Investigating and Comparing the Effect of Teach-Back and Multimedia Teaching Methods on Self-Care in Patients With Diabetic Foot Ulcers

This study was a single-blind, parallel clinical trial conducted with two groups of PWD with diabetic foot complications who wanted to be discharged from hospitals affiliated with Shahid Beheshti University in Tehran, Iran. The sample size was 30 people for each group. A convenience sampling method was used, and participants were randomly assigned to either the teach-back or multimedia teaching groups or a control group that offered routine care, including educational recommendations about nursing care offered at discharge time in the hospital wards.

Inclusion criteria included age of 20–80 years, physician’s diagnosis of diabetes based on the patients’ medical files, history of diabetic foot ulcer or risk factors for diabetic foot (e.g., sensory or motor neuropathy, or both), some degree of ulcer in an active foot that did not require amputation according to the physician's diagnosis, lack of previous amputation, lack of immunosuppressive drug therapy (e.g., corticosteroid treatment), ability to read and write in patient or a close family member, lack of education in medical sciences, lack of previous experience of formal training on ulcer care, appropriate mental and psychological conditions, ability to receive phone calls, and the ability to use a mobile phone to watch educational videos. Patients who expressed dissatisfaction with continuing research and those who had had an amputation were excluded.

Participants’ educational needs were determined and an educational program was developed and approved by the faculty professors. In the teach-back group, the researcher went to patients’ rooms before they were discharged and provided training in a single one-on-one, face-to-face session lasting 45 minutes, using simple, understandable language free of medical terminology. At the end of these sessions, the researcher asked patients to retell the material in their own words as they understood it. If a patient did not understand the material well, the researcher would repeat the material until the patient fully understood and could demonstrate understanding by retelling the information. Training was considered effective if patients responded correctly to 75% of the questions when asked to retell the information they were taught. For those who answered <75% correctly, the teaching process would continue. After 2 weeks, participants were evaluated during a mobile phone call.

In the multimedia group, the same content was used but was not provided orally in person. Instead, patients received educational videos via CD, DVD, and mobile device files. The content of these videos included everything that was taught in person in the teach-back group, and, as in that group, the education lasted for 45 minutes. As in the teach-back group, participant understanding was assessed 2 weeks later.

A demographic data questionnaire was used to gather information on 16 variables, including age, sex, education level, marital status, employment status, living place, history of hospitalization resulting from diabetes, number of hospitalizations due to diabetes, insurance status, lifestyle, diabetes duration of diabetes, ulcer site, time since ulcer emergence, membership in social institute (institutes who help the poor, the sick, the disabled, and the homeless), A1C, and medications. In addition, the 15-question Diabetes Management Self-Efficacy Scale (DMSES) was used to gather data on self-care during the previous 7 days and covered various aspects of self-care and related behaviors, including diet, exercise, blood glucose testing, foot care, and smoking. For this instrument, a score of 0–7 is given for each behavior, and a general compliance score is then calculated by summing those individual item scores. The total score can range from 0 to 99. This questionnaire was standardized with an α of 0.83. The patients with a self-care score of 0–33 were considered to have an undesirable level of self-care; those with a score of 34–66 were considered to have a moderate level of self-care, and those with a score of 67–99 were considered to have a desirable level of self-care. To resolve any ambiguities when answering the DMSES questions, the researcher sat with the participants and answered any questions they had.

Human rights were respected in this study in accordance with the Helsinki Declaration of 1975, as revised in 1983. Patients provided informed consent. The study was approved by the ethics committee of Bojnourd University of Medical Sciences of North Khorasan Province, Iran (ethical code #IR.SBMU.PHARMACY.REC.1398.201, trial identifier TCTR20200125002, available from http://www.thaiclinicaltrials.org).

Descriptive results are presented as mean ± SD or percentage. Paired t tests and ANOVA were used to compare means. P <0.05 was considered statistically significant. All data were analyzed using SPSS statistical software, v. 21.

There were 30 participants in each group (teach-back, multimedia, and control). Mean ages were 55.56 ± 11.23 years in the teach-back group, 56.33 ± 16.68 years in the multimedia group, and 55.80 ± 11.73 in the control group, and age did not differ significantly among the groups. The groups also did not differ significantly in terms of sex, employment status, living place, education level, or marital status (P >0.05 for each). There also were no significant differences among the three groups in terms of frequency of hospitalization (P = 0.319). The mean duration of diabetes was 12.76 ± 7.70 years in the teach-back group, 13.36 ± 7.37 years in the multimedia group, and 13.00 ± 6.70 years in the control group, and these means did not differ significantly among the groups (P = 0.949). There were also no significant differences in the distribution of diabetes durations among the three groups (P = 0.699) (Table 1).

The ulcer site in most of the patients in the three groups was the ankle or area under the ankle. There were no significant differences among the three groups in terms of the ulcer site using the χ² test (P = 0.981) (Table 2). There also were no significant differences among three groups in terms of time of ulcer emergence (P = 0.657) (Table 3).

