The report is a product of the VA/HSR Evidence Synthesis Program.

Systematic Review: The Effectiveness of Health Coaching

Chronic medical conditions are common among VA healthcare system users, with nearly 75% of Veterans who use VA healthcare having two or more chronic conditions. Optimizing beneficial patient health behaviors can help improve outcomes associated with chronic medical conditions. Yet making any kind of healthy changes can be a daunting task for many patients, especially those with multiple chronic conditions. Health coaching may be an effective tool to facilitate the uptake of health behaviors among people with one or more chronic medical conditions. While there is no consensus on how to define health coaching or what elements constitute a health coaching intervention, several characteristics serve to define the approach. At its core, health coaching is a patient-centered, collaborative model grounded in theories of health behavior change in which a coach collaborates with the patient to identify goals and action plans that maximize personal well-being and overall health. Health coaching includes solution-focused techniques like motivational interviewing, goal-setting, and problem-solving and has a central feature of patient empowerment toward autonomy. It is a modality grounded in the belief that patients are experts in their own life situations and can draw on these experiences to promote personal change. As such, health coaches work with patients to enhance activation and motivation to change by aligning health-related goals with the patient's personal values.

This systematic review evaluated the effects of health coaching interventions among adults with chronic medical conditions on clinical, behavioral, and self-efficacy outcomes. Investigators with VA's Evidence-based Synthesis Program Center located in Durham, NC searched MEDLINE^®, CINAHL, and PsycINFO for peer-reviewed, randomized controlled clinical trials (RCTs) of interventions that self-identified as health coaching. After reviewing more than 2,500 citations, they identified 41 RCTs, in addition to 4 companion studies, that met their eligibility criteria. Using data from these resources, investigators also explored whether or not the health coaching intervention effects varied by program elements, such as patient chronic disease status, intervention dose (i.e., number of coaching sessions), mode of coaching delivery, and individuals conducting health coaching (i.e., healthcare providers, peers, health coaches). In collaboration with key stakeholders, they also explored whether or not effects varied by concordance of health coaching intervention with an a priori list of key health coaching elements (i.e., patient-centeredness, patient-determined goals, and self-discovery process).

Study Characteristics
Across the 41 RCTs, the number of health coaching sessions ranged from 3 to 156 with a median of 12. The primary mode of coaching delivery was by phone (52%), followed by in-person (28%). Only one RCT used a "certified" health coach; 50% of the trials used healthcare providers (e.g., registered nurses) for coaches; 14% used peers; 11% used behavioral health providers (e.g., social workers); and 23% used non-professionals who did not qualify as "peers." The 41 trials included 11,390 subjects, and the majority of the trials (n=18) included individuals with diabetes. Only one trial was conducted in a VA setting with VA healthcare users.

Summary of Findings
Results suggest that when compared with inactive controls (e.g., waitlist, usual care) self-identified health coaching interventions have the potential to produce small, positive, statistically significant effects on:

• Decreases in HbA1c,
• Reductions in body mass index (BMI),
• Increases in physical activity,
• Reductions in dietary fat, and
• Improvements in self-efficacy.

It is important to note that many pooled estimates exhibited moderate to high statistical heterogeneity (I2 >50%). Further, results did not hold for the above outcomes when compared with active comparators.

In qualitative syntheses, results were mixed or inconclusive for effects of health coaching on functional status, smoking cessation, and medication adherence. However, limited qualitative evidence in two trials suggests that coaching has a positive effect on total calorie reduction. This systematic literature review also explored potential sources of variability in treatment effects, including population characteristics, intervention dose and delivery mode, type of individual conducting health coaching, and concordance with key elements of health coaching. Findings show that none of these factors were robust predictors of variability in treatment effects.

Limitations
The relatively large number of studies with high or unclear risk of bias and moderate to high heterogeneity in pooled estimates limit certainty about the interpretation of these findings. Also, none of the moderators were strong drivers of variability in treatment effects, suggesting that moderate to high heterogeneity in pooled estimates may be driven by various intervention characteristics. Investigators allowed studies to self-identify as health coaching interventions as opposed to applying a standard set of criteria and only including studies that met those criteria. Thus, variability in what the study authors considered health coaching may contribute to the overall variability in treatment effects.

FUTURE RESEARCH
While health coaching is a promising intervention, additional research is warranted on its impact, especially in areas with limited identified literature (e.g., medication adherence, smoking, and physical function), and when compared with active comparators. Also, it is unclear whether health coaching offers additional advantages over other behavioral intervention modalities. Thus, it may be premature to either dismiss or adopt health coaching in clinical or community-based settings. Future research should employ innovative and rigorous study designs to explore the central elements that distinguish health coaching from other behavioral counseling and self-management approaches – and how these unique elements have an impact on clinical and behavioral outcomes.

This report identifies gaps in evidence that warrant further research, which may help the Office of Patient Centered Care and Cultural Transformation (OPCC&CT) and the National Center for Health Promotion and Disease Prevention (NCP) prioritize future research projects.

Reference
Gierisch JM, Hughes JM, Edelman D, Bosworth HB, Oddone EZ, Taylor SS, Kosinski AS, McDuffie JR, Swinkels C, Razouki Z, Masilamani V. The Effectiveness of Health Coaching. VA ESP Project #09-010; 2017.

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