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The Use of Health Coaching to Improve Health Outcomes: Implications for Applied Behavior Analysis
Abstract
Chronic health conditions are predominant in the USA. Health coaching has demonstrated significant results in increasing health-promotion behaviors that impact the development or progression of chronic health conditions (Simmons & Wolever, 2011). Behavior analysis has also contributed to this body of research with effective behavior-change procedures (Allen & Hine, 2015). While often not cited, the methodology used in health coaching utilizes many principles that align with applied behavior analysis. The current paper serves several purposes: (1) introduces health coaching and the potential for application within a behavior analytic framework, (2) discusses commonalities and areas behavior analysis could impact, (3) suggests implications for future research and practice, and finally, (4) urges collaboration between behavior analysts, health coaches, physicians and other professionals practicing within fields that focus on improving individual health and healthcare.
... The immediacy of positive reinforcement cannot be understated in all the behavioural contingencies that we wish to change through diet and exercise, just as they are in other long-term lifestyle treatments (i.e. smoking cessation) (Erez and Kanfer, 1983;Finn and Watson, 2017;Hansen et al., 2016;Locke and Latham, 2006;Sidman, 1993). The use of incremental reinforcement can lead to changes in habitual behaviour through a mixture of short-lived punishments (i.e. ...
... Moreover, empirically guided and curated self-management treatment programmes can be developed through the self-selection of behaviours by the individual. This can occur even in environments outside of a supervised setting (Bandura, 2004;Finn and Watson, 2017;Lindner et al., 2003;Locke and Latham, 2006;Ninness et al., 1991;Winett, 1995), resulting in long-term improved health status, especially when support for self-management allows the professional to take on a coaching role (Hansen et al., 2016;Lavoie et al., 2017;Lindner et al., 2003;Sidman, 1993). For maximum effectiveness, this coaching should be interactive and include not only the modelling of healthy behaviours but also regular feedback on the appropriateness of choice of selfselected behaviours (Bandura, 2004;Finn and Watson, 2017;Lindner et al., 2003;Locke and Latham, 2006;Ninness et al., 1991;Winett, 1995). ...
... This can occur even in environments outside of a supervised setting (Bandura, 2004;Finn and Watson, 2017;Lindner et al., 2003;Locke and Latham, 2006;Ninness et al., 1991;Winett, 1995), resulting in long-term improved health status, especially when support for self-management allows the professional to take on a coaching role (Hansen et al., 2016;Lavoie et al., 2017;Lindner et al., 2003;Sidman, 1993). For maximum effectiveness, this coaching should be interactive and include not only the modelling of healthy behaviours but also regular feedback on the appropriateness of choice of selfselected behaviours (Bandura, 2004;Finn and Watson, 2017;Lindner et al., 2003;Locke and Latham, 2006;Ninness et al., 1991;Winett, 1995). Such an approach has features in common with other chronic illness management techniques (e.g. ...
The use of diet and exercise has become the cornerstone to treatment of overfatness issues. Yet, the implementation of such factors into lifestyle changes has not been able to meet intrinsic expectations or desires and has led to continuous repetition of short-term success within a coercive environment that is followed by rebound leading to secondary short-term success, that is yo-yo’ing. Even though this has become common, there has been little insight into how we might be able to improve suggestions for diet and exercise to better encourage long-term success as opposed to the short-term gains that are regularly met. In this commentary, we offer a narrative review describing how the use of behavioural analytic methodologies and techniques might allow for the development of self-selective lifestyle modifications (e.g. changes to diet, use of exercise) and choices in behaviour that better serve individuals attempting to reverse the health issues associated with overfatness, without the sense of their being coerced into their choices.
... Behavioral health coaching has caught the attention of behavior analysts in recent years (i.e., Finn & Watson, 2017;Normand & Bobber, 2020), and may be the ideal profession in which to incorporate ACT. Health coaches typically work in fitness centers, gyms, and clinics to help clients achieve goals related to their overall health (Normand & Bobber, 2020). ...
... Health coaches typically work in fitness centers, gyms, and clinics to help clients achieve goals related to their overall health (Normand & Bobber, 2020). Health coaches use several strategies that are consistent with applied behavior analysis, including tracking client progress, teaching self-management skills, and arranging for social reinforcement when goals are met (Finn & Watson, 2017;Rehfeldt, 2020). Its emphasis on measurement, skill generalization and maintenance, and data-based decision-making further aligns health coaching within the professional scope of applied behavior analysis (see Normand & Bobber, 2020). ...
Chronic health conditions are increasing at an alarming rate world-wide, and many could be prevented if people were to engage in specific lifestyle behaviors. Intervening on lifestyle behaviors is challenging due to the fact that the consequences associated with unhealthy behaviors are temporally distant and probabilistic, and the aversive functions of covert stimuli may interfere with people’s engagement in healthy, preventative behaviors. This paper explores the role of relational framing in the promotion of healthy lifestyle behaviors, and summarizes research supporting the use of Acceptance and Commitment Training (ACT) as a framework for prevention and intervention. We explore how ACT alters the context in which rigid patterns of rule-following occur. ACT loosens the literal functions of stimuli so that experiential avoidance behaviors are weakened and healthy, values-consistent behaviors are strengthened. We propose culture-wide interventions inspired by Contextual Behavior Science so that healthier societies can be cultivated.
