A Systematic Review of the Literature on Health and Wellness Coaching: Defining a Key Behavioral intervention in Healthcare

Ruth Q. Wolever, PhD, Leigh Ann Simmons, PhD, Gary A. Sforzo, PhD, Diana Dill, EdD, Miranda Kaye, PhD, Elizabeth M. Bechard, BA, Mary Elaine Southard, RN, MSN, Mary Kennedy, MS, Justine Vosloo, PhD, and Nancy Yang, BA

Ruth Q. Wolever, Duke Integrative Medicine, Duke University Health System, Durham, North Carolina and Department of Psychiatry and Behavioral Science, Duke School of Medicine, Durham, NC, United States.

Contributor Information.

Corresponding author.

Email: [email protected]

Abstract

摘要

SINOPSIS

INTRODUCTION

The global prevalence of preventable chronic diseases associated with unhealthy behaviors has reached epidemic proportions and negatively affects healthcare systems and economies worldwide.^1–3 Given the strain of chronic illness, public health, disease management, clinical practice, and employee wellness models are evolving to help individuals change their health behaviors to prevent and better manage chronic disease.^4–7 One rapidly emerging strategy to help individuals successfully change their health behaviors is health or wellness coaching. Health and wellness coaching has been defined in varying ways over the past decade. In 2003, Palmer et al defined health coaching as

the practice of health education and health promotion within a coaching context, to enhance the well-being of individuals and to facilitate the achievement of their health-related goals.⁸

In 2006, Butterworth, Linden, McClay, and Leo defined health coaching as

a service in which providers facilitate participants in changing lifestyle-related behaviors for improved health and quality of life, or establishing and attaining health promoting goals.^9,10

More recently, the National Consortium for Credentialing Health and Wellness Coaches (NCCHWC) proposed the following definition of health and wellness coaches, which delineates core elements of the practice of coaching:

Health and wellness coaches are professionals from diverse backgrounds and education who work with individuals and groups in a client-centered process to facilitate and empower the client to achieve self-determined goals related to health and wellness. Successful coaching takes place when coaches apply clearly defined knowledge and skills so that clients mobilize internal strengths and external resources for sustainable change.¹¹

Although these definitions share some similar components, there is no agreement on what exactly health coaching entails (eg, practices, strategies, delivery methods), what the role of the coach actually is (eg, educator, navigator, facilitator, partner),^9,12 and what background and training enable the coach to provide health coaching competently.

As use of the terms health coaching and wellness coaching proliferate without a clear and consistent definition of this intervention, additionally concerning is the increasing rate at which peer-reviewed journals are publishing research results that claim to evaluate “health coaching,” but use widely varying definitions,¹² thereby confusing the value of coaching results. Indeed, numerous studies have used the term health coaching to address chronic disease care in various settings and with mixed results. For example, Wennberg et al found that a targeted care-management program with telephonic health coaching for individuals insured by a large health plan reduced medical costs and hospitalizations.¹³ Similarly, studies of health coaching for patients with diabetes,^14–17 obesity,^18,19 cancer,²⁰ and risk of²¹ or diagnosed cardiovascular disease^22,23 demonstrate a positive effect on health behaviors or health outcomes. However, review of the literature reveals other evaluations of coaching that find non-significant benefits for health outcomes.^24–27

Likely, one major reason for the variability in findings on the effectiveness of health coaching is that highly disparate interventions are being investigated under the umbrella term of health or wellness coaching. When we consider the interventions carefully, we find a broad range in the following: (1) the techniques used during the coaching process; (2) the theoretical underpinnings of the approach; (3) the frequency and duration of the coaching process; (4) the extent of human contact provided; (5) the degree to which content education is included in the intervention; and (6) the professional background and training of the coaches. At one end of the continuum are well-described and theoretically based interventions delivered through one-on-one relationships that develop over months or years with a highly trained professional who employs well-developed and articulated processes and strategies to help individuals initiate and sustain behavior changes over time.^9,17,19,28 At the other end of the continuum are interventions that require no human contact,^29–31 that appear to be purely content education rather than skills-based training,^32,33 and/or have no stated theoretical backing. This lack of standardization in both the definition and the operationalization of health coaching makes it difficult, if not impossible, to determine whether health coaching is indeed an effective approach to improving health behaviors and reducing the global burden of chronic disease.

