QUESTION: The US Department of Health and Human Services defines health literacy as the "degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions".

Post a no less than 300 words reflection discussion about what you learned related to health literacy. Use the content from the CDC tutorial and from the readings.

1) Discuss what measure you can take to address health literacy in your everyday work.

2) How does health literacy relate to the course learning outcomes?

You must include citations and references to support your position.


Clear Communication by CDC (2019)


Screening Patients Who Speak Spanish for Low
Health Literacy
Kristie B. Hadden, PhD; Latrina Y. Prince, EdD; Martha O. Rojo, PhD; James P. Selig, PhD;
and Pearl A. McElfish, PhD
Background: Inadequate health literacy is a national health problem that affects about 90 million people from
all racial and ethnic groups in the United States. Conceptual and empirical models of health literacy position
language as one of the most significant contributors to health literacy. Objective: A validated Spanish health
literacy screening question asks how confident patients are at filling out medical forms, but it does not clarify
whether the forms are in English or in Spanish, contributing to ambiguity and potentially affecting validity.
The purpose of this study was to compare responses to questions that clarified the language of the forms
referenced in the validated screening question; to explore how the clarified items predicted scores on a measure of health literacy; and to compare the predictive ability of the clarified health literacy items to that of a
question about patients’ self-reported English proficiency. Methods: Participants who speak Spanish (N = 200)
completed the following surveys: Spanish Health Literacy Screening Question that clarified “English forms”
(HLSQ-E) and that clarified “Spanish forms” (HLSQ-S), self-reported English proficiency (SEP), demographic
questions, the Short Test of Functional Health Literacy for Adults Spanish (S-TOFHLA-S), and the Newest Vital
Sign-Spanish (NVS-Spanish). Key Results: Participants reported less confidence with English medical forms
than Spanish forms. The sensitivity of screening approaches varied; each predicted inadequate health literacy
on the NVS-Spanish and S-TOFHLA-S with different levels of sensitivity, specificity, and accuracy. In general,
the HLSQ-E was a better predictor of inadequate health literacy than the HLSQ-S; however, the SEP performed
nearly as well as the HLSQ-E. Conclusion: “How confident are you at filling out medical forms in English…” more
appropriately identified patients with inadequate health literacy who speak Spanish. Health literacy screening
practices should consider the patient’s language and the language of the health care system and use questions that are less ambiguous. [HLRP: Health Literacy Research and Practice. 2019;3(2):e110-e116.]
Plain Language Summary: This project focused on patients who speak Spanish and who have a hard time
understanding health information. We wanted to find out the best ways to identify these patients so that doctors and nurses can be sure to give them information in ways that they can understand. We tested screening
questions that can identify these patients.
Health literacy is a national health problem that affects
about 90 million people in the United States who represent
all races and ethnicities (Kutner, Greenburg, Jin, Paulsen,
2006). Although there are many definitions of health literacy, it is commonly defined as “the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make
appropriate health decisions” (Centers for Disease Control
and Prevention, 2000). Although there are many negative
health outcomes consistently associated with inadequate
health literacy, there are notable differences among U.S. patients who do not speak English. The latest national survey
of adult literacy reported that Hispanic people (41%) were
the race/ethnicity with the highest of inadequate health
literacy (Kutner et al., 2006). Research findings show that
patients who do not speak English with inadequate health
HLRP: Health Literacy Research and Practice • Vol. 3, No. 2, 2019 e111
literacy skills are less likely to comply with discharge instructions (Smith, Brice, & Lee, 2012), are less satisfied with their
medical care (Downey & Zun, 2008), and are more likely
to experience lower quality of care and poorer health outcomes (Calvo, 2016; Sentell & Braun, 2012) than their counterparts who speak English in the U.S. It is estimated that
the percentage of Americans who speak Spanish at home
will increase from 12%, which was reported in 2009, to 16%
in 2019 (Shin & Ortman, 2011). Conceptual and empirical
models of health literacy position language as one of the
most significant contributors to health literacy, along with
education and age (Paasche-Orlow & Wolf, 2007).
Validated measures of patient health literacy have been
prominent in research literature for decades. The differences
between measuring health literacy for research versus for the
purpose of identifying patient populations who are at risk
have emerged in published studies in the last few years. In
practice, patient health literacy screening data have been
used for quality improvement efforts focused on reducing
information demands on patients, identifying populations
of patients with low health literacy and specific health outcomes, as well as point-of-care interventions, and best practices implementation. Research has indicated that lengthy
health literacy measurement tools that put time and cognitive demands on patients’ and those administering the measures are not feasible in busy clinical settings (Chew et al.,
2008; Stagliano & Wallace, 2013; Wallace, Rogers, Roskos,
Holiday, & Weiss, 2006). The use of a single-screening question is a quick and efficient method of obtaining health
literacy data in clinical settings. A single health literacy
screening question has been validated for use in patients
who speak Spanish and identifies patients who do not speak
English who have low health literacy 8 of 10 times: “How
confident are you at filling out medical forms by yourself?”
(Cordasco, Homeier, Franco, Wang, & Sarkisian, 2012;
Sarkar, Schillinger, Lopez, & Sudore, 2011; Singh, Coyne, &
Wallace, 2015).
A validated method for identifying the health literacy in
patients who speak Spanish appears to be valuable for health
care systems that aim to address health disparities for this
population; however, for those health care systems that are
largely English speaking, the issue of Spanish versus English
health literacy becomes complex. Just as there are opposing
views about using language proficiency to identify patients
at risk for inadequate health literacy, researchers are not in
agreement regarding whether or not and when to consider
a patient’s health literacy in the dominant language of his
or her health care system versus native language (Soto et al.,
2015). Further, the validated screening question is ambiguous for patients who speak Spanish. “How confident are you
at filling out medical forms by yourself,” when administered
in Spanish as “¿Qué tan seguro(a) se siente al llenar formas
usted solo(a)?” could be interpreted to be asking how confident the patient is at filling out English medical forms or
Spanish medical forms. Singh et al. (2015) proposed that future research should focus on specifying whether the forms
referenced in screening questions are written in English or
the participant’s native language. Differences in a patient’s
level of confidence with English versus Spanish forms could
compromise the validity of the Spanish question. At a miniKristie B. Hadden, PhD, is an Associate Professor and the Executive Director, Center for Health Literacy, University of Arkansas for Medical Sciences.
