacy Theory (SET) by Albert Bandura was used to guide the process for the
project (Appendix C). The SET is derived from the Social Cognitive Theory and describes that
an individual’s behavior change is due to their environment, highlighting self-regulation
(Tougas, Hayden, McGrath, Huguet, & Rozario, 2015). Self-regulation includes the monitoring
of oneself, the judgment of oneself, and the evaluation of oneself (Tougas et al., 2015). The SET
stems from the judgment, or the belief in oneself to complete a task (Nursing Theories, 2012).
Three interrelated factors that affect one’s ability to complete a task are an individual’s
environment, behavior, and personal/cognitive factors (Nursing Theories, 2012). Self-efficacy is
a strong predictor for behavior change (Nursing Theories, 2012).
Patients with chronic illness, such as headaches, require a degree of self-efficacy for an
increase in health literacy (Ha Dinh, Bonner, Clark, Ramsbotham, & Hines, 2016). As the
individual becomes more comfortable with their knowledge, they will feel more confident to

TEACH BACK TOOL FOR HEADACHE PROGRAM

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self-manage their headaches. Individual’s self-efficacy is required to foster healthy behaviors and
assist with positive health outcomes (Alsem et al., 2017)). With appropriate interventions, such
as increasing health literacy with teach back, treatment failure and unwanted complications can
be avoided (Thomas, Edwards, & McArdle, 2017).
Evidence Based Practice Model
The evidence-based practice model that was used to guide this project was the Iowa
Model of Evidence Based Practice (Appendix D). This model is used to implement changes
within the healthcare system. It promotes quality of care by using a feedback system through
each step of the process (Iowa Model Collaborative, 2017). Developing and introducing
evidence-based guidelines into practice can be challenging. The goal was to address each
resistance to change in a quick and efficient manner.
Project Methods
The quality department at a large children’s hospital in the southwestern United States
approved this as a practice change and parent consent was not required. The project design was a
randomized controlled group: pretest-posttest design, quality improvement method. Participants
were chosen by convenience sample. Required diagnoses were headache or migraine. Each
group had 18 participants, for a total of 36 participants. Ages ranged from four to 18 years of
age, with legal guardians present for the intervention group only. New and follow-up patients
were included in the project. Demographics for each group were statistically similar. The
headache educational handout was a collaborative creation between a neurology provider and the
hospital education center, though not proven as valid and reliable. Questionnaires were created to
assess knowledge pre and post teach back (Appendix E). Self-management was measured by a
follow-up phone call after their appointment to determine if the headache diary was

TEACH BACK TOOL FOR HEADACHE PROGRAM
implemented. Charts were reviewed for both groups regarding the number and type of phone

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calls received by the office.
The project cost included the time of the provider, the practice staff, and the
patient/caregiver. The student initiated contact after the provider had seen the patient. The
student provided education included in the headache handout.
The stakeholders invested in the implementation of the program include the hospital, the
neurology clinic, the providers and staff at the clinic, and the family/caregiver of the child.
Outcomes
Descriptive statistics were used to review the demographics of the control and
intervention group (Appendix F). Gender, age, and patient status (new or follow-up patient) were
statistically significant for each group. Groups included differences in race but the proportion of
white/Caucasian, Hispanic/Latino, and black/African American was the same. Differences did
not impact the study. Paired sample t-test was used to evaluate mean differences in knowledge
from pre and post questions of teach back (Appendix G). Mean difference for pre-trigger
knowledge was 1.72 and mean difference for post-trigger knowledge was 4.89. Mean difference
for pre-prevention techniques was 2.06 and mean difference for post-prevention techniques was
4.94. Data analysis concluded statistical increase in knowledge of triggers and prevention
techniques. Cohen’s d for triggers was 2.21 and 1.87 for prevention. Cohen’s d showed strong
correlation. Self-management of behavior was measured by use of headache diary and
determined by a percentage (Appendix H). Sixty-seven percent of the participants started to use
the headache diary. All patients that used the headache diary reported a decrease in headaches.
However, this data was not statistically significant. Independent t-test was used to compare

TEACH BACK TOOL FOR HEADACHE PROGRAM

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number of phone calls from each group (Appendix H). Data concluded a decrease in phone calls.
However statistical significance could not be established.
The project results showed an increase in patient/caregiver knowledge regarding
headache triggers and prevention techniques using teach back. Data also revealed an increase in
use of the headache diary with possible reduction of headaches due to self-management. Finally,
there was a reduction in phone calls to the office.
Discussion
Teach back should be implemented during office visits for children with headaches. A
nurse can provide education with teach back after the HCP has completed the visit. Future
projects could focus on helping patients/caregivers to understand the importance of using a
headache diary and encourage use over time. Healthy People 2020 encourages the use of

technology to increase self-management. The headache handout included two phone applications
to assist with tracking the patient’s headache.
A primary strength of the project was stakeholder support. All HCPs appreciated the
impact of providing education with teach back to patients/caregivers at the time of the visit.
Another strength was patient/caregiver willingness to try the headache diary. One limitation of
the project was the small sample size. Another limitation was possible bias of the patients when
the student called the patient for the follow up phone call.
Conclusion
Teach back is an effective method to provide education in a patient-centered
environment. It assesses the patient’s knowledge and the need for correction of misinformation
to encourage patient/caregiver self-management. Teach back can be used during any office visit,
it is inexpensive, and can be implemented for all patient demographics.

Running head: TEACH BACK TOOL FOR HEADACHE PROGRAM
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U.S. Department of Health and Human Services, Office of Disease Prevention and Health
promotion. (2010). National action plan to improve health literacy. Retrieved from
https://health.gov/communication/HLActionPlan/pdf/Health_Lit_Action_Plan_Summary.
pdf
World Health Organization (WHO). (2018). Knowledge-to-action framework. Retrieved from
http://www.who.int/reproductivehealth/topics/best_practices/greatproject_KTAframewor
k/en/

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20

Appendix A
Table 1
Évaluation Table
Quantitative Studies
Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major Variables
& Definitions

Measurement/
Instrumentation

Data
Analysis
(stats used)

Findings/
Results

Duren-Winfield,
V. (2015). Health
literacy and
computer-assisted
instructed:
usability and
patient preference