... Behavioral health coaching has caught the attention of behavior analysts in recent years (i.e., Finn & Watson, 2017;Normand & Bobber, 2020), and may be the ideal profession in which to incorporate ACT. Health coaches typically work in fitness centers, gyms, and clinics to help clients achieve goals related to their overall health (Normand & Bobber, 2020). ...
... Health coaches typically work in fitness centers, gyms, and clinics to help clients achieve goals related to their overall health (Normand & Bobber, 2020). Health coaches use several strategies that are consistent with applied behavior analysis, including tracking client progress, teaching self-management skills, and arranging for social reinforcement when goals are met (Finn & Watson, 2017;Rehfeldt, 2020). Its emphasis on measurement, skill generalization and maintenance, and data-based decision-making further aligns health coaching within the professional scope of applied behavior analysis (see Normand & Bobber, 2020). ...
... Behavioral health coaching has also received recent attention in the published literature. Health coaches typically work with clients to identify their values centered on lifestyle behaviors and establish short-and long-term goals (Finn & Watson, 2017). Health coaches may be effective at teaching self-management repertoires and providing social reinforcement for goals obtained. ...
... Health coaches may be effective at teaching self-management repertoires and providing social reinforcement for goals obtained. Finn and Watson (2017) declared health coaching to be consistent with the tenets of applied behavior analysis, including measurement; plans for maintenance; and individualized, data-based assessment. ...
Devra Davis’s (2007) The Secret History of the War on Cancer, despite being published several years ago, is an important treatise for behavior analysts interested in utilizing behavioral principles to change important lifestyle behaviors that have been linked to long-term chronic conditions. This review summarizes the important points of the book, most specifically the role of government and industry in the etiology of chronic conditions such as cancer. Research on behavioral interventions for health-related behaviors is proposed as one possible means by which behavior analysis might contribute to the war on cancer, but so too might larger scale research on cultural change, including the study of meta- and macrocontingencies and the promotion of skeptical thinking and scientific literacy.
... Health coaching, at least currently, seems more usefully considered an arena for practice rather than a kind of practice, per se. Health coaching encompasses a range of activities (Johnson et al., 2018), and the activities commonly practiced by behavior analysts fit well within this range (see also Finn & Watson, 2017). Several reviews of the efficacy of health coaching interventions suggest that the effects are promising, if not variable (Dejonghe, Becker, Froboese, & Schaller, 2017;Kivelä et al., 2014;Lindner, Menzies, Kelly, Taylor, & Shearer, 2003;Olsen & Nesbitt, 2010;Wolever et al., 2013). ...
... Applied behavior analysis has produced an array of technologies ready to be deployed in the service of health coaching. It also constitutes an approach to understanding health behavior that is rooted in a strong conceptual and basic-research literature, combined with a robust applied research tradition of the kind that would be of service to the emerging field of health coaching (Finn & Watson, 2017). ABA is characterized by operational definitions of target behaviors, repeated direct observation of those behaviors across time, and a focus on individual behavior change evaluated using within-subject research designs (e.g., Baer et al., 1968;Baer et al., 1987;Cooper, Heron, & Heward, 2014) improve performance, including physical activity (e.g., Donaldson & Normand, 2009;Normand, 2008). ...
Approximately half of the U. S. population is living with a chronic disease that could be prevented or abated by lifestyle changes. We have a behavior problem of great social significance that requires carefully designed interventions that produce meaningful changes in behavior, ideally by drawing from the extensive basic and applied research literature in behavior analysis. But to truly address this problem, we will need many more behavior analysts in practice, given the scope of what is facing us. At least for now, behavior analysts who want to practice in the broad field of behavioral health need to establish and maintain professional credentials in new areas of practice. In this article we describe how BACB certificants can obtain certification as a health coach and why it might be fruitful to do so. Specifically, we define the emerging practice area of health coaching, identify some similarities and differences in professional competencies in health coaching as compared to behavior analysis, describe the necessary steps for behavior analysts in practice to become certified health coaches, and suggest ways in which behavior analysts can meaningfully contribute to the practice of health coaching. We conclude with suggestions for how to establish behavior-analytic services focused on health coaching.
... However the evidence for this approach is mixed [47]. On one hand, researchers have highlighted self-care as key to the management of chronic conditions [48], with findings of positive behavioural changes associated with increased patient activation [49,50]. On the other hand, they have found a range of barriers to self-management including low health literacy and the challenging burden associated with chronic conditions (especially for patients with multiple conditions) [51][52][53]. ...
... The model enabled the evaluation of a regional-level intervention using data from routine practice, with scope for external validity and generalisability of the results to other regions in England. Our findings are plausible and are supported by the logic model, our parallel qualitative research [15], and previous literature on health coaching [49,50]. ...
Background:
Health systems, globally, are attempting to strengthen primary care to promote a population-health management approach to care provision, incentivising prevention and self-management. This paper evaluates the "Enhanced Primary Care" model implemented in a geographical region in England. Enhanced Primary Care introduces a new non-medical role, health coaches, to the traditional primary care team to provide additional support for patients with chronic conditions. We evaluate effects of health coaching on patient outcomes using a quasi-experiment.
