Nailing Jello to a tree: the science and ethics of health coaching.
Abstract: A new paradigm of Work Place Health Promotion has entered the arena of public health education. Health Coaching is an attempt to influence personal choices and behaviors that promote health. However, the process is based on proprietary training and entails one-on-one interviews to elicit preferences and obstacles to healthy choices. By being all things to all people, it cannot be defined, and therefore cannot be studied. Any claims to success in promoting health must be suspected as unsupported if well-meaning advertising.
Subject: Quarantine
Public health
Ethics
Technology and civilization
Authors: Eddy, James M.
Robinson, Edward N., Jr.
Pub Date: 06/22/2009
Publication: Name: American Journal of Health Studies Publisher: American Journal of Health Studies Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 American Journal of Health Studies ISSN: 1090-0500
Issue: Date: Summer, 2009 Source Volume: 24 Source Issue: 3
Topic: Event Code: 290 Public affairs Advertising Code: 91 Ethics
Product: Product Code: 8000120 Public Health Care; 9005200 Health Programs-Total Govt; 9105200 Health Programs NAICS Code: 62 Health Care and Social Assistance; 923 Administration of Human Resource Programs; 92312 Administration of Public Health Programs
Accession Number: 308743746
Full Text: Eleven decades ago, our ancestors died of infectious diseases. In 1900 the leading causes of death were pneumonia, tuberculosis, diarrhea and enteritis. Our great, great, great grandparents were lucky to survive the diseases of childhood. During the last century, the tool chest of public health interventions contained sanitation, quarantine, antibiotics and vaccines. These are powerful tools; their uses are clearly defined and have biologically definable outcomes. The disappearances of typhoid fever, smallpox and polio and the historic low incidences of tuberculosis and measles are testaments to the effectiveness of these particular public health tools.

But the "plagues" of this century are heart disease, strokes, and cancers: the outcomes of hypertension, diabetes, cigarette use and obesity. The four historic tools of public health no longer work against what kills us now. One does not quarantine cigarette smokers. One does not vaccinate against obesity. Antibiotics do not exercise muscles and the heart. The targets are no longer terrorists (infectious diseases), but terrorism (behaviors). Terrorism cannot be eliminated; behaviors cannot be quarantined.

Undaunted, we Public Health Educators search for the "Message". The Message is that magical piece of healthful information, given at the right time, in the right setting, with the right inflection that will change people's behaviors. Stop smoking. Stop having unprotected sex with multiple partners of either gender. Stop eating those foods we crave most. Start sweating more.

The delivery of the Message is complex and requires specialization. Some efforts target school children. Others are directed to adults. Others still, adults at work.

In this vein, Worksite Health Promotion programs have been evolving for five decades. Many workplace programs have been designed, implemented and evaluated using theory based practices. As a result, we have gained a clear picture of what activities yield anticipated outcomes and lead to behavioral change. Yet, often, the corporate decision-maker and program buyer has little background on all the factors that influence health behavior and even less awareness of health behavior theory. Why should they? Consequently, but not unexpectedly, some programs do not conform to best practice and yield disappointing results. When products and services are promoted with great fanfare and high expectations, their predictable failure to achieve the intended results implies that health education and health promotion collectively do not work. The rotten apple does spoil the bunch.

As example, the promotion of Health Risk Appraisal (HRA) tools as prescriptions led to disappointments. Vendors extolled the virtues of HRAs as a computerized intervention that would yield mass behavior change and thereby lead to health care cost containment. Pleas of caution espoused by seasoned health educators and health promotion specialists were drowned out by the slick promotions of HRA vendors. In the end, HRAs were found to be useful surveys but only when used as one part of an ecologically and theory based comprehensive program. As a stand-alone intervention, HRAs have limited effect. A lesson learned here was that the Message, even when polished by computerization, has limited impact.

Enter Health Coaching (HC). Health Coaching is being promoted as a new and improved approach to health behavior change and health promotion. Founded in motivational interviewing, it lacks a clear theoretical underpinning of health theory. Promotion of HC relies on testimonials rather than on evidence based research studies. The rhetoric that surrounds Health Coaching is hard to contradict. Many of us remember and have been impacted by that especially adept teacher or coach. So why not train a cadre of them to inspire a flagging workplace?

We have three overlapping areas of concern about Health Coaching: (1) the ethical concerns that arise from the blatant promotion of Health Coaching, (2) the lack of clarity of the health coaching process leads to a lack of research on HC performed by disinterested, unbiased parties, (3) the atheoretical nature of the HC process.

ETHICAL CONCERNS ARISE AROUND PROMOTIONAL EFFORTS

The tagline of HC interventions is that "Coaching always gets results". Proponents claim that by focusing on each worker over time HC is effective in changing their behavior in ways that collective interventions or group messages cannot. It is expensive as its chief component is a person (or persons) trained in motivational interviews. Of course, the training is proprietary and prolonged... and thereby it starts with a significant investment in and of personnel that demand returns with interest. Statements made by HC advocates are vague, but strong. Academics would expect such claims to be supported by research studies. Yet such studies are virtually impossible to construct. By what means can one replicate the methods of the intervention when the intervention is based upon proprietary knowledge applied in infinite combinations? How can one document that HC had an impact both on improving the health behaviors of individuals and changing organizational culture to the extent that employees not exposed to the HC intervention benefit from these programs?

