Research Paper By Karo-Lyne David
(Anxiety Coach, CANADA)
Introduction
In the year 2017, cardiovascular diseases were still the leading cause of death globally followed by cancer. Yet, according to the World Health Organization (WHO),
at least 80% of all heart disease, stroke and type 2 diabetes could be prevented; over 40% of cancer could be prevented.
Since these chronic diseases progress slowly and are influenced by a person’s lifestyle, eliminating modifiable risk factors such as tobacco use, physical inactivity, unhealthy diet, and excessive stress could help prevent the onset, reduce the symptoms and in some instances, even reverse the illness. The issue is that most people lack the behavioral skills they need to implement and maintain healthy lifestyle changes.
All over the world, comprehensive and integrated approaches are already being adopted. Population-wide approaches form the central strategy while individual interventions are suggested as a complementary course of action. Among these, health coaching might be one of the most promising.
In fact, several recent studies have shown that health and wellness coaching can be effective in improving health outcomes related to coronary heart disease, type 2 diabetes, weight loss and tobacco cessation.
This research paper focuses on health coaching as a blended coaching approach influenced by behavioral change theory. It presents health coaching as an effective intervention to support patients’ self-management of healthcare and achieve sustainable results.
1. Definitions
Since coaching is an unregulated profession, there is a wide range of definitions in regards to what it actually is. For the purposes of this research paper, and in order to avoid confusion related to these inconsistencies, let’s consider the definition of pure coaching to be that of the International Coach Federation (ICF).
ICF defines coaching as partnering with clients in a thought-provoking and creative process that inspires them to maximize their personal and professional potential.
Of course, the same disparities can be found in the various definitions of health coaching. Fortunately, a systematic review of the literature on health and wellness coaching published in 2013 was able to establish a consensus definition:
[…] 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.
While this definition encompasses the core concepts related to the coaching vision and process, it also exposes a major difference in comparison to pure coaching: the education provided by health professionals. Thus, health and wellness coaching seems to be first and foremost what is referred to as a blended coaching approach, that is, a combination of coaching and consulting.
2. Blended Coaching
In his book “Blended Coaching: Skills and Strategies to Support Principal Development”, the lead author Gary Bloom explains that an effective coach must be prepared to support his coachee in developing new ways of doing and new ways of being. He also represents blended coaching as a Möbius strip where a coach must learn to move seamlessly between instructional strategies and facilitative strategies. It is not a continuum but a dynamic process.
In order to better serve a client, it is sometimes appropriate for a coach to share information directly and to adopt a more didactic approach. Usually, this strategy seems to be beneficial when addressing the client’s way of doing. The difficulty lies in not undermining the client’s capacity for intrinsic learning throughout the process. Too much instructional coaching could in fact lead to the client developing dependence on the coach rather that independence.
This nuance is corroborated by Chery Belles in her article “Blending Consulting and Coaching for Real Value”. She suggests that for each consultation, there exists an optimum blend of coaching and consulting behaviors.In some cases, providing a client with information might be the best strategy to move them forward and offer the most benefit. But this must not be done to the detriment of the client’s self-exploration or it could end up being counterproductive. As a general rule, she states that it is of vital importance that the coach not tell the client what to do too quickly. This also brings into question the motivation of the coach for sharing information with the client in the first place.
The coaching philosophy is based on the belief that each person is creative and resourceful. The coaching process simply enhances the client’s ability to discover their own answers. This premise does not change because a coach chooses to adopt a blended style. The coaching must still be centered on the client and the client’s agenda… and not on the coach’s ability to deliver results. This is a matter of self-management for the coach; it requires focus, discipline and self-control to be able to hold a space for the client and hold back the need to offer advice. An effective coach must learn to develop proper judgement in order to determine what strategy is most appropriate and beneficial for a specific client in a specific situation.
3. The Transtheoretical model & health coaching
When it comes to preventing and managing chronic illnesses, treatment strategies are evolving towards more personalized approaches. These are not only based on the patients’ psychosocial factors, but also on their readiness and willingness to implement change in their lifestyle. Recently, this has been reflected by a growing interest in theories and models that could support health behavior interventions. The objective is to understand why individuals behave the way they do, and thus attempt to tailor health programs accordingly and increase their effectiveness.
