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Health&WellnessCoaching:Evidence,ChallengesandOpportunities
RuthQ.Wolever,PhDDirectorofVanderbiltHealthCoaching:
Education,Research&PracticeOsher CenterforIntegrativeMedicine
AssociateProfessorofPhysicalMedicine&RehabilitationAssociateProfessorofPsychiatry&BehavioralScience
VanderbiltUniversityMedicalCenterAssociateProfessorofNursing
VanderbiltUniversitySchoolofNursing
Disclosures
ChiefScientificOfficerforeMindfulConsultantforNokia
GrantFundingfromUSAirForce,NationalHeart,Lung&BloodInstitute
ExecutiveCommitteeforNCCHWC
Objectives
1. Overviewcurrentstateofevidenceforhealthandwellnesscoaching(HWC)
2. Understandchallengestobuildingmorerigorousevidencebase
3. Recognizepotentialsolutionsforthesechallenges
• PressingneedtomanageburgeoningchronicdiseasehasledtotheemergenceofjobrolessuchasHWC
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Publication Years
Wolever,Simmons,Sforzo,etal(2013).GlobalAdvancesinHealthandMedicine,2(4),34-53.
Background
Palmeretal,2003
“thepracticeofhealtheducationandhealthpromotion withinacoachingcontext,toenhancethewell-being ofindividualsandtofacilitatetheachievementoftheirhealth-relatedgoals”
Butterworth,Lindenetal,2006
“aserviceinwhichprovidersfacilitateparticipantsinchanginglifestyle-relatedbehaviors forimprovedhealthandqualityoflife,orestablishingandattaininghealthpromotinggoals”
Lindneretal.,2003
“interactiveroleundertakenbypeerorprofessionalindividualtosupportapatient tobeanactiveparticipantintheself-managementofchronicillness”
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NationalConsortiumforCredentialingHealth&WellnessCoaches(NCCHWC),2013
“professionalsfromdiversebackgroundsandeducationwhoworkwithindividualsandgroupsinaclient-centeredprocesstofacilitateandempowertheclienttoachieveself-determinedgoalsrelatedtohealthandwellness.Successfulcoachingtakesplacewhencoachesapplyclearlydefinedknowledgeandskillssothatclientsmobilizeinternalstrengthsandexternalresourcesforsustainablechange.”
Overpast7years,9attemptstosystematicallysynthesizetheliteratureonHWC
Whatisasystematicreview?Overviewofprimarystudiestoansweranaprioriresearchquestionbycollectingandsummarizingallempiricalevidencethatfitspre-specifiedeligibilitycriteria.Intentistransparencysocanbereproduced.• clearlystatedobjectiveswithpre-definedeligibilitycriteriafor
studies• asystematicsearchthatattemptstoidentifyallpotentially
relevantstudies• assessmentofthevalidityofthefindings(e.g.,riskofbias)• systematicprocesstocullandsynthesizethecharacteristicsand
findingsoftheincludedstudies
A little about the reviews………….
FirstSystematicReview:Lindner,etal.,2003
Methods
• 25studiesof“coaching”orahealthcareprofessionalsupportingself-managementforchronicillness
• IncludedRCTs,quasi-experimentalandnon-experimentalcontrolledtrials
• HCdefinedas“interactiveroleundertakenbypeerorprofessionalindividualtosupportapatient tobeanactiveparticipantintheself-managementofchronicillness”
- Lindneretal.,2003
Findings• Educationhassignificantroleinself-management,butnotsufficient;needbehavior-changefocusedcoaching
• Interventionsgenerallycoveredatleastoneofthreedomains:– disease-relatededucation– behaviorchangestrategies– psychosocialsupport
• Noteveryonereadyforchange:Needtomovepatienttoaction,andneedtoconsideremotionalstateofpatient
- Lindneretal.,2003
AnnotatedBibliography:Newnham-Kanasetal.,2009
• Purpose:1)Summarizecriticallyappraisedlifecoachingstudiesrelatedtohealthresearch;and2)Tooutlinepossibleavenuesforfuturehealth-relatedcoachingresearch.
