Introduction
An aging population is bringing about a global demographic shift. This is causing an increase in chronic conditions such as type 2 DM among people 65 and older (Sinclair et al., 2020). The increase in cases has led to a need to explore the difficulties older adults face in light of the complexity of medication adherence concerns in this population.
Medication adherence has persisted as a problem in DM management despite advancements, particularly for older adults who face cognitive decline and practical difficulties with insulin administration (Sugandh et al., 2023). Customized interventions, such as the teach-back approach based on adult learning and cognitive psychology theories, have become a way of addressing cognitive obstacles and improving precise insulin administration in older adults (Kim et al., 2022). The main goal of this review is to find out how well the teach-back approach works to improve the adherence of older adults with type 2 DM to insulin.
Review of Literature
Farahaninia et al.’s Study
Farahaninia et al. (2020) conducted a level II evidence pretest/posttest clinical trial to investigate the effect of the teach-back method on the self-management of 74 Iranian patients diagnosed with type 2 DM (T2D). The objective of the research is to evaluate the immediate impact on patients’ self-efficacy (Farahaninia et al., 2020). Convenience sampling was employed, and participants’ literacy, mental health, and lack of recent involvement in DM education programs were requirements for inclusion (Farahaninia et al., 2020).
The sample was split into training and control groups. For a month, the former participated in a 5-session teach-back program (Farahaninia et al., 2020). The results show that the intervention group’s self-efficacy significantly increased (p < 0.001), highlighting the method’s short-term effectiveness (Farahaninia et al., 2020). However, the study notes certain limitations that could affect response reliability and generalizability, such as differences in educational attainment and attendance issues.
Kim et al.’s Study
A randomized controlled trial (RCT) with a Level II level of evidence is what Kim et al. (2020) studied. Kim et al. (2020) conducted a study investigating the impact of health literacy on managing Type 2 DM in first-generation Korean American immigrants. 250 people with uncontrolled Type 2 DM were included in the sample; most were middle-aged (average age = 58.7 years) (Kim et al., 2020). Data were collected at baseline and at 3, 6, 9, and 12 months of the intervention, which included a 6-week didactic class, monthly telephone counseling, and daily blood sugar monitoring at home (Kim et al., 2020).
According to Kim et al. (2020), the intervention group showed statistically significant improvements in health literacy measures when compared to the control group. These improvements persisted for a full year. For path analyses, the study’s sample size was comparatively small (n = 209), and the internal consistency of one DQOL subscale was low (.66) (Kim et al., 2020). According to Kim et al. (2020), the RMSEA suggested that the data’s fit to the model was insufficient.
Zare et al.’s Study
The research done by Zare et al. (2021) had a level of evidence of III and was semi-experimental controlled. It examined how teach-back and videotape training approaches affected patients with type 2 DM’s self-efficacy and capacity for self-care (Zare et al., 2021). 105 patients, ages 30-55, were included in the sample; they were chosen from the DMResearch Center in Birjand, Iran (Zare et al., 2021). Three groups participated in the intervention: control, teach-back, and videotape training (Zare et al., 2021).
Seven days, one month, and three months after the intervention, the teach-back group had higher mean total scores of self-care (P < 0.001), suggesting that the teach-back method was significantly more effective than the videotape method (Zare et al., 2021). In comparison to the videotape and control groups, the teach-back group’s self-care and self-efficacy scores significantly increased (P < 0.001) (Zare et al., 2021). The reliance on self-reported data and the lack of direct observation of self-care behaviors were two of the study’s limitations (Zare et al., 2021).
Nas et al.’s Study
At Level II of evidence, Nas et al.’s randomized controlled trial from 2020 evaluated the effects of the teach-back educational approach on patients’ clinical parameters and DM knowledge at the start of insulin therapy. Seventy people with type 2 DM aged at least 18 years were included in the study; those with dementia or sensory impairments were excluded (Nas et al., 2020). The Intervention Group (IG) underwent a personalized explanation and evaluation process using the teach-back method, while the Control Group (CG) continued to receive regular DMeducation (Nas et al., 2020).
Following education, the IG showed a significant increase in their knowledge of DM, with mean scores of 16.9 ± 2.1 compared with 14.1 ± 2.0 in the CG (P <.05) (Nas et al., 2020). Notably, at the 3-month follow-up, clinical parameters, including hemoglobin A1c and fasting blood glucose, showed favorable changes in the IG (Nas et al., 2020). Nevertheless, the research has certain drawbacks, including being a single-center study, a 3-month evaluation period, and a lack of validation for the DM knowledge test (Nas et al., 2020).
Hong et al.’s Study
Hong et al. (2020) investigated the use and effects of teach-back, an interactive communication loop, in the delivery of DM care through a cross-sectional analysis of MEPS data from 2011-2016, categorized as Level III evidence. Examining patterns of teach-back utilization across different patient demographics was done using survey-design adjusted analyses. The sample comprised 2,901 adult US citizens with DM aged 18 or older (Hong et al., 2020).
