Abstract
Introduction
Due to the chronic nature of the diabetes, patients who suffer from this disease need education to take care of themselves and increase self-care. Therefore, the present study was conducted with the aim of comparing the effect of e-learning and teach-back methods on the performance of diabetic patients.
Methods
In this study, 144 patients with type 2 diabetes were selected based on purposive sampling. Considering the inclusion and exclusion criteria, the subjects were divided into two groups of intervention (n = 48) and control (n = 48) by simple randomization. The two intervention groups included the e-learning group whose subjects were trained by entering the training site for three months and the teach-back group whose subjects were trained during four 60-minute sessions for three months. The control group was followed up according to routine care. Before and one month after the intervention, data were collected using self-care questionnaires in the areas of knowledge and performance based on interviews and blood glucose tests and self-reporting. The data were analyzed using SPSS 21 and statistical tests of ANOVA, independent t and Pearson’s correlation coefficient.
Results
The results showed that both e-learning (P = 0.001) and teach-back training (P = 0.008) methods were associated with a significant increase in self-care compared to before the intervention, but only in the teach-back group, this increase was significant compared to control group(P = 0.002) and the training methods showed no significant effect on blood sugar level and BMI of the patients (P > 0.05).
Conclusion
The results of the present study showed that both electronic and teach-back training methods have been effective on the level of self-care of diabetic patients. However, the teach-back method had a greater impact on the level of self-care.
Keywords: E-learning, Teach-back, Self-care, Diabetic
Introduction
Diabetes is a serious chronic disease that is considered to be the most common disease caused by metabolic disorders. The global epidemics of diabetes is associated with changes in lifestyle, and mental and behavioral factors [1].
According to the latest statistics of the International Diabetes Federation (IDF), about 463 million people (20–79 years) suffer from this disease in the world in 2019 and it is predicted that this number will increase to 700 million people by 2045 [2].
Studies have shown that in 2016, the UAE, along with North America (11.5%), had the highest prevalence of diabetes (10.7%) in the world [1]. In Iran, more than 11% of the adult population are diabetics, half of which are still unaware of their diabetes [3].
Diabetes reduces life expectancy in people by one third and the prevalence of disability in these patients is two to three times higher than the normal range in the community. Type 2 diabetes has a special relationship with human lifestyle in today’s modern world [4]. For example, one of the biggest challenges that diabetics face is learning how to live with diabetes and control their blood sugar on a daily basis. Therefore, educating the patients to empower themselves in self-care and optimal control of blood sugar is an important part in the treatment of diabetes.
In most conducted studies, high treatment costs, limited access to special care centers for diabetic patients, and the lack of educational programs tailored to their needs have been considered as obstacles to self-care in these patients [4]. According to Orem’s Self-Care Deficit Theory, lack of information and understanding reduces the power of judgment and decision-making and leads to limitations in a person’s self-care performance. On the other hand, in the matter of education (as an inseparable aspect of communication between health care workers and patients), it is necessary for health care workers to use different patient-centered communication approaches along with evaluating the patient’s understanding in their education in order to improve and adhere to the patient’s behavior [5]. Teaching methods vary from traditional to modern methods. Conventional educational methods usually cannot improve patients’ self-care skills due to the inefficient educational skills of the training staff and insufficient attention to patients, as well as the inappropriate content of the program and forgetting of information by patients. Teach-back training is a modern training method that is done through face-to-face questions and answers. This method allowed the patients to express in their own words what they heard and understood, while the trainer corrected their mistakes by reminding them of the material. This method helps to maintain optimal levels of self-care in patients [6]. In the study of Crawl et al., the positive effect of the TB educational method in the control of diabetes has been reported [7]. In his thesis, Hosseini also emphasizes the greater effect of the educational method of learning feedback (Teach back) on the self-efficacy and self-care of type 2 diabetic patients [8]. On the other hand, the TB method is a face-to-face method, and like other face-to-face methods, it requires the presence of the patient and spending time traveling and possibly booking an appointment in advance, and it is not a suitable method for disabled people or those who have difficulty moving or those who live at a far distance from education centers [9]. One of the common guidelines for self-care education of diabetic patients is their continuous and frequent access to up-to-date educational resources, which should be focused on general knowledge of diabetes, medication orders, change in lifestyle and, if possible, self-control of blood sugar and self-care training. Therefore, it is possible to cover more people through electronic education, technologies such as the Internet, television, video tape, and computer-based education, and leave some care to the patient himself/herself [10].
