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Health Coaching Service

Health Coaching Service Interim Review

Eleanor Bull, MSc, MBPsS

Health Psychologist in Training, Public Health

July 2012

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Acknowledgments The Health Coach Service is the result of the collaborative efforts of many: The ‘first 50’ clients took up the opportunity to use the service, and contributed to this review The early adopter GP practices participating in Keep Well signposted clients who would benefit, and the trained Health Coaches worked with practices and patients. Dorothy Ross-Archer, Keep Well Programme Manager, facilitated the intervention in KW practices, building in conjunction with the Trainee Health Psychologists, a team of trained Health Coaches. NHSG Corporate Graphics guided production of the Keep Well Health Coaching Service patient information Dr Stephan Dombrowski, NHSG’s first Health Psychologist in Training, designed and piloted the initial intervention. Dr Linda Leighton-Beck and Professor Marie Johnston, workplace and academic supervisors to our Trainee Health Psychologists respectively, guided our approach to Health Behaviour Change.

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Table of Contents

Executive Summary .......................................................................................................4

Introduction ..................................................................................................................6 Background.....................................................................................................................................................................6 This review......................................................................................................................................................................7

Health Coaching at the Practice Level ............................................................................9 Activities...........................................................................................................................................................................9

1) What is the implementation strategy?........................................................................................................9 2) What has been conducted to engage Practices?.....................................................................................9 3) What has been conducted to increase referrals? ................................................................................ 10

Initial Outcomes.........................................................................................................................................................10 4) How many practices have taken up the service? ...................................................................................... 10 5) How many practices have referred patients?............................................................................................. 11 6) What are practitioner views of uptake and effectiveness? .................................................................. 11

Health Coaching at the Client Level.............................................................................. 14 Activities........................................................................................................................................................................14

7) What has been conducted to engage clients?............................................................................................. 14 8) What has been conducted to maximise service effectiveness? ........................................................... 14

Initial Outcomes.........................................................................................................................................................15 9) What is the uptake of the service? ................................................................................................................... 15 10) What are the characteristics of clients attending the service? ....................................................... 17 11) Are the techniques being used as planned? .............................................................................................. 20 12) Do clients using the health coaching service make changes? .......................................................... 21 13) What are client views of service effectiveness?....................................................................................... 25 14) What is the health coach perspective of the service? ........................................................................... 27

Discussion ................................................................................................................... 29 Progress against key outcomes ...........................................................................................................................29 Challenges.....................................................................................................................................................................30 Recommendations.....................................................................................................................................................31

Conclusion................................................................................................................... 33

Appendix 1: Health Coaching Service Content and Delivery Method............................. 34

Appendix 2: The Health Coaching Framework in action................................................ 35

Appendix 3 : Table comparing client health behaviour in session 1 and final session .... 36

Appendix 4: References ............................................................................................... 37

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Executive Summary Background The Health Coaching Service was developed and piloted during 2009 as part of the Keep Well Programme which is implemented in primary care settings in NHS Grampian. The service was designed to provide additional behaviour change support to patients (‘clients’) from deprived areas of NHS Grampian following their Keep Well health check. The service consists of up to four one-to-one sessions of 45 minutes with one of the trained health coaches who are existing NHSG staff trained in health coaching. The health coach uses a structured framework to introduce the client to evidence-based behaviour change techniques to support them to decide whether and how to make positive changes to either diet, activity, smoking or alcohol levels. The service is client-led: the client decides whether, what and how to change in the context of their own lives and resources. The main aims are to support the patient to think about change to enhance motivation and then strengthen their confidence using their existing experience to make lifestyle changes using behaviour change techniques. This emphasis on strengths fits well with the asset approach to improving health. Over 50 clients have now taken part so it is timely to share intervention activities and initial outcomes, focussing on service uptake and effectiveness. The review summarises activities and initial findings at practice and client levels. The review could not, nor did it set out to, ascertain effectiveness, cost-effectiveness, long-term behaviour change or health outcomes. Practice level activities and findings At the practice level, the long-term implementation aim is to enable the GP practices (29 currently) participating in the NHSG Keep Well Programme to access health coaching and the strategy has been to match capacity and demand whilst being flexible with practice needs. Initially engaging practices begins with meetings with the practice staff and culminates with a 3 month pilot being organised. Activities to increase referrals have included providing supporting materials, regular feedback and face-to-face contact with staff. To date, initial meetings have been conducted with 17 practices, and 9 practices have conducted a pilot with an available health coach organising three slots a week at a convenient NHS/community venue. 6 practices successfully referred at least one client to the service. Practitioners from 3 practices shared their views, which suggested that flexibility in appointments, sessions to improve staff understanding and reminders to practitioners to refer were important to uptake. Practitioners felt the service was useful and appreciated by clients, and that a review appointment could help promote long-term behaviour change. Client level activities and findings At the client level, activities to improve engagement have been to develop, pilot and then improve an engaging patient information leaflet, to incorporate evidence-based psychological strategies used elsewhere to reduce non-attendance, and to telephone clients beforehand. Maximising service effectiveness has involved improving manuals and materials, data collection and feedback collected from clients. A health coach group has also been established for peer support and an expert supervision session attended. Refresher shadowing sessions are also available. A structured training programme for new health coaches now incorporates an array of interactive training activities and a practice-based assessment. 50 clients were included in the review, from 3 practices. The majority of these attended in the last 12 months, although only 28% of available appointments were attended by clients. 16 clients (32%) attended all four sessions of health coaching. 20 clients (40%) were