The purpose of the present study was to establish a consensus definition of health and wellness coaching through a systematic review of the related literature. The intention is threefold. First, we intend to answer repeated calls in the literature for evidence-based identification of conceptual and interventional components of health and wellness coaching.^28,34,35 Second, with a standardized definition, components of this approach can be used as targets to clarify the professional skills needed to appropriately train health and wellness coaches.^12,34,36 Finally, with a standardized definition, we can more rigorously evaluate both the efficacy and the effectiveness of health and wellness coaching.¹² To these ends, we conducted a comprehensive, systematic review of the peer-reviewed medical literature to determine how health and wellness coaching is operationalized. Using an adapted population, intervention, comparison, outcome (PICO) format, our primary research question was, “How are interventions described as health or wellness coaching defined and operationalized in the peer-reviewed medical literature?” This review will serve as the foundation for future effectiveness research and identification of best practices in health and wellness coaching that may be widely disseminated to mitigate the negative consequences of the global chronic disease epidemic.

METHODS

We conducted a systematic review of the peer-reviewed literature on health and wellness coaching using the international guidelines established by PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses).^37,38 The PRISMA standards were published in 2009 to update the Quality of Reporting of Meta-Analyses (QUOROM) statement based on conceptual advances in the science of systematic reviews. According to the definitions established by the Cochrane Collaboration, a systematic review addresses “a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise relevant research, and to collect and analyze data from the studies that are included in the review.”³⁹

RESULTS

1. What Kind of Peer-reviewed Articles Are Describing Health (or Wellness) Coaching?

The bulk of peer-reviewed articles have been empirical trials. For the 284 full-text articles included, 185 (65.1%) were empirical studies wherein data were systematically collected; 31 (10.9%) were protocol descriptions for which data collection was planned but not yet reported; 37 (13.0%) were accounts of existing practices labeled as health or wellness coaching that have reportedly been operationalized and conducted but not formally evaluated; and 31 (10.9%) were concept articles that presented no data.

As seen in Figure 2, the rapidly increasing slope of peer-reviewed publications is noteworthy. For example, whereas 22 articles were published on health or wellness coaching before 2003, in 2010 through 2012 alone, 152 articles on the topic were published.

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Figure 2

Frequency of peer-reviewed articles published on health and wellness coaching across time.

2. What Approaches, Practices, Strategies and Methodologies Constitute Health Coaching as Described?

Depending on the specific feature, between 11% and 23% of the articles did not report adequate details to code the processes used in their coaching interventions. Of those that did, a clear majority of articles operationalized health or wellness coaching as a process that was fully or partially patient-centered (86%), included patient-determined goals (71%), incorporated self-discovery and active learning processes (63%) (vs more passive receipt of advice), encouraged accountability for behaviors (86%), and provided some type of education to patients along with using coaching processes (91%). Details on these components are described below.

2.1 Patient-centeredness. Was the coaching patient-centered, ie, were coaching strategies and processes tailored to the individual’s specific needs, concerns, circumstances, or readiness to change, or was the coaching instead applied uniformly without regard to individual differences? Twenty percent of articles did not provide sufficient detail to judge whether the coaching was patient-centered. Of those articles which gave sufficient detail to allow judgment, 61% described a coaching process that was patient-centered and an additional 25% described a coaching process that was partially patient-centered (Table 2). For example, Hendren et al (2010) tested a coaching intervention that appeared to be fully patient-centered, tailored in both intensity and content to patients’ assessed barriers to obtaining care.⁴¹ Others used partially patient-centered processes, including some strategies that were individualized in combination with some standardized processes. Aoun et al (2009), for example, used the patient-centered approach of motivational interviewing in combination with standardized guidelines for weight loss and physical activity.⁴²