There were no statistically significant differences among the three groups in terms of membership in a supportive institute (P = 0.140) (Table 4).

Mean A1C did not significantly differ among the three groups (P = 0.107). The distribution of A1C levels also did not differ significantly among groups (P = 0.086) (Table 5). Mean pre-intervention self-care scores did not differ significantly among the groups (P = 0.925). Mean post-intervention self-care scores did differ among groups: 58.43 ± 11.38 in the teach-back group, 60.26 ± 6.70 in the multimedia group, and 41.60 ± 9.18 in the control group, and the difference between the teach-back group and the control group was significant (P <0.001). In the teach-back group, mean self-care scores increased from 42.46 ± 14.38 before the intervention to 58.42 ± 11.38 after the intervention, and in the multimedia group, scores increased from 41.60 ± 12.97 to 60.26 ± 6.70, and these increases were statistically significant (P <0.001 for each). Mean self-care scores in the control group changed from 41.23 ± 9.27 before the intervention to 41.60 ± 9.18 after the intervention, which was not significant (P = 0.155) (Table 6).

To date, no studies have been conducted to compare the effects of two educational methods (teach-back and multimedia presentation) on self-care scores in PWD. Our study was conducted to fill this gap. In this study, the three groups (teach-back, multimedia, and control) did not differ significantly in age, sex, job status, living place, education level, or marital status. Mean self-care scores after the intervention were 58.43 ± 11.38 in the teach-back group, 60.26 ± 6.70 in the multimedia intervention group, and 41.60 ± 9.18 in the control group. These scores differed significantly among groups, and score increases in the two intervention groups were also significant (Table 6).

In a study similar to ours, Kandula et al. (23) investigated the health literacy and lifelong learning of PWD using multimedia and teach-back teaching methods to test the durability of what had been learned by the patients 2 weeks post-intervention. The study was conducted to evaluate both the level of retention of information 2 weeks after learning and to evaluate the impact of each teaching method on the level of information retention. The results showed that the median health literacy score increased from 6 to 12 immediately after the multimedia intervention and was 9 at 2 weeks after the intervention. This study also showed that, although the teach-back teaching method did not improve the durability of the received information, the level of health literacy significantly increased immediately after receiving this training.

The results of the study by Kandula et al. (23) were consistent with ours in that they revealed the positive effects of multimedia and teach-back teaching methods on increasing patient scores. One of the limitations of the former study, however, was that it lacked a control group. An advantage of our study was the inclusion of a control group, which enabled us to attribute our findings to the interventions.

Another study, conducted by Salavati et al. (24), investigated the effect of teach-back training on quality of life in patients with myocardial infarction. Three 45-minute training sessions were held over a 10-day period for each patient in the experimental group using the teach-back method. The investigators found a significant difference in mean quality of life scores between the experimental and the control groups after the intervention. Thus, the teach-back method was found to improve quality of life in patients with myocardial infarction (24). These results were also in line with those of the current study, because we found self-care scores to be significantly different between the teach-back group (58.43 ± 11.38) and control group (41.60 ± 9.18). In addition to the teach-back and control groups, our study also tested a multimedia teaching method, which can also be considered an innovative aspect of the study.

Oshvandi et al. (22) investigated the impact of the teach-back method on self-care behaviors of people with type 2 diabetes and found a significant post-intervention increase in the knowledge of the patients in the experimental group compared with the control group. Also, there was a significant post-intervention difference between the experimental and control groups in the DMSES regarding diet, physical activity, foot care, and regular use of medications. The investigators concluded that the teach-back method had a positive impact on knowledge (P <0.001) and self-care behaviors (P <0.001) among patients of the intervention group.

These results were in line with the results of our study, because both of the methods used in our study showed positive effects on enhancing the self-care in PWD. Although quality of life was not evaluated in our study, it was affected by self-care, meaning that enhanced self-care led to increased quality of life.

The results of our study were also in line with those of a study conducted by Farahani et al. (25), who compared the effects of a multimedia teaching method to the live presentation of successful patient experiences on quality of life in patients with type 2 diabetes. The investigators provided five sessions of 45 minutes each of multimedia education for each patient in one group, whereas another group received live presentations of successful experiences of patients with diabetes. There was a significant difference in mean quality of life scores before and after the multimedia intervention. The authors concluded that both the multimedia teaching method and the live presentation of successful experiences increased quality of life compared with the control group (25).

Based on the results of the current study, both teach-back and multimedia teaching interventions could increase self-care scores in PWD. This study revealed the effectiveness of both methods in enhancing self-care, which promotes better health and thus leads to increased quality of life.

The authors thank Bojnourd University of Medical Sciences for its contributions and support in the implementation of this study.

Work on this project was funded by Bojnourd University of Medical Sciences.

No potential conflicts of interest related to this article were reported.

M.Z., H.B.D., and M.N. were the principal investigators of the study. S.B.S., M.Z., and H.B.D. were involved in developing the study concept and design and writing and revising the manuscript. All authors read and approved the content. M.Z. is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.