Latrina Y. Prince, EdD, is an Assistant Dean for Academic Affairs, Graduate School. Martha O. Rojo, PhD, is an Assistant Professor, College of Nursing.
James P. Selig, PhD, is an Associate Professor, College of Public Health, Department of Biostatistics. Pearl A. McElfish, PhD, is the Vice Chancellor (Northwest Arkansas Campus), and the Director, Office of Community Health and Research. All authors are affiliated with the University of Arkansas for Medical
© 2019 Hadden, Prince, Rojo, et al.; licensee SLACK Incorporated. This is an Open Access article distributed under the terms of the Creative Commons
Attribution-NonCommercial 4.0 International ( This license allows users to copy and distribute, to remix, transform, and build upon the article non-commercially, provided the author is attributed and the new work is non-commercial.
Address correspondence to Kristie B. Hadden, PhD, Center for Health Literacy, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Slot
#599A, Little Rock, Arkansas 72205-7199; email:
Grant: This study was supported by the Translational Research Institute grant (UL1TR000039) through the National Institutes of Health (NIH) National
Center for Research Resources and the National Center for Advancing Translational Sciences.
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
Disclosure: The authors have no relevant financial relationships to disclose.
Acknowledgments: The authors thank the University of Arkansas for Medical Sciences Center for Health Literacy for its contributions to this work and
other work that promotes evidence and best practices for health literacy research, services, and policies.
Received: April 25, 2018; Accepted: October 9, 2018
e112 HLRP: Health Literacy Research and Practice • Vol. 3, No. 2, 2019
mum, the question imposes unnecessary ambiguity for
the patient who speaks Spanish. The purpose of this study
was to explore whether patients would respond differently to the clarified question and explore the extent to
which two clarified versions of a single health literacy
screening question accurately predict inadequate health
literacy for rural participants who speak Spanish as measured by two validated Spanish health literacy measures.
One version clarified “How confident are you at filling
out English medical forms?” and the other clarified “How
confident are you at filling out Spanish medical forms?”
The performance of these two clarified items was also
compared to an item assessing patients’ self-reported
English proficiency.
This research project used an accepted conceptual and
empirical model of health literacy that positions language
as a contributor to health literacy skills (Paasche-Orlow
& Wolf, 2007), and experience in using clinical screening
for inadequate health literacy in English in rural primary
care practices. Our first aim was to clarify the best method for administering health literacy screening in Spanish
(i.e., How confident are you at filling out medical forms
by yourself?). Because it is unclear if the forms referenced
in the question are in English or Spanish, researchers
explored the difference in item performance when this
clarification is given to the patient (How confident are
you at filling out English medical form? and How confident are you at filling out Spanish medical forms?). It
was hypothesized that patients who speak Spanish would
report less confidence for English forms than for Spanish
forms, and there would be differences in the performance
for these clarified questions and from the current validated version. We also aimed to explore the validity of selfreported English proficiency (SEP) in identifying patients
who speak Spanish with inadequate health literacy.
Our methods aimed to adapt validated health literacy
screening questions in Spanish to reduce ambiguity, and
to compare their performance psychometrically.
Based on statistical power analysis for the psychometric and analytical models proposed and exploration of the
site population, a convenience sample of 200 patients who
speak Spanish and were at least age 18 years was recruited
from a rural clinic site and surrounding community. Persons with known cognitive or sensory issues that would
preclude them from completing a facilitator- and selfadministered survey in person were excluded from the
study. Recruitment began with a data extraction of clinic
patients who responded to the SEP question in the electronic medical record (EMR). Additionally, participants
were recruited through community-based organizations
to ensure the sample also included those outside the rural
clinic site. Because only 17 patients were identified using
EMR identification, limited snowball sampling, meaning
participants were asked to bring one eligible participant
with them to the data collection sessions, was used to recruit more participants from the community.
To collect data for patients who speak Spanish at the
study site, the self-reported English proficiency question was added to the EMR and staff were trained to
administer the question. After 3 months of implementation, a data extraction request was submitted to secure
an Institutional Review Board-approved list of eligible
participants to be recruited over the phone. In addition
to phone recruitment, participants were recruited from
community-based organizations. Two hundred Hispanic
participants were recruited and consented by a bilingual
research assistant. The data collection sessions were conducted wholly in Spanish with about 20 participants in
each session. The survey was administered on paper; all
study materials were translated to Spanish prior to data
collection. All questions were read aloud to participants
except the Newest Vital Sign-Spanish, which was selfadministered. Each session lasted about 45 minutes, and
participants received a $25 gift card at the end of the session. The study protocol was approved by the University
of Arkansas for Medical Sciences Institutional Review
Board prior to study activities.
The SEP scale consisted of a single validated question that was adapted and used to measure English proficiency (scores of 3 or 4 indicate limited English proficiency): “Since you speak a language other than English
at home, we are interested in your own opinion of how
well you speak English. Would you say that you speak
English (1) well, (2) very well, (3) not well (3), (4) not at
all (Sentell & Braun, 2012). The participant survey was
written in Spanish by a bilingual co-investigator and included demographic questions that assessed age, gender,
and education.