Most of the studies conducted in this field have shown the positive effects of e-learning. In his study about electronic education for diabetic patients, Ranaei points out lifestyle modification through e-learning and increasing self-management of diabetic patients [11]. He suggests planning for e-learning for diabetic patients on a wider level [12]. On the other hand, Salehi Omran, in his study about e-learning, believes that the position of using e-learning in education, though it has attracted a lot of attention, is currently not very significant in terms of performance and effect, and e-learning suffers from lack of proper human interaction, delay in feedback, postponement in asynchronous learning and lack of motivation to read online electronic materials [13]. In his research, Hosseini considers the need for smartphones or computers and the issue of internet availability as the challenges facing e-learning [14]. In summarizing the mentioned materials, we have found the positive effect of TB and e-learning methods compared to other traditional methods. [[10]–[11]] On the other hand, each of these methods has its own disadvantages as well. Considering the importance of chronic diseases, especially diabetes and its irreversible complications, and the effect that education can have in postponing or eliminating these complications, and the challenges facing researchers to choose the right method, this study aims to determine the effect of e-learning and Teach-Back methods on the performance of patients with type 2 diabetes.
Materials and methods
This is a Quasi-experiment with a pretest-posttest design, which was performed within six months in 2020–2021. The study population of this study includes all type 2 diabetic patients who referred to the Diabetes Clinic in Shoushtar. Considering 10% dropout in the study, 48 people were considered for each study group (control group, e-learning group and teach-back training group) and a total of 144 people were selected based on the inclusion criteria (having a medical record in the relevant unit, being literate, not participating in diabetes training program during the last two years and diabetes duration of at least 5 years) and exclusion criteria (hospitalization during the study period, being absent for more than two training sessions and patient death). This is a double-blind study in which the allocation of people to the intervention and control groups was done using simple random allocation. 144 cards were in three different colors (where each color identified a group) and each patient who met the inclusion criteria was asked to randomly take out a card from the box and according to the color of the person’s card, he/she was placed in a group already specified for each color (Fig. 1).
Fig. 1.
Consort flow diagram illustrating the process of selecting and following the participants
Data collection scales in this study included:
Demographic information form (age, gender, marital status, level of education) and disease information (duration of illness, family history of disease, history of smoking in family members).
The Self-Care Performance Questionnaire, which includes 15 questions in the sections of self-control performance (blood sugar control, medication use, etc.) and general performance (level of activity and exercise, diet, etc.) and foot care and smoking, examines patients’ self-care during the past seven days (Tobert et al., 2000) [15]. In this scale, each behavior was given a score from zero to seven, and a total compliance score was obtained by adding the scores of each question. The validity and reliability of this scale has been examined in various studies. In the study of Hamdzadeh et al. in 2012, the mean reliability index score was 84.9% and the Cronbach’s alpha was 78% [16]. In the present study, its reliability based on Cronbach’s alpha was calculated as 0.80.
In order to conduct the research, after the approval of the project in the Research Council of Shoushtar Faculry of Medical Sciences and obtaining the code of ethics, the researcher referred to the clinics of Shoushtar. In a meeting with patients, research objectives were explained and written consent was obtained from patients who were willing to participate in research.
One week before the start of the intervention, the necessary arrangements were made with the research units to determine the time, place and conditions necessary to participate in the research. It was emphasized to all the patients of all three groups that with 10 h of fasting on the appointed day, together with a family member who has the necessary knowledge regarding the use of the Internet, refer to the diabetes clinic of Khatam al-Nabiya Hospital to participate in the initial meeting and providing blood sample (free of charge). Then, 1 cc of blood was taken to check fasting blood sugar and sent to the laboratory of Khatam Al-Nabiya Hospital.
The people responsible for completing the questionnaires, taking samples, determining the body mass index and performing the fasting blood sugar test before and after the intervention were not aware of the group of patients (control and intervention).
Then, the patients of the intervention group were taught the necessary training to connect to the network and enter the website with electronic training (http://www.edm.kmu.ac.ir/diabetes). It should be mentioned that the educational site was designed and created by the researcher together with an IT expert. The content of this site was determined and finalized using new and reliable scientific sources such as Iranian Diabetes Association, other existing valid associations and related books. Content validity and its compliance with the current conditions was determined using the opinion of relevant experts. The training was designed based on a web-site program and then as a scheduled training for three months for patients to use in a simple and understandable way.