Methods:
We estimate the programme's effects on health status (EQ-5D-5L, physical functioning, psychological wellbeing, and resilience), health behaviour (smoking habit), experience of care (person-centeredness and continuity of care), and health care (primary care) utilisation using data from 3.5 million respondents to the national GP Patient Surveys between 2013 and 2017. We use a weighted difference-in-differences design to compare changes in outcomes over time between intervention practices and comparable control practices in the rest of England. We conduct our main analysis on multimorbid patients and additional analysis on all patients to assess population-level effects.
Results:
For multimorbid patients, we find reductions in psychological wellbeing (short and medium term) of -0.0174 (95% confidence interval -0.0283 to -0.0065), relative difference -2% from the pre-intervention mean; and person-centeredness (short term) of -0.0356 (-0.0530 to -0.0183), -4%. We find no significant effects on other outcome measures. For population-level effects, in the short term we find reductions in primary care utilisation of -0.0331 (-0.0448 to -0.0214), -5%. All other outcomes are not consistently statistically significant.
Conclusions:
Our results show that there is very little effect of health coaching on patient experience and outcomes in the short-to-medium term (up to 14 months). Introduction of Enhanced Primary Care was associated with slightly lower psychological wellbeing and person-centeredness amongst multimorbid patients (it might be initially difficult for patients to adjust to the model). However, it was also associated with a decline in primary care visits at the population-level (potentially freeing up practitioner time for more complex patients). The results raise important questions regarding primary care workforce changes advocated in the NHS Long Term Plan, and the time horizon of any benefits of prevention strategies.
... In addition to the special series on public health in this journal, a 2019 special issue of Perspectives on Behavior Science focused on addictions, and showcased substantial basic, translational, applied, and public health contributions of behavior analysis (Washington & Galizio, 2019). Recent conceptual and empirical work has focused on diabetes prevention and management (Raiff et al., 2020), disease transmission in the workplace injury prevention in sports (Quintero et al., 2020;Harris et al., 2020), physical activity (Nieto & Wiskow, 2020;Stedman-Falls & Dallery, 2020), cigarette smoking , and health and wellness coaching (Finn & Watson, 2017;Normand & Bober, 2020). The strengths of behavior analysis (e.g., rigorous experimental methods, conceptual account of the causes of health behavior) increase the chances, but do not guarantee, that behavioral technology may lead to public health impact (Hantula, 2019). ...
Human behavior plays a central role in all domains of public health. Applied behavior analysis (ABA) research and practice can contribute to public health solutions that directly address human behavior. In this paper, we describe the field of public health, identify points of interaction between public health and ABA, summarize what ABA research has already contributed, and provide several recommendations for how ABA research and practice could continue to promote public health outcomes. A clearer focus on behavior and widespread adoption of research designs and interventions informed by the ABA literature could lead to better public health outcomes. Reciprocally, better integration of public health goals and strategies into ABA research, harnessing of technology, and more collaboration would help diversify and disseminate our applied science and could yield more effective and scalable interventions to prevent and treat public health problems.
... Counseling approaches and integrative theories of behavioral change, such as motivational interviewing and the transtheoretical model, are often used to facilitate longer term lifestyle changes and are well-supported by the available evidence base (6)(7)(8). More recently, health coaching has also emerged as a supporting tool for health professionals to overcome behavioral barriers (9)(10)(11). Whilst no consensual definition exists, health coaching is considered to be a goal-oriented, client-centered partnership focused on health, and based on a process of enlightenment and empowerment of the client (12,13). ...
Health coaching has emerged as a potential supporting tool for health professionals to overcome behavioral barriers, but its efficacy in weight management remains unclear. We conducted a systematic review and meta-analysis to synthesize and evaluate the quality of evidence supporting the use of self-reported health coaching for weight loss. Seven electronic databases (PubMed, Web of Science, Scopus, Cochrane, Psyinfo, Virtual Health Library, and Scielo) were independently searched from inception to May 2020. This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation recommendations. Any study that investigated a self-reported health coaching intervention with the goal of inducing weight loss in individuals of any age, health, or training status was considered for inclusion. Quantitative data were analyzed using multilevel hierarchical metaregression models conducted within a Bayesian framework. A total of 653 studies were screened and 38 were selected for inclusion. The quality of evidence supporting outcomes based on the entire evidence base was very low and studies were deemed to have high risk of bias. Meta-analysis of controlled studies provided evidence of an effect favoring coaching compared with usual care but was trivial in magnitude [effect size (ES)0.5: −0.09; 95% credible interval (CrI): −0.17, −0.02]. The multilevel extension of Egger's regression-intercept test indicated the existence of publication bias, whereas a sensitivity analysis based only on those studies deemed to be of high quality provided no evidence of an effect of coaching on weight loss (ES0.5: −0.04; 95% CrI: −0.12, 0.09). Considered collectively, the results of this investigation indicate that the available evidence is not of sufficient quality to support the use of self-reported health coaching as a health care intervention for weight loss. This trial was registered at Prospective Register of Systematic Reviews (PROSPERO) as CRD42020159023.
Leveraging existing and emerging technologies, tools, and solutions can improve and democratize care and provide ‘future-ready approaches to be used by health organizations around the globe.’ This chapter provides an overview of existing and emerging technologies that contribute and will continue to contribute to a shift from ‘sick care’ to ‘health care.’KeywordsDigital healthEmerging technologiesExponential technologies
Translated and published article
Purpose:
Health coaching is effective for chronic disease self-management in the primary care safety-net setting, but little is known about the persistence of its benefits. We conducted an observational study evaluating the maintenance of improved cardiovascular risk factors following a health coaching intervention.
