Health Literacy Strategies to Engage Cancer Patients and Caregivers

March 2021 Vol 12, No 3


Original Research
Debbie Bickes, MN, RN, OCN, ONN-CG
Northside Hospital Cancer Institute, Atlanta, GA
Keisha Jennings, MSN, RN, OCN
Northside Hospital Cancer Institute, Atlanta, GA
Iris Feinberg, PhD
Georgia State University, Atlanta, GA

Background: The importance of engaging patients in their cancer care cannot be ignored. Health literacy communication skills like Teach-Back may help improve patient engagement by providing patients with accessible, understandable, and usable information and then confirming that patients understand what they are being told, thereby improving patient self-efficacy. Teach-Back is a method in which patients confirm their understanding by responding to questions that are framed by the navigator saying, “I gave you a lot of information, and I want to make sure I was clear.”

Objective: To evaluate implementation of the Teach-Back method and to measure patient understanding of information and engagement.

Methods: We collected data on the number of patient questions using a standard navigator script (N = 65). Navigators were trained on use of Teach-Back, and the navigator script was modified to include Teach-Back language. Patients (n = 55) called in to the navigator center to talk with a navigator who used the modified navigator script. Navigators collected data on each call, identifying which Teach-Back question they used, correctness of patient responses, and types of information Teach-Back by patients.

Results: By adding Teach-Back language to standardized navigator scripts, navigators found patients more conversational and more focused in their questions.

Conclusions: Teach-Back is an effective method of reinforcing or confirming patient education and will be implemented and measured by the Cancer Center in all standard navigator scripts.

The incidence of cancer is projected to be 2.1 million people in the United States in 2030.1 The most advanced scientific treatments delivered in state-of-the-art settings by skilled health providers are the means to providing effective cancer care. However, data show that clear and meaningful provider–patient communication may be lacking. Some patients report higher levels of satisfaction with care and feel more in control when healthcare providers communicate clearly and often; others are more likely to adhere to treatment and discharge instructions.2-4 The most common way patients and providers share information is through verbal exchanges; however, more than 75% of what is discussed is forgotten immediately, and only one-half of what is remembered is correct.4,5 When patients understand comprehensibly delivered yet still scientifically exact information, they are more likely to participate in prevention and detection activities and are often more successful in completing treatment.4,6

Health literacy is the interplay between how health providers communicate information and how patients can access, understand, and use that information to make informed decisions about their health.7 It is estimated that only 12% of adults in the United States have proficient health literacy, which means more than 300 million adults are at high risk for miscommunication with health providers, failure to adhere to medication and discharge instructions, and cannot fully participate in making informed decisions about their care.8 A critical communication link in cancer care is the patient navigator; as part of the interdisciplinary team supporting the patient, the navigator can impact this disparity by clarifying information provided by the doctors and nurses, as well as directing the patient and caregiver(s) in the cancer journey.9

The Cancer Institute is the largest and most integrated comprehensive cancer hospital network in Georgia. It consists of a network of 5 hospitals and affiliations with 3 large medical oncology groups with more than 30 medical oncology offices. The Cancer Institute is fully accredited by the American College of Surgeons Commission on Cancer (CoC) and ranks in the top 2 among community cancer programs in the nation for newly diagnosed and treated cancer cases. The oncology patient navigation program is a part of the Cancer Institute’s Support Care Services. The mission of the patient navigation program is to guide patients, families, and caregivers to informed decision-making by collaborating with multidisciplinary teams to help overcome barriers to timely screenings, diagnosis, treatment, and supportive care. The oncology navigation team is made up of oncology nurse navigators (ONNs) and cancer care liaisons (CCLs). The ONNs are registered nurses with extensive cancer-related knowledge and training. ONNs serve as a personal resource for patients by providing them with clinical information and education. The CCLs are nonclinical personnel who have been trained to work with patients and their families to identify and address nonclinical barriers to care. The CCL assists the ONN by helping to identify patient concerns and providing a referral for all clinical issues. The team consists of 8 ONNs with disease-specific knowledge and 11 CCLs.