• Reviewof14literaturedatabases(1806– current)
Newnham-Kanas, C., Gorczynski, P., Morrow, D. & Irwin, J. (2009). Annotated Bibliography of Life Coaching and Health Research. International Journal of Evidence Based Coaching and Mentoring, 7(1), 39 - 103.
Annotated Bibliography
• Of 209 studies found, 72 met inclusion criteria(English;theinterventionwasaformofcoaching,groupcoaching,lifecoaching,orderivedfromcoaching;andoutcomewashealthrelated)
• Grouped by health outcomes with implications for future research noted
• Only34RCTs,20ofwhichwereeducationalapproachesratherthanprofessionalcoachingand12didnotdefine“coaching”
Newnham-Kanas, et al. (2009). Intern J of Evidence Based Coaching & Mentoring, 7(1), 39 - 103.
AnnotatedBib:StateofResearch
• Moststudiesdidnotofferoperationaldefinition• Randomization&controlgrps werelacking• Lackoftreatmentconsistency(e.g.,differentnumbersofsessions,different,differentprogramdurations)
• Authorssuggestuseofmoreheterogeneoussamplestoincreasegeneralizability(e.g.,differencesinage,sex,race,etc.)forsameoutcome
Newnham-Kanas, et al. (2009). Intern J of Evidence Based Coaching & Mentoring, 7(1), 39 - 103.
IntegrativeReview:Olsen&Nesbitt,2010
Methodology• Integrativereviewof15studies,litfrom1999-2008• Not“systematicreview”sinceincludesstudiesofvariousmethodologies - bothquantitativeandqualitativestudies
• Healthprofessionalsfunctioningascoaches(nursesmostcommon,6/15studies)
• Researchquestions:1) Howeffectivearehealthcoachinginterventions
forimprovinghealthylifestylebehaviors?2) Whatarethekeyfeaturesofaneffectivehealth
coachingprogram?
Take-home• 6studiesshowedsignificantimprovementsinnutrition,physicalactivity,weightmanagementormedicationadherence
• Commonfeaturesofeffectiveprograms:– goalsetting(73%ofstudies)– motivationalinterviewing(27%)– collaborationwithhealthcareproviders(20%)
• Healthcoachingprogramsshouldbedesignedtolast6-12monthsforoptimalhealthbehaviorchangeoutcomes
NextSteps
• Studiesneedmoredetaildescribingspecificconceptualdesigns,tools,orskillsets
• Qualitativeresearchisperhapsmoreappropriateandmeaningfulforhealthcoaching
• Studiescomparingvariousmethodsofdelivery,programdurationandsessionfrequencywillbetterinformdesignofhealthcoachingprograms
SystematicReview:Ammentorp etal.,2013
Methodology• Systematicreviewof5studies• Focuson"lifecoaching”(authorsdefined“healthcoaching”as
havingafixedagendaandpre-definedgoalsvs “lifecoaching”wherebetweenclientscometosessionswithwhateverissuestheywanttoaddress)
• Inclusioncriteria:Interventionstudiesusingquantitativeorqualitativemethods,randomassignment,controlgroup,validatedoutcomesmeasure
• Professionalcoachesorhealthcareprofessionalswithcoachtraining
• Ofn=4,359studies,25titlesrelevant,136abstractsrelevant,5metinclusioncriteria
• Diabetesptswerefocusof3of5studies
Take-home(1of2)
• Conclusionsre:methodology– Duetodifferencesinterminology,methods,andqualityofstudies,itisdifficulttodrawconclusions
– Rangeoftermsusedinthesestudies:“lifecoaching,”“integrativehealthcoaching,”“wellnesscoaching,”“co-activecoaching"
– Mainchallengewasdistinguishinglifecoachingvs.healthcoaching
Take-home(2of2)• Conclusionsre:patientoutcomes
– Twostudiesmeasuringdiabetesglycemiccontrol(HbA1c)showpromisingresults
– Disadvantagedptsmayespeciallybenefitfromanotherapproachanddifferenttypeofcommunicationthantypical
– Coachingimprovesself-efficacyandself-empowerment– Resultssupportimprovedgoalattainment,self-reportedadherence,improvedhealthstatusandself-esteem
NextSteps
• Futurestudiesmustcomprehensivelydescribecoachingmethods
• Coachingresearchshouldbesupplementedbyqualitativeapproachinvestigatingcontent,communicationprocessandinteraction
SystematicReview:Kivela etal2014
Methodology• Systematicreviewof13studies• Databasesearchonlitfrom2009-2013for“coaching”ANDanotherdescriptiveword(“lifestyle,”“motivation,”“healtheducation,”“support,”etc.)
