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PLoS One. 2018 Oct 31;13(10):e0206473. doi: 10.1371/journal.pone.0206473. eCollection 2018.

A stepped wedge cluster randomised trial of nurse-delivered Teach-Back in a consumer telehealth service.

Author information

Sydney School of Public Health, The University of Sydney, Sydney, Australia.
Health Literacy Lab, Sydney School of Public Health, The University of Sydney, Sydney, Australia.
Healthdirect Australia, Sydney, Australia.
Eastern Health Clinical School, Monash University, Box Hill, Australia.



To evaluate the impact of Teach-Back on communication quality in a national telephone-based telehealth service, for callers varying in health literacy.


Cross-sectional stepped wedge cluster randomised trial with continuous recruitment, short (fixed) exposure and blinded outcome assessors. Nurses were stratified by hours worked and randomised into training groups using a computer generated sequence.


An Australian national pregnancy and parenting telephone helpline.


Complex intervention involving a single 2-hour group Teach-Back training session, combined with ongoing nurse self-reflection on their communication following each call and each shift.


Participants were 637 callers to the telephone helpline aged 18-75 (87% female), of whom 127 (13%) had inadequate health literacy (measured with the Single Item Literacy Screener); and 15 maternal and child health nurses with 15 years' experience on average.


Primary outcome was a modified subscale of the Health Literacy Questionnaire, 'having sufficient information to manage health'. Secondary caller outcomes included caller confidence, perceived actionability of information and nurse effort to listen and understand. Nurse outcomes were perceptions of their communication effectiveness.


Over a 7 week period, 376 surveyed callers received usual care and 261 Teach-Back. Ratings on the primary outcome increased over time (OR 1.17, CI 1.01 to 1.32, p = 0.03) but no independent Teach-Back effect was observed. A consistent pattern suggests that, compared with usual care, Teach-Back helps callers with inadequate health literacy feel listened to (OR 2.3, CI 0.98 to 5.42, p = 0.06), confident to act (OR 2.44, CI 1.00 to 5.98, p = 0.06), and know what steps to take (OR 2.68, CI 1.00 to 7.17, p = 0.06). Nurse perceptions of both their own communication effectiveness (OR = 2.31; CI 1.38 to 3.86, p<0.0001), and caller understanding (OR = 2.56; CI 1.52 to 4.30, p<0.001) both increased with Teach-Back. No harms were reported.


Teach-Back appears to benefit telephone health service users with inadequate health literacy, but the extent of this is unclear due to smaller numbers of lower literacy participants. Improving caller ratings over time are likely due to increasing nurse communication competence.

Conflict of interest statement

The authors have read the journal's policy and the authors of this manuscript have the following competing interests: SM was funded by a grant from Healthdirect Australia, during the conduct of the study; JB was employed by Healthdirect Australia, during the conduct of the study. All other authors have declared that no competing interests exist. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

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