The health literacy measures used in this study included the Health Literacy Screening Question that clarified
HLRP: Health Literacy Research and Practice • Vol. 3, No. 2, 2019 e113
“English forms” (HLSQ-E) (Singh et al., 2015), the Health
Literacy Screening Question that clarified “Spanish forms”
(HLSQ-S) (Singh et al., 2015), the Short Test of Functional Health Literacy Adults Spanish (S-TOFHLA-S)
(Baker, Williams, Parker, Gazmararian, & Nurss, 1999),
and the Newest Vital Sign (NVS)-Spanish (NVS-Spanish),
(Weiss et al., 2005) all administered in Spanish. Response
options for both HLSQ-E and HLSQ–S questions were
(1) extremely, (2) quite a bit, (3) somewhat, (4) a little,
or (5) not at all. Scores of 1 or 2 indicate adequate health
literacy and scores of 3 or higher indicate inadequate
health literacy based on validation studies (Stagliano &
Wallace, 2013). The S-TOFHLA-S assesses functional
health literacy using reading passages from health material. The assessment consists of 36 questions and can
be completed in approximately 7 minutes. S-TOFHLA-S
scores of 0 to 16 indicate inadequate health literacy, 17 to
22 marginal functional health literacy, and 23 to 36 adequate functional health literacy. The NVS-Spanish is a
validated measure of health literacy that uses an ice cream
label and six corresponding questions as stimuli (Weiss
et al., 2005). The NVS-Spanish yields a continuous score
of 0 to 6 and also groups participants’ health literacy into
three categories: (scores of 0-1) likelihood of limited literacy, (scores of 2-3) possibly limited literacy, and (scores
of 4-6) adequate literacy.
Participant responses to the SEP question, HLSQ-E and
HLSQ-S, demographics, S-TOFHLA-S, and NVS-Spanish
were entered into an Excel spreadsheet for data cleaning
and imported into SPSS statistics (version 24) software
for analysis. Analyses were used to determine whether
patients responded differently to the HLSQ-E versus the
HLSQ-S; Area Under the Receiver Operating Characteristic Curve (AUROC), sensitivity, specificity, and overall
accuracy for each of the predictor (independent) variables (SEP, HLSQ-E and HLSQ-S), and a paired-samples
t test were used to test for differences between patients’
HLSQ-E and HLSQ-S scores. ROC curve analyses and
analyses of contingency tables were used to estimate Area
AUROC, sensitivity, specificity, and overall accuracy.
Table 1 illustrates the sample characteristics. All participants were Hispanic (N = 200) and 28% spoke Spanish
only. Most participants were female (75%) and completed grade 12 or higher (54.5%). Table 2 details participant health literacy screening results, including 42% of
the sample being categorized as having adequate health
literacy for the English clarified screening question and
72% for the Spanish clarified question. The NVS-Spanish
results revealed that 34% of the sample scored in the adequate health literacy range, compared to 86% on the
Table 3 details the AUROC, sensitivity, specificity,
and accuracy of each of the screeners tested. The HLSQ-S
(M = 1.96, [standard deviation] SD = 1.27) responses
were significantly different from HLSQ-E (M = 2.94,
SD = 1.42) responses [t (df = 198) = –8.43, p < .001)]
suggesting that participants who speak Spanish reported
less confidence with English forms than Spanish forms.
The three approaches to screening varied with regard
to AUROC, sensitivity, specificity, and accuracy. The
HLSQ-E and SEP items preformed similarly with both superior to the HLSQ-S in predicting inadequate (limited)
health literacy.
This research aimed to clarify the best methods for
administering health literacy screening questions in
Spanish. Because it is unclear if the forms referenced in
a validated question are in English or Spanish, researchers explored the differences in item performance when
this clarification is given to the patient. As suspected,
participants who speak Spanish reported less confidence
for English forms than for Spanish forms, and there were
differences in the performance for these clarified questions and from the current validated version in detecting
inadequate (limited) health literacy based on the NVSSpanish. The question that clarified “English” forms performed best when considering sensitivity and specificity.
This suggests that a change should be made to the wording of the validated health literacy screening question
in Spanish to reduce ambiguity and maintain predictive
screening value.
Our findings contribute to previous work that has
developed and tested Spanish health literacy screening
questions as predictors of inadequate health literacy and
the utility of these questions in clinical practice. The results of our research address limitations of previous research that noted ambiguity in the questions that have
been validated (Singh et al., 2015). Prior studies have relied on patients who speak Spanish to infer the language
in which “medical forms” are written. Our results confirm that levels of self-reported confidence for filling out
forms and the predictive ability of the confidence with
forms question depends upon the language specified for
the forms. Our results indicate that clarifying “English”
medical forms in the question results in better identification
e114 HLRP: Health Literacy Research and Practice • Vol. 3, No. 2, 2019
of inadequate health literacy for these patients. Because most
health systems in the U.S. are primarily English-speaking,
this clarification recognizes the barriers that language poses
to health literacy and is therefore an appropriate component
of the health literacy screening question. Generalizing these
results to Spanish-speaking health systems is difficult, beTABLE 1
Participant Demographics (N = 200)
Characteristic n %
Never attended school or only attended kindergarten
Grades 1 through 8 (elementary)
Grades 9 through 11 (some high school)
Grade 12 or GED (high school graduate)
College 1 to 3 years (some college or technical school)
College 4 years or more (college graduate)
Note. GED = General Education Diploma.
All data not available.
Health Literacy Screening Results (N = 200)
Question n %
How confident are you filling out ENGLISH medical forms by yourself?a
Quite a bit
A little bit
Not at all
How confident are you filling out SPANISH medical forms by yourself?
Quite a bit
A little bit
Not at all
NVS-Spanish Score
Possibly limited
Likely limited
S-TOFHLA-Spanish Score
Note. NVS = Newest Vital Sign; S-TOFHLA = Short Test of Functional Health Literacy in Adults.
All data not available.
HLRP: Health Literacy Research and Practice • Vol. 3, No. 2, 2019 e115
Screener Characteristics
Health Literacy
Measure Screener AUROC Sensitivity Specificity Accuracy
S-TOFHLA-Spanish HLSQ (Singh et al., 2015)
“¿Qué tan seguro(a) se siente
al llenar formas médicas usted” [How confident are you
filling out medical forms?]