Social
Cognitive
Theory

Design: RCT

N= 263
LL n= 146
AL n= 117

QNT:
IV: Two different
educational
computer programs

1. REALM. Not
valid to assess
health literacy
2. Post program
Evaluation
survey

QNT/QLT:
chi-square
tests for
proportions
and t-tests
for means,
multivariate
logistic
regression
model

QNT:
DV: 98% of
patients reported
easy to use
program. Limited
group 73%- no
assistance
Adequate literacy86%- no assistance

Country: US
Funding:
American Cancer
Society
Bias: Channeling
Bias

Purpose:
Feasibility of
using computerassisted
instruction in
patients of
varying literacy
levels by
examining
patients’
preferences for
learning and
their ability to
use two
computer-based
educational
programs

Mean age 58.8
(SD=7.2)
Demographic:
Studies from
2007-2008,
population was
50-74 years of
age
Settings:
Medical office
Inclusion:
Patients with
various health
literacy

DV: Number of
times a patient
needed assistance,
ease of computer
program use, and
understanding of
material presented
DV: Patients’ selfrelated learning
from the program,
patients’
preferences for the
program
QLT:
Question: selfrelated learning

QLT:
DV: 80% of
patients reported
learning something
new LG
LL = 124
AL = 87
p= 0.24
98% of both groups
preferred computer
programs rather
than brochure

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
Level 3
Weakness:
practices from
single health
system, portal
was
administered
during study
and not
voluntarily
used, short
follow up
period
Conclusions:
Portal adaption
unlikely in
short term, but
have potential
for benefits to

Key: A- Attitude; AL- Adequate Literacy; CFG- Clinical Focus Groups; CG- Control Group; CLB- Control of Learning Beliefs; COPD- Chronic Obstructive
Pulmonary Disease; DL- Days Logged In; DV- Dependent Variable; E- Exposure; EGO- Extrinsic Goal Orientation; eHEALS- eHealth Literacy Scale; EHRElectronic Health Record; FU- Follow-up; FG- Focus Group; HLH- High Health Literacy; HLS- Health Literacy Score; HLSN- Health Literacy Score
Numeracy; HLSR- Health Literacy Score Reading; IG- Intervention Group; IGO- Intrinsic Goal Orientation; IR- Information Recall; IV- Independent Variable;
LHL- Low Health Literacy LL- Low Literacy; M- Mean; METER- Medical Term Recognition Test; n- Number of participants; N- Number of studies; NPIRQNetherlands Patient Information Recall Questionnaire; NS- None Stated; NVS- Newest Vital Sign; PCO- Primary Care Office; PH- Participant’s Home; POProvider’s Office; PS- Phone Survey; QLT- Qualitative; QNT- Quantitative; RCT- Randomized Control Trial; REALM- Rapid Estimate of Adult Literacy in
Medicine; SAHL-D- Short Assessment of Health Literacy in Dutch; SE- Self-Efficacy; SET- Self Efficacy Theory; SILS- Single Item Literacy Screener; STOFHA- Short Test of Functional Health Literacy in Adults; TA- Technology Attitude; TV- Task Value; TL- Times Logged In; US- United States

TEACH BACK TOOL FOR HEADACHE PROGRAM
from the program
and patients’
preferences for the
program

LL = 143
AL = 112
p= 0.59

21

communication

LL more likely than
AL to state they
learned more from
program

Key: A- Attitude; AL- Adequate Literacy; CFG- Clinical Focus Groups; CG- Control Group; CLB- Control of Learning Beliefs; COPD- Chronic Obstructive
Pulmonary Disease; DL- Days Logged In; DV- Dependent Variable; E- Exposure; EGO- Extrinsic Goal Orientation; eHEALS- eHealth Literacy Scale; EHRElectronic Health Record; FU- Follow-up; FG- Focus Group; HLH- High Health Literacy; HLS- Health Literacy Score; HLSN- Health Literacy Score
Numeracy; HLSR- Health Literacy Score Reading; IG- Intervention Group; IGO- Intrinsic Goal Orientation; IR- Information Recall; IV- Independent Variable;
LHL- Low Health Literacy LL- Low Literacy; M- Mean; METER- Medical Term Recognition Test; n- Number of participants; N- Number of studies; NPIRQNetherlands Patient Information Recall Questionnaire; NS- None Stated; NVS- Newest Vital Sign; PCO- Primary Care Office; PH- Participant’s Home; POProvider’s Office; PS- Phone Survey; QLT- Qualitative; QNT- Quantitative; RCT- Randomized Control Trial; REALM- Rapid Estimate of Adult Literacy in
Medicine; SAHL-D- Short Assessment of Health Literacy in Dutch; SE- Self-Efficacy; SET- Self Efficacy Theory; SILS- Single Item Literacy Screener; STOFHA- Short Test of Functional Health Literacy in Adults; TA- Technology Attitude; TV- Task Value; TL- Times Logged In; US- United States

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22

Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major Variables
& Definitions

Measurement/
Instrumentation

Data
Analysis
(stats used)

Findings/
Results

Hasum, L.K.E.
(2017). The
long-term
effects of using
telehomecare
technology on
functional
health literacy:
results from a
randomized
trial

SET

Design: RCT

N= 90
IG = 47
Mean age: 70.2
CG = 43
Mean age: 69.5

IV: use of
telehomecare
technology

Danish Test of
Functional
Health Literacy
in Adults

Chi-square
test,
independent
t-test,
paired ttest,
multiple
regression
analysis

IG
HLS:
Baseline 70.26
Follow-up:75.40

Country:
Denmark
Funding: None
declared

Purpose:
Explore how
the use of
telehomecare
technology
affects the
level of
functional
health literacy

Demographics:
patients with
COPD
Settings: in
home
Inclusion:
diagnosed
COPD, listed
with a general
practitioner,
fixed residence,
speak Danish,

DV Groups:
unadjusted mean:
IG, CG with
HLS, HLSN,
HLSR
DV: level of
functioning
health literacy

HLSN:
Baseline: 37.26
Follow-up: 39.60
HLSR:
Baseline: 33.0
Follow-up: 35.81
CG:
HLS:
Baseline: 72.84
Follow-up: 77.21

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
Level 2
Weakness:
specific
knowledge
about COPD
should have
been assessed
before and
after study,
sample was not
balanced
Conclusion:
Significant
increase in
functional
health literacy