It has been observed that in order to achieve health goals, patient education is critical, but traditional patient education strategies seem to be insufficient. This is where health coaching is beneficial; it builds on the patients’ core values to enhance their motivation in order to achieve self-determined health goals. The role of the health coach is to facilitate the process of change and support the patients in acquiring the necessary knowledge and self-management skills.
In this regard, health coaching techniques are strongly influenced by The Transtheoretical Model (TTM) of health behavior change. The “Stages of Change” is one of the core constructs of this model and reflects a person’s readiness for change. It implies that change occurs over time as a process and that each person has to go through six stages in order to successfully change a habit or behavior.
By using this model to asses a patient’s readiness for change, an effective health coach can adapt the coaching process accordingly and provide optimal support. For instance, a patient at the stage of Pre-contemplation may not be ready to consider behavioral change or coaching, but may be open to receiving some information about his/her health condition.A patient at the stage of Preparation, though not quite ready to take action yet, may still want to start the coaching process and seek guidance in designing a plan to implement in the near future.
Processes of change are another key construct of TTM. They are processes that people use to progress from one stage to the next. All of these can be supported by a coaching partnership.
During the early stages of change, an effective health coach could guide the patient towards more experiential processes (1-2-3-4-5), whereas behavioral processes (6-7-8-9-10) might be better suited for a patient in the late stages.
The role of the health coach is also to support the patient in gaining self-efficacy, as defined by psychologist Albert Bandurain the Social Cognitive Theory (SCT), namely
how well one can execute courses of action required to deal with prospective situations.
It is a person’s confidence in their ability to cope with temptation and prevent relapse. This is relevant in the context of health coaching since a patient’s self-efficacy seems to be closely correlated with the patient’s ability to implement self-management strategies in chronic diseases. A coach could also strengthen the patient’s perceived self-efficacy through acknowledgement of their progress throughout the whole process.
4. Effective coaching strategies for healthcare
Many interventions can be included as part of an integrative health coaching approach. Here are some of the coaching strategies that have been proven to be effective.
During the initial consultation, the coach can ask the patient what is important to them in terms of healthcare and prevention/management of the disease. This will enable the coach to guide the patient in the creation of a long-term vision of health. This powerful motivation is necessary because it is usually the driving force for the patient to follow through on specific health goals. Reminding the patient of this vision is also a way for the coach to hold the patient accountable on his/her own terms.
When defining specific goals, the coach might use coaching tools such as a Health Wheel(see appendix I) to help the patient visualize the interconnection between different aspects of their health. This allows the patient to determine their current level of satisfaction in each section, facilitating the process of establishing priorities and action steps. The coach can then provide support during coaching sessions in the form of positive reinforcement based on the values and interests previously identified by the patient.
Throughout the health coaching process, education may be offered by the coach, but only when the patient is ready for it and when it is relevant to the patient’s goal. The coach might also ask the patient permission before giving direct information; this enhances the patient’s control and responsibility in regards to their own health. Though most of the time, the coach can simply encourage the patient’s curiosity and support their learning style. For instance, a coach might ask a patient what aspects of managing the disease is most confusing to them and where they could find the information.
The coach can also inquire about past experiences, asking what strategies have worked for them, or on the contrary, what strategies haven’t worked. Exploring the challenges that have been the most difficult to overcome can indicate an area that might require more support in the future. It is important for the coach to help the patient focus on what they can do to change their current behaviors, how they can successfully alter their habits, and avoid getting stuck in why they exist.
Because it is a process, the coach and the patient must both be aware of the possibility that there might be setbacks. For this reason, it is necessary that the coach help the patient determine a plan of action and accountability measures beforehand. As previously stated, these measures have more impact when tied to the patient’s values and personal motivation. By asking a patient how they would prefer a situation to be handled when they do not follow through on a commitment, it usually increases their receptivity to this kind of feedback.
Conclusion
Though further examinations are necessary to draw unequivocal conclusions, current evidence would suggest that health coaching has the potential to positively impact public health advances. More and more studies are pointing to health coaching as an effective intervention to improve patients’ self-management and health outcomes through health behavior change.