Methods:
We performed a naturalistic follow-up to the Health Coaching in Primary Care Study, a 12-month randomized controlled trial (RCT) comparing health coaching to usual care for patients with uncontrolled diabetes, hypertension, or hyperlipidemia. Participants were followed up 24 months from RCT baseline. The primary outcome was the proportion at goal for at least 1 measure (hemoglobin A1c, systolic blood pressure, or LDL cholesterol) that had been above goal at enrollment; secondary outcomes included each individual clinical goal. Chi-square tests and paired t-tests compared dichotomous and continuous measures.
Results:
290 of 441 participants (65.8%) participated at both 12 and 24 months. The proportion of patients in the coaching arm of the RCT who achieved the primary outcome dropped only slightly from 47.1% at 12 to 45.9% at 24 months (P = .80). The proportion at goal for hemoglobin A1c dropped from 53.4% to 36.2% (P = .03). All other clinical metrics had small, nonsignificant changes between 12 and 24 months.
Conclusions:
Results support the conclusion that most improved clinical outcomes persisted 1 year after the completion of the health coaching intervention.
Objective Medication adherence requires underlying behavior skills and a supporting mindset that may not be addressed with education or reminders. Founded in the study of internal motivation and health psychology, integrative health coaching (IHC) helps patients gain insight into their behaviors and make long-term, sustainable lifestyle changes. The purpose of the study is to determine whether IHC improves oral medication adherence, glycated hemoglobin (HbA1c), and psychosocial measures, and to assess whether adherence changes are sustained after the intervention.
Methods Using a prospective observational design, participants (n=56) received 14 coaching calls by telephone over 6 months. Medication possession ratio (MPR) was calculated for time intervals before, during, and after the intervention. HbA1c and patient-reported psychosocial outcomes were obtained to test interactions with MPR.
Results Medication adherence (MPR) increased from 0.74±0.197 to 0.85±0.155 during coaching, and was sustained at 0.82±0.175 during a 6-month period after the study. Better adherence correlated with a greater decrease in HbA1c. HbA1c decreased from 8.0±1.92% to 7.7±1.70% over the 6-month intervention. All psychosocial measures showed significant improvement. In addition to discussing medication adherence strategies with their coach, patients discussed nutrition and exercise (86.9% of calls), stress management (39.8%), and social support and relationships (15.4%).
Conclusions IHC targets internal motivation and supports behavior change by facilitating patients’ insight into their own behaviors, and it uses this insight to foster self-efficacy. This approach may yield sustainable results for medication adherence and warrants further exploration for health-related behavior change.
Applied behavior analysts have been, and still are, working directly to address the prevention and treatment of problems of physical health, many of which are relatively common and have the potential to increase both the visibility and acceptance of ABA. The purpose of this chapter is to highlight three programs of research in ABA that have addressed prevention and treatment of chronic medical problems in pediatric neurology (recurrent headaches), pediatric dentistry (distress during invasive dental procedures), and otolaryngology
(voice dysphonias). Each program of research provides guidance in the treatment of these specific medical problems and also serves as one type of model for how applied behavior analysts might conduct
programs of research with medical problems. Each section defines and describes the prevalence and social significance of the medical problem, outlines the methods of behavioral assessment to guide data-based decision making, and describe the systematic analysis of interventions that has led to
viable treatment protocols for use in practice.
The term behavioral coaching has been used inconsistently in and outside the field of behavior analysis. In the sports literature, the term has been used to describe various intervention strategies, and in the organizational behavior management literature it has been used to describe an approach to training management personnel and staff. This inconsistency is problematic in terms of the replication of behavioral coaching across studies and aligning with Baer, Wolf, and Risley's (1968) technological dimension of applied behavior analysis. The current paper will outline and critique the discrepancies in the use of the term and suggest how Martin and Hrycaiko's (1983) characteristics of behavioral coaching in sports may be used to bring us closer to establishing a consistent definition of the term. In addition, we will suggest how these characteristics can also be applicable to the use of the term behavioral coaching in other domains of behavior analysis.
Modifiable behavioral risk factors such as cigarette smoking, physical inactivity, and obesity contribute to over 40 % of premature deaths in the USA. Advances in digital and information technology are creating unprecedented opportunities for behavior analysts to assess and modify these risk factors. Technological advances include mobile devices, wearable sensors, biomarker detectors, and real-time access to therapeutic support via information technology. Integrating these advances with behavioral technology in the form of conceptually systematic principles and procedures could usher in a new generation of effective and scalable behavioral interventions targeting health behavior. In this selective review of the literature, we discuss how technological tools can assess and modify a range of antecedents and consequences of healthy and unhealthy behavior. We also describe practical, methodological, and conceptual advantages for behavior analysts that stem from the use of technology to assess and treat health behavior.
ABSTRACT
We argue that the field of behavior analysis would be best served if behavior analysts worked to extend the reach of behavioral services into a more diverse range of settings and with more varied populations, with an emphasis on the establishment of new career opportunities for graduating students. This is not a new proposal, but it is a tall order; it is not difficult to see why many would choose a surer route to gainful employment. Currently, the most fruitful career path for behavior analysts in practice is in the area of autism and developmental disabilities. For the continued growth of the field of behavior analysis, however, it is important to foster new career opportunities for those trained as behavior analysts. Toward this end, we identify several fields that seem well suited to behavior analysts and summarize the training requirements and likely professional outcomes for behavior analysts who pursue education and certification in these fields. These fields require relatively little additional formal training in the hopes of minimizing the response effort necessary for individuals who have already completed a rigorous program of graduate study in behavior analysis.