Key: A- Attitude; AL- Adequate Literacy; CFG- Clinical Focus Groups; CG- Control Group; CLB- Control of Learning Beliefs; COPD- Chronic Obstructive
Pulmonary Disease; DL- Days Logged In; DV- Dependent Variable; E- Exposure; EGO- Extrinsic Goal Orientation; eHEALS- eHealth Literacy Scale; EHRElectronic Health Record; FU- Follow-up; FG- Focus Group; HLH- High Health Literacy; HLS- Health Literacy Score; HLSN- Health Literacy Score
Numeracy; HLSR- Health Literacy Score Reading; IG- Intervention Group; IGO- Intrinsic Goal Orientation; IR- Information Recall; IV- Independent Variable;
LHL- Low Health Literacy LL- Low Literacy; M- Mean; METER- Medical Term Recognition Test; n- Number of participants; N- Number of studies; NPIRQNetherlands Patient Information Recall Questionnaire; NS- None Stated; NVS- Newest Vital Sign; PCO- Primary Care Office; PH- Participant’s Home; POProvider’s Office; PS- Phone Survey; QLT- Qualitative; QNT- Quantitative; RCT- Randomized Control Trial; REALM- Rapid Estimate of Adult Literacy in
Medicine; SAHL-D- Short Assessment of Health Literacy in Dutch; SE- Self-Efficacy; SET- Self Efficacy Theory; SILS- Single Item Literacy Screener; STOFHA- Short Test of Functional Health Literacy in Adults; TA- Technology Attitude; TV- Task Value; TL- Times Logged In; US- United States

TEACH BACK TOOL FOR HEADACHE PROGRAM
HLSN:
Baseline: 36.95
Follow-up: 40.26

phone
connection

Bias:
Channeling
Bias

Exclusion:
cognitive
impairment,
unable to
understand
Danish
sufficiently to
complete
questionnaires

HLSR:
Baseline: 35.88
Follow-up: 36.95

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major Variables
& Definitions

Measurement/
Instrumentation

Data
analysis
(stats used)

Findings/
Results

Meppelink, C.
(2015). The
effectiveness of
health
animations in
audiences with
different health
literacy levels:
an experimental
study

SET

Design: RCT

N= 231
Mean age
68.22,
52.4% male

IV: Text
modality (written
verses spoken)

1. SAHL-D
2. NPIRQ
Valid
instrument
3. 7 point
Likert Scale
4. 7 semantic
differential

MANOVA,
PROCESS

Text:
IR, A
LHL:
IR: written 9.12
IR: spoken 11.42
p=0.03
A: written 5.75
A: spoken 6.20
P= 0.02

Country:
Netherlands
Funding: Not

Low SAHL-D
score </= 24
(108 patients)
High SAHL-D
score >/= 25
(123 patients)
Demographics:
55 years or
older

score in both
groups, but
study is unable
to provide
cause of
increase

HLS p=0.62
HLSN p= 0.71
HLSR p= 0.61

Citation

Purpose:
Investigate what
features of
spoken health
animations
improve
information
recall and
attitudes and
whether there
are differences
between literacy
groups

23

IV: Visual
format
(illustrations
verses
animations
DV: Information
recall
DV: Attitudes

HHL:
IR: written 14.83
IR: spoken 15.77
A: written 5.83
A: spoken 6.11

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
Level 2
Limitations:
the animation
was divided up
into short
segments
Conclusion:
Animated
visual
information
combined with
spoken text is
the best way to

Key: A- Attitude; AL- Adequate Literacy; CFG- Clinical Focus Groups; CG- Control Group; CLB- Control of Learning Beliefs; COPD- Chronic Obstructive
Pulmonary Disease; DL- Days Logged In; DV- Dependent Variable; E- Exposure; EGO- Extrinsic Goal Orientation; eHEALS- eHealth Literacy Scale; EHRElectronic Health Record; FU- Follow-up; FG- Focus Group; HLH- High Health Literacy; HLS- Health Literacy Score; HLSN- Health Literacy Score
Numeracy; HLSR- Health Literacy Score Reading; IG- Intervention Group; IGO- Intrinsic Goal Orientation; IR- Information Recall; IV- Independent Variable;
LHL- Low Health Literacy LL- Low Literacy; M- Mean; METER- Medical Term Recognition Test; n- Number of participants; N- Number of studies; NPIRQNetherlands Patient Information Recall Questionnaire; NS- None Stated; NVS- Newest Vital Sign; PCO- Primary Care Office; PH- Participant’s Home; POProvider’s Office; PS- Phone Survey; QLT- Qualitative; QNT- Quantitative; RCT- Randomized Control Trial; REALM- Rapid Estimate of Adult Literacy in
Medicine; SAHL-D- Short Assessment of Health Literacy in Dutch; SE- Self-Efficacy; SET- Self Efficacy Theory; SILS- Single Item Literacy Screener; STOFHA- Short Test of Functional Health Literacy in Adults; TA- Technology Attitude; TV- Task Value; TL- Times Logged In; US- United States

TEACH BACK TOOL FOR HEADACHE PROGRAM

24

Settings: Nonclinical settings

specified
Bias: Recall

Visual:
IR, A
LHL:
IR: WI = 29
IR: WA =35
IR: SI = 23
IR: SA = 21

Inclusion:
Patients with
low or high
health literacy,
55 years or
older

Bias

communicate
complex health
message to
people with
LHL

A: WI = 5.78
A: WA = 5.71
A: SI = 6.22
A: SA = 6.19

Excluded:
Literacy levels
did not meet
inclusion
criteria

HHL:
IR: WI = 33
IR: WA =29
IR: SI = 29
IR: SA = 32

Mixed Method
Citation

Fiks, A.G.

