Psychol Rec DOI 10.1007/s40732-017-0241-4

THEORETICAL ARTICLE

The Use of Health Coaching to Improve Health Outcomes: Implications for Applied Behavior Analysis Heather E. Finn 1 & Rebecca A. Watson 2

# Association for Behavior Analysis International 2017

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 behaviorchange 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. Keywords Health coaching . Behavior analysis . Chronic health conditions . Self-management . Individual feedback With the widespread epidemic of chronic health conditions, there is urgent need for action. In the USA, as of 2014, 70% of the population is overweight or obese (Centers for Disease

* Rebecca A. Watson [email protected] Heather E. Finn [email protected] 1

Vida Health, 26 O’Farrell St., Suite 310, San Francisco, CA 94108, USA

2

Private Practice, 225 Zane Grey Dr, Sedona, AZ 86336, USA

Control and Prevention [CDC], 2016). Those that fall into the obese/overweight category are at risk for: high blood pressure (hypertension), high low-density lipoprotein (LDL) cholesterol, low high-density lipoprotein (HDL) cholesterol, or high levels of triglycerides (dyslipidemia), type 2 diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea and breathing problems, some cancers (endometrial, breast, colon, kidney, gallbladder, and liver) as well as mortality. In addition, they are at risk for a low quality of life, mental illness such as clinical depression, anxiety, and other mental disorders, body pain and difficulty with physical functioning (CDC, 2015). About half of all adults in the USA—117 million people—had one or more chronic health conditions as of 2012 and one of four adults had two or more chronic health conditions (CDC, 2016). According to the CDC, seven out of ten deaths are due to chronic conditions and treating chronic conditions accounts for 86% of health care spending in the USA. Research indicates that weight loss by as much as 5–10% can have a significant impact on an individual’s health such as improving blood pressure, cholesterol, and reversing or preventing diabetes (CDC, 2015, 2016). Lifestyle behaviors are often the cause of chronic health conditions and the CDC has identified four behaviors that are most often tied to the development of these conditions: exercise, nutrition, alcohol use and smoking. According to the CDC data, 52% of adult Americans did not meet the recommendations for aerobic exercise and 76% did not meet the recommendations for strength-training exercise. In 2011, approximately one third of adults and adolescents reported eating less than one fruit a day and 23% of adults and 38% of adolescents reported eating less than one vegetable a day. About one out of five adults in 2012 reported being a current smoker. Binge drinking leads to 88,000 deaths per year in the USA alone and 38 million Americans reported binge drinking

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(at least eight drinks in a setting) an average of four times a month (CDC, 2016). Despite the fact that many chronic health conditions stem from lifestyle behavior choices, individuals rarely make and sustain behavior changes that positively impact their health outcomes. Many healthcare providers do not have the time or training to successfully help their patients implement significant change (Simmons & Wolever, 2011; Calloway Rankins, 2016). Behavior analysis is uniquely situated to play a key role in designing behavior-change programs that address lifestyle choices and related behavioral risk factors that contribute to the development of chronic health conditions. The role of behavior analysis in addressing these types of behaviors is not without notice within the behavioral research literature. However, often the lines of research in a particular area lack replication or further long-term study. There have been a wide range of publications that address specific health-related behaviors, including physical activity, diet, diabetes, obesity, dental care, burns, and arthritis to name a few (Allen & Hine, 2015; Normand & Osborne, 2010; Van Camp & Hayes, 2012). Increasing physical activity and making healthier dietary choices are two lifestyle behaviors tied directly to premature mortality and reduced quality of life as it relates to chronic health conditions. Normand (2008) looked specifically at designing a package intervention that would increase physical activity through the use of self-monitoring, goal-setting and feedback. In this study, the results showed an effective, relatively simple intervention package that increased the number of steps taken per day, increasing overall physical activity for the participants. However, no weight loss was indicated for participants. In a similar study that also used self-monitoring and feedback, participants set goals to increase their physical activity. Calorie expenditure was measured individually across participants and all five participants showed an increase in expenditure (Donaldson & Normand, 2009). Other studies support the effective use of feedback paired with self-monitoring, and feedback paired with a contingency management program to increase physical activity for overweight or sedentary adults (Kurti and Dallery, 2013; VanWormer, 2004). When looking at lifestyle behaviors related to obesity, interventions that increase physical activity and healthier food choices are critical to making a positive impact on individual health. Effective package interventions, including goal-setting, self-management, contingency management procedures, and individual feedback show promise within the literature (Van Camp and Hayes, 2012; Normand and Osborne, 2010). The intent of the current paper is to discuss chronic health conditions and their relationship to lifestyle behaviors, introduce health coaching while highlighting how the principles of applied behavior analysis align with its practice, and provide reasoning for the need to extend behavior analysis into other public health domains. In addition, this paper intends to urge