• Inclusioncriteria:coachingbyhealthcareprofessional,adultswithchronicdisease,biopsychosocial outcomes,RCTorquasi-experimentaldesign
• Of1,276studies,20metinclusioncriteria,13metqualityassessment
Take-home
• Healthcoachingimprovesmanagementofchronicdiseases
• Positiveeffectsonpatients’physiological,behavioralandpsychologicalconditionsandontheirsociallife
• Betterweightmanagement,increasedphysicalactivity,andimprovedphysicalandmentalhealthstatus
• Telephonecoachingmostpopular
NextSteps
• Healthpromotionprogramsneedtobescientificallyresearchedtoexplainhowbehaviorallifestylechangesoccur
• Evaluatelong-termeffectiveness(positiveeffectsaftertheintervention)
• Studycost-effectivenessforchroniccaremanagement• “Healthcoaching”isambiguouslydefined,terminologydiffersamonginterventions
RapidReview,NHS2014
RapidReviewforNHS:2014
• AssessimpactofHCforpts andNHS(morespecificquestionscouldnotbewelladdressed)
• InitiativeinEastofEnglandbegunin2010• 3weekreviewof10databases(>7000studies),275metinclusioncriteria(publishedorgreyliterature,labeledas“healthcoaching”)
• 7%reviews,40%RCTS,53%other• HCas“umbrellaterm”describingmanyinterventions
Findings
• 75%ofRCTs&92%otherstudiesfoundpositiveimpactonmotivationtochangehealthbehaviorsandself-confidencetodoso
• 59%ofRCTS&89%otherstudiesfoundpositiveeffectonbehaviors(alcoholintake,tobaccouse,fruits&vegetables,exercising)
• MixedevidenceonphysicaloutcomessuchasBP,BG,cholesterol,weight(33%reviews,37%RCTS,84%other)
• Insufficientevidenceaboutcostreduction(25%of4reviews,30%RCTs,70%otherstudiesnotepositiveimpact -NHSEvidenceCentre,2014
SystematicReview:Hilletal,2015
Methods
• RCTSthatusedhealthcoachingtoinfluencehealth-relatedoutcomes;hadtoreportoutcome
• HC,healthbehaviorchangefacilitation,healthbehaviormanagementANDchronicdisease,
• English,peer-reviewed,pubJan2000– Oct2012• 94studiesreducedto16• AppliedtaxonomyofbehaviorchangetechniquesasdescribedbyMichie etal.,2011CALO-RE
• Goaltoassesseffectivenessaswellasspecific?s
Findings• Interventionsdetailslacking,unclearortooheterogeneoustosynthesize(e.g.,9of16didnotdefineHC)
• Useofmanybehaviorchangetechniques(25of40)acrossall16studies
• 3-15techniquesnoted,withmean=6.8• Diversityofoutcomes• 94%reportedatleasonepositiveoutcome• Overallstudyqualityfair
SystematicReviewtoCharacterizeHWC:Wolever Simmons,Sforzo etal.,2013
How is HWC operationalized in the
literature?
Wolever,Simmons,Sforzo,etal(2013).ASystematicReviewoftheLiteratureonHealthandWellnessCoaching:DefiningaKeyBehavioralInterventioninHealthcare,GlobalAdvancesinHealthandMedicine,2(4),34-53.