A: WI = 5.87
A: WA = 5.80
A: SI = 6.03
A: SA = 6.18
Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major Variables
& Definitions

Measurement/
Instrumentation

Data
analysis
(stats used)

Findings/
Results

Level/Quality
of Evidence;
Decision for
practice/
application to
practice

Conceptual

Design: Mixed-

N= 9133

QNT:

1. Logistic

Chi-square

QNT:

Level 3

Key: A- Attitude; AL- Adequate Literacy; CFG- Clinical Focus Groups; CG- Control Group; CLB- Control of Learning Beliefs; COPD- Chronic Obstructive
Pulmonary Disease; DL- Days Logged In; DV- Dependent Variable; E- Exposure; EGO- Extrinsic Goal Orientation; eHEALS- eHealth Literacy Scale; EHRElectronic Health Record; FU- Follow-up; FG- Focus Group; HLH- High Health Literacy; HLS- Health Literacy Score; HLSN- Health Literacy Score
Numeracy; HLSR- Health Literacy Score Reading; IG- Intervention Group; IGO- Intrinsic Goal Orientation; IR- Information Recall; IV- Independent Variable;
LHL- Low Health Literacy LL- Low Literacy; M- Mean; METER- Medical Term Recognition Test; n- Number of participants; N- Number of studies; NPIRQNetherlands Patient Information Recall Questionnaire; NS- None Stated; NVS- Newest Vital Sign; PCO- Primary Care Office; PH- Participant’s Home; POProvider’s Office; PS- Phone Survey; QLT- Qualitative; QNT- Quantitative; RCT- Randomized Control Trial; REALM- Rapid Estimate of Adult Literacy in
Medicine; SAHL-D- Short Assessment of Health Literacy in Dutch; SE- Self-Efficacy; SET- Self Efficacy Theory; SILS- Single Item Literacy Screener; STOFHA- Short Test of Functional Health Literacy in Adults; TA- Technology Attitude; TV- Task Value; TL- Times Logged In; US- United States

TEACH BACK TOOL FOR HEADACHE PROGRAM
(2016). Adoption
of a portal for the
primary care
management of
pediatric asthma:
a mixed-methods
implementation
study

Mode of
Factors

Country: US
Funding: Grant
from Agency for
Healthcare
Research and
Quality and
Eunice Kennedy
Shriver National
Institute of Child
Health & Human
Development

method study
Purpose:
feasibility of
using a patient
portal for
pediatric asthma
in primary care,
impact on
management,
and barriers and
facilitators of
implementing
success

Demographic:
Parents with
children with
asthma
Setting:
Primary care
practices
Inclusion:
English
speaking parent
of children 6-12
years of age
with asthma
diagnosis within
12 months,
Medicaid
insurance

IV: use of patient
portal
DV: adoption of
portal

regression.
Valid and
reliable
2. 5- point
Likert scale

tests, ttests,
Fisher, and
MannWhitney U

DV: sustained use
of portal

DV:
Adoption: n=237
DV:
Sustained use: n=
156

QLT:
1. Speak to the
doctor. 2. Make a
change to their
child’s medication
dosage. 3. Make a
change to their
home environment

QLT:
First survey
CD: 20
CM: 12
CE: 15
Secondary
CD: 49
CM: 11
CE: 8
QLT:
Themes:
1. importance of
practice
organizations,
asthma severity,
and innovation
characteristics for
implementation
success
Findings/
Results

Bias: Authors
were involved
with other online
platforms

Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major Variables
& Definitions

Measurement/
Instrumentation

Data
analysis
(stats used)

Irizarry, T.

Stages of

Design: Mixed-

N= 100

QNT:

1. Likert-scale

Descriptive

QNT:

25
Weakness:
practices from
single health
system, portal
was
administered
during study
and not
voluntarily
used, short
follow up
period
Conclusions:
Portal adaption
unlikely in
short term, but
have potential
for benefits to
communication

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
Level 3

Key: A- Attitude; AL- Adequate Literacy; CFG- Clinical Focus Groups; CG- Control Group; CLB- Control of Learning Beliefs; COPD- Chronic Obstructive
Pulmonary Disease; DL- Days Logged In; DV- Dependent Variable; E- Exposure; EGO- Extrinsic Goal Orientation; eHEALS- eHealth Literacy Scale; EHRElectronic Health Record; FU- Follow-up; FG- Focus Group; HLH- High Health Literacy; HLS- Health Literacy Score; HLSN- Health Literacy Score
Numeracy; HLSR- Health Literacy Score Reading; IG- Intervention Group; IGO- Intrinsic Goal Orientation; IR- Information Recall; IV- Independent Variable;
LHL- Low Health Literacy LL- Low Literacy; M- Mean; METER- Medical Term Recognition Test; n- Number of participants; N- Number of studies; NPIRQNetherlands Patient Information Recall Questionnaire; NS- None Stated; NVS- Newest Vital Sign; PCO- Primary Care Office; PH- Participant’s Home; POProvider’s Office; PS- Phone Survey; QLT- Qualitative; QNT- Quantitative; RCT- Randomized Control Trial; REALM- Rapid Estimate of Adult Literacy in
Medicine; SAHL-D- Short Assessment of Health Literacy in Dutch; SE- Self-Efficacy; SET- Self Efficacy Theory; SILS- Single Item Literacy Screener; STOFHA- Short Test of Functional Health Literacy in Adults; TA- Technology Attitude; TV- Task Value; TL- Times Logged In; US- United States

TEACH BACK TOOL FOR HEADACHE PROGRAM
(2017). Patient
portals as a tool
for health care
engagement: a
mixed-method
study of older
adults with
varying levels of
health literacy
and prior patient
portal use
Country: US
Funding: Aging
Institute of
University of
Pittsburg Medical
Center
Bias: Sampling
Bias

Change Model

method study
Purpose:
explore attitudes
toward portal
adoption and its
perceived
usefulness as a
tool in health
care
management

Demographic:
Participants 65
years or older
with cognitive
ability to answer
questions
Setting: in
home
Inclusion: NS
Exclusion:
participants
must be living
in an
independent
residence

IV: Apply health
literacy tool
DV Groups: PS,
FU, FG
DV: Technology
attitudes
DV: Portal use
QLT:
1. experience with
technology-HRI
2. Impressions
about patient portal
demonstration and
usefulness and PU

questions.
Valid and
reliable
2. Patient
Activation
Measure. Valid
and reliable

statistical
analysis

DV-TA:
PS n=5.72
FU n= 6.33
FG n= 6.26
p=0.01
DV-PU:
PS n= 0
FU n= 25
FG n=11
p= <0.001
QLT:
1. Don’t want to
feel pushed into
doing anything
2. Adopt only if
required
3. Somebody
needs to help me
4. General
convenience of
the portal for
simple tasks and
medical history
5. Appreciates
current features
and excited about
new ones

26
Weakness:
statistically
significant
differences of
the population
between the
groups, low
literacy group
was larger,
75% of groups
were white,
portal was in
English only
Conclusion:
Health care
organizations
should
consider: 1.
Portal adoption
campaign
tailored to
needs of
adults. 2. Taskspecific
training 3.
Target
caregiver
proxy uses as
part of
training. 4.
Info line for