Fewer than one out of six articles (14%) described a process that was classified as not at all patient-centered as evidenced by every participant receiving the same intervention without any tailoring or interventions that involved non-individualized instruction or prompting. For example, in one wellness program, coaching for weight loss was provided via highly scripted responses to patient statements.⁴³ In another intervention, the coaching content involved instructions from pharmacists in the correct use of medications without apparent variation according to the individual’s situation.⁴⁴

2.2 Patient-determined goals. Did patients choose their own change goals as a target of the coaching, or were their goals preset or created by a professional? Twenty-four percent of articles did not provide sufficient detail to judge whether goals were set by the coaching patients themselves or by others. Of those articles that did allow us to judge, 45% described coaching processes in which patients determined their own goals and 26% reported that patients partially determined their coaching goals (Table 3). Examples of interventions with patient-determined goals include Hanks et al’s (1995) study of weekly coaching sessions to support patients’ capabilities as new mothers. In this intervention, coaches explored and clarified patients’ values, provided information as needed, and encouraged design and commitment to achievable goals while constructing a plan sheet.⁴⁵ Examples of programs in which patients partially determined their coaching goals include a primary care-based intervention designed to help older adults adhere to medication for hypertension. Although the overall objective was medication adherence, coaches helped participants choose the barriers and habits they wished to change, set their own specific goals around them, and defined action steps to achieve them.⁴⁶ Similarly, a program that had the overall intention of improving participants’ exercise persistence supported participants in setting individualized exercise plans.²⁷

Almost 30% of the literature described a coaching process in which goals were set externally without input from the patients. In Elbers et al’s (2011) study of personal injury victims, health coaches executed a physician-driven care plan.⁴⁷ Likewise, in Allen et al (2008), all patients were given the goal of preparing for their physician visit. While the intervention was patient-centered, the goals themselves were not self-determined.⁴⁸

2.3 Use of self-discovery process. Was there a process of discovery, or active learning, included in the coaching process, or was the coaching instead instructional? Thirty-four percent of articles did not provide sufficient detail to judge whether or not self-discovery was involved in the coaching. Of those that did, 42% of the articles reviewed described a self-discovery process, and an additional 21% described a process that was mixed, ie, partly self-discovery and partly instructional or advice-giving (Table 4). Saleh et al’s (2010) study of a rural workplace wellness program engaged patients as active learners through goal setting, action planning, self-monitoring, review of results, and conclusions about persisting with the action plan.⁴⁹ Another example is Ottaviano et al’s (2010) proposed intervention to promote self-efficacy in patients with coronary heart disease. Here the coach continuously helps the patient assess their readiness to make lifestyle changes.⁵⁰

Thirty-seven percent of the articles did not include self-discovery processes as part of the definition of coaching. Examples where study participants did not engage in self-discovery or active learning include Margolius et al’s (2012) study of coaching for hypertension control in a low-income sample.⁵¹ In this program, patients were instructed in the importance of blood pressure control and medication adherence without the opportunity to learn about themselves by exploring the relationship of their hypertension to their own overall health, well-being, or key values and drawing conclusions. Similarly, Ovbiosa et al (2012) described a workplace wellness program for weight reduction where participants received instructions on how to increase their physical activity to a preset target, including general educational handouts and calorie-counting books.⁴³

2.4 Accountability. Coaching that involves patient accountability is coaching in which it is possible for patients to self-monitor in order to observe their progress (or lack of it) toward their goal using some type of data and that encourages reflection on progress. Thirty-one percent of articles did not provide sufficient detail to judge whether the coaching being evaluated encouraged patient accountability. Of those that did, the vast majority of articles (81%) described a coaching process in which accountability of some form was built in, as shown in Table 5. In these programs, patients actively monitored their efforts, observed results, either reported them or discussed them with their coach, and drew conclusions. Data collection formats ranged from qualitative self-report using coaching preparation forms^17,52 to sophisticated web- programs^31,52 and innovative mobile apps.³¹ For example, in a study reported by Debar et al (2006), adolescent girls’ recordings of their diet and exercise goals and achievements were regularly shared with their peer group and their coach.⁵³ In another study reported by Wennberg et al (2010), participants in a telephone-based care management intervention signed a behavioral contract with their wellness coaches, and had access to a computer program that tracked progress toward goals through the intervention.⁵⁴ An additional 5% of articles described coaching in which accountability was partially built in.