other behavior analysts to collaborate with healthcare professionals and behavior support professionals to unify efforts to make an impact on socially significant behaviors affecting a large portion of our population. Behavior analysts are in a unique position, being experts in behavior change, to become partners in healthcare to help society move towards better health while also further disseminating our science in mainstream applications. This paper is not meant to be an exhaustive literature review of health coaching (see Linden et al., 2003; Olsen & Nesbitt, 2010; Wolever et al., 2013) or health behavior research in behavior analysis (see Allen & Hine, 2015). The authors hope to bring to light the potential crossroads of behavior-change strategies, an opportunity for collaboration in a socially significant area of treatment that behavior analysts are not yet impacting in a large-scale way.

Health Coaching Health coaching is a relatively new field that has demonstrated significant results in helping individuals improve their health outcomes (Clark & Hampson, 2001; Jones et al., 2003; Kivela et al. 2014; Lawson et al., 2013; Linden et al. 2003; Olsen & Nesbitt, 2010; Sharma et al., 2016; Simmons et al., 2014; Simmons & Wolever, 2011; Wolever et al., 2010, 2013; Wolever & Dreusicke, 2016). Specifically, Kivela et al. (2014) examined 13 separate studies from 2009–2013 that looked at the impact of health coaching on improving health outcomes. The results of these studies demonstrated better weight management, increased physical activity and improved both physical and mental health status. Research has also shown health coaching to lead to improvements in measures that impact cardiovascular health, pain management for cancer patients, diabetes management and improved outcomes in obese patients who had a BMI over 30 (Simmons & Wolever, 2011). In addition, research has also shown that the results of health-coaching interventions persist 1 year following the intervention (Sharma et al., 2016). In a recent 1-year pilot project utilizing health coaching over a smartphone application paired with an activity tracker and a smart scale, the majority of 700 participants had positive health outcomes (Vida Health, unpublished). The results showed 55% of the participants lost at least 2% of their body weight with 31% losing more than 5% of their weight from baseline. The participants who had 8 sessions with their coach had the lowest percentage of weight loss and those with at least 20 sessions with their coach having the highest percentage of weight loss. In addition to weight loss, 83% of participants moved from stage 2 hypertension to stage 1 hypertension and 75% moved from stage 1 to no hypertension. Some limitations to replicating the intervention are that “health coaching” was not clearly defined for the project and no one model of health coaching was