Key: A- Attitude; AL- Adequate Literacy; CFG- Clinical Focus Groups; CG- Control Group; CLB- Control of Learning Beliefs; COPD- Chronic Obstructive
Pulmonary Disease; DL- Days Logged In; DV- Dependent Variable; E- Exposure; EGO- Extrinsic Goal Orientation; eHEALS- eHealth Literacy Scale; EHRElectronic Health Record; FU- Follow-up; FG- Focus Group; HLH- High Health Literacy; HLS- Health Literacy Score; HLSN- Health Literacy Score
Numeracy; HLSR- Health Literacy Score Reading; IG- Intervention Group; IGO- Intrinsic Goal Orientation; IR- Information Recall; IV- Independent Variable;
LHL- Low Health Literacy LL- Low Literacy; M- Mean; METER- Medical Term Recognition Test; n- Number of participants; N- Number of studies; NPIRQNetherlands Patient Information Recall Questionnaire; NS- None Stated; NVS- Newest Vital Sign; PCO- Primary Care Office; PH- Participant’s Home; POProvider’s Office; PS- Phone Survey; QLT- Qualitative; QNT- Quantitative; RCT- Randomized Control Trial; REALM- Rapid Estimate of Adult Literacy in
Medicine; SAHL-D- Short Assessment of Health Literacy in Dutch; SE- Self-Efficacy; SET- Self Efficacy Theory; SILS- Single Item Literacy Screener; STOFHA- Short Test of Functional Health Literacy in Adults; TA- Technology Attitude; TV- Task Value; TL- Times Logged In; US- United States

TEACH BACK TOOL FOR HEADACHE PROGRAM

27

Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major Variables
& Definitions

Measurement/
Instrumentation

Data
analysis
(stats used)

Findings/
Results

King, G. (2017).
Connecting
families to their
health record and
care team: the
use, utility, and
impact of a
client/family
health portal at a
children’s
rehabilitation
hospital

SET

Design: Mixedmethod study

n= 869

QNT:
IV: patient portal

1. Pediatric
Rehabilitation
Intervention
Measure of
Engagement
for Parents
(unpublished
instrument).
2. Content
Analysis
Approach

Aggregate
scores,
survey
scales

QNT:
M:
E = 253
TL = 22.2
DL = 19.2
Average log in 2.5
times/month

Country: Canada
Funding: Canada
Health Infoway
Inc.
Bias: An author
is affiliated with
Canada Health
Infoway

Purpose:
examine the use,
utility, and
impact on
engagement in
care and
caregiverprovider
communication
of a
client/family
portal providing
access to EHR
and e-messaging

Demographics:
Jan 2015March 2016
parents of
children with
special health
care needs
Setting: PH/PO
Inclusion:
Printed in
English
Exclusion: NS

DV: portal use
Groups: E, TL, DL
QLT:
1. caregiver themes
2. provider themes

QLT:
Themes:
Caregiver: 1.
Information
benefits
2.
Recommendations
to increase use
and utility
3. Scope of
adoption and
future vision
Themes: Provider:
1. Utility to set up

patients to call
and ask portal
questions
Level/Quality
of Evidence;
Decision for
practice/
application to
practice
Level 3

Strengths:
data collection
on login info,
breadth of info
collected,
included
caregiver and
provider
Weakness:
descriptive
nature, short
time frame (68 weeks), may
not have reach
data saturation
for qualitative
portion
Conclusion:
Caregivers saw
benefit while

Key: A- Attitude; AL- Adequate Literacy; CFG- Clinical Focus Groups; CG- Control Group; CLB- Control of Learning Beliefs; COPD- Chronic Obstructive
Pulmonary Disease; DL- Days Logged In; DV- Dependent Variable; E- Exposure; EGO- Extrinsic Goal Orientation; eHEALS- eHealth Literacy Scale; EHRElectronic Health Record; FU- Follow-up; FG- Focus Group; HLH- High Health Literacy; HLS- Health Literacy Score; HLSN- Health Literacy Score
Numeracy; HLSR- Health Literacy Score Reading; IG- Intervention Group; IGO- Intrinsic Goal Orientation; IR- Information Recall; IV- Independent Variable;
LHL- Low Health Literacy LL- Low Literacy; M- Mean; METER- Medical Term Recognition Test; n- Number of participants; N- Number of studies; NPIRQNetherlands Patient Information Recall Questionnaire; NS- None Stated; NVS- Newest Vital Sign; PCO- Primary Care Office; PH- Participant’s Home; POProvider’s Office; PS- Phone Survey; QLT- Qualitative; QNT- Quantitative; RCT- Randomized Control Trial; REALM- Rapid Estimate of Adult Literacy in
Medicine; SAHL-D- Short Assessment of Health Literacy in Dutch; SE- Self-Efficacy; SET- Self Efficacy Theory; SILS- Single Item Literacy Screener; STOFHA- Short Test of Functional Health Literacy in Adults; TA- Technology Attitude; TV- Task Value; TL- Times Logged In; US- United States

TEACH BACK TOOL FOR HEADACHE PROGRAM

Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major Variables
& Definitions

Measurement/
Instrumentation

Data
analysis
(stats used)

Li, Tim. (2013).
Evaluation of a
web-based social
network
electronic game
in enhancing
mental health
literacy for young
people

SET

Design: Mixed
Method

N= 73
Mean age 20.82
Female = 42
Male = 31

QNT:
IV: Web-based,
electronic game

1. Motivational
Strategies for
Learning
Questionnaire
(MSLQ).
Instrument is
reliable and
valid 2. 7point Likert
scale

t-test,
Descriptive
statistics,
Linear
regression

Country: Asia
Funding: Health

Purpose:
To assess the
effectiveness of
fully automated,
Web-based,
social network
electronic game
enhancing
mental health
knowledge and

Demographics:
Nov 2011- Dec
2011
Setting: in
home
Inclusion: ages

DV: mental
health knowledge
QLT:
Learning
motivation
1. Value
2. Expectancy

appointments
2. Identified
technical
shortcomings
3. Uncertainty in
portal use related
to lack of
knowledge,
comfort, or
confidence using
portal
4. Concerned use,
effort, and
investment in the
portal
Findings/
Results