Conversely, 14% of articles described a coaching process where there was no opportunity for patients to be accountable to either themselves (eg, through self-monitoring or observation of change against target) or to their coach (eg, through regularly providing information on progress toward goals and getting feedback). Coaching approaches where the coach and patient met once fell into this category since there is no opportunity for support of behavior change over time. For example, Brook et al (2003, 2005) reported on a program in which pharmacists instructed new users of anti-depressant medication about potential side effects in a one-time visit.⁴⁴

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2.5 Content education. Content education refers to providing expert information to the patient to facilitate knowledge and understanding of a specific health condition for which behavior change is desirable (eg, disease information, standardized guidelines for clinical markers, consensus recommendations for behavior change, professional opinions on target goals). Eighteen percent (51 of 284) of articles did not provide sufficient information to determine whether or not content education was provided to coaching participants. Of those that did, 91% documented provision of content education. In terms of the type of education provided to participants, 40% of the interventions provided disease-specific information, while 22% more generically defined their content education as lifestyle or health education or specified teaching about nutrition (19%) or physical activity (18%). Only 8% provided the participants with content education on behavior change processes, such as goal setting and the importance of self-monitoring (Table 6).

The depth of content and mode of delivery varied substantially. Common delivery modes for content education included provision of written material (eg, notebooks, pamphlets), static and interactive websites, and in-person visits and classes. Many programs used multiple tactics. For example, one disease management program described mailing quarterly newsletters and disease-specific educational pamphlets to participants with diabetes who were also involved in coaching.⁵⁶

2.6 Coaching “Dose.” In the majority of articles reviewed, it was not possible to calculate the “dose” of coaching that was being evaluated in terms of length of individual coaching sessions, number of coaching sessions, or duration of the coaching intervention. Overall, 75% (212 of 284) of the peer-reviewed articles did not specify the length of each individual coaching session, 52% (148 of 284) did not specify the total number of coaching sessions used, and 64% (181 of 284) did not specify the duration of the coaching process. Of those that did specify the session length, sessions lasted for an average of 35.8 minutes, ranging from 5 minutes^57,58 to 2.5 hours.⁵⁹ Of those that specified the number of coaching sessions, the average reported was 10.1 sessions, ranging from 1 to 90,⁶⁰ median = 6. For those articles that reported the length and number of coaching sessions (n = 68), the average contact hours with a coach was 6.2, ranging from 15 minutes⁶¹ to 135 hours,⁶⁰ median = 3 hours.

A wide range was also observed in the duration of the entire coaching intervention. As depicted in Table 7, coaching ranged from a single session to 6 years. For interventions that had a consistent coaching schedule, frequency of coaching ranged from biannual sessions to access to a coach twice per week, with the majority reporting weekly sessions. Coaching frequency appeared to be related to length of the intervention, with shorter programs employing more weekly coaching whereas longer interventions were more likely to use monthly coaching.

2.7 Was there a consistent coaching relationship? Just over half of the articles (154 of 284, or 54%) provided adequate information to assess whether the participant had an ongoing relationship with the same coach over time. Of these articles, 60% (92 of 154 articles) overtly stated that participants were matched with the same coach over multiple sessions, and another 18% (28 of 154) implied a consistent relationship. In contrast to the 78% that thus indicated a consistent relationship was formed, only 21% (32 of 154) of the programs clearly did not pair the same coach with the same participant over time. Of those programs that did not rely on a consistent coaching relationship, a third of the programs only offered a single coaching session, precluding development of a relationship, and the rest either used interchangeable coaches or automated contacts that were algorithm driven.

3. Who Delivers the Coaching?

3.1 Are they professionals? In 13% (38 of 284) of the studies, there was not enough information provided to determine the coaches’ professional background. Of the remaining articles, 95% (234 of 246) of the studies/practices employed human coaches, while the remaining 5% (12 of 246) employed technology-based coaching only. Of those that employed human coaches, 93% (217 of 234) used professionals while only 7% (17 of 234) used lay individuals.