HLSQ English Forms
“¿Qué tan seguro(a) se siente
al llenar formas médicas en
Ingles usted solo(a)?” [How
confident are you filling out
English medical forms by
HLSQ Spanish Forms
“¿Qué tan seguro (a) se siente
al llenar formas médicas en
Espanol solo(a)?” [How
confident are you filling out
Spanish medical forms by
Not reported
Not reported
Not reported
NVS-Spanish HLSQ (Sarkar et al., 2011)
HLSQ English Forms
“¿Qué tan seguro(a) se siente
al llenar formas médicas en
Ingles usted solo(a)?” [How
confident are you filling out
English medical forms by
HLSQ Spanish Forms
“¿Qué tan seguro (a) se siente
al llenar formas médicas en
Espanol solo(a)?” [How
confident are you filling out
Spanish medical forms by
“Como usted habla un idioma
aparte de Ingles en casa, estamos interesados en su propia
opinion de lo bien que habla
Inglés. Diria que habla Ingles”
[Since you speak another
language besides English at
home, we want to know in
your opinion, how well you
speak English. Would you say,
you speak English”]
Note. AUROC = Area Under the Receiver Operating Characteristic; HLSQ = health literacy screening question; NVS = Newest Vital Sign SEP = self-reported English proficiency;
S-TOFHLA = Short Test of Functional Health Literacy in Adults.
e116 HLRP: Health Literacy Research and Practice • Vol. 3, No. 2, 2019
cause the validation of the questions tested was conducted
with patients who speak Spanish in English-speaking health
systems in the U.S.; it is unclear whether using the “Spanish”
forms clarification in these systems will provide more valid
identification of patients with inadequate health literacy.
SEP also adequately identified participants with inadequate health literacy and performed somewhat equally
in regards to sensitivity, specificity, and accuracy in detecting inadequate (limited) health literacy according to
the NVS-Spanish. For practices that serve patients who
speak Spanish and have limited resources and/or opportunities to integrate a validated health literacy screening
question into workflows and/or EMRs, administering SEP
questions may serve multiple purposes; SEP can not only
identify patients who are at risk for low health literacy
and need Spanish plain language and health literacy best
practices at the point of care and follow up, but also those
who need interpreters and other support services.
The limitations of this study influence the interpretation of these results. First, the sample consisted of patients
who speak Spanish who are representative of a single
community in the South, but may not be representative
of other communities. Sample characteristics should be
considered when generalizing results to groups for which
our sample may not be representative. The participants
represent a convenience sample and included self-reported measures for which bias is a potentiality. Lastly, we explored criterion validity using measures of health literacy
accepted in published literature and did not conduct analysis on distal health outcomes or status.
Screening patients who speak Spanish for inadequate health literacy for the purposes of identifying people who would benefit from resources, interventions, and
best practices is feasible in clinical practice. Clarifying an
existing screening question in Spanish reduces ambiguity
and adequately identifies such patients. Asking patients
about their perceived English proficiency also adequately
predicts inadequate health literacy for similar purposes.
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Spanish-speaking patients using single-item literacy screening
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Kutner, M., Greenburg, E., Jin, Y., & Paulsen, C. (2006). The health
literacy of America’s adults: Results from the 2003 National Assessment of Adult Literacy. Retrieved from National Center for Education Statistics website:
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The 5Ts for Teach Back: An Operational Definition for
Teach-Back Training
Kathryn M. Anderson, MA; Sarah Leister, MA; and Ruth De Rego, DNP
Background: Teach Back is a health communication strategy used to confirm patient understanding in a nonshaming way. Although Teach Back is widely recommended as a best practice strategy for improving patient
outcomes and organizational health literacy, there is lack of consensus in the literature on the definition of
Teach Back and the best methods for training health care workers (HCWs). Our experience suggests that if
you teach specific, observable skills, these can be identified in practice and potentially measured in research.
Brief description of activity: We created a training program, the 5Ts for Teach Back, based on a standardized
operational definition of Teach Back and five specific, observable components. Participants use a Teach-Back
Observation Tool to identify the 5Ts in practice and during peer evaluation. The program incorporates lecture,
observation, practice, and videos with good and bad examples of Teach Back. Implementation: The training
was offered to HCWs in a large academic health care system. Flexible training options ranged from a single
4-hour training to a more comprehensive program that included clinic-specific scenarios, peer coaching, and
refresher activities over a 6-month period. Results: The 5Ts for Teach Back operationalizes the definition of
Teach Back and provides a model for training HCWs in the use of Teach Back. The 5Ts for Teach Back can be
used to train any HCW. A single training session does not guarantee proficiency in practice. Through coaching
and refresher activities, competence in Teach Back increases. Lessons learned: Teaching entire clinical units
may increase effectiveness, because Teach Back becomes embedded in the unit culture. The Observation Tool
can be used for training, coaching, and evaluation. The standardized method and Observation Tool are potentially useful when evaluating Teach Back during outcomes and patient satisfaction research. [HLRP: Health
Literacy Research and Practice. 2020;4(2):94-103.]
Plain Language Summary: Health care workers may be clearer when giving information to patients if they
use Teach Back. Studies do not show what methods are best for training health care workers how to do Teach
Back. The 5Ts method breaks Teach Back into five skills that help health care workers do it well. The 5Ts can also
confirm use and may be helpful for research.
Teach Back is a health communication strategy used to
confirm patient understanding in a non-shaming way. Teach
Back is among the most important skills health care workers (HCWs) need for effective communication with patients
(Coleman, Hudson, & Pederson, 2017). The goal for this
project was to train HCWs in the use of Teach Back, using a
standardized operational definition, which transforms Teach
Back into a set of skills that are easy to learn, verifiable in
practice, and, potentially, measurable in research.