Moreover, the researcher’s telephone and e-mail address were provided to the group members in case they had questions. The content of this website, according to the program, contained educational-supportive materials that were prepared based on receiving information from the needs assessment form. Access to the educational website was provided only to the intervention group and with an individual password and they could visit the website at any time during the intervention period. Lack of following the training by patients in the intervention group was predicted as one of the limitations. To control this limitation, educational software equipped with a user counter that determined the order of use of the website for each person and to attract participation, free internet was considered as a gift.
Those who reached at least 15 visits in the first month were considered as full recipients of the training package. People whose referral rate had not reached this level were contacted so that they could reach a high level in the continuation of the study. The intervention in electronic education lasted three months, then one month after the end of the intervention, the blood sugar test, self-care level and body mass of the patients were evaluated and recorded.
In the Teach-Back training method, in addition to determining self-care needs, the observational checklist of insulin injection skills and blood sugar control skills, which lasted about 20 min, was used to evaluate patients. Then, during four 60-minute sessions for three months in the implementation phase, the training process was carried out by observing the transfer of the desired content and concepts in a simple and clear manner, emphasizing key points and using short sentences. At the end, feedback was obtained from the patient and the skill level of the person was measured with the same observational checklists. It should be noted that the patients were divided into smaller groups of 16. Then, one month after the end of the intervention, the blood sugar test, self-care level and body mass of the patients were evaluated and recorded and the control group subjects were followed up according to routine care.
One month after the end of the educational intervention in the control group, blood sugar test, self-care level and body mass of the patients were evaluated and recorded.
In order to maintain ethical standards, the address of the training website, which contained training-support programs and a self-care training booklet derived from teach-back training, were provided to the people in the control group.
Kolmogorov–Smirnov test was used to check the normality of the data; Chi-square test was used to examine the relationship between variables and independent t-test was used to compare the means. Data analysis was performed using SPSS-21 software.
Results
The mean age of participants was 55.42 ± 12.01 (MEAN ± SD) and the duration of illness was 9.85 ± 8.26 years and the gender of 102 cases (71%) was male (Table 1).
Table 1.
Frequency and mean of demographic variables of patients
| Variable | Frequency (percentage) | |
|---|---|---|
| Sex | Male | 102 (71) |
| Female | 42 (29) | |
| Having a history of diabetes | Yes | 67 (47) |
| Smoking | Yes | 71 (49) |
| Drug | Tablet | 41 (28.47) |
| Insulin | 90 (62) | |
| Tablet and insulin | 13 (9) | |
| Education | Illiterate | 28 (20) |
| High school | 97 (67) | |
| University | 19 (13) | |
| Disease side effects | Yes | 36 (25) |
| Mean ± standard deviation | ||
| Age | 55.42 ± 12.01 | |
| Duration of disease | 9.85 ± 8.26 | |
Using independent t-test, it was found that the mean value of self-care in patients in the e-learning (P = 0.01) and teach-back group increased significantly compared to before the intervention (P = 0.008). Nevertheless, training had no effect on blood sugar and BMI variables (P > 0.05) (Table 2).
Table 2.
Evaluation of self-care, blood sugar and BMI of patients in intervention groups (e-learning and teach-back) and control
| (Variable) | Significance level | ||||
|---|---|---|---|---|---|
| Self-care | Before training | After training | |||
| Mean ± standard deviation | |||||
| Intervention | (e-learning) | 40.85 ± 18.44 | 56.70 ± 18.46 | *P = 0.001 | |
| Teach back | 43.9 ± 19.94 | 63.90 ± 17.52 | *P = 0.008 | ||
| Control | 48.35 ± 11.61 | 47.65 ± 13.54 | P = 0.775 | ||
| Significance level | p = 0.382 | **p = 0.012 | |||
| FBS | |||||
| Intervention | (e-learning) | 167 ± 74.74 | 190.9 ± 81.79 | P = 0.357 | |
| Teach back | 228.20 ± 116.18 | 219.40 ± 107.44 | P = 0.822 | ||
| Control | 203.95 ± 64.91 | 198.10 ± 72.14 | P = 0.369 | ||
| Significance level | p = 0.096 | p = 0.573 | |||
| BMI | |||||
| Intervention | (e-learning) | 27.65 ± 4.48 | 27.84 ± 6.72 | P = 0.920 | |
| Teach back | 28.37 ± 4.5 | 28.41 ± 4.62 | P = 0.966 | ||
| Control | 28.02 ± 4.88 | 27.99 ± 4.43 | P = 0.956 | ||
| Significance level | P = 0.889 | p = 0.94 | |||
*Independent T-test
** ANOVA test
Using ANOVA test, it was found that there was a statistically significant difference only in the level of self-care in comparing the three groups after the intervention (P = 0.012); the mean level of self-care in the teach-back group (63.90 ± 17.52) is higher than e-learning (56.70 ± 18.46) and higher than the control group (47.65 ± 13.54) (Table 2).