The role of patient engagement as an important risk factor for healthcare outcomes has not been well established. The objective of this article was to systematically review the relationship between patient engagement and health outcomes in chronic disease to determine whether patient engagement should be quantified as an important risk factor in health risk appraisals to enhance the practice of personalized medicine.
A systematic review of prospective clinical trials conducted between January 1993 and December 2012 was performed. Articles were identified through a medical librarian-conducted multi-term search of Medline, Embase, and Cochrane databases. Additional studies were obtained from the references of meta-analyses and systematic reviews on hypertension, diabetes, and chronic care. Search terms included variations of the following: self-care, self-management, self-monitoring, (shared) decision-making, patient education, patient motivation, patient engagement, chronic disease, chronically ill, and randomized controlled trial (RCT). Studies were included only if they: (1) compared patient engagement interventions to an appropriate control among adults with chronic disease aged 18 years and older; (2) had minimum 3 months between pre- and post-intervention measurements; and (3) defined patient engagement as: (a) understanding the importance of taking an active role in one's health and health care; (b) having the knowledge, skills, and confidence to manage health; and (c) using knowledge, skills and confidence to perform health-promoting behaviors. Three authors and two research assistants independently extracted data using predefined fields including quality metrics.
We reviewed 543 abstracts to identify 10 trials that met full inclusion criteria, four of which had "high" methodological quality (Jadad score >= 3). Diverse measurement of patient engagement prevented robust statistical analyses, so data were qualitatively described. Nine studies documented improvements in patient engagement. Five studies reported reduction in clinical markers of disease (e.g., HbA1C). All studies reported improvements in self-reported health status.
This review suggests patient engagement should be quantified as part of a comprehensive health risk appraisal given its apparent value in helping individuals to effectively self-manage chronic disease. Patient engagement measures should include assessment of the knowledge, confidence and skills to prevent and manage chronic disease, plus the behaviors to do so.
Review the operational definitions of health and wellness coaching as published in the peer-reviewed medical literature.
As global rates of preventable chronic diseases have reached epidemic proportions, there has been an increased focus on strategies to improve health behaviors and associated outcomes. One such strategy, health and wellness coaching, has been inconsistently defined and shown mixed results.
A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-guided systematic review of the medical literature on health and wellness coaching allowed for compilation of data on specific features of the coaching interventions and background and training of coaches.
Eight hundred abstracts were initially identified through PubMed, with 284 full-text articles ultimately included. The majority (76%) were empirical articles. The literature operationalized health and wellness coaching as a process that is fully or partially patient-centered (86% of articles), included patient-determined goals (71%), incorporated self-discovery and active learning processes (63%) (vs more passive receipt of advice), encouraged accountability for behaviors (86%), and provided some type of education to patients along with using coaching processes (91%). Additionally, 78% of articles indicated that the coaching occurs in the context of a consistent, ongoing relationship with a human coach who is trained in specific behavior change, communication, and motivational skills.
Despite disparities in how health and wellness coaching have been operationalized previously, this systematic review observes an emerging consensus in what is referred to as health and wellness coaching; namely, a patient-centered process that is based upon behavior change theory and is delivered by health professionals with diverse backgrounds. The actual coaching process entails goal-setting determined by the patient, encourages self-discovery in addition to content education, and incorporates mechanisms for developing accountability in health behaviors. With a clear definition for health and wellness coaching, robust research can more accurately assess the effectiveness of the approach in bringing about changes in health behaviors, health outcomes and associated costs that are targeted to reduce the global burden of chronic disease.
As rates of preventable chronic diseases and associated costs continue to rise, there has been increasing focus on strategies to support behavior change in healthcare. Health coaching and motivational interviewing are synergistic but distinct approaches that can be effectively employed to achieve this end. However, there is some confusion in the literature about the relationship between these two approaches. The purpose of this review is to describe a specific style of health coaching-integrative health coaching-and motivational interviewing, including their origins, the processes and strategies employed, and the ways in which they are similar and different. We also provide a case example of how integrative health coaching and motivational interviewing might be employed to demonstrate how these approaches are synergistic but distinct from each other in practice. This information may be useful for both researchers and clinicians interested in investigating or using behavior change interventions to improve health and cost outcomes in chronic disease.
To describe the evolution, training, and results of an emerging allied health profession skilled in eliciting sustainable health-related behavior change and charged with improving patient engagement.
Through techniques sourced from humanistic and positive psychology, solution-focused and mindfulness-based therapies, and leadership coaching, Integrative Health Coaching (IHC) provides a mechanism to empower patients through various stages of learning and change. IHC also provides a method for the creation and implementation of forward-focused personalized health plans.
Clinical studies employing Duke University Integrative Medicine's model of IHC have demonstrated improvements in measures of diabetes and diabetes risk, weight management, and risk for cardiovascular disease and stroke. By supporting and enabling individuals in making major lifestyle changes for the improvement of their health, IHC carries the potential to reduce rates and morbidity of chronic disease and impact myriad aspects of healthcare.
