|Year : 2012 | Volume
| Issue : 1 | Page : 66-69
Experiences of Persons with Type II Diabetes Receiving Health Coaching: An Exploratory Qualitative Study
LM Howard, BF Hagen
Faculty of Health Sciences, The University of Lethbridge, Alberta, Canada
|Date of Submission||14-Feb-2011|
|Date of Decision||05-May-2012|
|Date of Acceptance||21-May-2012|
|Date of Web Publication||30-Jul-2012|
L M Howard
Faculty of Health Sciences, The University of Lethbridge, 4401 University Drive, Lethbridge, Alberta T1K 0N1
Source of Support: None, Conflict of Interest: None
Introduction: The objective of this exploratory qualitative study was to examine the experience of persons living with type II diabetes who participated in a health coaching intervention. Methods: The researchers used a qualitative phenomenological hermeneutic research design to explore the experiences of people undergoing health coaching for self-management of their diabetes. Results: Qualitative data analysis resulted in three themes that best described participants' experience of health coaching for diabetes: (1) "the driving force," which described how health coaches helped clients to find powerful motivators for change; (2) "I'm not a child," which described how people wanted to be treated by the health coaches; and (3) "meeting the inner coach," which described how health coaches helped clients develop their own inner wisdom. Discussion: The participants' descriptions of coaching challenge a more traditional paradigm of expert-driven and information-laden diabetes education practices. The findings suggest that the process of health coaching may help persons with diabetes become confident self-managers of their diabetes.
Keywords: Diabetes, health coaching, health education, qualitative research, phenomenology
|How to cite this article:|
Howard L M, Hagen B F. Experiences of Persons with Type II Diabetes Receiving Health Coaching: An Exploratory Qualitative Study. Educ Health 2012;25:66-9
| Introduction|| |
Along with many other countries, Canada has identified chronic disease management as a crucial element of healthcare reform. Among chronic diseases, diabetes is growing at a particularly high rate, and due to its significant effects on morbidity, mortality, and use of healthcare services, there is an urgent need to find ways to help people better manage their diabetes. 
One form of chronic disease management receiving increased attention is health coaching. Health coaching is defined as a form of health education that "…guides and prompts a patient to be an active participant in behavior change".  Health coaching - with its focus on supporting people to reach new goals - is different than didactic teaching or expert-driven education, which typically emphasizes imparting new knowledge. In this regard, health coaching is often compared with motivational interviewing, and health coaches often make use of motivational interviewing techniques.
Researchers have begun to investigate the potential outcomes of health coaching for diabetes. At least three coaching intervention outcome studies ,, found significant reductions in HbA1c levels of participants who received diabetes health coaching. Four other health coaching studies found that diabetes patients demonstrate improvements in adherence to medications,  diet and exercise regimens, ,, and lower levels of depression.  Although only one of these studies was outside of North America,  health coaching is relevant for many international settings, since it focuses on an individual's unique motivations for change, including culture, ethnicity, and religion.
Despite promising results from preliminary studies on diabetes health coaching, there have been no qualitative studies on coaching from the perspective of diabetes patients. While there is emerging evidence on the effectiveness of diabetes coaching, there is no clear sense of how such coaching leads to change, or which components of coaching are most effective. Therefore, the purpose of this exploratory qualitative study was to examine the experiences and perceptions of diabetes patients receiving health coaching.
| Methods|| |
The researchers employed a qualitative phenomenological hermeneutic research design,  used in this context to uncover the explicit and implicit aspects of the experience of persons coached for diabetes. The University of Calgary Research Ethics Board granted ethical approval for this study.
Participants and Setting
Participants were recruited from a pool of patients enrolled in a community-based chronic disease management program, staffed by nurses providing individual and group self-management education for diabetes, heart failure, hypertension, and obesity. All nurses had workshop training in health coaching that incorporated motivational interviewing and chronic disease management. The researchers asked these nurses to identify and recruit diabetes patients who had received health coaching from them for at least six sessions. Over a 2 month recruitment period, approximately 10 eligible patients were approached, and 3 agreed to participate in the study.
Health Coaching Intervention
The health coaching approach used by the nurses was based on the work of Rollnick et al.  This approach rejects a traditional health education philosophy that positions the "clinician as expert." Instead, the nurses strove to value the clients' experiences and knowledge and viewed the change process from the clients' frame of reference.