The setting for this project is the University of New Mexico Hospitals (UNMH), an academic medical center in the
Southwest, which includes a 550-bed hospital and 29 outpatient primary care and specialty clinics. Built on Pueblo
land, UNMH has a longstanding relationship with Native
American communities, including a 1952 federal contract
that allowed them to use the land on which the main hospital
stands. All of the training is done by the two full-time employees of the hospital’s Health Literacy Office. Since the pro-
HLRP: Health Literacy Research and Practice • Vol. 4, No. 2, 2020 e95
gram’s inception, we have trained more than 1,300 HCWs,
including nurses, physicians, nurse practitioners, physician
assistants, appointment schedulers, clerks, medical assistants,
social workers, interpreters, physical therapists, occupational therapists, technicians, hospital leadership, pharmacy
students, and nursing students.
In conversations with patients, HCWs tend to focus
more on delivering information than checking for understanding. October, Dizon, and Roter (2018) found that
HCWs dominate the conversation and that their speaking
turns are denser, with more statements per turn, whereas
patients have fewer statements per turn. When providers
talk too much, neither provider nor patient can evaluate
accurate reception of the information. HCWs often define
their job as making sure they give the patient all the information they need. This may result in a “tendency toward
long monologues, even if they offer the patient a chance to
speak when they are finished” (Roter, 2011, p. 82). The use
of Teach Back ensures that the opportunity for both delivery and reception occurs.
Definitions of Teach Back vary widely. Many are conceptual and do not provide the specificity necessary to identify
the occurrence of Teach Back in practice or research. Teach
Back is generally defined as a procedure during which the
patients describe information they have been taught, using
their own words, to confirm understanding of the information. Many authors have expanded the definition to include
additional components considered central to performing
this skill.
Included in many definitions is the concept that Teach
Back is a measure of the HCW’s ability to clearly communicate information (Institute for Healthcare Advancement,
2012; Kornburger, Gibson, Sadowski, Maletta, & Klingbeil,
2013; Morony et al., 2018). It is not a test of the patient’s
ability (Institute for Healthcare Advancement, 2012).
Teach Back should be performed in a way that mitigates
the possibility that patients feel ashamed for lack of understanding and encourages patients’ participation in their
care (Kornburger et al., 2013).
Several definitions of Teach Back explicitly indicate that
if the patient is not able to accurately restate the information, the HCW should reteach the information (Institute
for Healthcare Advancement, 2012; Bogue & Mohr, 2017;
Griffey et al., 2015; Ha Dinh, Bonner, Clark, Ramsbotham,
& Hines, 2016; Kornburger et al., 2013; Morony et al.,
2018). After reteaching the information, the HCW should
perform Teach Back again and continue the cycle until patient understanding is achieved (Ha Dinh et al., 2016; Kornberger et al., 2013). Kornberger et al. (2013) include two
other components of Teach Back: the use of plain language
and delivering a limited amount of information in an education session.
In a systematic review, Ha Dinh et al. (2016) found that
there was little consistency among studies evaluating the effectiveness of use of specific communication skills (including Teach Back) to improve patient outcomes. Although
not all studies achieved statistical significance in the outcome measure, overall, the use of Teach Back improved
disease-specific knowledge, adherence, self-efficacy, and
proper use of inhalers (Ha Dinh et al., 2016). Teach Back
has been associated with increased recall and understanding of information, reduced hospital readmission, and
decreased length of stay when readmission was necessary
(Bravo et al., 2010; Griffey et al., 2015; Peter et al., 2015).
No evidence exists favoring one method of teaching
communication strategies, including Teach Back, over another (Coleman, 2011). Methods found in the literature for
Kathryn M. Anderson, MA, is a Senior Health Literacy Specialist, University of New Mexico Hospitals. Sarah Leister, MA, was a Health Literacy Educator,
University of New Mexico Hospitals. Ruth De Rego, DNP, was an Assistant Professor, University of New Mexico College of Nursing.
© 2020 Anderson, Leister, De Rego; licensee SLACK Incorporated. This is an Open Access article distributed under the terms of the Creative Commons
Attribution-NonCommercial 4.0 International ( This license allows users to copy and distribute, to remix, transform, and build upon the article non-commercially, provided the author is attributed and the new work is non-commercial.
Address correspondence to Kathryn M. Anderson, MA, University of New Mexico Hospitals, 2211 Lomas NE, Albuquerque, NM 87131; email:
Disclosure: The authors have no relevant financial relationships to disclose.
Received: December 7, 2018; Accepted: April 22, 2019
e96 HLRP: Health Literacy Research and Practice • Vol. 4, No. 2, 2020
training communication skills include didactic teaching,
workshops, small-group activities, peer role play, videos,
standardized patient encounters, observation, modeling,
feedback, service learning, and online trainings (Institute
for Healthcare Advancement, 2012; Coleman, 2011). More
research into training methods is needed (Coleman, 2011;
Toronto & Weatherford, 2015).
A program that employs multiple teaching techniques is
likely to be the most effective (Coleman, 2011). After a TeachBack training that included viewing a poster, observing a
video, guided practice, handouts, and follow-up, Kornburger
et al. (2013) found that nurses’ knowledge of Teach Back increased by 33%, measured at 4 weeks after training. In the
same study, self-reported use of Teach Back increased by
more than 40%; however, participants were still only using
Teach Back in 45% of encounters. Mahramus et al. (2014)
used a combination of demonstration and guided practice,
followed by summative feedback, to train 150 registered
nurses on an inpatient cardiac unit in the use of Teach Back
when teaching self-care skills to patients with heart failure.
Ninety-three percent of participants achieved competence in
the use of Teach Back by the end of the training (measured
by direct observation), and 96% reported using Teach Back
in a 3-month follow-up survey (Mahramus et al., 2014). In
a small qualitative study, a 2-hour training that combined
video demonstration, handouts, role play, and peer learning
was effective for Teach-Back training (Morony et al., 2018).