3.2 What kind of professionals? Of coaches with professional training, coaches were overwhelmingly medical (53%) and allied health (51%) professionals (Table 8).^* Nurses comprised the clear majority of these professionals (42%). Mental health providers were the second most common (21%: divided between 11% psychologists [doctorate level] and 10% social workers and other master’s-level psychotherapists). Dieticians were the third most common professionals to provide coaching (11%), with health educators/health promotion experts (8%), unspecified health professionals (8%) and exercise physiologists/specialists (6%) also well-represented.

3.3 Training received by the coaches. We considered both intensity of training and content of training given to coaches for the specific coaching under investigation. As can be seen in Tables 9 and ​and10,10, only 22% (59 of 272) of the articles using human coaches provided information on the amount of training obtained by those performing the coaching (Figure 3a). Of these, there was a large range in intensity of coaching-specific training, from less than 2 hours to close to 2 years, median between 6 and 40 hours. At the least intensive end, only 1.5 hours of training were provided to content experts in weight loss and consisted of the rationale for health coaching⁶² or 2 hours of coaching-specific training were provided to MD, PharmD, or RN student health coaches to support uninsured patients with hyperten-sion.⁶³ At the most intensive end, a 9-month curriculum was provided to medical assistants to coach patients with chronic health issues,⁶⁴ and an estimated 600 hours of training were provided to non-medical professionals to help newly diagnosed cancer patients navigate the healthcare system and their treatment.⁴¹

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Figure 3a

Frequency of articles reporting various amounts of coach training.

In terms of the specific content of the training received by the coaches, only half (50.4% or 143 of 284) of the articles included descriptive information. Of these, three broad types of training could be identified: (1) behavior change skills, (2) health information briefing (content education), and (3) job training.

3.3.1 Behavior change skills include training in specific behavioral theories and skills used to facilitate behavior change. Table 11 presents these data. Sixty-one percent (87 of 143) of articles in which training content was described reported training coaches in behavior change methods (eg, goal setting, action planning, problem solving, navigating obstacles/barriers to goals, finding resources, self-monitoring, and building self-efficacy) based on multiple theories, including the following: Health Beliefs Model,⁶⁵ Social Cognitive Theory,^66,67 Theory of Planned Behavior,^68,69 the Trans theoretical Model,^70–72 Self-Determination Theory,^73–75 Self-Perception Theory, ⁷⁶ and Motivational Enhancement.^77–79 Sixty-seven percent of articles reported training coaches in communication skills specifically for developing rapport, expressing empathy, and/or providing emotional support. Sixty-three percent of articles reported training coaches in other communication skills that would enhance the change process: these included the use of powerful questions, assertiveness training, negotiation skills, providing feedback, and various types of reflections including those that emphasize possibilities, underline the positive side of an issue, or high-light the gap between where a patient wants to be and where he or she is now. Note that 42% of articles that documented the content of the coaches’ training specifically referred to training in “a communication method” called motivational interviewing (MI).^78–80 Training in MI typically includes education in five key skill sets that reflect the “four guiding principles” of MI: expressing empathy, developing discrepancy, rolling with resistance, and supporting self-efficacy. The five key skill sets include (1) use of open-ended questions, (2) affirmations, (3) reflections, (4) summaries that highlight both sides of ambivalence, and (5) reinforcement of the patients use of “change talk.” (For a greater understanding, see the article by Simmons and Wolever in this issue.⁸⁰) Because MI covers both types of communication strategies coded in our study, we also credited articles that explicitly reported MI training with both types of communication training. In addition to the 42% that reported training in MI, training in other motivational approaches was mentioned by 14% of the articles and an additional 4% specifically noted the use of whole-person approaches. Other motivational techniques included additional aspects of Motivation Enhancement Therapy, patient activation, visioning, and exploration of personal values. Finally, 13% reported training coaches in cognitive behavioral skills (CBT) for working with patients’ specific health conditions, including reframing, cognitive restructuring, and CBT-based self-management skills.