The CoC Standard 8.1 Addressing Barriers to Care requires an organization to identify at least 1 patient-, system-, or provider-based barrier to accessing health and/or psychosocial care faced by cancer patients and develop and implement a plan to address the barrier.10 Barriers are assessed by our oncology navigators, documented into our navigator software system, and barrier reports are generated from the system. The barrier report used at the time of this study was for calendar year 2019.

The oncology patient navigation department currently performs a health literacy screen on all new patients using the BRIEF Health Literacy Screening Tool.11,12 The BRIEF health literacy screen consists of 3 questions: (1) “How often do you have someone (like a family member, friend, hospital/clinic worker or caregiver) help you read hospital materials?” (2) “How often do you have problems learning about your medical condition because of difficulty understanding written information?” and (3) “How confident are you filling out forms by yourself?” Likert scale responses range from 1 = always to 5 = never.11,12 Total BRIEF scores range from 4 to 20, with 4 to 12 categorized as Inadequate Health Literacy, 13 to 16 as Marginal, and 17 to 20 as Adequate.11,12

When the health literacy barrier was identified, appropriate reading materials and resources for patients were limited. There was not a method in place to measure the patient’s comprehension of what had been taught. The Teach-Back method, a technique for verifying patient understanding of health information, has been recommended by the Agency for Healthcare Research and Quality and the Institute for Healthcare Improvement to be used for every patient at every visit. Studies have shown that most patients do not recognize their lack of comprehension, and a substantial proportion of medical information is forgotten immediately.5,9 This quality improvement study evaluated navigator implementation of the Teach-Back method and measured patient understanding of information and engagement. This study will also inform if Teach-Back can be incorporated into the daily work routine of the patient navigator to improve patient understanding.


Our study has 3 objectives:

  1. Implement a standardized health literacy intervention for navigators at Northside Hospital Cancer Institute.
  2. Assess navigator perceptions of use of the Teach-Back script when talking with cancer patients.
  3. Evaluate patient responses to information provided by navigators before and after the standardized Teach-Back intervention.

To meet these objectives, a health literacy expert was engaged to design a study that would evaluate use of a standardized Teach-Back script. For the preintervention segment, navigators used current telephone scripts, which ended with asking the patient if he/she had any questions. Eight ONNs and 5 CCLs entered call information for 5 patients each with regard to questions patients had and the topics for the questions, with a total of 65 patient responses entered into the survey. Navigators then watched the AMA Health Literacy short video ( and met during a conference call with the health literacy expert to discuss health literacy, the Teach-Back method, and how to revise their standardized script to incorporate Teach-Back. With navigator input, the health literacy standardized script was changed to include Teach-Back questions, patient response to Teach-Back, and if the patient had any questions (Figure). Data were collected again in a Qualtrics survey (45 responses). To measure use by navigators, a sample of the navigators (n = 6) were sent an additional survey to assess their perception of ease of use of Teach-Back and the level of patient engagement.


The top 3 questions used in the standardized Teach-Back script by the navigation staff at the end of each patient call were “What are the next steps?” “What’s our plan?” and “What are you going to do first/next?” The majority of patients (n = 55, 85%) were able to Teach-Back complete information following implementation of the standardized Teach-Back script. Financial assistance and appointment- related questions were the most frequently discussed topics during the time of the standardized Teach-Back script implementation. See Table for details.

Comments from navigators after the standardized health literacy script implementation include:

  • “I used the conversation recap phrase twice yesterday, and it worked well. Thanks for bringing this Teach-Back method into our education arsenal”
  • “I was surprised that 1 patient who told me that she was taking great notes had forgotten to write something down when I quizzed her…”
  • “I think this intervention is going to be very effective”

Other navigation team members commented that they believed the intervention was effective because using Teach-Back empowered patients to be more involved and engaged in their healthcare.