Participants felt that follow-up with the trainers, providing
cues in the workplace, and more peer interaction would have
increased competence.
Few tools to measure the occurrence of Teach Back exist, and none are validated (Badaczewski et al., 2017).
Badaczewski et al. (2017) proposed the Teach Back Loop
Score, a scale grading the extent to which the educator attempts Teach Back, corrects misunderstanding, and repeats
Teach Back on a 2-point scale. Mahramus et al. (2014)
deemed that participants achieved Teach Back competence
if they educated the patient, used Teach Back, and communicated the purpose of Teach Back to the patient. No tools were
found that measured the specific components of Teach Back.
The 5Ts for Teach Back
Teach Back is defined as asking patients, in a non-shaming
way, to repeat, in their own words, specifically what they need
to know or do. Based on this definition, the first author (K.A.)
developed the 5Ts for Teach Back (5Ts), a training framework intended to make the process of Teach Back more
concrete and easier to learn. The 5Ts is a standardized, operational definition of Teach Back containing five specific,
observable steps: Triage, Tools, Take Responsibility, Tell
Me, and Try Again. The Triage, Tools, and Try Again steps
focus on effective information delivery, whereas the Take
Responsibility and Tell Me steps serve to evaluate whether
the patient received the information. We refer to the Take
Responsibility and Tell Me steps as the “Teach Back leadin.” Using all 5Ts encourages the inclusion of both delivery
and reception (Figure 1).
Triage. During the Triage step, the HCW determines
which 1 to 3 topics are most important and will be the
focus for education and Teach Back. Research has shown
that the more information a clinician delivers, the less
information the patient will remember correctly (Anderson, Dodman, Kopelman, & Fleming, 1979; Bravo et al.,
2010). The Triage step is based on the concept of triage
in a crowded emergency department, where HCWs must
choose which patients to treat first based on their levels
of acuteness. Similarly, a HCW who has several pieces
of information to cover must triage the information by
choosing Teach Back topics that are most important for
the patient to remember or understand. This step is the
key to Teach Back efficiency, discouraging the HCW from
providing too much information. The HCW selects topics
for Teach Back based on what are “can’t miss” or frequently
forgotten pieces of information.
When more than one topic is chosen for Teach Back, we
encourage HCWs to use “chunk and check” (Brega et al.,
2015). The HCW gives one topic, or “chunk,” of information at a time, each of which is followed by Teach Back.
This process allows the HCW to deliver a larger amount
of information in one teaching session, while making this
amount of information manageable for the patient. By selecting the key points and stopping the delivery to perform
Teach Back, HCWs are ensuring repetition and turn-taking, checking reception, and encouraging recall.
Tools. A tool is broadly defined as any aid that can assist the clinician with providing a clear explanation. Reader-friendly handouts, simple pen-and-paper drawings,
models or diagrams, use of the HCW’s own body (such as
using the fist to represent the heart pumping), or even a
relatable story are possible tools (Brega et al., 2015; Rubin,
2012). Tools should be accessible to patients with disabilities (e.g., braille, large print, read aloud, described) and
professionally translated, if necessary (Brega et al., 2015).
Take responsibility. The Take Responsibility step is
critical for the non-shaming aspect of the Teach-Back
HLRP: Health Literacy Research and Practice • Vol. 4, No. 2, 2020 e97
definition. This step happens once the HCW has delivered
a chunk of information. The HCW may state, “That was a
lot of information and it can be hard to remember all that
at once, so I want to make sure I did a good job explaining
The ideal Take Responsibility line contains two elements. The first is an acknowledgment of the quantity or
complexity of the information given. This normalizes misunderstandings if they do occur, thereby reducing shame
for the patient. The second is a statement implying that
the HCW is the one being tested rather than the patient.
This element also reduces the burden on the patient and
reflects the impact of Teach Back on the HCW’s communication skill development (Morony et al., 2018).
Tell me. During the Tell Me step, the HCW invites patients to state, in their own words, what they understood.
The specificity of the Tell Me line impacts its effectiveness. Suppose an HCW spends 20 minutes explaining a
new diagnosis of diabetes and then states, “Tell me what
you learned about diabetes.” In this case, the patient may
be overwhelmed by the quantity of information she is required to say back and therefore may not know where to
start. Furthermore, the HCW will not be able to focus on
the most important elements of the explanation. A more
specific Tell Me line, such as, “How will you use your glucose meter when you go home?” allows the patient and the
HCW to focus on one specific piece of information so they
are both on the same page. An effective Triage step leads
more naturally to specific Tell Me questions.
Try again. If the patient does not understand, the HCW
must explain the information again, modifying the explanation to make it clearer. Depending on the magnitude of
the error, another round of Teach Back may be needed.
The HCW can assume responsibility for the error by returning to a Take Responsibility line, for example, “I’m
sorry. I must not have explained that well enough.” Taking
responsibility again may reduce the shame of an error for
the patient.
An extensive review of available Teach Back videos did
not reveal a video demonstrating each of the 5Ts. We colFigure 1. The 5Ts for Teach Back. Teach Back is about delivery and reception.
e98 HLRP: Health Literacy Research and Practice • Vol. 4, No. 2, 2020
laborated with our Information Technology department to
produce a 15-minute video featuring a patient receiving
discharge instructions from a physician and nurse. In the
first part of the video, the HCWs do not perform Teach
Back, and the patient demonstrates confusion about what
she was taught. In the second part, the same discharge scenario is repeated, but with the HCWs demonstrating each
of the 5Ts.
Figure 2. Teach-Back Observation Tool. Sometimes, “chunking and checking,” using a “tool” or “trying again” is not appropriate. This is the reason
for the “N/A” column.