Table 11

Frequency (Percentage) of Articles Describing Content of Training to Professionals and Non-professionals Who Delivered the Coaching

Content of Training (when described)	All literature (n = 143)a	When coaches were professionals (n = 116)a	When coaches were non-professionals (n = 19)a	When unclear or n/A (n =
Skills Training
Behavior change (including training in health behavior models and methods)	87 (60.8%)	69 (59.5%)	14 (73.7%)	4 (50.0%)
Communication skills to develop rapport, express empathy, and provide emotional support	96 (67.1%)	78 (67.2%)	12 (63.2%)	6 (75.0%)
Other communication skills (eg, powerful questions, various types of reflection, negotiation skills, assertive-ness, providing feedback)	90 (62.9%)	74 (63.8%)	11 (57.9%)	5 (62.5%)
Motivational interviewing	60 (42.0%)	50 (43.1%)	5 (26.3%)	5 (62.5%)
Other motivational approaches (eg, other aspects of motivation enhancement therapy, patient activation, visioning, values exploration)	20 (14.0%)	16 (13.8%)	3 (15.8%)	1 (12.5%)
Whole person	6 (4.2%)	6 (5.2%)	0 (0.0%)	0 (0.0%)
Cognitive-behavioral skills, including reframing, cognitive restructuring, and self-management	18 (12.6%)	16 (13.8%)	2 (10.5%)	0 (0.0%)
Content Education
Exercise or physical activity guidelines, information	12 (8.4%)	12 (10.3%)	0 (0.0%)	0 (0.0%)
Nutrition	13 (9.1%)	13 (11.2%)	0 (0.0%)	0 (0.0%)
Disease- or condition-based information	52 (36.4%)	39 (33.6%)	11 (57.9%)	2 (25.0%)
Job Training
Protocol-specific training	39 (27.3%)	32 (27.6%)	6 (31.6%)	1 (12.5%)
Navigating the health system	13 (9.1%)	10 (8.6%)	3 (15.8%)	0 (0.0%)

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^aThe five articles that reported using both professional and lay staff as coaches were counted in both relevant columns. Hence, the total number of articles was considered to be 143 to avoid inflating the percentages.

3.3.2 Health information briefing includes content education regarding healthy lifestyles (eg, physical activity guidelines, nutrition information) and/or information specific to the disease or health condition under investigation (eg, pathophysiology, onset and course of the illness or condition, treatments). Of those articles that described training content, 36% described briefing coaches with disease-or health condition—specific information (eg, regarding diabetes, heart disease risk, etc). Nine percent described providing coaches with information on nutrition, and 8% of articles described providing coaches with information on physical activity/exercise.

3.3.3 Job training includes training related to the coach’s job role (eg, training on clinic flow) or study-specific training (eg, review of protocol). Twenty-seven percent of the articles that described the coach training described protocol-specific training, whereas 9% of articles provided coaches with education on navigating the health system.

POTENTIAL SOURCES OF BIAS

While we evaluated our questions of interest using all the obtained medical literature, we also compared the literature on empirical studies and existing, operationalized practices to the literature that was conceptual only to assess potential sources of bias. Several differences emerged that merit mention. First, as can be seen in Tables 2 through ​through4,4, a considerably higher percentage of conceptual articles fully support a definition of coaching as a patient-centric process that uses patient-determined goals and self-discovery processes. Second, compared to research and existing practice articles, a somewhat lower percentage of conceptual articles discusses the inclusion of accountability mechanisms (Table 5) and proposes content education as part of the coaching intervention (Table 6). Third, the conceptual articles, taken together, posit a more intense training trajectory than do the articles on empirical work and existing practices (Figure 3b). Finally, the conceptual articles cite greater use of nurses and mental health providers.

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Figure 3b

Percentage of research and existing practice articles versus conceptual articles reporting various amounts of coach training.

SUMMARY AND DISCUSSION

Early reviews of the effectiveness of health coaching have called for conceptual and operational clarification of health and wellness coaching.³⁴ Indeed, as the trajectory of peer-reviewed articles on this approach rapidly increases, continued variability in definitions of health coaching precludes the ability to perform rigorous reviews or meta-analyses. This variability also insures continued confusion over the coaching approach and confounds the skills needed by the rapidly growing number of professionals providing health and wellness coaching. To move the field forward, we must first clarify what the intervention is. With an evidence-based, consensus definition, stronger efficacy and effectiveness studies can ensue, and professional training can be improved. Eventually, we will be able to consistently replicate and widely disseminate the intervention while also assessing the cost:benefit ratio of using health coaching to address the myriad behavior changes needed to prevent and manage chronic disease.