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implemented. The coaches that participated in the pilot project were trained in a variety of health-coaching philosophies and had a vast array of backgrounds, expertise and experience in coaching. In addition, the number of sessions, the duration of the sessions as well as the content of the sessions was not consistent across participants and coaches. While there is a growing body of research demonstrating the effectiveness of health coaching, a consistent definition of what comprises “health coaching” across studies makes it a challenge to evaluate what components of the intervention are effective. In a review of the health-coaching research Linden et al. (2003) separated the research into three separate broad categories of coaching: (1) disease-related education, (2) psychosocial support and (3) behavior-change strategies. They concluded that those studies implementing a disease education-based approach alone were less effective than those paired with behavior-change strategies. Linden et al. describes self-management, or an individual’s ability to take ownership of their healthy behavior changes, as the crucial behavior to target for change. The research utilizing behavior-change strategies as part of the coaching and specifically focusing on self-efficacy and goalsetting demonstrated significant improvements in the individual’s ability to self-manage their chronic conditions (Linden et al., 2003). The research utilizing psychosocial support as part of the coaching, defined as calling the individual on a weekly basis to listen and provide emotional support, also demonstrated an improvement in the participant’s medication adherence. Additionally, within the behavior-change strategies, research using the Transtheoretical Model of Change as well as Motivational Interviewing were reviewed and shown to prove effective in creating behavior change to improve health outcomes. Using the Transtheoretical Model of Change, Jones et al. (2003) saw their participants exposed to the intervention move from one stage of change to another when coached on two or less goals. When the participants were coached on more than two goals, there was no significant difference between the experimental and control group (Jones et al., 2003). The authors concluded that health coaching is effective and important next steps in research are identifying those specific components that make it effective (Linden et al, 2003). Another review of the literature attempted to identify the key components of health coaching and in the 15 studies examined noted that 40% saw significant outcomes in one or more of the areas of nutrition, physical activity, weight loss and/or medication adherence (Olsen & Nesbitt, 2010). The core components in the studies demonstrating significant results were goal-setting, Motivational Interviewing and collaboration with health care providers. Again, the authors concluded that more research is warranted with well-specified methodologies and rigorous designs (Olsen & Nesbitt, 2010). Wolever et al. (2013) followed this review with an examination of the literature on coaching with the purpose of identifying the core components making up “health coaching”. Research on

health coaching has shown its effectiveness in reducing hospitalizations and medical care costs, in addition to positive outcomes for those with diabetes, obesity, cancer and at risk for cardiovascular diseases (Wolever et al., 2013). At the same time, there have also been studies that demonstrate little or no positive outcomes in the use of health coaching. From their analysis of the literature, they found that of the 284 articles reviewed, one third of them provided no description of the coaching intervention, making it difficult to understand what type of coaching was implemented and what components of the coaching may have been effective or ineffective (Wolever et al, 2013). Within the articles that did describe health coaching, there were differences in the delivery, type, and description of coaching. Despite these differences, common themes emerged as crucial components of the coaching process including: a patient-centered process with goals determined by the patient, self-discovery and accountability (Wolever et al., 2013). The International Consortium of Health and Wellness Coaches (ICHWC) recently developed a national certification for health coaches which went into effect February 2017. The ICHWC (2015) defines health coaching as: “Health and Wellness Coaches partner with clients seeking self-directed, lasting changes, aligned with their values, which promote health and wellness and, thereby, enhance well-being. In the course of their work health and wellness coaches display unconditional positive regard for their clients and a belief in their capacity for change, and honoring that each client is an expert on his or her life, while ensuring that all interactions are respectful and non-judgmental.” Health coaching incorporates strategies and learning from many disciplines such as that of Motivational Interviewing, Transtheoretical Model of Change, positive psychology as well as life coaching and executive coaching to name a few. Integrative health coaching (IHC) has emerged from Duke Integrative Medicine as an attempt to address both the need to help individuals make behavior changes that positively impact their health and the need for a profession to address this utilizing a consistent methodology and type of health coaching (Smith et al., 2013). IHC has its roots in integrative medicine and a whole-person approach, patient-centeredness, mindfulness, and healthy lifestyle (Smith et al., 2013). It is a type of health coaching with a focus on addressing the individual’s whole health including physical health, emotional health, social connections, physical space, personal and career growth and spirituality (Simmons & Wolever, 2013). The individual works with the integrative health coach to develop a vision for their health on all of these domains and then develops their own goals around the areas they want to focus while their coach helps them identify the values underlying their vision of health to motivate them (Wolever & Dreusicke, 2016). Research using IHC has demonstrated positive health outcomes for chronic conditions such as diabetes, risk for cardiovascular disease and stroke, weight loss, psychosocial

