The healthcare needs of the population are becoming more complex. The incidence of long-term health conditions is rising (World Health Organization, 2018) and so too is the number of individuals living with multimorbidity (i.e. more than one medical condition). The evolving health needs of the population raises important questions about how we can respond optimally to the challenges that face us.
This article examines the potential contribution of health and wellness coaching (HWC) to the healthcare needs referred to above. Specifically, it introduces HWC as a distinct and rapidly emerging intervention, examines the status of its evidence base and offers some reflections on its increasing popularity as a service offering. The article also considers what is currently known about those delivering HWC and some critical next steps if this specialism is to realize its potential as a mainstream offering that can attract funding from commissioning bodies.
From sickness to health: empowerment and partnership
It has been estimated that only approximately 20% of adults are currently thriving (Keyes, 2002; Kobau et al., 2010). Although this finding relates specifically to the population of the USA, it would seem reasonable to anticipate a similar pattern in the UK and Australia. An additional challenge is that many individuals struggle to master the type of changes
that would enable improvement (Prochaska & Prochaska, 2016). Whilst a variety of conditions call for health-related behavioural changes, many prove unable to make or sustain these and it would seem that the traditional methods of information-sharing and professional advice alongside other efforts to modify health-related behaviours have been of limited effectiveness (Kelly & Barker, 2016). In a context where there is both a growing number of individuals with pressing health needs and significant difficulties in helping many of those individuals engage in appropriate lifestyle changes, there would seem to be a compelling case for alternatives to the ‘expert-led approach’ and for developing innovative approaches that can assist with building and maintaining health and well-being.
What is health and wellness coaching?
HWC is a relatively new, but rapidly developing, discipline. Originating at the start of the 21st century, coach training programmes began to emerge in North America in 2002 and grew rapidly so that as of 2016, in excess of 53 academic and private sector programmes had trained over 20,000 health care professionals (Kreisberg & Mara, 2017). However, many coaches call themselves health and/or wellness coaches without any recognised training.
As with many emerging disciplines, debates concerning definition, scope and differentiation abound as HWC attempts to delineate its terrain at the levels of theory and practice and claim its place alongside other, more established health care professions. For the purposes of this introductory article, however, we find it conducive to draw from the definition provided by Wolever et al. (2013) which defines HWC as: “a patient-centered approach wherein patients at least partially determine their goals, use self-discovery or active learning processes together with content education to work toward their goals, and self-monitor behaviors to increase accountability, all within the context of an interpersonal relationship with a coach” (p. 52). HWC can be understood, then, as a client-centred, collaborative intervention whose primary aim is sustainable lifestyle change. Whilst coaches bring defined skills and knowledge to the process, the goals selected are client-determined and relate specifically to health and wellness needs with the coach positioning the client explicitly as the expert on their own life (National Board for Health and Wellness Coaching, 2020). As such, client accountability is central to the process. In general terms, HWC seeks to combine the insights from psychological theories concerned with motivation and behaviour change in order to devise coaching interventions that are bespoke for the individual client (Jordan & Livingstone, 2013; Mettler et al., 2014).
Thus, a comprehensive training programme in HWC is likely to draw upon fields as broad and diverse as motivational interviewing; self-determination theory; transtheoretical models of change; positive psychology; cognitive behavioural principles and methods; social cognition; theories of emotional intelligence; mindfulness and neuroscience (e.g. Dossey et al., 2014; Jordan, 2013; Moore et al., 2015).
The diversity of approaches and perspectives that currently underpin the training and practice of HWC raises important conceptual and technical questions about whether this is a distinctive form of coaching working towards the development of its own original knowledge-base or an amalgamation of theories and models from other fields that are being ‘packaged’ in ways that meet the needs of a particular segment of the coaching market. In order to begin to explore questions of this nature, it is necessary to examine what is known about the effectiveness of HWC and its evidence base in relation to different areas of health need.
