Graduation Date

Summer 8-9-2019

Document Type


Degree Name

Doctor of Philosophy (PhD)


Health Promotion and Disease Prevention Research

First Advisor

Fabio Almeida, PhD, MSW


Background: In 2001, the Diabetes Prevention Program was published evaluating the efficacy of a pharmaceutical intervention, Metformin, and a behavioral lifestyle intervention (LI) to reduce incidence of Type 2 diabetes mellitus. The LI was observed to reduce the incidence of the disease by 58% relative to 31% in the medication treatment. Amongst technology based LIs, little has been done to address different health literacy populations.

Objectives: This dissertation evaluated how teach-back and teach-to-goal can influence the uptake of information obtained in each health education lesson, behaviors and its influence on engagement and weight loss.

Methods: Four hundred forty-two participants were analyzed in study #1, and only 425 were maintained for study #2 and #3. General regression modeling with White’s Standard Error heteroskedacity adjustments was performed assessing the differences in engagement and comprehension performance by health literacy level and modality.

Results: In a teach-back/teach-to-goal call, differences in reverse score performance (DVD-15.4±2.5; Class-14.8±2.6; F(3, 425)= 13.72, p<0.001), number of teach-back rounds (DVD-1.9±0.7; Class-2.1±0.7; F(3, 425)=5.98, p<0.001) and number of round 1 questions (DVD-4.2±1.6; Class-3.4±1.8; F(3,425)=20.95, p<0.001) was observed. While not significant, 38.7% of LHL participant completed all 22 lessons vs. 28.7% of HHL. Mean overall comprehension average scores improved 0.8±1.1 to 1.2±0.3 and 0.7±1.0 to 1.5±1.1 for those LHL and HHL participants completing only 1 call versus all 22 calls, respectively, as did physical activity and muscle strengthening minutes per week. Models evaluating IVR-reported weight change against engagement and overall comprehension average revealed engagement had an indirect relationship (β= -0.59, p<0.01) with magnitude of weight change (R²=0.13, F(3, 420)=20.8, p<0.001), and a direct relationship with aerobic physical activity, muscle strengthening and fruit and vegetable intake.

Conclusions: Amongst high and low health literacy groups, both groups benefited from teach-back and teach-to-goal health literacy techniques to improve patient comprehension, which in turn, improved engagement rates, especially in the low health literacy population. Reinforcement strategies to promote information uptake is necessary to allow for behavior uptake lending to greater weight loss.