As a model of educational and clinical innovation aimed at patient empowerment and lifestyle modification, IHC is aligned well with the tenets and goals of recently sanctioned federal healthcare reform, specifically the creation of the first National Prevention and Health Promotion Strategy.
IHC may allow greater patient-centricity while targeting the lifestyle-related chronic disease that lies at the heart of the current healthcare crisis.
Emerging healthcare delivery models suggest that patients benefit from being engaged in their care. Integrative health coaching (IHC) is designed to be a systematic, collaborative, and solution-focused process that facilitates the enhancement of life experience and goal attainment regarding health, but little research is available to describe the mechanisms through which empowerment occurs in the health coaching process. The purpose of this qualitative study is to describe apparent key components of the empowerment process as it actually occurs in IHC. A sample of 69 recorded health coaching sessions was drawn from 12 participants enrolled in a randomized controlled study comparing two different methods of weight-loss maintenance. Two researchers coded the word-for-word transcripts of sessions focusing on the structure of the sessions and communication strategies used by the coaches. Three basic sections of a coaching session were identified, and two main themes emerged from the communication strategies used: Exploring Participant's Experience and Active Interventions. In IHC, health coaches do not direct with prefabricated education based on the patient's presenting problem; rather, they use a concordant style of communication. The major tenets of the health coaching process are patient-centeredness and patient control focused around patient-originated health goals that guide the work within a supportive coaching partnership. As the field of health coaching continues to define itself, an important ongoing question involves how the structure of the provider-patient interaction is informed by the role of the healthcare provider (eg, nurse, therapist, coach) and in turn shapes the empowerment process.
Health coaching is a client-centric process to increase motivation and self-efficacy that supports sustainable lifestyle behavior changes and active management of health conditions. This study describes an intervention offered as a benefit to health plan members and examines health and behavioral outcomes of participants.
High-risk health plan enrollees were invited to participate in a telephonic health coaching intervention addressing the whole person and focusing on motivating health behavior changes. Outcomes of self-reported lifestyle behaviors, perceived health, stress levels, quality of life, readiness to make changes, and patient activation levels were reported at baseline and upon program completion. Retrospectively, these data were extracted from administrative and health coaching records of participants during the first 2 full years of the program.
Less than 7% of the 114 615 potential candidates self-selected to actively participate in health coaching, those with the highest chronic disease load being the most likely to participate. Of 6940 active participants, 1082 fully completed health inventories, with 570 completing Patient Activation Measure (PAM). The conditions most often represented in the active participants were depression, congestive heart failure, diabetes, hyperlipidemia, hypertension, osteoporosis, asthma, and low back pain. In 6 months or less, 89% of participants met at least one goal. Significant improvements occurred in stress levels, healthy eating, exercise levels, and physical and emotional health, as well as in readiness to make change and PAM scores.
The types of client-selected goals most often met were physical activity, eating habits, stress management, emotional health, sleep, and pain management, resulting in improved overall quality of life regardless of condition. Positive shifts in activation levels and readiness to change suggest that health coaching is an intervention deserving of future prospective research studies to assess the utilization, efficacy, and potential cost-effectiveness of health coaching programs for a range of populations.
Despite the link between inactivity and premature mortality, most adults exercise less than the Centers for Disease Control and Prevention (2008) recommends; thus, interventions to increase exercise are needed. The present study employed an Internet-based intervention to increase walking in 12 sedentary adults over 50 years of age. In Experiment 1, participants received monetary consequences for meeting an increasing series of step goals on at least 3 days during consecutive 5-day blocks. Across participants, steps increased 182% from screening to the end of the intervention, and 87% of step goals were met. In Experiment 2, goals were set using the same schedule as in Experiment 1, but no monetary consequences were provided for meeting them. Across participants, steps increased 108%, and 52% of goals were met. Across both studies, 11 of 12 participants increased their steps according to experimenter-arranged criteria. These results support the efficacy of an Internet-based intervention to increase walking in sedentary adults.
Self-management is a necessary aim in the treatment of chronic illnesses, such as diabetes, heart disease, arthritis, lupus, and chronic obstructive pulmonary disease. Although the effective treatments are available for these serious conditions, the rate of adherence to medication, dietary changes, physical activity, blood monitoring, or attendance to regular medical screenings is reported to be approximately only 50%. The role of health professional support in effective self-management of chronic illness has been recently acknowledged. Furthermore, numerous studies on professional support for self-management of chronic illness have focused on the health professional as a "coach". Coaching has been defined as an interactive role undertaken by a peer or professional individual to support a patient to be an active participant in the self- management of a chronic illness. A review of the literature revealed a limited number of empirical studies on coaching, with these focusing on one of three areas: disease-related education; behaviour change strategies; or, psychosocial support. Due to the small number of research investigations, only tentative support can be given to the efficacy of the different coaching approaches. However, it was apparent that education-based interventions have a significant role in self-management, but that these were not sufficient by themselves. The role of behaviour change-focused coaching was also shown to be an important factor. However, not all patients are ready for change, and therefore the need for coach interactions that move a patient to a stage of action were evident, as was the need to consider the emotional state of the patient. The challenges for future research is to investigate the relative strengths of these coaching approaches for the support of patient self-management of chronic illness, and the means to effectively integrate these approaches into routine health care, through a wide range of health professional groups.