The current status of the evidence base for HWC
To date, the most comprehensive summary of the evidence base for HWC is that provided by Sforzo et al. (2017). Their compendium of the literature represents a landmark study in the field in that it summarises and synthesises the available studies for the purposes of assisting practitioners and advancing scholarly activity1. It comprised of a dataset of 219 articles with a further 104 peer-reviewed coaching-related articles added in 2019 (Sforzo et al., 2019). Drawing on Wolever et al.’s (2013) definition of health co (see above) together with the similar findings of Olsen (2014) the compendium reviewed the literature in relation to six clinical categories: weight loss and obesity, diabetes, heart disease, hypertension, cancer and cholesterol management. An additional category of ‘wellness’ covered multiple minority conditions.
Overall, the authors of the 2017 Compendium and the 2019 Addendum conclude that there is sufficient evidence to support the claim that HWC is an effective intervention – at least in certain contexts and in relation to some specific, chronic, lifestyle-related diseases. Moreover, the pattern of results suggests that HWC is potentially effective for improving numerous aspects of behavioural change associated with increased well-being. Nonetheless, there is a need for caution. 1 To ensure that readers are provided with the most up to date information in the field, and given its importance to furthering understanding of the existing knowledge-base, we have based our evaluation of HWC on the compendium rather than reviewing individual studies.
As noted by the authors, interpretation of the findings is confounded by a range of methodological limitations and complexities. Variations exist as follows:
• HWC was often delivered as an adjunctive intervention or as one of multiple
• The number of coaching sessions and length of coaching programmes
fluctuated as did the length of each session.
• The nature of the coaching intervention provided is also unclear – what was
delivered by whom?
• Some participants had co-morbid or multimorbid conditions creating complications in understanding the precise impacts of any coaching intervention on individual clinical conditions.
What can be concluded from this research? The wide scope of the literature reviewed in the compendium makes an important contribution to the knowledge-base underpinning HWC. However, it should be noted that the focus of the majority of studies reviewed was on the reduction of medical risk factors that are prevalent in the population today. The research was conducted predominantly in healthcare settings and would have been influenced by cultural aspects and demographic diversity. It is clear then, that the evidence base for HWC is still emerging. Nonetheless, both the compendium and addendum offer some cause for optimism that the use of HWC in the medical field has at the very least, the potential to be a valuable adjunctive intervention to more traditional interventions such as information sharing and psychoeducation. Moreover, HWC can potentially enable other well-being outcomes as outlined above.
The literature reported improvements in the following areas:
• Psychosocial benefits including quality of life, reduced depressive symptoms and perceived stress levels (Clark et al., 2014).
• Increased motivational levels in wellness-related areas including life satisfaction, energy level, healthy weight, mental/emotional fitness and managing health (Mettler et al., 2014 ).
• Importance, confidence and readiness to change significantly improved in all areas.
These studies support the contention that there is potential for HWC to be used outside of the medical arena.
Who is delivering HWC? Identifying an emerging workforce
To the best of the authors’ knowledge, a systematic investigation of this emerging workforce is yet to take place and knowledge of those drawn to train as health and wellness coaches is currently sketchy. However, work being undertaken by one professional body – the National Consortium for Credentialing Health and Wellness Coaches (NCCHWC), based in the USA started to create standards around who might legitimately qualify for this title. Following a summit in 2010, it was decided that the industry itself would define how such coaches would work rather than rely on criteria decided by the medical profession (Wolever et al., 2016a).
In 2014, a job task analysis conducted via a validation survey of over 4,000 practicing HWCs identified the core knowledge and skills required to perform the role and in 2015 the training and education standards were published (Jordan et al., 2015). I In 2016 an agreement was signed between the NCCHWC and the Medical Board of Examiners. A further name change of the NCCHWC to the International Consortium for the credentialing of Health and Wellness coaches (ICHWC) occurred in 2017, in the same year as national certification began. In 2019, applications opened for international training organisations to apply for approval and to gain eligibility for their graduates to sit for Board Certification. (NB: ICHWC is now known as the National Board for Health and Wellness Coaching (NBHWC), referred to earlier. At the time of writing, 24 programmes have final approval with another 57 being transitionally approved by the NBHWC.)