In this study, based on independent t-test, it was determined that the level of self-care in the teach-back group increased significantly compared to the control (P = 0.002), but this change was not observed in the e-learning group (P = 0.84) (Table 3).
Table 3.
Evaluation of self-care of patients in intervention group (e-learning and teach-back) and control
| Group | ||
|---|---|---|
| Self-care | Before training | After training |
| Mean ± standard deviation | ||
| Intervention (e-learning) | 40.85 ± 18.44 | 56.70 ± 18.46 |
| Control | 48.35 ± 11.61 | 47.65 ± 13.54 |
| Significance level | p = 0.132 | p = 0.84 |
| Intervention (Teach-back) | 43.9 ± 19.94 | 63.90 ± 17.52 |
| Control | 48.35 ± 11.61 | 47.65 ± 13.54 |
| Significance level | p = 0.394 | *p = 0.002 |
*Independent T-test
In the study of the effect of demographic variables on the level of self-care, which was significant between groups, Pearson correlation coefficient showed that the complications of the disease have a significant relationship with the level of self-care (P = 0.021); the control group had more complications than the intervention groups (Table 4).
Table 4.
The effect of demographic variables on self-care in patients in intervention and control groups
| Self-care / variable | Group | ||
|---|---|---|---|
| Control | E-learning | Teach back | |
| Age | p = 0.101 | p = 0.543 | p = 0.635 |
| Duration of disease | p = 0.517 | p = 0.734 | p = 0.804 |
| FBS | p = 0.914 | p = 0.53 | p = 0.499 |
| BMI | p = 0.104 | p = 0.780 | p = 0.595 |
| Disease background | p = 0.962 | 0 | p = 0.391 |
| Cigarettes | p = 0.564 | p = 0.779 | p = 0.818 |
| Gender | p = 0.651 | p = 0.412 | p = 0.998 |
| Disease complication | * p = 0.021 | p = 0.412 | p = 0.2 |
| Education | p = 0.129 | p = 0.575 | p = 0.59 |
Using Pearson correlation coefficient
Discussion
Various factors, including self-care, are effective in controlling diabetes. Self-care in people with diabetes is considered a tool to control the disease [17].
The aim of this study was to investigate the effect of self-care training based on e-learning and teach-back methods on the performance of type 2 diabetic patients. The results showed that the level of self-care in both teach-back and e-learning groups had a significant increase compared to before the intervention. The results of similar studies on the level of self-care of diabetic patients can be found in the study of Nouhi et al., where the patients were trained by electronic means [10]. In the study of Hooshmandja et al [18]. and the study of El-Galyar et al [19] who used mobile applications to educate diabetic patients. According to Jacobson et al., the necessity of diabetes control is the self-management of patients, which is an effort throughout life to maintain the quality of life [20]. Communication systems such as the Internet and mobile phones are needed for the purpose of educating and monitoring diabetic patients. Contrary to the findings of the present study, in the study of KIM et al., the use of mobile phones was not associated with a significant effect on the amount of sports activity of diabetic patients, and the reason for this difference can be considered due to the high age of the participants in the study of KIM et al. Because the old age of patients due to disorders and chronic diseases causes lower interaction to participate in physical activities [21].
The results of the present study showed that the level of self-care in the teach-back method has increased significantly compared to before the educational intervention, which is similar to the results of a study by Oshvandi in the field of self-care [5] and a study by Raznahan [22] in the field of quality of life among diabetic patients. However, some studies reported results that contradict the findings of the current study. In a study by Kandula, the use of teach-back training had no effect on the care and retention of information in diabetic patients. These contradictory results can be attributed to the low education of the patients in this study, because less education is associated with lower knowledge retention. A person with more education and health-related background knowledge may have an easier time integrating new care information into long-term memory than someone with less education [23].