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measures related to diabetes as well as improved management of intractable tinnutis (Caldwell, Gray & Wolever, 2013; Wolever et al., 2010; Wolever & Dreusicke, 2016). Using IHC with 56 patients who received 14 coaching calls over the course of 6 months, Wolever and Dreusicke (2016) saw an improvement in medication adherence, a decrease in HbA1c (a measure of average blood sugar levels over a short period of time) and improvement in psychosocial measures. In addition, these results persisted for 6 months following the study (Wolever & Dreusicke, 2016). In a qualitative study that examined the components of coaching that creates behavior change and positive health outcomes, Caldwell et al. (2013) analyzed the transcripts of 69 coaching calls and categorized the integrative health coaching interaction. They were able to organize the coaching call into three main components: (1) brief check in, (2) follow-up on previous goals and any barriers that may have emerged, and (3) the development of future goals and follow-up appointment. The researchers were able to identify 23 different themes of communication from the IHC calls and were able to group them into two main categories: exploring the participant’s experience, and active intervention. The category of “exploring the participant’s experience” was described as more of a facilitative approach and included affirmation of the participant’s progress no matter how small, rapport building, and reflection to check understanding. The category of “active intervention” included reframing, tentative suggestions/advice, offering information/rationale, and guiding to specifics which involved setting specific, measureable, attainable, realistic and timely (SMART) goals. Based on the analysis of these coaching sessions, the authors concluded that health coaching was not about providing education, instead it consisted primarily of following the participant’s lead on goals as well as focus, and providing additional education only as needed or requested by the participant. The analysis of the transcripts also revealed that the coach tended to talk slightly less than the participant which is different than most patient/medical provider interactions. In addition, it was noted that unlike patient/medical provider interactions that typically involve a concept of “compliance with recommendations” if the patient engages in the behaviors recommended, coaching was more the idea of “concordance” or mutual responsibility between the coach and the patient (Caldwell, et al., 2013).

Behavior Analytic Framework Coaching Defined & Unit of Analyses Health-coaching practices have commonalities and differences when compared with the practices of an applied behavior analyst. It is desirable to look closer at health

coaching through the lens of a behavior analyst in order to better understand the behavioral processes that may be at play. Within the field of behavior analysis, the term coaching may be used to describe a wide variety of intervention techniques and procedures that can be applied to business, athletic performance or staff training. Conducting a behavioral analysis of health coaching warrants further definition and outlining of the components that make up an intervention package of coaching. Seniuk et al. (2013) propose defining “behavioral coaching” according to Martin and Hrycaiko’s (1983) outline of characteristics for sports coaching. These characteristics were developed based the dimensions of applied behavior analysis according to Baer, Wolf and Risley (1968) and seem useful in discussing a behavioral analytic account of coaching. Martin and Hrycaiko (1983) outlined the following criteria to operationally define behavioral coaching: 1) Measurement of behavior that is specific and occurs regularly; 2) Determines a plan for acquiring the new behavior and maintaining the behavior over time with the use of positive reinforcement procedures; 3) Improvement is measured against the individual’s own performance, rather than others; 4) Utilizes evidence-based procedures that are effective in changing behavior; 5) Feedback to the coach’s behavior occurs on his/her coaching techniques; and 6) Inclusion of social validity measures to ensure acceptability and satisfaction of the intervention. Although Martin and Hrycaiko’s (1983) definition of coaching was developed with respect to athletic performance, it appears succinct with applications that will address behaviors related to physical and mental health. When selecting specific behaviors that would be applicable for health coaching, encompassing a myriad of health-related behaviors, it is valuable to consider the conceptual basis for the functional relationships in a client’s environment. Health behaviors are operant behaviors and, as such, individuals engage in daily habits operating their environment for better health choices and improved long-term health outcomes. The conceptual framework of the four-term functional unit of analysis provides a behavioral account of the process occurring. This functional unit of analysis is comprised of these relations: motivating operation, antecedent/discriminative stimulus, behavior/operant responses, and consequences. (Dallery, Kurti, and Erb, 2015). In looking at health coaching through this behavior analytic lens, the behavior analyst could consider the process one in which a coach introduces the fourterm contingency to guide the individual through their own behavior and its relationship to their environment. Although

