A Qualitative Study of How Health Coaches Support Patients in Making Health-Related Decisions and Behavioral Changes

We appreciate the work of Thom et al. in bringing to light the relationship between health coaches and patients. Using a qualitative study design, Thom and colleagues set out to identify the themes involved in the health coach-patient relationship at six community centers in California. They believe that the themes that they identified - shared characteristics, availability, trusting relationships, education, personal support, decision making support and the role as a bridge between patient and physician - are the foundation for effective health coaching.

Our discussion group had very limited exposure to the role of health coaching in patient care, and most were not aware that such an option was available. It is clear to us now that health coaches can play an important role in patient care, especially in resource-poor settings.

Specifically, areas with high rates of chronic disease are particularly effective regions for coaches to function as a peer support system to help with both disease management and decision-making. It did strike our group as interesting that one half of the patients in the study were Hispanic, and half were born outside of the United States. We discussed whether the cultural and language differences between patients and their doctors may have contributed to the decision of patients to participate in health coaching. It was also of note that in both the health coaches and the patient participants, females were overly represented. This may be due to inherent differences in the way women and men interact with health care providers in general.

The themes identified by the study seemed very fitting when viewed through the lens of an effective patient-provider relationship and providing effective treatment for the patient. Shared characteristics were felt to be important in being able to relate to one another, and it seemed intuitive that patients may be more comfortable and willing to talk to and take advice from those who they perceive to be similar to themselves. The group did find it noteworthy however, that far fewer patients shared experiences identified for this theme than any of the other themes, with much of these experiences being brought up by either clinicians or health coaches - perhaps suggesting that physicians believe this to be more important to patients than actually is the case.

Physicians are often not as available as health coaches; hence, availability also seemed like an important theme for health coaching. This theme was the most referenced theme identified in all of the focus group interviews. The discussion group took this as a sign that both patients and clinicians saw the value in close, frequent contact between patients and providers.

As far as a trusting relationship between coach and patient is concerned, the group did feel as though this theme may be dependent on other themes of the study, such as having shared characteristics, and thus may be slightly redundant. It was interesting to us, however, that the study authors noted that patient confidentiality was an interesting aspect of this theme. Thom et al. noted that patients would often tell their health coaches things that they did not want their physician to know and the coaches were torn between a duty of confidentiality to the patient and that of communication with the provider. The group thought that this was an aspect of health coaching worth exploring further.

Education was discussed as an obvious theme for health coaching, as one of the primary goals of the profession is to educate patients to make better informed decisions about their health care and goals. Our group did find, however that the themes of personal and decision making support seemed as though they could be combined into a single theme, given the similarities between them. In terms of being bridges between patients and physicians, it was striking to us that this theme was most often identified from experiences brought up by physicians and less often by patients. The group offered that this may suggest clinicians value having another window into their patients' lives more so than the inverse.

Overall, the discussion group felt that this study may have been limited to the outcomes of preventative medicine and lifestyle modifications, as health coaching cannot be applied to strictly clinical situations, which the authors did acknowledge. Furthermore, the patients involved must be engaged and motivated to derive benefit from these interactions. The group believes there to be significant room for further studies in this regard to examine which types of patients are more likely seek out, and subsequently benefit from health coaching. We were also interested to know if the number of themes identified in this study met by health coaches in the field correlated with patient satisfaction and attainment of health goals. These studies would help target health coaching to the patient populations that would derive the maximum benefit from it, as well as potentially set guidelines for health coaching to attain the best patient outcomes.

The group was also interested in any alternatives to health coaching that the authors may have considered, as this study was not concerned with the superiority of health coaching to any alternatives, but rather its overall effectiveness. In the same light, the group was of the opinion that "A Qualitative Study of How Health Coaches Support Patients in Making Health-Related Decisions and Behavioral Changes" was perhaps a misleading title, as the study itself did not collect any data on the actual decision-making process or any behavioral changes that were made. We suggest a better title may be "A Qualitative Study on the Criteria for Effective Relationships between Health Coaches and Patients", as this more accurately captures the authors' intentions of eliciting the themes behind the interaction between health coaches and their patients.

Competing interests: None declared

While we cited Dr. Benzo's most recent publication in our paper, space limitations kept us from including his work in our discussion. We are therefore especially grateful for his letter as it elaborates the common ground of our work including recognition that the relationship built between health coach and patient is key to successful coaching. We also appreciate his note that this model is consistent with the humanistic therapy model proposed by Carl Rogers and with the principles of Motivational Interviewing. Dr. Benzo's letter cites additional studies which have provided evidence for this model, including his own recent study (1,2) which showed that an intervention that included motivational interviewing-based health coaching for patients discharged from the hospital following treatment for a COPD exacerbation reduced the risk of readmission for up to 6 months.

Studies done by our group, Dr. Benzo's group, and others, support the view that a personal relationship is important not just between the patient and doctor, but between the patient and other members of the care team as well. We look forward to seeing further work in this area from Dr. Benzo.

1. Benzo R, Vickers K, Ernst D, Tucker S, McEvoy C, Lorig K. Development and feasibility of a self-management intervention for chronic obstructive pulmonary disease delivered with motivational interviewing strategies. J Cardiopulm Rehabil Prev. 2013;33(2):113-123.

2. Benzo R, Vickers K, Novotny PJ, Tucker S, Hoult J, Neuenfeldt P, et al. Health Coaching and Chronic Obstructive Pulmonary Disease Rehospitalization. A Randomized Study. American journal of respiratory and critical care medicine 2016;194(6):672-680.

Competing interests: None declared