In the comparison of all three groups, it was found that the level of self-care was significantly higher in the teach-back group than in the e-learning and control groups.
In the studies by Oshvandi et al. [5] and Mahmoudi Rad [24], the level of self-care in diabetic patients in the group that was trained by the teach-back method was significantly higher than in the control group. Moreover, the results of a study by Zarea et al. demonstrated that the level of self-care in diabetic patients using teach-back method compared to video and control group had a significant positive effect [8], which is similar to the results of the present study. The use of the teach-back method has helped the retention of information. One of the factors that can explain these results is the face-to-face interaction between the researcher and the patient. Repetition of specific information in the human mind can strengthen short-term memory. As explained, teach-back training uses the repetition of training materials. It seems that this feature has led to better performance in retaining self-care information [8].
This is despite the fact that in the author’s study, immediately after the educational intervention with two methods of video and teach back in diabetic patients, an increase in awareness in the level of diet and medication compliance was reported, but the follow-up after 6 weeks showed that there was no significant difference between the educational methods [25], and the reason for the difference with the results of the present study can be attributed to the lack of follow-up by the researcher on the level of self-care in diabetic patients.
Furthermore, in a study by Kola, there was no significant difference in the level of self-care between multimedia training and teach-back in patients with heart disease. The reason for this discrepancy with the results of the present study can be contributed to the difference in the research community and the use of a combined method in this study and the follow-up of patients. In the present study, both training methods were compared with the control group, but in the study of Kola, it was compared with combined training group. At the time of discharge, self-care was higher in the combined training group, but with follow-up at different times, this difference between the training methods was not significant in the study of Kola [6].
In the study of Sahebzamani, it was also found that the effect of both educational methods on the efficiency of type 2 diabetic patients is the same and they do not differ from each other. There are several factors influencing the educational methods. In the present study, the teach-back method has been more effective maybe due to the feedback of the instructor or the cooperation of the learners compared to e-learning method and their age conditions [26].
The results of the present study showed that e-learning and teach-back training did not affect the blood sugar level and BMI of diabetic patients.
In this regard, Kim et al. in their study using e-learning did not observe a significant difference in fasting blood sugar levels between the two intervention and control groups, which was due to the short duration of the training (12 weeks) [21]. In the current study, the training period was 3 months.
Nelson also noted that the reason for not obtaining a significant result in fasting blood sugar levels between the two intervention and control groups after the training was insufficiency of e-learning for patients, especially the elderly [27]. In the study of Satehi, there was no significant difference in blood sugar levels in all three groups of teach-back and multimedia and control patients with diabetic foot ulcers [28], which is similar to the results of our study.
Meanwhile, in the study of Nouhi [10], e-learning has been associated with blood sugar and BMI reduction, and in the study of Lee, self-care education using the internet has been associated with improved blood sugar control [29]. It seems that the reason for this is the increase in the active role of patients in self-care in the aforementioned studies, because patients have experienced a new type of education and communication, and their motivation for learning and self-care has increased.
It should be noted that this study also has some limitations that need to be considered. Knowledge, previous experiences, clients’ interest in accepting education, and patients’ emotional, psychological and cultural backgrounds all affected the level of performance and learning, interests and motivation, which in some cases was beyond the researcher’s control.
Conclusion
The results of the present study indicate that the implementation of educational programs, especially the use of new teaching methods that make learning more attractive, are necessary for a more successful management of diabetes. Both e-learning and teach-back methods have been effective on the level of self-care of diabetic patients. However, the teach-back method had a greater effect on the level of self-care and had no effect on blood sugar and BMI.
Acknowledgements
This study is taken from the research work numbered 98000005. It is financially supported by the Vice Chancellor for Research of Shoushtar Faculty of Medical Sciences. Finally, I would like to thank the participants in this study and my dear colleagues.
Author Contribution
Data collection: Hemmatipour. Data analysis and interpretation: Jahangirimehr. Drafting of the article: Karami, Hatami, Hemati. Critical revision of the article: Mehri.
Funding
The Ethics Committee of, Shoushtar Faculty of Medical Sciences.Shoushtar, Iran, approved this study (code: IR.SHOUSHTAR.REC.2020.034). The study adhered to all ethical principles for human subjects.
Declarations
Conflict of Interest
The authors also state that there is no conflict of interest in the present study.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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