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few health coaches use this language or identify with this as using a behavior analytic process, the intersection of the practices becomes evident with a behavioral account of what occurs. Health coaching in practice is a partnership with the client and coach, in which the framework for coaching process begins with informally addressing the problem and the supporting environmental factors that exist for the client. What is the behavior that they want to change? The coach helps the individual create an operational definition of their behavior (specifically, what does the behavior include and not include for the individual; e.g., “eating healthy” means different things to different people). What is the baseline occurrence of the behavior or how frequently it is occurring? Why is it currently occurring or what is the function of the behavior? How can they meet that same need with a different behavior or what is the replacement behavior? How will they reinforce the new, replacement behavior and how will they set up antecedents and consequences to reduce the likelihood of the target behavior that they identified to change? The coach works with an individual to complete an analysis of the behavior, identifying each term in a four-term unit of analysis and determining surrounding environmental variables that may be manipulated in order to help the client achieve their goals. The individual’s motivation to create change is an integral part of the coaching process and their success in achieving their behavior change goals. Often, the difficulty with making behavior change occur and sustain is the discrepancy between short-term and long-term contingencies. The coach bridges this discrepancy by restating the individual’s long-term goals and connecting their present behavior to those long-term contingencies. Paralleling the type of plans a behavior analyst creates, health coaches work with an individual to develop a “wellness plan” that incorporates SMART goals. During the development of these plans, the coach works with an individual to shape their own behavior in order to achieve their health and wellness vision (short- and long-term goals). A health coach provides feedback (e.g., reflecting, pointing out and reinforcing successes) to an individual on successive approximations towards their long-term desired behavior. The coach is shaping the behavior of the individual and supporting the individual to learn to shape their own behavior. The coach can do this by drawing connections to the reinforcing consequences in the environment that the individual is contacting through their changes in behavior. In this way, a coach is teaching the individual self-management skills in order to effectively control contingencies in their environment. An example to consider is that of an individual giving up eating candy for the week. The coach uses questions and reflections to help the individual identify the immediate benefits to this behavior change, such as increased energy, improved sleep, improved mood, while continuing to move them towards their longer-term goal of weight loss. Throughout the coaching process, feedback is

frequently solicited to determine the effectiveness of the coach’s techniques for the individual, acceptance of the strategies utilized and satisfaction with the process.

Collaboration and Extending the Reach In considering a behavior analytic account of coaching and moving towards a union of effective approaches to impact chronic health conditions, behavior analysis has much to offer and much to gain. The importance of the work many behavior analysts currently do is not to be over-shadowed; this work is incredibly valuable and impactful within our field and communities. However, from early behaviorism and B.F. Skinner’s (1987) vision of how a science of behavior could improve the human condition, it appears particularly relevant to extend the work into healthcare and improve the impact of individual choices such that our society’s quality of life improves rather than diminishes. Winett (1995) discussed a framework for health promotion and prevention programs that health psychology could use to bridge the overlapping disciplines for a common goal of improving health across the nation. In this framework, theories and models were organized by core principles and procedures in a manner that would support the most effective outcome for the common goal. These ranged from gathering epidemiological data and other pertinent data, national policies and goals, prevention and treatment programs, and marketing to disseminate effectives programs. Overarching each of these areas would be a heavy emphasis on research to inform each area. In this framework, behavior analytic procedures included contingency management, shaping successive approximations, feedback and goal-setting, modeling, reinforcement, prompts and discriminative stimulus. In proposing this framework, Winett hoped to develop an approach for behavior change that would focus health psychology’s efforts to collaborate across disciplines to achieve a shared goal—“helping America reach health promotion, health protection, and preventative service objectives to reduce the burden of unnecessary morbidity and premature mortality” (Winett, 1995, p. 349). Over recent years, various prominent behavior analysts (Friman, 2010, Poling, 2010, Normand & Kohn, 2013) have brought to light the need for behavior analysis to extend its reach in the future by investing in work outside of the majority, collaborating with other professions and disciplines, and applying behavior analysis to make an impact on mainstream socially significant behavior of societal concern. Poling (2010) suggested the need to grow our discipline to ensure a future for behavior analysis. Although the field has continued to grow significantly, it is small in comparison and with that comes limited impact to greater society. Also pointed out is the reality of applied behavior analysis becoming synonymous with autism spectrum disorder treatment. This important work will continue to grow and