The importance of engaging patients in their cancer care cannot be ignored. Patient engagement is a National Quality Strategy priority and is especially pertinent to oncology care because cancer treatment can be complex and involves shared decision-making between patients and different healthcare providers. One strategy cited in which patient education can be delivered to support patient engagement is employing the Teach-Back method to confirm that patients understand what their care providers are sharing with them.10

This method also was cited as a strategy to make the most of educational opportunities in the Advisory Board Oncology Roundtable presentation, “Strategies to Engage Cancer Patients and Caregivers.”

This quality improvement study examined the use and effectiveness of the Teach-Back method in patient health education. Findings support the use of the Teach-Back method as an effective method in reinforcing or confirming patient education. Yen and Leasure report that routinely screening patients for individual health literacy has not been shown to improve outcomes and is not recommended13; healthcare providers must be more responsible for using health literacy tools like Teach-Back to ensure patients receive information that is accessible, understandable, and usable. Many professional organizations recommend using universal health literacy precautions to provide understandable and accessible information to all patients, regardless of their literacy or education levels.14,15 As a result of the positive outcomes of the study with increased patient understanding and increased patient engagement, the patient navigation program will be adopting the Teach-Back method into the daily routine of the navigators when interacting with patients. The method will be incorporated into our program’s customized electronic medical record to track and provide future health literacy metrics related to Teach-Back.


  1. Rahib L, Smith BD, Aizenberg R, et al. Projecting cancer incidence and deaths to 2030: the unexpected burden of thyroid, liver, and pancreas cancers in the United States. Cancer Res. 2014;74:2913-2921.
  2. Bylund CL, Brown R, Gueguen JA, et al. The implementation and assessment of a comprehensive communication skills training curriculum for oncologists. Psychooncology. 2010;19:583-593.
  3. Jenerette CM, Mayer DK. Patient-provider communication: the rise of patient engagement. Semin Oncol Nurs. 2016;32:134-143.
  4. Epstein RM, Street RL Jr. Patient-Centered Communication in Cancer Care: Promoting Healing and Reducing Suffering. NIH Publication No. 07-6225. Bethesda, MD: National Cancer Institute; 2007.
  5. Kessels RPC. Patients’ memory for medical information. J R Soc Med. 2003;96:219-222.
  6. Rudd RE. Health literacy considerations for a new cancer prevention initiative. Gerontologist. 2019;59(suppl):S7-S16.
  7. Feinberg I, Ogrodnick MM, Hendrick RC, et al. Perception versus reality: the use of Teach Back by medical residents. Health Lit Res Pract. 2019;3:e117-e126.
  8. Kutner M, Greenberg E, Jin Y, Paulsen C. The Health Literacy of America’s Adults: Results from the 2003 National Assessment of Adult Literacy (NCES 2006-483). US Department of Education. Washington, DC: National Center for Education Statistics; 2006.
  9. Hendren S, Chin N, Fisher S, et al. Patients’ barriers to receipt of cancer care, and factors associated with needing more assistance from a patient navigator. J Natl Med Assoc. 2011;103:701-710.
  10. Bosworth HB, Pini TM, Walters CB, Sih-Meynier R. The future of patient engagement in the oncology setting: how practical patient engagement recommendations and innovative inter-professional education can drive change. The Journal for Participatory Medicine. 2017;9:e7.
  11. Haun J, Noland-Dodd V, Varnes J, et al. Testing the BRIEF Health Literacy Screening Tool. Federal Practitioner. 2009;26(12):24-31.
  12. Chew LD, Bradley KA, Boyko EJ. Brief questions to identify patients with inadequate health literacy. Fam Med. 2004;36:588-594.
  13. Yen PH, Leasure AR. Use and effectiveness of the Teach-Back method in patient education and health outcomes. Federal Practitioner. 2019;36:284-289.
  14. Wittink H, Oosterhaven J. Patient education and health literacy. Musculoskelet Sci Pract. 2018;38:120-127.
  15. US Department of Health and Human Services. National Action Plan to Improve Health Literacy. 2010.
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Last modified: November 15, 2022

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