According to the results, 25.0% of participants reported experiencing teach-back during their care visits. Those who had teach-back also showed improved confidence in self-care (75.7% vs. 70.3%), higher interaction quality scores, and more dietary and exercise guidance (67.0% vs. 60.9%). Nonetheless, the research highlighted certain drawbacks, including the use of patient self-reports as a teach-back tool, the possibility that unmeasured clinical variables could influence results, and the lack of provider-level data in the analysis (Hong et al., 2020).
Kakahthum et al.’s Study
Level II evidence was provided by the randomized control trial by Kakahthum et al. (2022), which examined the effects of a program to improve health literacy on the self-care practices and health outcomes of older adults with comorbid DM and hypertension. The sample, which consisted of 60 individuals between the ages of 60 and 69, was chosen at a private primary care facility in Bangkok, Thailand, using simple random sampling (Kakahthum et al., 2022).
While the control group received standard care, the experimental group participated in an eight-week program that focused on functional, interactive, and critical health literacy (Kakahthum et al., 2022). The experimental group’s post-intervention health literacy scores were 123±4.90, while the control group’s scores were 94.17±5.86 (Kakahthum et al., 2022). The small sample size and possible biases were acknowledged as limitations of the study (Kakahthum et al., 2022).
Qiong et al.’s Study
Qiong et al.’s 2022 study is a two-arm, parallel-group, randomized controlled trial with single-masked and Level II evidence. It evaluated how well a Teach-Back Health Education (TBHE) WeChat mini-program taught urban older adults health education information for fall prevention (Qiong et al., 2022). Three residential communities in Fuzhou, China, were used to recruit the sample, including 59 participants who were 60 or older (Qiong et al., 2022). Participants were randomized to either the control group, which received traditional health education, or the intervention group, which received TBHE through the WeChat mini-program (Qiong et al., 2022).
The intervention group attended biweekly sessions for eight weeks, focusing on particular fall prevention topics (Qiong et al., 2022). The results showed that both groups had significant within-group knowledge score differences (p<0.001) and that there was a significant difference in the groups’ knowledge of the home environment (p=0.003) (Qiong et al., 2022). Potential problems with authenticity in WeChat feedback, a small sample size, infrequent interventions, and a brief duration were among the limitations that affected the study’s robustness (Qiong et al., 2022).
Parra et al.’s Study
Level II evidence applies to the Parra et al. (2021) randomized clinical trial, which used a parallel-group design. In people with type-2 DM and hypertension, the study evaluated the effect of a nursing intervention on therapeutic regimen adherence (Parra et al., 2021). 200 patients who were enrolled in primary care initiatives that addressed cardiovascular risk factors were included in the sample (Parra et al., 2021).
To improve therapeutic adherence, the intervention used affective support, behavioral modification, and individual teaching (Parra et al., 2021). The intervention group showed a significant improvement in adherence after six months (0.87 points) (Parra et al., 2021). Potential compromise from doctors treating both arms, the Hawthorne effect, baseline optimal levels potentially hiding changes, potential insufficiency of study power, and lack of documentation about prompt pharmacological treatment are some limitations (Parra et al., 2021).
Talevski et al.’s Study
A systematic review (Level I of evidence) on the application of teach-back in various healthcare settings is presented in the Talevski et al. (2020) study. Although implementation strategies were not frequently reported, teach-back was primarily delivered with an organized educational approach (Talevski et al., 2020). Nineteen out of twenty studies showed effectiveness, indicating gains in knowledge and health-related outcomes (Talevski et al., 2020). However, there are also drawbacks, such as possible publication bias, incomplete reporting of implementation details in some studies, and the inability to perform a meta-analysis due to heterogeneity in outcome measures (Talevski et al., 2020).
Hesselink et al.’s Study
In order to assess the efficacy of the teach-back method for older patients, Hesselink et al. (2021) carried out a nonrandomized pre-post pilot study in the emergency department of a Dutch academic hospital, with an evaluation level of evidence of III. Teach-back reduced the odds of ED revisits within 8–30 days (AOR 0.42; 95% CI 0.14 to 1.33), according to Hesselink et al.’s 2021 analysis of a sample of 648 participants that included 154 older adults. According to Heselink et al. (2021), teach-back participants retained more information about ED diagnosis, medication, and follow-up appointments. A nonrandomized design, a single-site study, a small sample size, potential bias, the Hawthorne effect, selection bias, and the inability to prove a causal relationship between teach-back and observed ED return visits were among the study’s limitations (Hesselink et al., 2021).
Discussion of Resources
The literature review offers information about a range of studies on the application of teach-back techniques in DM care. Numerous studies, including Kim et al. (2020) and Farahaninia et al. (2020), demonstrate how the teach-back method improves patients with Type 2 DM’s health literacy and sense of self-efficacy. In particular, Farahaninia et al. (2020) highlight the short-term efficacy of a 5-session teach-back program.
Despite limitations in sample size and internal consistency, Kim et al. (2020) continue this positive trend by demonstrating consistent improvements in health literacy measures over 12 months. Hesselink et al. (2021) and Kakahthum et al. (2022) broaden the focus to encompass health literacy improvement initiatives and older adults. Teach-back was linked by Hesselink et al. (2021) to improved knowledge retention. Based on the results of these studies, it can be concluded that the teach-back approach has demonstrated benefits for several DM management domains, such as medication adherence, health literacy, self-efficacy, and self-care skills.