Increasing physical activity is a crucial component of any comprehensive approach to combat the growing obesity epidemic. This review summarizes recent behavioral research on the measurement of physical activity and interventions aimed at increasing physical activity and provides directions for future research.
Behavior analysis is a generic science, and Skinner's vision for it was that it would become a mainstream force, relevant for most if not all human concerns, major and minor. Clearly his vision has not been realized. Determining why this is the case would require a complex multifactorial analysis. One likely factor is that the majority of its basic science findings have been obtained from the study of rats and pigeons. Another likely factor, one directly addressed by this paper, is that the majority of its applied science findings have been obtained from the study of people in only one tail of the normal distribution. Regardless, those outside the field see the relevance of behavior analysis to general human affairs as very limited. Whether the path behavior analysis is on will lead to widespread perception of mainstream relevance anytime soon seems doubtful. An alternative route would involve integrating it with a field that has already made the trip successfully. A premier example involves primary medical care. This paper argues for the integration of behavior analysis with pediatric primary care, sketches a method for its accomplishment, and uses diurnal enuresis to illustrate the requirements of the method.
Behavior analysis as a discipline currently is doing relatively well. How it will do in the future is unclear and depends on how the field, and the world at large, changes. Five current characteristics of the discipline that appear to reduce the probability that it will survive and prosper are discussed and suggestions for improvement are offered. The areas of concern are (a) the small size and limited power of the discipline, (b) the growing focus of applied behavior analysis on autism spectrum disorders and little else, (c) the esoteric nature of much basic research, (d) the proliferation of "applied" research that really isn't applied, and (e) the widespread use of imprecise and potentially harmful technical language.
The purpose of this study was to evaluate the effectiveness of integrative health (IH) coaching on psychosocial factors, behavior change, and glycemic control in patients with type 2 diabetes.
Fifty-six patients with type 2 diabetes were randomized to either 6 months of IH coaching or usual care (control group). Coaching was conducted by telephone for fourteen 30-minute sessions. Patients were guided in creating an individualized vision of health, and goals were self-chosen to align with personal values. The coaching agenda, discussion topics, and goals were those of the patient, not the provider. Preintervention and postintervention assessments measured medication adherence, exercise frequency, patient engagement, psychosocial variables, and A1C.
Perceived barriers to medication adherence decreased, while patient activation, perceived social support, and benefit finding all increased in the IH coaching group compared with those in the control group. Improvements in the coaching group alone were also observed for self-reported adherence, exercise frequency, stress, and perceived health status. Coaching participants with elevated baseline A1C (>/=7%) significantly reduced their A1C.
A coaching intervention focused on patients' values and sense of purpose may provide added benefit to traditional diabetes education programs. Fundamentals of IH coaching may be applied by diabetes educators to improve patient self-efficacy, accountability, and clinical outcomes.
In recent decades, pediatric medicine has undergone a shift in focus from infectious diseases to the effects of behavior on the health and development of children. At the same time, behavior analysts have increasingly evaluated the direct application of their technology to the development and maintenance of child health behavior. Unfortunately, applied behavior analysts have developed their technology parallel to, rather than collaboratively with, pediatricians and, as a result, are not recognized as experts in the treatment of child health behavior. In addition, behavioral technology is not widely recognized as the treatment of choice by pediatricians. This paper provides a behavioral prescription for behavior analysts who wish to enter pediatrics as expert scientists and technicians. Specific recommendations are provided for stimulating collaborative rather than parallel development between applied behavior analysis and pediatrics in the promotion and maintenance of child health behavior. Strategies for maintaining this collaborative relationship and for strengthening the social relevance of behavior analysis are discussed.
This study compared diabetes Treatment As Usual (TAU) with Pathways To Change (PTC), an intervention developed from the Transtheoretical Model of Change (TTM), to determine whether the PTC intervention would result in greater readiness to change, greater increases in self-care, and improved diabetes control.
Participants were stratified by diabetes treatment and randomized to treatment with PTC or TAU as well as being randomized regarding receipt of free blood testing strips. The PTC consisted of stage-matched personalized assessment reports, self-help manuals, newsletters, and individual phone counseling designed to improve readiness for self-monitoring of blood glucose (SMBG), healthy eating, and/or smoking cessation. A total of 1029 individuals with type 1 and type 2 diabetes who were in one of three pre-action stages for either SMBG, healthy eating, or smoking were recruited.
For the SMBG intervention, 43.4% of those receiving PTC plus strips moved to an action stage, as well as 30.5% of those receiving PTC alone, 27.0% of those receiving TAU plus strips, and 18.4% of those receiving TAU alone (P < 0.001). For the healthy eating intervention, more participants who received PTC than TAU (32.5 vs. 25.8%) moved to action or maintenance (P < 0.001). For the smoking intervention, more participants receiving PTC (24.3%) than TAU (13.4%) moved to an action stage (P < 0.03). In intention-to-treat (ITT) analysis of those receiving the SMBG intervention, PTC resulted in a greater reduction of HbA(1c) than TAU, but this did not reach statistical significance. However, in those who moved to an action stage for the SMBG and healthy eating interventions, HbA(1c) was significantly reduced (P < 0 0.001). Individuals who received the healthy eating intervention decreased their percentage of calories from fat to a greater extent (35.2 vs. 36.1%, P = 0.004), increased servings of fruit per day (1.89 vs. 1.68, P = 0.016), and increased vegetable servings (2.24 vs. 2.06, P = 0.011) but did not decrease weight. However, weight loss for individuals who received the healthy eating intervention and who increased SMBG frequency as recommended was significantly greater, with a 0.26-kg loss in those who remained in a pre-action SMBG stage but a 1.78-kg loss in those performed SMBG as recommended (P <or= 0. 01).
