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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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

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• 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.

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Simmons&Wolever(2013).IntegrativeHealthCoachingandMotivationalInterviewing:SynergisticApproachestoBehaviorChangeinHealthCare.GAHM,2(4),24-31.