Purpose• toestablishaconsensusdefinitionofHWCthroughsystematicreviewofrelatedlit
3intentions:• answerrepeatedcallsforevidence-basedidentificationofconceptualandinterventionalcomponentsofHWC
• withastandardizeddef,componentsofapproachcanbeusedtoclarifytheprofessionalskillsneededtoappropriatelytrain
• AllowformorerigorousevaluationofHWC
PICOPrimaryResearchQuestion
“Howareinterventionsdescribedashealthorwellnesscoachingdefinedandoperationalizedinthepeer-reviewedmedicalliterature?”1.Whattypeofliteraturehasbeenpublishedonhealthandwellnesscoaching?2.Whatapproaches,practices,strategies,andmethodologiesconstitutehealthcoachingasdescribed?3.Whodeliverstheservicethatisreferredtoas“healthorwellnesscoaching?
Methods
• InternationalguidelinesestablishedbyPRISMA(PreferredReportingItemsforSystematicReviewandMeta-Analyses)
• SearchonPubMedbyprofessionallibrarian– MeSH term“human”,languageEnglishorSpanish,datethroughJanuary2013
– Indexterms:health,wellness,coach;subtermseducator,mentor,navigator,teacher,training,feedback,mentoring.
– Articlesscreenedforeligibility:coachinginthecontextofprofessionaldevelopmentineligible
PRISMAFlowØ Recordsidentifiedthruinitialdatabasesearch(n=800)
• Irrelevantabstractsremoved(n=506)Ø Full-textarticlesassessedforeligibility(n=294)
• Additionalpapersidentifiedthroughauthors’collectionsandreviewarticles(n=55)
Ø Totalfull-textarticlesassessed(n=349)• Full-textarticlesexcluded(n=65)
Ø Studiesincludedinquantitativesynthesis(n=284)
Whatapproaches,practices,strategies,andmethodologiesconstituteHWC?
• Wasthecoachingpatient-centered?• Werethepatients’goalsself-determinedvs recommendedbya
providerorthecoach?• Wasaself-discoveryprocessusedtofindsolutionsvs advice-giving?• Didthecoachingprocessencouragept accountabilityinbehavior
towardthestatedgoal?• Wascontenteducationprovidedaspartofthedefined“coaching”?• Whatwasthetypicalcoaching“dose”(lengthofsession,frequency
ofsessions,anddurationofprocess)?• Didthept developarelationshipwiththesamecoachovertime?
SystematicReviewShowedKeyAspectsofDefinitionofHC
(n=#articleswithadequate infotoratethis) Yes/partiallyPatient-centered(n=228) 196(85.9%)Patient-determinedGoals(n=217) 153(70.5%)Self-discovery (n=188) 119(63.3%)Accountability(n=196) 168(85.7%)Contenteducation(n=233) 212(91.0%)ConsistentRelationship(n=154) 120(78.0%)
Wolever,Simmons,Sforzo,etal(2013).GlobalAdvancesinHealthandMedicine,2(4), 34-53.
Whatwasthecoaching“dose”?• Dosedatawereoftennotprovided:
– Over75%ofarticlesdidnotspecifylengthofsession– 52%didnotspecify#ofsessions– 64%didnotspecifydurationofseriesofsessions
Duration Allarticles(N=184)1session– 1month 22(12.0%)5weeks– 3months 43(23.4%)3.5months– 6months 46(25.0%)6.5months– 9months 9(4.9%)10months- 12.5months 41(22.3%)15months– 2years 19(10.3%)3years– 6years 4(2.2%)
3.WhodeliverstheservicereferredtoasHWC?
• Aretheseindividualsprofessionallytrained?• Ifso,whattypeofprofessionalswerethecoaches?Specifically,weretheyhealthprofessionalsornot?Ifso,whattype?
• Inaddition,whattypeoftraininghavetheyreceived,ifany,inthespecificsofthecoachingprocessandthecontentofthecoachingtheyaredelivering?