HLRP: Health Literacy Research and Practice • Vol. 4, No. 2, 2020 e99
Observation Tool
The observation tool (Figure 2), based on the Always
Use Teach Back! Toolkit model (Institute for Healthcare
Advancement, 2012), lists each of the 5Ts, along with two
additional “delivery” components. The tool is first used to
rate the HCWs in the videos and again during practice
sessions when participants observe their peers.
Pre- and Post-Training Surveys
We distribute an electronic pre-training survey about
1 week before the training date. We send a similar posttraining survey 6 weeks after the training date (Figure 3).
General Teach-Back Class
From 2014 to 2015, we developed an initial 4-hour
class using the basic structure previously created by K.A.
We obtained continuing nursing education credit for the
class. Since 2016, we have been offering the training to
HCWs in a large hospital. The class is listed on the hospital’s centralized educational web page, offered regularly, and open to all hospital staff.
The training begins with a brief exercise in remembering a set of pill-taking instructions and a 1-hour didactic
portion that encourages participants to think about why
Teach Back is a useful tool. We talk about the complexity
of the health care system, the overwhelming burden of
detailed biomedical information that patients are given,
and the fact that patients are seldom in an optimal condition for processing and retaining information.
We then introduce the 5Ts in an hour-long segment.
We emphasize discussion of Triage and Take Responsibility. We also stress plain language and chunk-andcheck as key concepts underlying effective delivery.
During the third hour of training, we show the two
videos demonstrating patient education at the time of
hospital discharge. In the first, the HCWs do not use
Teach Back. In the second, the HCWs demonstrate all
5Ts. Using the Teach-Back Observation Tool, participants identify the 5Ts. The video observations provide
a foundation for the final hour-long practice portion of
the training. In the general training, because participants
come from many different areas in the hospital system,
we encourage participants to develop scenarios from
their own experience. We also offer one or two simple,
general topics. Participants work in groups of three: one
acting as a patient, one acting as an HCW, and one acting
as an observer. Before they start the practice, we encourage discussion of how to Triage the information and ask
participants to write down the Take Responsibility and
Tell Me lines they plan to use. Participants rotate roles,
allowing each person to practice Teach Back as the HCW
and to experience it as the patient and the observer.
Targeted Teach-Back Training
Later in 2016, in response to requests from units for
trainings specific to their areas and appropriate to their
schedules, we developed 1.5- to 2-hour targeted TeachBack trainings. We also recognized that there might be
advantages to training all staff from one unit as opposed
to individuals. We hypothesized that this would be more
effective for embedding the use of Teach Back in practice. HCWs could observe the strategy performed by their
peers, learn from each other, and share their experiences.
This process may serve as a continuation of the training
and reinforce the expectation of its use. When we trained
a specific unit, we worked in advance with unit leadership
to tailor the practice session with scenarios and tools relevant to that unit, as well as to differing roles within the
clinics or units.
Midcourse Adjustments
By 2017, we saw clearly that one training did not ensure the use of the strategy in practice. We presented a
proposal to ambulatory (outpatient/clinic) leadership for
an extended version of the 5Ts training. The success of
our proposal resulted from our growing reputation within the institution and our relationships with ambulatory
management. We presented a clear outline and timeline
(Figure 4) of the project and provided pre- and posttraining survey data from the previous year of Teach-Back
training. We proposed adding a 5-month follow-up period of peer coaching and skills validation, and two refresher activities to the targeted Teach-Back offering. Hospital
leadership mandated the extended training, called Closing the Gap (CTG) With Teach Back, for all ambulatory
CTG consists of a 2-hour training, three meetings with
leadership, and a Teach-Back team responsible for coaching and skills validation. We developed a detailed toolkit,
which provides the framework and tools to guide clinics
through the process. The toolkit contains instructions for
the unit, a coaching guide, and sample refresher activities. We embedded as much flexibility into the program
as possible, recognizing that much variability exists in the
way clinics arrange their staff and clinic flow.
Before the training, the health literacy (HL) staff shadows staff at the clinic to observe conversations, note op-
e100 HLRP: Health Literacy Research and Practice • Vol. 4, No. 2, 2020
portunities for Teach Back, and develop relevant scenarios for practice during training. The shadowing has the
added benefit of introducing the HL staff to the unit and
creating buy-in; staff have said that they feel the training
is about them, not just another generic initiative (clinic
leader, personal communication, January 19, 2018). After shadowing, the initial 2-hour training, which uses the
same methods as the 4-hour class, is offered once or multiple times to ensure that all the staff were trained. Unit
leadership identifies peer coaches, who receive an additional 1-hour training. These peer coaches observe HCWs
using Teach Back and provide them with feedback for imFigure 3. Pre- and post-training survey questions. *Only on the pre-training survey; **Only on the post-training survey.
Figure 4. Closing the gap with Teach Back timeline.
HLRP: Health Literacy Research and Practice • Vol. 4, No. 2, 2020 e101
provement. Two refresher activities are required during the
course of the 5 months. Refresher activities could include
game-based Teach-Back review sessions at staff meetings
or visual reminders of the 5Ts on bulletin boards. The unit
Teach-Back team decides on and creates the activities, with
help from the HL Office as needed.
To provide an opportunity for continued skill building
beyond the basic class, we developed three advanced TeachBack classes. These trainings focus on (1) development and
use of documents as tools for Teach Back, (2) listenability
(Rubin, 2012), and (3) use of Teach Back during the discharge process. The addition of these three classes enables
participants who have taken the first 4-hour training to
keep working on their skills. It also allows units who participated in CTG to send newly hired staff for training and
others for refreshers.
We have successfully trained more than 1,300 HCWs
to use the 5Ts when delivering any type of information to
patients. We find that anyone who gives information to patients can benefit from a Teach-Back training. The flexibility
of the 5Ts model and our training method allows us to tailor
instruction to many different roles in the health care system.