However, the question remains as to the background and credentials needed by health and wellness coaches to train and work in the field. For example, is a health and wellness coach competent to work in this field without having previously completed a healthcare qualification? Wolever et al.’s (2013) definition, cited above, is clear that health and wellness coaches are healthcare professionals who have previous training in the theory of behaviour change, motivational theories and communication skills that are used to support their clients in achieving sustained change in their health and well-being. Nonetheless, the anecdotal observation by the authors that HWC is gathering momentum as an industry-wide initiative suggests that it may be a choice of career for others for whom working in the health arena is a vocation.
Confusion also exists in relation to the terms ‘health coach’, ‘wellness coach’ and ‘health and wellness coach’, the interchangeability of these terms and who should be permitted to use which title. This question has been debated by several authors. In an interview with Snyder (2013), the view was expressed that the difference was arbitrary as wellness coaches would end up working with people who have health issues. It has also been suggested that health coaches work with people with chronic health issues, whereas wellness coaches are more focused on prevention and maintaining current health status (Kreisberg, 2015). This view was supported by Huffman (2016) who stated that wellness coaches worked to guide and inspire healthy people who wished to maintain or advance their overall health and that their work was more likely to focus on smoking cessation, fitness, nutrition and body weight management than on managing chronic illness. Where the line is drawn in terms of the needs of clients, or whether a line should be drawn at all remains unclear.
What can be concluded with greater certainty at this stage is that those drawn to training in HWC have varied professional backgrounds. The professions and professional groups represented within the specialism are highly diverse and include nurses, fitness and allied health professionals, health and other practitioner psychologists, coaching practitioners, human resources personnel, counsellors, yoga teachers, chefs, nutritionists, dieticians, exercise physiologists and physicians, amongst others (Snyder, 2013; Wolever et al., 2016b).
Although much of the work in HWC originated in the USA, groups are coming together in other countries to create standards and routes for credentialing and for formally recognising the contribution of HWC to the health of the population. The UK Health Coaches Association offers coach membership and is currently designing standards and criteria for certification purposes. The Health Coaches Australia and New Zealand Association has recently been formed to represent coaches in that part of the world. The Global Wellness Institute has recently established an initiative on wellness coaching to explore, report and recommend action in relation to HWC activities globally. There is, therefore, a coming together of the community in recognition of the need for a united voice and a shared understanding of HWC and its delivery.
Unanswered questions and next steps for HWC
The introduction to HWC presented in this article reinforces the need for further investigation of this rapidly growing field. The evidence base is growing and overall suggests that HWC can have favourable outcomes in the field of chronic illness. However, there are still many confounding factors that can create a degree of confusion over the results reported in the compendium. Additionally, HWC is being offered in a highly diverse range of contexts but most of the research to date has been performed in healthcare settings. There are currently limited studies reporting the impacts of HWC conducted in settings where individuals have goals that do not relate to overcoming chronic health conditions.
It has been noted that those delivering HWC come from varied professional backgrounds (Jordan & Livingstone, 2013) and the question of what they need to know to work safely and effectively in this field is still to be determined. As coaching is used in diverse settings professionals may need to be trained to focus on targeting specific client needs. For example, a health psychologist may be trained specifically to coach cancer patients. A care worker specialising in elderly care may have in-depth knowledge of dementia and seek coach training to complement their existing knowledge and skill-set. The specialist knowledge base needed to work in HWC still needs to be determined and is a task for the future.
At the time of writing, the impact of behaviour change on health and well-being takes on an additional meaning in the context of COVID-19. HWC could have an important role to play in responding nationally and globally to the challenges posed by pandemics. Coping with state-imposed restrictions such as lock down and social distancing measures, anxiety related to separation from and the feared loss of loved ones, and financial pressures associated with threats to local, national and global economies, create a climate of considerable uncertainty and stress for everyone. For those additionally managing long term conditions, maintaining health regimes in the context of self-isolation and changes to the accessibility of health care services creates an additional set of challenges. As understanding of COVID develops, HWC may have an important role to play in designing and delivering interventions tailored to those having to manage complex health issues in the context of exceptional circumstances.
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