The Society for Public Health Education (SOPHE) (www.sophe.org) Code of Ethics for the Health Education profession advocates, "Health Educators [must] accurately communicate the potential benefits and consequences of the services and program with which they are associated." The claims made that Health Coaching produces benefits that surpass traditional health promotion... traditions that are grounded in health behavior theory and supported by research findings ... appear to violate that tenant.

Promotion of HC has two pitfalls: one macro, one micro.

On a macro level, a company invests thousands of dollars to hire health coaches with the expectation that coached employees will improve their health and thereby save health care dollars. The HC approach does not focus on any specific health behavior that can be measured and modified and does not discuss any studies that show health care cost containment results. When corporate health improvement does not happen, company treasurers may conclude that all health education and health promotion do not work. Health behavior is complex and is mediated by more than inspirational words. Claims that Health Coaching will always get results are true, if one defines "results" as any outcome ... even outcomes that are unintentional.

On the micro level, the employee who participates in HC and does not succeed may think that they can't ever change, especially when the HC intervention was touted as a sure thing. Over-inflated expectations can lead to disappointments for those unfortunate who fail to meet the goals to eat less or better, to exercise more and to lose weight. Keep in mind that years of research have documented varying levels of success in their attempts to change behavior, but none that we know of claim a 100% success rate. Contentment with the process is not a reasonable substitute for success, when success is a healthier work force.

THE "HEALTH COACHING PROCESS" LACKS CLARITY AND THEREFORE LACKS RESEARCH SUPPORT BY DISINTERESTED PARTIES.

Green has stated that if "we want more evidence-based practice; we need more practice-based evidence." But evidence for HC is and will be hard to derive. As proprietary training in motivational interviewing is the methodology, the specific processes implemented in HC efforts are not clearly reproducible by outside researchers. To gain approval of the academic world of public health education, Health Coaching proponents need to make explicit the health education methods. Research requires a degree of specificity of the intervention in order to explain its impact on various populations in disparate settings. The information provided by advocates of HC do not provide the specificity required to answer related research questions or hypotheses, leading to Types I, II and III errors. At a minimum, the HC process needs to outline the rationale, educational objectives, methodologies, support materials, and evaluation protocol.

THE ATHEORETICAL NATURE OF HC

Health Coaching looks to Motivational Interviewing as the foundation of its process. But

Motivational Interviewing is a style of conversation, not a theory of behavioral advancement or change. Health Behavior Theory has been shown to be useful to both explain Health Behavior and to serve as guidelines to define interventions. The atheoretical nature of the HC process also influences the ability of others to test the effectiveness of the HC process in various settings.

A CALL TO ACTION FOR HEALTH EDUCATORS

1. Take a Realistic View of HC. Health behavior is complex and influenced by a number of factors. Research has shown that there are numerous techniques that can shape health behavior. Sympathetic and knowledgeable encouragement and direction given by compassionate health educators surely can be part of the process, but as a stand alone process it can represent no panacea for health behavior change.

2. Adhere to Ethical Standards for Health Education. Health educators should accurately communicate the potential of health education interventions to yield behavior change. Previous research in health behavior topics in the workplace (e.g. smoking cessation, weight loss, medication compliance, etc) clearly shows the success of various interventions. HC researchers and practitioners should strive to develop a literature base that could accurately depict the potential success of the HC process in worksites and other settings.

3. HC needs to develop theory-based applications to enable practitioners and researchers to explain health behavior in light of the HC process and to provide guidelines for others to design, implement, and evaluate HC interventions. Practitioners and researchers should examine the HC process in light of proven health behavior theories such as social cognitive theory and the transtheoretical stages of change theory.

4. Diffusion of Innovation. Once the HC process has conducted sufficient theory-based research to support the claims of effectiveness, then the HC innovation should be disseminated for use by other health education researchers and practitioners.

REFERENCES

Chapman, L. S., Lesch, N., & Baun, M. P. The role of health and wellness coaching in worksite health promotion. American Journal of Health Promotion, 2007, Jul-Aug;21(6):suppl 1-10, iii

Fritsch, M. A., Montpellier, J., & Kussman, C., Worksite wellness: a cholesterol awareness program. AAOHNJournal. 2009 Feb;57(2):69-76.

Green, L. W., Mercer S. L. Can public health researchers and agencies reconcile the push from funding bodies and the pull from communities? American Journal of Health Promotion, 2001; 91(12) 1926-1929

Huffman M. Health Coaching: A new and exciting technique to enhance patient self-management and improve outcomes. Home Healthcare Nurse. 2007;25 (4): 271-4.

Kreitzer MJ, Sierpina VS, Lawson K. Health coaching: innovative education and clinical programs emerging. Explore (NY). 2008 Mar-Apr;4(2):154-5.

James M. Eddy, D.Ed, CHES

Edward N. Robinson, Jr., MD

James M. Eddy, D.Ed, CHES, is affiliated with Department of Public Health Education, University of North Carolina at Greensboro. P.O. Box 26170, Greensboro, NC 27402-6170. Tel: (336) 256-8506. E-mail: jmeddy@uncg.edu. Edward N. Robinson, Jr., MD, is a Masters Degree Candidate at Department of Public Health Education of University of North Carolina at Greensboro.
Gale Copyright: Copyright 2009 Gale, Cengage Learning. All rights reserved.