CONCLUSIONS

This study is not without its limitations. Indeed, for each of the domains for which we abstracted data, there were data missing because the authors did not provide the information in their report. First, we included all studies of health coaching, even when there were multiple reports of the same intervention. This may have inflated certain counts of the various domains of coaching reported. Second, although two to three investigators reviewed each study, there were many instances in which the team made judgment calls regarding a particular domain of the coaching based on limited descriptions in the articles that may or may not have been what was actually implemented. Thus, our review may have mischaracterized some of the coaching interventions in the literature. Third, and relatedly, for several of the review questions for which we abstracted data, anywhere from 11% to 78% of articles did not describe the pertinent domain in sufficient detail to allow us to code them. Finally, our methods included only articles in the PubMed database. Though we expect the vast majority of health and wellness coaching articles to be indexed within PubMed, we are aware that some relevant articles may exist outside this database. Thus, the picture presented here likely does not fully reflect all of the coaching models in the literature. Similarly, health coach training paradigms and programs that are not reflected in PubMed are also not reflected in this systematic review.

Despite these limitations, our systematic review of health and wellness coaching is the first in the literature to characterize this growing field in healthcare. Variation in approaches and practices that have been defined and operationalized as health or wellness coaching makes it difficult to compare approaches and identify those that are most effective for chronic disease prevention and management. Indeed, our findings point to the critical need for future systematic investigations of the effectiveness of various health and wellness coaching approaches in order to identify the best practices in the field, further refine the definition, and iteratively operationalize health or wellness coaching in research and practice. These “best practices” should include both the coach’s minimum necessary skills and the coaching processes that facilitate a patient-centric approach to behavioral change. Moreover, future reports of coaching interventions should aim to describe in as much detail as possible the coaching intervention, including a thorough description of the individuals providing coaching with professional background and coaching-specific training, and the breadth and depth of the skills and processes used. These detailed descriptions will enable robust comparison of approaches across disease states and populations, so that a compendium of coaching models that have proven most effective can be generated and disseminated. These efforts will help to ensure that health and wellness coaching is an evidence-based practice that can make a demonstrable difference in the prevention and management of chronic disease in healthcare systems worldwide.

Acknowledgments

Notes

Disclosures The authors completed the ICMJE Form for Potential Conflicts of Interest and declared no relevant conflicts.

Footnotes

Contributor Information

Ruth Q. Wolever, Duke Integrative Medicine, Duke University Health System, Durham, North Carolina and Department of Psychiatry and Behavioral Science, Duke School of Medicine, Durham, NC, United States.

Leigh Ann Simmons, Duke Integrative Medicine, Duke University Health System, Durham, North Carolina and Duke School of Nursing, Durham, United States.

Gary A. Sforzo, Department of Exercise and Sport Sciences, School of Health Science and Human Performance, Ithaca College, Ithaca, NY, United States.

Diana Dill, Working Together For Health, Boston, Massachusetts, United States.

Miranda Kaye, Department of Exercise and Sport Sciences, School of Health Science and Human Performance, Ithaca College, Ithaca, NY, United States.

Elizabeth M. Bechard, Duke Integrative Medicine, Duke University Health System, Durham, North Carolina, United States.

Mary Elaine Southard, Integrative Health Consulting and Coaching, LLC, Scranton, Pennsylvania, United States.

Mary Kennedy, Institute of Lifestyle Medicine, Department of Physical Medicine and Rehabilitation at Spaulding Rehabilitation Hospital, Boston, Massachusetts, United States.

Justine Vosloo, Department of Exercise and Sport Sciences, School of Health Science and Human Performance, Ithaca College, Ithaca, NY, United States.

Nancy Yang, Duke School of Nursing, Durham, United States.

REFERENCES