The literature review does, however, also highlight some drawbacks and difficulties. Research frequently highlights problems such as small sample sizes, possible biases, dependence on self-reported data, and methodological flaws(Kim et al., 2020; Zare et al., 2021; Hesselink et al., 2021). The use of teach-back techniques for insulin use in older adults with Type 2 DM and its impact on medication adherence is a specific research question that has notable gaps in the literature despite the support for the efficacy of the teach-back method.
Crucially, the use of insulin is not explicitly focused on by researchers. A single study by Nas et al. (2020) assesses how the teach-back educational approach affects patients starting insulin therapy. As a result, the body of research directly addressing insulin use and medication adherence in older adults is relatively small.
The chosen studies’ age ranges vary, but few articles target people 65 and beyond. Only two studies, by Kakahthum et al. (2022) and Hesselink et al. (2021), mention participants who are 60 or older. Most studies focus on middle-aged adults, whereas focusing on this age group is essential because older adults may face particular challenges managing their DM. In the context of insulin use, none of the studies directly examines the effect of teach-back methods on medication adherence. While some research evaluates health literacy, there is still little research on the direct relationship between this factor and medication adherence, particularly regarding insulin therapy.
Conclusion
There is a clear research gap concerning the effects of the teach-back technique on medication adherence in older adults using insulin. Nonetheless, the literature contains evidence on the usefulness of teach-back methods in DM management. Subsequent research endeavors ought to concentrate on this particular demographic, utilize uniform metrics concerning medication compliance, and investigate the obstacles linked to insulin treatment in elderly individuals diagnosed with Type 2 DM.
References
Farahaninia, M., Hoseinabadi, T. S., Raznahan, R., & Haghani, S. (2020). The teach-back effect on self-efficacy in patients with type 2 diabetes. The Review of Diabetic Studies, 16(1), 46–50.
Hesselink, G., Sir, Ö., Koster, N., Tolsma, C., Munsterman, M., Rikkert, M. G. M. O., & Schoon, Y. (2021). Teach-back of discharge instructions in the emergency department: A pre–post pilot evaluation. Emergency Medicine Journal, 39(2), 139–146.
Hong, Y., Jo, A., Cardel, M. I., Huo, J., & Mainous, A. G. (2020). Patient-provider communication with teach-back, patient-centered diabetes care, and diabetes care education. Patient Education and Counseling, 103(12), 2443–2450.
Kakahthum, P., Lagampan, S., & Amnartsatsue, K. (2022). Effects of health literacy improvement program on self-care behaviors and health outcomes in older adults with type 2 diabetes and hypertension comorbidities. Journal of Public Health and Development, 20(2).
Kim, C., Kim, M., Lee, G., Park, E. Y., & Schlenk, E. A. (2022). Effectiveness of nurse‐led interventions on medication adherence in adults taking medication for metabolic syndrome: A systematic review and meta‐analysis. Journal of Clinical Nursing, 32(15–16), 5328–5356.
Kim, M. T., Kim, K. B., Ko, J., Murry, N., Xie, B., Radhakrishnan, K., & Han, H. R. (2020). Health literacy and outcomes of a community-based self-help intervention. Nursing Research, 69(3), 210–218.
Nas, M. A., Çayır, Y., & Bilen, A. (2020). The impact of teach‐back educational method on diabetes knowledge level and clinical parameters in type 2 diabetes patients undergoing insulin therapy. International Journal of Clinical Practice, 75(4).
Parra, D. I., Guevara, S. L. R., & Rojas, L. Z. (2021). ‘Teaching: individual’ to improve adherence in hypertension and type 2 diabetes. British Journal of Community Nursing, 26(2), 84–91.
Qiong, Y., Yang, Y., Yao, M., Yang, Y., & Lin, T. (2022). Effects of teach-back health education (TBHE) based on WeChat mini-programs in preventing falls at home for urban older adults in China: A randomized controlled trial. BMC Geriatrics, 22(1).
Sinclair, A. J., Saeedi, P., Kaundal, A., Karuranga, S., Malanda, B., & Williams, R. (2020). Diabetes and global ageing among 65–99-year-old adults: Findings from the International Diabetes Federation Diabetes Atlas, 9th edition. Diabetes Research and Clinical Practice, 162.
Sugandh, F., Chandio, M., Raveena, F., Kumar, L., Karishma, F., Khuwaja, S., Memon, U. A., Bai, K. V. K., Kashif, M., Varrassi, G., Khatri, M., & Kumar, S. (2023). Advances in the management of diabetes mellitus: A focus on personalized medicine. Cureus.
Talevski, J., Shee, A. W., Rasmussen, B., Kemp, G., & Beauchamp, A. (2020). Teach-back: A systematic review of implementation and impacts. PLOS ONE, 15(4).
Zare, M. H., Nikraftar, F., Madarshahian, F., & Mahmoudirad, G. (2021). Comparing the effect of teach back and video tape education on self-efficacy and self-care in type 2 diabetes patients. Modern Care Journal, 18(2).