This study demonstrates that this intervention has the potential of positively impacting the health of broad populations of individuals with diabetes, not just the minority who are ready for change.
A number of experiments have demonstrated the considerable potential of behavior modification techniques for improving performance of beginners in sport and physical education. Several books have presented a consistent behavioral analysis of factors that influence the development and maintenance of athletic behavior. From these sources, an approach is beginning to emerge that might be called "effective behavioral coaching." This paper discusses six characteristics that appear to make this approach distinctive and potentially valuable for coaches.
Obesity has become a leading cause of health problems in America, many of which can be combated by increasing physical activity. As a result, interventions targeting increased physical activity are greatly needed. In this study, a package intervention consisting of goal setting, self-monitoring, and feedback was evaluated across five participants in a multiple baseline design with a brief reversal for three of the five participants. The intervention package increased calorie expenditure for all five participants. Copyright © 2009 John Wiley & Sons, Ltd.
A healthy diet is a key ingredient to good health and can help prevent a number of adverse health conditions. Although many people can describe a healthy diet, they often cannot accurately report the nutritional content of their own diets. In this study, daily dietary feedback consisting of recommended daily nutrient values accompanied by estimated calorie and fat data of daily food purchases was provided to four college undergraduates. The estimated calorie and percentage of calories from fat data were based on records of participant purchases at university dining establishments. The introduction of daily dietary feedback resulted in the students purchasing fewer calories and fewer calories from fat per day. Copyright © 2010 John Wiley & Sons, Ltd.
Excess body weight, especially obesity, is a problem of increasing social significance, and weight gain is often correlated with age. Because physical activity can both decrease current body weight and prevent weight gain, it is an especially suitable target for behavioral intervention. A package intervention consisting of self-monitoring, goal setting, and feedback was used to increase the physical activity of healthy adults. A combined multiple-baseline and reversal design was arranged to evaluate the effects of the intervention on the number of steps taken each day by participants, as recorded by a pedometer. The intervention increased the number of steps taken across participants, but there were no changes in participant body weight during the intervention. The results suggest that a relatively simple and low-cost intervention can be used to increase the physical activity of some adults. Copyright © 2008 John Wiley & Sons, Ltd.
Physical inactivity has emerged as a public health epidemic and is associated with the rising obesity rate. A multiple-treatments reversal design was utilized to test whether pedometer-aided self-monitoring and brief e-counseling could help 3 overweight adults increase their physical activity. Dependent measures were taken for pedometer steps and weight. Two participants approximately doubled their daily step totals and lost a modest amount of weight by study end.
Chronic diseases account for 70% of U.S. deaths. Health coaching may help patients adopt healthy lifestyle behaviors that prevent and control diseases. This integrative review analyzed health coaching studies for evidence of effectiveness and to identify key program features.
Multiple electronic databases were utilized, yielding a final sample of 15 documents.
The search was limited to peer-reviewed research articles published between 1999 and 2008. Studies were further analyzed if they (1) specifically cited coaching as a program intervention, and (2) applied the intervention to research.
Articles describing various quantitative and qualitative methodologies were critically analyzed using a systematic method.
Data were synthesized using a matrix format according to purpose, method, intervention, findings, critique, and quality rating.
All 15 studies utilized nonprobability sampling, 7 (47%) with randomized intervention and control groups. Significant improvements in one or more of the behaviors of nutrition, physical activity, weight management, or medication adherence were identified in six (40%) of the studies. Common features of effective programs were goal setting (73%), motivational interviewing (27%), and collaboration with health care providers (20%).
Health coaching studies with well-specified methodologies and more rigorous designs are needed to strengthen findings; however, this behavioral change intervention suggests promise.
This article provides the reader with a basic understanding of the importance of employee health promotion in a rapidly changing health care delivery system. The rationale, basic components, interdisciplinary emphasis, and future directions have been cited as important elements in successful programming. The leadership role of the primary care physician is also discussed as it relates to effective employee health promotion programs.
Lifestyle and behavioural factors play an important role in the development of Type 2 diabetes and management of this illness involves a combination of medication and lifestyle change. However, diabetes lifestyle programs have been found unsuccessful unless they are intensive and continued over long periods of time. The present study, which is one of the few randomised controlled trials of lifestyle interventions to be conducted outside of the US, aims to evaluate a brief psychological intervention that can be integrated into routine usual care to assist people to make the recommended lifestyle changes. Subjects are allocated to either an intervention or usual care control group. The intervention includes assessment and a personalised programme in which realistic manageable goals for lifestyle change and overcoming barriers are negotiated using brief motivational interviewing. Maintenance issues are addressed by follow-up telephone contact. Implementation of this study is described and baseline data presented on initial participants, and implications for practice are discussed.
Your patient should get a health coach. Here’s why. Medpage Today’s KevinMD
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Upon further reflection Why we are not acting to save the world
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Why we are not acting to save the world
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Applied behavior analysis
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The impact of telephonic health
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A framework for health promotion and disease prevention programs
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