The participants initially attended two group education classes to receive mutual support and information about diabetes self-management. Clients then attended individual coaching sessions with a nurse to set and achieve specific goals. Clients continued with individual coaching sessions until they believed they had reached their self-management goals. Follow-up coaching appointments were arranged every 3 to 12 months, depending on the client's ability to self-manage care.
Each participant had a 2-h long in-person interview, conducted and tape-recorded by the first author. The interviewer used a semistructured interview guide and probing questions, as necessary, to explore participants' experiences with diabetes health coaching. As per hermeneutic interviewing, specific words, phrases, or metaphors were probed further during the interview to uncover deeper meanings.
The researchers transcribed all interview tapes verbatim, and any comments that were made after each interview. The transcripts were reviewed several times until initial meanings and surface themes emerged. The surface themes and interpretations were then reviewed and major themes identified. These tentative themes were presented to participants during follow-up telephone calls, and feedback from participants further refined the themes presented in this study.
| Results|| |
Three patients were recruited, including one woman and two men (all married), ranging in age from mid 40s to late 60s, and coping with diabetes from 5 to 30 years. All three lived in a rural area of Western Canada with a population of approximately 70,000. All participants had completed a minimum of high school (grade 12) education.
The data offered a rich initial understanding of how diabetes patients perceived coaching. Three themes emerged from the data analysis process describing participants' experiences with the health coaching: (1) "the driving force," which describes the way coaches teased out the motivations that participants had for change; (2) "I'm not a child," which described participants' desire for coaches to respect their need for autonomy and control; and (3) "meeting the inner coach," which described how health coaches facilitated patients to develop their own wisdom and expertise around their diabetes.
The driving force theme described how health coaches helped participants uncover the most powerful motivator for them to engage in diabetes self-management. One participant, for example, explained how her health coach helped her find the "driving force" for self-management:
I'm receptive because I want good health, I want to retire, I want to see my children settle, and that's the driving force for me. But don't tell me I HAVE to do it…. adjust to the uniqueness of my life, my situation, and the things I need to do…and yes…. I'll eventually fit into that dress!
Similarly, another participant, a middle-aged businessman, described how his health coach helped to tie diabetes management to other areas in his life:
Diabetes is not the first thing I worry about in my life -- it's not the second, it's not the third even… you have to connect with somebody to make it (diabetes) real and she [diabetes coach] connected it to something in my life like my business... then your ears are opened and then the teaching means something.
Participants also described how coaches helped them uncover how diabetes self-management could improve other health concerns. One respondent, for example, having diabetes for 30 years, described how coaching helped him to connect diabetes to his struggles with depression:
She listened to me and got to know how my sugars affected my mood, because my mood was dying you know. Before I met that nurse over there my sugar was always out of whack, but she motivated me - when your mood and attitude is different, you feel like you can do something different.
Thus, through discerning what was important to clients and personalizing it to their experience, health coaches motivated clients to become confident self-managers of their diabetes.
In relation to the I'm not a child theme, all three participants expressed frustration when professionals seemed to treat them as children, incapable of knowing what to do. Therefore, patients appreciated it when health coaches gave them responsibility and choices. One participant, a middle-aged woman, described how this approach gave her autonomy and control:
She (the nurse) would provide several options. 'You know, well if this (blood sugar) is high, then maybe try this way, but you could also try it this other way', and also explained why I could manage my diabetes in different ways, instead of saying 'well this is how you have to do it'…. If I can juggle it, work it myself, then that gives me the control and that's really what I was striving for…because I don't want to need a nurse or a doctor every time my sugars go up or down.
Another respondent echoed this theme, emphasizing that when he was given options rather than orders, it encouraged him to take responsibility for putting the "teeth" into what he learned:
…I used to go and ask the nurses what I should do…and they can tell me how much to eat, how big the portions should be…all that stuff -- that's kind of what the other nurses used to do before. But now it has no teeth unless I decide I'm gonna make it have some teeth…. and there's nothing that she could really do to change that.
Both participants' accounts highlight the potential futility of educators merely telling patients with diabetes what to do, as well as the importance of coaching approaches that maintain autonomy, responsibility and free choice.