The Take Responsibility step, although primarily aimed
at creating a non-shaming environment for patients, may
shift how HCWs approach information delivery and patient
education. One nurse described Teach Back as “a different paradigm,” citing concepts introduced by the Take Responsibility step (nurse, personal communication, June 18,
2018). Perhaps it is because of this paradigm shift that Take
Responsibility is the most often forgotten step in training
practice. It is often a new habit to incorporate into practice
and even a culture shift for a highly educated workforce that
is taught to demonstrate confident expertise. One participant noted:
We are self-centered in the way that we deliver our education
and Teach Back totally changed the way we look at it. It’s our job
to get the information through, and not the patients’ to soak it up.
They [the patients] are not from here [the hospital] so we can’t
expect that. I don’t think we mean to expect that of the patients,
but we do. (nurse, personal communication, June 18, 2018)
The Take Responsibility step, therefore, not only lessens the patient’s shame of not understanding, but can also
change how health care staff view the education process
We have anecdotal evidence that training participants do
not correctly retain the operational definition of Teach Back
(including the 5Ts) after a single training. For example, a
year after he had taken a one-time training, an appointment scheduler defined the Tell Me step as asking the patient, “Did you understand what I just mentioned? Is there
anything you’d like to go over once more? Does that make
sense?” (appointment scheduler, personal communication,
June 18, 2018). These questions suggest that a 2- to 4-hour
training does not ensure retention of the 5Ts concept.
When discussing barriers to Teach Back, training participants often cite a lack of time. However, participants also
seem to recognize that Teach Back saves time when looking at longer-term efficiency. For example, after completing
the CTG program, a clinic leader stated that patients were
more often prepared for their appointments because they had
completed required pre-appointment laboratory assessments
and tests (clinic leader, personal communication, January 19,
2018). Similarly, an appointment center scheduler noted that
Teach Back improved efficiency of his call center because patients were not calling back with questions that could have
been answered during the initial phone call. In the short
term, however, staff often estimate that using Teach Back
takes more time than patient encounters without Teach Back.
Given time limitations, it is likely that HCWs may only use
Teach Back with those whom they perceive to have trouble
understanding (appointment scheduler, personal communication, June 18, 2018; Jager & Wynia, 2012). Therefore, Teach
Back, when conceptualized strictly within short-term time
constraints, seems to be less efficient. However, information
included in our trainings about increased efficiency over time
as the skill is practiced, as well as longer-term operational efficiency (e.g., fewer patient call-backs), can counter worries
about time barriers.
Although we have not conducted a scientific research
study, we have learned a great deal while conducting our
Teach-Back trainings. During our classes, the observers in
the practice sessions learn almost as much as the HCWs. Using the Observation Tool to recognize the 5Ts reinforces the
skills. Follow up with some of our participants has shown
that they do not retain knowledge of the 5Ts after a single
Teach-Back training session. We expect post-training surveys to show that the follow-up component of our CTG with
Teach-Back program will begin to rectify some of these misunderstandings.
Teach-Back training is becoming firmly entrenched in
our institution. Units that adopted the universal use of Teach
Back early have seen anecdotal successes, motivating other
units to institute Teach Back. Support from all levels of leadership, through active participation in trainings and demon-
e102 HLRP: Health Literacy Research and Practice • Vol. 4, No. 2, 2020
stration of its use, reinforced the value and importance of the
As entire units complete the CTG training, we are finding that Teach Back becomes embedded into the unit culture.
Because the 5Ts are standardized and observable, managers
can send new hires and HCWs needing review to our hospital-wide Teach-Back classes. Unit-based peer coaches use
a modified version of the Teach-Back Observation Tool to
evaluate and provide feedback on the effective use of Teach
Back in practice.
We found that flexibility of the program is key to sustainability. Tailoring the program to an individual unit’s staffing and schedule facilitates engagement. Shadowing on the
unit ahead of the training also allows training scenarios to
be tailored to the unit and increases the relevance for staff.
Limiting the number of formal training sessions but supporting them with unit-based coaching allows for more frequent
reinforcement of the 5Ts without significantly affecting unit
Our organizational structure does not allow mandated
Teach-Back training for physicians or other providers, who
rarely participate in the trainings. Because providers deliver
much of the patient education in our outpatient settings, increased provider participation is likely needed before we can
measure whether Teach Back impacts Press Ganey patient
satisfaction metrics for patient education. Anecdotally, providers feel there is not enough evidence to show the benefits
of Teach Back outweigh the amount of time necessary to do
Teach Back. As further research demonstrates the effectiveness of Teach Back, we hope that our providers will better
appreciate the value of Teach Back.
While reviewing the literature, we noted that many researchers do not publish their operational definitions of
Teach Back. The 5Ts could be useful in further research to
determine the effect on patient outcomes when a standardized method of Teach-Back training is implemented.
The 5Ts model is a helpful tool when training HCWs in
the use of Teach Back. The 5Ts model breaks Teach Back into
individual observable skills, making it ideal for teaching the
skill in small steps. Because all of the 5Ts steps are observable,
they can be easily identified during training, coaching, and
evaluation. Development of an institution-wide Teach-Back
training program requires time and dedicated staff to complete. Obtaining high-level leadership support is critical to
the success of the program.
As Coleman (2011) noted, there is a lack of data on the
effectiveness of health literacy training methods and curricula. Our next steps would address this gap by validating the
Teach-Back Observation Tool as well as the pre- and posttraining surveys distributed to participants. Validating these
tools will allow for their effective use in research. We will
pursue mandatory 5Ts training for providers. We hypothesize that training both staff and providers will maximize the
potential for improved patient satisfaction scores, lower readmission rates, and better patient outcomes.
Anderson, J. L., Dodman, S., Kopelman, M., & Fleming, A. (1979). Patient information recall in a rheumatology clinic. Rheumatology and
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M. J., López, M. N.,. . .Hidalgo, J. L. (2010). Effect of the evaluation
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Brega, A. G., Barnard, J., Mabachi, N. M., DeWalt, D. A., Brach, C.,
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A system




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