A blended coaching style allows for incremental education on the patients’ terms. Thus coaches can offer their clients what they’re willing to receive while still supporting the development of their self-efficacy and self-management skills. Taking into account patients’ readiness to change, effective health coaches can also adapt coaching interventions to better assist their clients in modifying their behaviors and attaining self-determined goals.
In the end, patients have the right and responsibility to choose what health goals they want to make a priority.Health coaches respect that right and uphold that responsibility. That is what makes coaching an effective approach for sustainable results in health and wellness.
Appendix I
Example of health wheel
Source
- Q. Wolever, M. Dreusicke, J. Fikkan, T. V. Hawkins, S. Yeung, J. Wakefield, L. Duda, P. Flowers, C. Cook and E. Skinner, Integrative Health Coaching for Patients With Type 2 Diabetes: A Randomized Clinical Trial, The Diabetes Educator 2010 36: 629 originally published online 9 June 2010, DOI: 10.1177/0145721710371523
Appendix II
Examples of health coaching questions:
- What is important to you in terms of healthcare?
- What long-term vision of health do you want to create for yourself?
- How well do you believe you are currently managing your health?
- What do you perceive to be a challenge or area that needs support?
- In your experience, what works for you? What doesn’t work for you?
- How will goals in this area support the bigger picture?
- How will achieving this make your life better?
- How will this enable you to achieve your vision?
- What do you already know about …?
- Where can you find more information on the subject?
- What aspects of managing the disease is most confusing to you?
- What do you want to change about…?
- What do you need to make this change successfully?
Resources
[1]http://www.who.int/en/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds)
[2]http://www.who.int/en/news-room/fact-sheets/detail/cancer
[3]
[4]https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/757469
[5]https://www.nescon.medicina.ufmg.br/biblioteca/imagem/4442.pdf
[6]https://link.springer.com/article/10.1007%2FBF03325280
[7]https://www.liebertpub.com/doi/abs/10.1089/pop.2010.0026
[8]https://coachfederation.org/about
[9]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3833550/
[10] https://sdcoetraining.learning.powerschool.com/jessica.rappmccreary/leadershipcoachingcadre/cms_file/show/ 33552599.pdf?t=1416593383
[11] https://www.sageleaders.com/wp-content/uploads/2009/03/CheryBelles.pdf
[12] http://learnsite.icacoach.com/english-campus/foundation-coach-course/what-is-coaching/
[13] http://learnsite.icacoach.com/english-campus/coaching-presence-course/self-management/
[14] https://extension.purdue.edu/extmedia/HHS/HHS-792-W.pdf
[15]Wolever, R. Q.; Dreusicke, M.; Fikkan, J.; Hawkins, T. V.; Yeung, S.; Wakefield, J.; Duda, L.; Flowers, P.; Cook, C.; Skinner, E. (9 June 2010). “Integrative health coaching for patients with type 2 diabetes: a randomized clinical trial” (PDF). The Diabetes Educator. 36 (4): 629–639. doi:10.1177/0145721710371523. PMID 20534872
[16]https://pdfs.semanticscholar.org/d8d1/915aa556ec4ff962efe2a99295dd2e8bda89.pdf
[17]http://www.cpe.vt.edu/gttc/presentations/8eStagesofChange.pdf
[18]https://pdfs.semanticscholar.org/8bee/c556fe7a650120544a99e9e063eb8fcd987b.pdf
[19]http://journals.sagepub.com/doi/abs/10.1177/014572170302900411
[20]http://learnsite.icacoach.com/english-campus/coach-skills-course/acknowledgement/
[21]Wolever, R. Q.; Dreusicke, M.; Fikkan, J.; Hawkins, T. V.; Yeung, S.; Wakefield, J.; Duda, L.; Flowers, P.; Cook, C.; Skinner, E. (9 June 2010). “Integrative health coaching for patients with type 2 diabetes: a randomized clinical trial” (PDF). The Diabetes Educator. 36 (4): 629–639. doi:10.1177/0145721710371523. PMID 20534872