The final theme describes how coaches helped participants to recognize their own inner wisdom and knowledge, and to start consulting their own "inner coach." For example, one respondent described how her newfound inner coach helped her problem solve in ways when her blood sugars rose:
I was doing everything and wasn't losing weight and my blood sugars were high. So, I thought when my blood sugar is higher in the morning I should increase the insulin, but that just seemed like it was too easy of a solution. I talked this over with Roberta (the nurse coach) and she asked how I was sleeping and we talked over the idea of checking my blood sugar during the night. So, I set my alarm a couple of times and yes, I was dipping low at night. So I decreased instead of increased, I actually decreased my insulin!
Another participant described this process of gaining his own inner coach in a somewhat different manner, pointing out that the process of introspection and insight became circular between client and coach, with both parties engaging in a mutual process of exploration. As he noted about his nurse coaches:
…we are learning from the girls, but they are also learning from me!
| Discussion|| |
Due to the paucity of qualitative research on people's experiences with diabetes health coaching, it is difficult to compare and contrast the results of this preliminary study with other similar studies. The one qualitative study by Whittemore et al.  that focused on diabetes health coaching found similar themes to ours. For example, their themes of "composing a structure" and "exploring self and conflicts" were similar to our theme of "the driving force." That is, while our participants stated coaches helped them identify motivations for change, the Whittemore et al. themes described the various barriers and opportunities surrounding health-related changes. However, the Whittemore et al. study did not actually look at persons' experiences of health coaching, only their experiences of diabetes self-management.
While another qualitative study by Parry et al.  did explore some aspects of older people's experiences with health coaching for chronic illness, they did not specifically include diabetes. In their study, two of the three resulting themes dealt with consequences of health coaching, such as care continuity and increased self-management ability. Only one of their themes, "the importance of the caring relationship," had strong parallels with our themes describing the experience of coaching. That is, their participants described how health coaches entered into a caring relationship with them. Similarly, our participants emphasized that their health coaches treated them as equals and adults, and that a caring and supportive coaching relationship allowed them to find their own "inner coach."
The results from this exploratory study hold a number of potential implications for diabetes health educators. First, the theme of "the driving force" highlights the importance of the motivational component of coaching.  That is, whereas traditional expert-driven forms of education typically stress outcomes important to healthcare providers - such as HbA1c levels - health coaches aim to uncover the individual's unique motivators for change. This seems to have significant international and cultural implications, in that health coaching can elicit important motivators for change, regardless of culture and context.
Second, our participants stated they did not want to be told what to do by health educators and that didactic expert-driven approaches often made them feel like belittled children. Rather, participants preferred it when coaches collaboratively supported their ability to explore choices, even if the coach disagreed with some of the choices. This finding is important, particularly in light of widespread programs based around chronic disease self-management. For example, Holman and Lorig  encouraged healthcare providers to adopt a partnership role with patients learning to self-manage chronic disease. They also emphasized that healthcare providers still need to teach patients certain skills and knowledge. Our preliminary findings, however, suggest that healthcare providers may need to approach the teacher role sensitively and to focus as much as possible on uncovering individual motivators for change. Finally, the theme "meeting the inner coach" reflects the ability of coaches to help people with diabetes tap into their intuitive sense of what their bodies needed. Such coaching techniques as motivational interviewing are very helpful, as they help people to not only assess their readiness to change, but also engage in changes that are meaningful to them.
Overall, the results from this exploratory study offer an important preliminary glimpse into how diabetes coaching works from the patient's perspective, and which aspects of coaching are perceived as most effective. Additional research is needed to further determine which specific aspects of coaching health educators can use with diabetes patients to find their "inner coach" and successfully self-manage their diabetes.
As with most qualitative studies, the intent of this research was not to produce results that are generalizable in a more traditional empirical sense, but to gain a deeper understanding of how patients perceive diabetes coaching. While the authors acknowledge that the research was exploratory in nature, and potentially limited by a sample size of three, it is also not uncommon for qualitative studies to have similarly small samples.  However, future studies with larger sample sizes and diverse cultural groups will help to flesh out a richer understanding of how coaching helps patients to self-manage their diabetes. In the meantime, this exploratory study provides initial insights into how diabetes patients perceive and value the experience of health coaching.
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