QNT:
Mental health
knowledge
groups: Pre-post
tests
M:
Pre-score: 19
Pre-score: 21.21
Improvement:
2.21
p<0.001

28

providers did
not, possible
future portal
change: more
patient
engagement
with portal
itself

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
Level 3
Weakness:
exploratory
study, lack of
control group,
small sample
size, high
dropout rate,
biased sample
Conclusion:

Key: A- Attitude; AL- Adequate Literacy; CFG- Clinical Focus Groups; CG- Control Group; CLB- Control of Learning Beliefs; COPD- Chronic Obstructive
Pulmonary Disease; DL- Days Logged In; DV- Dependent Variable; E- Exposure; EGO- Extrinsic Goal Orientation; eHEALS- eHealth Literacy Scale; EHRElectronic Health Record; FU- Follow-up; FG- Focus Group; HLH- High Health Literacy; HLS- Health Literacy Score; HLSN- Health Literacy Score
Numeracy; HLSR- Health Literacy Score Reading; IG- Intervention Group; IGO- Intrinsic Goal Orientation; IR- Information Recall; IV- Independent Variable;
LHL- Low Health Literacy LL- Low Literacy; M- Mean; METER- Medical Term Recognition Test; n- Number of participants; N- Number of studies; NPIRQNetherlands Patient Information Recall Questionnaire; NS- None Stated; NVS- Newest Vital Sign; PCO- Primary Care Office; PH- Participant’s Home; POProvider’s Office; PS- Phone Survey; QLT- Qualitative; QNT- Quantitative; RCT- Randomized Control Trial; REALM- Rapid Estimate of Adult Literacy in
Medicine; SAHL-D- Short Assessment of Health Literacy in Dutch; SE- Self-Efficacy; SET- Self Efficacy Theory; SILS- Single Item Literacy Screener; STOFHA- Short Test of Functional Health Literacy in Adults; TA- Technology Attitude; TV- Task Value; TL- Times Logged In; US- United States

TEACH BACK TOOL FOR HEADACHE PROGRAM
Care and
Promotion Fund

problem-solving
skills of young
people

Bias:
Performance Bias

17-25, adequate
internet literacy
and a Facebook
account,
reachable via
local network

3. Affect: test
anxiety

Exclusion:
None specified

Qualitative
Studies
Citation

Kim, H. (2017).
Health literacy in
the ehealth era: a
systematic review
Country: US,
Europe, Oceania,
North America
Funding: No
Funding
Bias: Transfer
Bias

QLT:
Value:
M:
IGO= 4.97
EGO = 3.91
TV = 4.70
Expectancy:
CLB = 4.75
SE= 4.80
Affect:
TA= 3.34

social and
gaming
features may
enhance the
effectiveness
of internetbased
intervention on
health
education for
young adults
Level/Quality
of Evidence;
Decision for
practice/
application to
practice
Level 5

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major Variables
& Definitions

Measurement/
Instrumentation

Data
analysis
(stats used)

Findings/
Results

SET

Design:
Systematic
Review

N= 644

Demographics:
Articles were
published
between 2010
and 2014

eHEALS, STOFHA,
REALM, NVS,
METER, SILS,
Web
Performance
tests, Active
Australia
Questionnaire

Thematic
Synthesis

Purpose: aimed
to identify
studies on online
health services
use by people
with limited
health literacy to
understand how
health literacy
should be
addressed in the

How do studies
online health
services used by
people with
limited health
literacy
understand health
literacy should
be addressed in
the ehealth era?

Themes:
1. Evaluation of
health-related
content 2.
Development and
evaluation of
ehealth services
3. Development
and evaluation of
health literacy
measurement
tools 4.
Interventions to
improve health

n= 74

Setting: in
home
Inclusion: focus
on health or

29

Weakness:
word search
did not use
controlled
vocab, exact
keywords were
excluded, only
English
studies, time
frame was
2010-March
2014

Key: A- Attitude; AL- Adequate Literacy; CFG- Clinical Focus Groups; CG- Control Group; CLB- Control of Learning Beliefs; COPD- Chronic Obstructive
Pulmonary Disease; DL- Days Logged In; DV- Dependent Variable; E- Exposure; EGO- Extrinsic Goal Orientation; eHEALS- eHealth Literacy Scale; EHRElectronic Health Record; FU- Follow-up; FG- Focus Group; HLH- High Health Literacy; HLS- Health Literacy Score; HLSN- Health Literacy Score
Numeracy; HLSR- Health Literacy Score Reading; IG- Intervention Group; IGO- Intrinsic Goal Orientation; IR- Information Recall; IV- Independent Variable;
LHL- Low Health Literacy LL- Low Literacy; M- Mean; METER- Medical Term Recognition Test; n- Number of participants; N- Number of studies; NPIRQNetherlands Patient Information Recall Questionnaire; NS- None Stated; NVS- Newest Vital Sign; PCO- Primary Care Office; PH- Participant’s Home; POProvider’s Office; PS- Phone Survey; QLT- Qualitative; QNT- Quantitative; RCT- Randomized Control Trial; REALM- Rapid Estimate of Adult Literacy in
Medicine; SAHL-D- Short Assessment of Health Literacy in Dutch; SE- Self-Efficacy; SET- Self Efficacy Theory; SILS- Single Item Literacy Screener; STOFHA- Short Test of Functional Health Literacy in Adults; TA- Technology Attitude; TV- Task Value; TL- Times Logged In; US- United States

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ehealth era

Citation

Theory/
Conceptual
Framework

Design/
Method

Melholt, C.
(2018). Cardiac
patients’
experiences with
a
telerehabilitation
web portal:
implications for
ehealth literacy

SET

Design:
Descriptive
Exploratory
Purpose: To
explore how
cardiac patients
experience their
use of a
telerehabilitation

literacy 5.
Online health
information
seeking behavior

ehealth literacy,
addressing ICTs
on the internet
and/or mobile
apps for health
purpose, printed
in English,
original
empirical
articles
Exclusion:
studies which
did not meet all
five inclusion
criteria, target
audience was
health
professionals,
non-empirical

Sample/
Setting

Major Variables
& Definitions

Measurement/
Instrumentation

Data
analysis
(stats used)

Findings/
Results

N=49
Mean age 60.64
=/- 10.75
82% male

When using the
telerehabilitation
tool, how to
patient’s’ view tool
for recuperation
and how does the
use of the w\web
portal affect their
ehealth literacy
skills?