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develop; however, since behavior analysis is useful in treating a wide variety of problems, it must broaden the scope of problems it tackles and create training programs that enable graduates to work in varied applications and diverse populations (Poling, 2010). Normand and Kohn (2013) call for extending the work of behavior analysis to foster new career opportunities for behavior analysts and, thus, support sustaining the field. In this light, offering training programs that result in numerous career opportunities could attract individuals to the field who may otherwise select a different discipline that allows them to work with a particular population or specialty interest (e.g., health and wellness). Some professions outside of ASD or DD treatment may be considered well-suited for someone with training in behavior analysis; although health coaching is not specifically identified, related professions such as certified personal trainers and alcohol & drug counselors have been delineated. Extending the reach of varied applications will ultimately maximize the overall impact of behavior analysis research and the practice as a whole (Normand & Kohn, 2013). Integrating with existing disciplines, such as medicine or healthcare, to expand the work of behavior analysis and harness the power of behavior analysis to improve the individual, human condition is not only possible but essential (Allen, Barone, & Kuhn, 1993; Friman, 2010). Friman (2010) notes “To achieve mainstream status, behavior analysis needs to compromise neither its principles nor its practices. A much more practical and efficient way to enter the mainstream is to integrate with a field that is already there” (p. 20). In an effort to broaden the reach of behavior analysis, join forces with other professions, and impact a growing public health epidemic, it seems the marriage of behavior analysis and health coaching is seemingly one to consider.

General Discussion The positive impacts of health coaching are significant as an effective behavior-change intervention. The role of a health coach can be compared to that of a behavior analyst assessing problem behavior through the four-term unit of analysis and developing effective interventions that are maintained over time. Further analysis is warranted into how behavior analysts can help society promote individual and community health through effective yet simple interventions that produce significant outcomes. Although the field of behavior analysis has contributed to a wide variety of interventions that treat chronic health conditions, there is a need for ongoing lines of research that show its potential to make large-scale impact across a variety of lifestyle behaviors. As a science devoted to the understanding and improvement of human behavior (Cooper, Howard, & Heron, 2007), applied behavior analysts are well-equipped to address behaviors associated with chronic health conditions, particularly as it relates to lifestyle choices and decisions. Behavior analysts could play an integral role in supporting individuals to make behavioral

changes for improved health. As experts in behavior-change procedures, focusing on maladaptive choice as a risk factor for chronic health conditions would enable behavior analysts to use their specialized skills to further broaden the applications of behavior analysis towards a socially significant, societal problem impacting people across every community. Behavior analysts would benefit from increased collaboration with medical professionals and the emerging field of health coaching to support individuals in making sustainable behavior change for their own health. Furthermore, collaboration with health coaches and medical professionals to determine target behaviors while prioritizing health risk factors would be optimal healthcare. There would be value to helping coaches identify behaviors that may serve as behavioral cusps for an individual, thus identifying target behaviors that result in increased access to reinforcers and maintenance over time. Behavior analysis as a science could contribute to the field of health coaching by helping to design interventions in a scientifically rigorous way. While there is significant research in the field of health coaching demonstrating its efficacy, there is a need for more controlled scientific studies. Further investigations would be important to better understand which components of self-management intervention were most effective for behavior change. The use of contingency management programs may also be effective in changing physical activity levels; however, it is not yet clear if incentives are necessary for behavior change to occur. Kurti and Dallery (2013) show preliminary support for the efficacy of self-management, goal-setting and feedback without contingency management (incentives) to increase walking in sedentary adults over the age of 50. Additionally, identifying what aspects of the coaching and how many coaching sessions are optimal for significant outcomes would be an avenue for further exploration. Future studies would do well to operationally define coaching, and ensure all coaches are trained in this model of coaching implementation. Normand and Kohn (2013) capture Skinner’s message for behavior analysis and the importance of cultivating, sharing and expanding the science: “As Skinner (e.g., 1982, 1987) noted, virtually all of the problems facing modern society are problems of human behavior. To solve these problems, we need to foster a natural science of behavior and broadly disseminate the applications derived from that science.” (p. 110)

Compliance with ethical standards Conflict of Interest One of the authors is employed by Vida Health as a coach lead and participated as a health coach in the unpublished study mentioned in the manuscript. No financial incentives were provided for participation in the study beyond pay for services as an employee, and no financial incentives were offered for submitting the manuscript for publication.

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