Whodeliversit?
Figure3.Frequencyofarticlesdescribinggiven
amountofcoach-specifictraining(n=57)
Figure3b.Percentageofarticlesdescribing
coach-specifictrainingbytypeofarticle
Lackofagreementon:
• whatexactlyhealthcoachingentails(e.g.,practices,strategies,deliverymethods)
• whattheroleofthecoachactuallyis(e.g.,educator,navigator,facilitator,partner)
• whatprofessionalbackgroundisneeded• whattrainingenablesthecoachtoprovidehealthcoachingcompetently
ResearchImplicationsThusFar• CleardefinitionofHWC• Mustclearlydescribemethodsusedinintervention,aswellasbackground&trainingofcoaches
• Short-cut:UseNCCHWC- certifiedcoachesASAP(2017)
National Consortium for Credentialing Health & Wellness Coaches
(ncchwc.org)
StandardizingtheDefinition&Training
53
• Creationofanon-profittodevelopanationalstandardofcoachingcompetencies,trainingandeducation,andcredentialingofprofessionalhealthandwellnesscoaches
• 75organizationsinhealthcare,academia,industryandprofessionaldisciplines
• CompletedJobTaskAnalysis,largevalidationstudyondefinitionofhealthandwellnesscoaching,andcompetenciesneededtoprovideit
NCCHWC partners with National Board of Medical ExaminersFirst National Exam in 2017
ResearchImplications• CleardefinitionofHWC• Mustclearlydescribemethodsusedinintervention,aswellasbackground&trainingofcoaches
• StudyDesign:Effectivenessoverefficacy• Measurementofmediators• Measurementofoutcomes• ConsiderationofStakeholders
PotentialMediators• Knowledge• Skillsacquisition/Behavioralimplementation• Self-efficacy• LocusofControl/HealthControl• StagesofChange• PatientEngagement• PatientActivation• HealthEngagement
PatientEngagement(1) recognizingandunderstandingthe
importanceoftakinganactiveroleinone’shealthandhealthcare;
(2) havingtheknowledge,skills,andconfidencetomanagehealth;and
(3) usingthatknowledge,skillsandconfidencetoengageinhealth-promotingbehaviorstoobtainthegreatesthealthbenefit.
HealthEngagement(HE)definedbyLongetal(JOEM,2016)as:• apersonalcommitmenttooptimizewellbeingandsubsequentactiondemonstratingthatcommitment
ValueChainProposition
• Precursor1:Promotions&incentivesforH&W• Precursor2:ParticipationinIntervention• OD1:Motivation toImproveHealth&Well-being• OD2:Behavior (activity,diet,substance use)• OD3:Emotion (stress,support,perceived health)• OD4:Biometrics (e.g.,BP,BMI,cholesterol,BG)• OD5: Compliance(e.g.,Rxadherence)• OD6: Claims (HealthcareUtilization&Cost)• OD7:Productivity atWork/Performance• OD8: Employee Retention;HealthEngagement
LongetalJOEM2016
It starts with YOU
Your research will take us forward!
HealthEducation &Counseling
Medicalmodel(disease)
Diagnosableillnessinparadigmofpathology
Focusonfixingaproblem(motivated byfear)
Professionalasexpert
“Why”questionswithpresentandpastfocus
Restoreclient’sleveloffunctioning
HealthCoaching
Learning/developmentmodel(health)
Desirablegoals&achievementinparadigmofpossibility
Focusonoptimalperformance(byhappiness&growth)
Coachasnon-judgmentalpartner/allyofequalstature
“How”questionswithpresentandfuturefocus
Moveclienttopersonalfulfillmentoroptimalperformance
Wolever et al (2011). Explore, 7(1), 30-36.
61
Simmons&Wolever(2013).IntegrativeHealthCoachingandMotivationalInterviewing:SynergisticApproachestoBehaviorChangeinHealthCare.GAHM,2(4),24-31.