Questionnaires
using 5 point
Likert scale,,
Survey Xact

Wilcoxon
Signed-Rank
test

Themes:
1. Easy to access,
user-friendly, and
written in
understandable
language.
2. Using an online
rehabilitation portal
generally improves
cardiac patients’

Demographics:
Sept 2014-Feb
2015
Setting: in

30
Conclusion:
Efforts should
be made to
make ehealth
services easily
accessible to
low-literacy
individuals and
to enhance
individual
health literacy
through
educational
programs

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
Level 6

Weakness:
cardiac patients
already using
computers,
telephones, and
internet
Conclusion: use

Key: A- Attitude; AL- Adequate Literacy; CFG- Clinical Focus Groups; CG- Control Group; CLB- Control of Learning Beliefs; COPD- Chronic Obstructive
Pulmonary Disease; DL- Days Logged In; DV- Dependent Variable; E- Exposure; EGO- Extrinsic Goal Orientation; eHEALS- eHealth Literacy Scale; EHRElectronic Health Record; FU- Follow-up; FG- Focus Group; HLH- High Health Literacy; HLS- Health Literacy Score; HLSN- Health Literacy Score
Numeracy; HLSR- Health Literacy Score Reading; IG- Intervention Group; IGO- Intrinsic Goal Orientation; IR- Information Recall; IV- Independent Variable;
LHL- Low Health Literacy LL- Low Literacy; M- Mean; METER- Medical Term Recognition Test; n- Number of participants; N- Number of studies; NPIRQNetherlands Patient Information Recall Questionnaire; NS- None Stated; NVS- Newest Vital Sign; PCO- Primary Care Office; PH- Participant’s Home; POProvider’s Office; PS- Phone Survey; QLT- Qualitative; QNT- Quantitative; RCT- Randomized Control Trial; REALM- Rapid Estimate of Adult Literacy in
Medicine; SAHL-D- Short Assessment of Health Literacy in Dutch; SE- Self-Efficacy; SET- Self Efficacy Theory; SILS- Single Item Literacy Screener; STOFHA- Short Test of Functional Health Literacy in Adults; TA- Technology Attitude; TV- Task Value; TL- Times Logged In; US- United States

TEACH BACK TOOL FOR HEADACHE PROGRAM
Country:
Netherlands
Funding: Eir
Research and
Business Park
Bias: Recall Bias

Citation

Theory/
Conceptual
Framework

tool for
recuperation
from surgery
and study how
the patients’ use
of the interactive
‘Active Heart’
web portal
affected their
health

home

Design/
Method

Sample/
Setting

Inclusion:
patients that had
ischemic heart
or heart failure,
above 18, live in
Hjoerring or
Frederikshavn
Municipalities,
have internet
connection, use
information
technology, able
to understand
the study info
Exclusion: lack
of ability to
speak and
understand
Danish,
pregnant,
breastfeeding,
neuro disease,
use of
wheelchair,
patient in other
studies

Major Variables
& Definitions

Measurement/
Instrumentation

Data
analysis
(stats used)

31

interest in ehealth
literacy

of a cardiac
telerehabilitation
web portal can
be beneficial for
patient education
and can increase
cardiac patients’
ehealth literacy
skills

Findings/
Results

Level/Quality
of Evidence;
Decision for
practice/
application to
practice

Key: A- Attitude; AL- Adequate Literacy; CFG- Clinical Focus Groups; CG- Control Group; CLB- Control of Learning Beliefs; COPD- Chronic Obstructive
Pulmonary Disease; DL- Days Logged In; DV- Dependent Variable; E- Exposure; EGO- Extrinsic Goal Orientation; eHEALS- eHealth Literacy Scale; EHRElectronic Health Record; FU- Follow-up; FG- Focus Group; HLH- High Health Literacy; HLS- Health Literacy Score; HLSN- Health Literacy Score
Numeracy; HLSR- Health Literacy Score Reading; IG- Intervention Group; IGO- Intrinsic Goal Orientation; IR- Information Recall; IV- Independent Variable;
LHL- Low Health Literacy LL- Low Literacy; M- Mean; METER- Medical Term Recognition Test; n- Number of participants; N- Number of studies; NPIRQNetherlands Patient Information Recall Questionnaire; NS- None Stated; NVS- Newest Vital Sign; PCO- Primary Care Office; PH- Participant’s Home; POProvider’s Office; PS- Phone Survey; QLT- Qualitative; QNT- Quantitative; RCT- Randomized Control Trial; REALM- Rapid Estimate of Adult Literacy in
Medicine; SAHL-D- Short Assessment of Health Literacy in Dutch; SE- Self-Efficacy; SET- Self Efficacy Theory; SILS- Single Item Literacy Screener; STOFHA- Short Test of Functional Health Literacy in Adults; TA- Technology Attitude; TV- Task Value; TL- Times Logged In; US- United States

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Schaffler, J.
(2018). The
effectiveness of
self-management
interventions for
individuals with
low health
literacy and/or
low income: a
descriptive
systematic review
Country: US
Funding: No
funding
Bias: Transfer
Bias

Chronic Care
Model

Design:
Descriptive
Systematic
Review
Purpose:
Review selfmanagement
interventions in
populations with
low income or
low health
literacy and
synthesize the
efficacy of the
interventions

N = 23
n = 5457
Demographics:
Groups of adults
with low
income or low
selfmanagement
Settings:
provider’s office
Inclusion:
English and
French full text

How does selfmanagement
interventions
impact individuals
with low health
literacy and/or low
income?

Quality
Summary
Score, Efficacy
Assessment
Based on SelfManagement
Skills, peerreviewed,
quasiexperimental

Thematic
Synthesis

Themes:
1. No patterns
linking mode of
delivery or the
person
implementing the
intervention to
efficacy.
2. Interventions
using three or four
self-management
skills were more
effective than
those presenting
less than three or
five skills.
3. Problem
solving is a key
component of
effective selfmanagement
across various
chronic conditions

32

Level 5
Weakness:
few studies did
not explain
core
components of
selfmanagement,
low
methodological
quality of some
studies, some
illnesses had
small number
of analysis,
health
comorbidities
not
documented
well
Conclusion:
Effective
interventions
focused on
problemsolving, taking
action, and
resource
utilization

Key: A- Attitude; AL- Adequate Literacy; CFG- Clinical Focus Groups; CG- Control Group; CLB- Control of Learning Beliefs; COPD- Chronic Obstructive
Pulmonary Disease; DL- Days Logged In; DV- Dependent Variable; E- Exposure; EGO- Extrinsic Goal Orientation; eHEALS- eHealth Literacy Scale; EHRElectronic Health Record; FU- Follow-up; FG- Focus Group; HLH- High Health Literacy; HLS- Health Literacy Score; HLSN- Health Literacy Score
Numeracy; HLSR- Health Literacy Score Reading; IG- Intervention Group; IGO- Intrinsic Goal Orientation; IR- Information Recall; IV- Independent Variable;
LHL- Low Health Literacy LL- Low Literacy; M- Mean; METER- Medical Term Recognition Test; n- Number of participants; N- Number of studies; NPIRQNetherlands Patient Information Recall Questionnaire; NS- None Stated; NVS- Newest Vital Sign; PCO- Primary Care Office; PH- Participant’s Home; POProvider’s Office; PS- Phone Survey; QLT- Qualitative; QNT- Quantitative; RCT- Randomized Control Trial; REALM- Rapid Estimate of Adult Literacy in
Medicine; SAHL-D- Short Assessment of Health Literacy in Dutch; SE- Self-Efficacy; SET- Self Efficacy Theory; SILS- Single Item Literacy Screener; STOFHA- Short Test of Functional Health Literacy in Adults; TA- Technology Attitude; TV- Task Value; TL- Times Logged In; US- United States

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33

Appendix B
Synthesis Table
Year
Theory/Framework
Level of Evidence
Design
Sample Size

Setting
At home
Medical office
Non-clinical setting
Primary Care
Practice
Provider’s Office
Demographics
Studies from 20072008
Studies from 20152016
Over 50 years old
Parents
Chronic illness

DurenWinfield
2015
Social
Cognitive
Theory

Hasum

Meppelink

III
RCT

II
RCT

II
RCT

263

90

231

X

2017
SEM

X

2015
SEM

X

Fiks

2016
Conceptual
Mode of
Factors
III
MixedMethod
9133

Irizarry

X
X

X

Kim

Melholt
2018
SEM

2018
Chronic
Care Model
V
Descriptive
Systematic
Review
N=23
n=5457

2017
SEM

2013
SEM

2017
SEM

III
MixedMethod

III
MixedMethod

VI
Systematic
Review

VI
Descriptive
Exploratory

X

X

X

X

X

100

X

X
X

Li

2017
Stages
of
Change
Model
III
MixedMethod

869

73

N= 644
n= 74

49

X

X
X

King

X

X
X

Schaffler

X

X

Key: A- Attitude; AL- Adequate Literacy; CFG- Clinical Focus Groups; CG- Control Group; CLB- Control of Learning Beliefs; COPD- Chronic Obstructive
Pulmonary Disease; DL- Days Logged In; DV- Dependent Variable; E- Exposure; EGO- Extrinsic Goal Orientation; eHEALS- eHealth Literacy Scale; EHRElectronic Health Record; FU- Follow-up; FG- Focus Group; HLH- High Health Literacy; HLS- Health Literacy Score; HLSN- Health Literacy Score
Numeracy; HLSR- Health Literacy Score Reading; IG- Intervention Group; IGO- Intrinsic Goal Orientation; IR- Information Recall; IV- Independent Variable;
LHL- Low Health Literacy LL- Low Literacy; M- Mean; METER- Medical Term Recognition Test; n- Number of participants; N- Number of studies; NPIRQNetherlands Patient Information Recall Questionnaire; NS- None Stated; NVS- Newest Vital Sign; PCO- Primary Care Office; PH- Participant’s Home; POProvider’s Office; PS- Phone Survey; QLT- Qualitative; QNT- Quantitative; RCT- Randomized Control Trial; REALM- Rapid Estimate of Adult Literacy in
Medicine; SAHL-D- Short Assessment of Health Literacy in Dutch; SE- Self-Efficacy; SET- Self Efficacy Theory; SILS- Single Item Literacy Screener; STOFHA- Short Test of Functional Health Literacy in Adults; TA- Technology Attitude; TV- Task Value; TL- Times Logged In; US- United States

TEACH BACK TOOL FOR HEADACHE PROGRAM

Independent
Variables
Computer
programs
Telehomecare
technology
Text
modality/Visual
format
Use of patient
portal
Health Literacy
Tool
Web-based
electronic game
Dependent
Variables
Patient Assistance
Portal use
Understanding
materials
Increase in health
literacy/Info recall
Attitudes
Findings
Portal adoption
Increase in literacy
Visual graphics
Communication
Problem-solving

X

X

X
X

X
X
X
X

X

X
X

X

34

X
X

X

X

X
X
X

X

X
X

X

X

X
X

X

X

X

X

X

X

X

X

X

X

Running head: TEACH BACK TOOL FOR HEADACHE PROGRAM

Appendix C
Self-Efficacy Model

(Image of Self-efficacy model, n.d.)

35

TEACH BACK TOOL FOR HEADACHE PROGRAM
Appendix D
Iowa Model of Evidence Based Practice

(Image of Iowa model of Evidence Based Practice, n.d.)

36

Running head: TEACH BACK TOOL FOR HEADACHE PROGRAM
Appendix E
Questionnaire of Knowledge Questions
#
Date of Visit:
Age:
Current headache? Yes/No
Focus: prevention/triggers
Pre-Questionnaire

1. In a few words, what does the word ‘headache mean to you’?

2. What other symptoms do you have when you get a headache?
3. Can you name a few triggers?

4. How could you prevent your headaches?

Post-Questionnaire
1. After talking about ways to prevent headaches, could you tell me a few ways how
you will prevent your headaches?
a.
2. Can you name some of your triggers that you will avoid?
a.

Additional Comments:
Increase awareness for “prevention” topic?
Increase awareness for “trigger topic”

Yes
No

37

TEACH BACK TOOL FOR HEADACHE PROGRAM
Appendix F
Patient Demographics

38

TEACH BACK TOOL FOR HEADACHE PROGRAM
Appendix G
Mean Pre and Post Triggers and Prevention

39

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Appendix H
Percentage of Patients who Used Headache Diary

Assessment of Phone Calls

40