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identified as from the Keep Well population. The typical client was female, in her forties, a non-smoker who drinks alcohol, moderately active with a relatively poor diet and with a low estimation of her health. The majority of consultations were ‘complex’ in some way, such as the client having multiple behaviours which they could make a change to, or a longstanding mental or physical health condition. The majority of sessions focussed on diet. There seemed good intervention fidelity: most techniques were reported to be undertaken as planned in the sessions. All 27 clients attending 2 or more sessions set and achieved a specific behavioural goal to improve their health. Comparing health behaviour in the first and final session for 16 clients who attended four sessions, many clients’ smoking, drinking, eating and activity levels improved – more people made improvements than reductions in healthy behaviour in all domains. In particular, 9 of the 16 clients engaged in physical activity more often after the intervention. Perceived health also improved over the intervention – there were significantly more positive changes than negative changes recorded. Mean confidence to improve health behaviour was high and increased slightly from end of session 1 (8.6/10) to end of final session (9.3/10). Confidence before using the service was not measured. Clients were extremely positive about the service, tending to rate it as completely helpful (mean 9.7/10) and being completely satisfied (mean 9.7/10). Their written feedback suggested that the service strengthened their motivation and confidence, that the various specific techniques were useful, and they appreciated the non-judgmental counselling approach. Health coaches indicated the value of their own training to deliver the health coach model, the tools they were able to deploy and the reward of working in ways that build a client’s assets, rather than simply providing advice, the benefits of which were beginning to be realised in clients’ response to the intervention. Conclusion and recommendations Findings against the key service outcomes indicated that the Health Coaching Service is making good progress. However, service uptake remains a big challenge. Recommendations proposed at the practice level include organisation of open access ‘experiential health coaching sessions’ for practitioners, streamlining of the booking process, and ideas to help practitioners remember to refer. At the client level, increasing flexibility of appointments and further testing of psychological strategies to enhance commitment to attend the next appointment were some suggestions made. Moving towards a community model, where health coaches are community members, may be an exciting and ambitious development. Overall, the service draws upon and strengthens clients’ assets for change such as their motivation and confidence. It is now time to draw on the Keep Well Programme team’s assets to build on what has been achieved so far.

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Introduction

Background The Keep Well Programme Early health improvement intervention directed at the most disadvantaged in the population has long been a key policy approach to reducing health inequalities in Scotland (e.g. Scottish Government 2005, 2007, and 2008). The Keep Well programme is one such targeted anticipatory care programme designed to help people sustain and improve their health, aiming particularly to prevent ill health before it arises, including by supporting people to make lifestyle changes. The programme was launched by Scottish Government in October 2006, and revolves around provision of a cardiovascular health check and appropriate advice and services to 40-64 year olds living in the most deprived geographic areas of Scotland, indicated by the Scottish Index of Multiple Deprivation. Near to 4500 people have received Keep Well health checks in NHS Grampian to date, mainly delivered by local primary care staff. The Health Coaching Service Local practitioners expressed a need for additional support for some within the Keep Well programme who were unlikely to benefit from referral to existing services. They reported that during the health check, many of their ‘Keep Well’ patients appeared undecided about whether to make a lifestyle change, were unclear on what behaviour to change, how to go about it, and/ or had experienced failure when trying to make a change or using the available services, with a resulting loss of confidence. In the practitioners’ view, more focussed support and time was vital to help people decide whether and what to change, and to support them in taking action. During 2009, The Keep Well Programme team therefore designed and piloted a health behaviour change intervention to provide that extra focussed support to Keep Well patients following their Keep Well health check. The framework of the intervention was designed by the team’s first Health Psychologist in Training, using evidence of ‘what works’ in health behaviour change and from other interventions such as the Health Trainer Initiative in England (see appendix 1: Health Coaching Service Content and Delivery Method ) and now consists of an overarching introduction, detailed manuals and supporting materials. The Health Coaching Service, as it is now known, has been implemented since 2010. In essence, the Health Coaching intervention consists of the Keep Well patient attending up to four, one-to-one sessions of 45 minutes with a trained health coach following their health check. The health coach and the Keep Well patient complete several evidence-based activities, or behaviour change techniques, to support the patient to decide whether and how to change one of the four health behaviours which are crucial to maintaining good health: healthy eating, being more active, stopping smoking and drinking sensibly . The main aims of the intervention are to support the patient to begin to think about change, enhancing motivation, and if they would like, furnish confidence in making sustainable steps towards health improvement, using behaviour change techniques. There is a brief explanation of each technique in appendix 2: Health Coaching Framework in action . The approach of health coaching is as important as the techniques used, since the psychological literature shows that, especially in one-to-one interventions, the working relationship between the practitioner and the person is one of the most important predictors of intervention success (Miller and Rollnick, 2002). Furthermore, feeling in control of health is a key predictor of health behaviour change and better health outcomes in both ‘healthy’ and ill populations (e.g. Abraham and Gardner 2009). A key principle within health coaching is that the health coach and service user have equal status. This is

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reinforced through the terminology of ‘client’ rather than ‘patient’. The client decides whether and what to change since they are the experts in their life, and are introduced to techniques which they may find useful to employ in other areas of life in future. In this way, health coaching is very much in line with the Asset Approach to Health Improvement (e.g. Glasgow Centre for Population Health, 2011). Clients are encouraged to use their own resources for change such as their learning from previous success and strengthen assets such as confidence and motivation. Clients are referred by Staff from the current GP practices participating in Keep Well with an arrangement to run Health Coaching sessions. Currently there are 5 trained health coaches, who are existing NHS Staff members trained in health coaching. The health coach usually offers around 3 appointments a week (1 session a week), and uses a room at the surgery, or at a community clinic or other nearby community venue. Therefore activities to implement the intervention can be thought of at two levels: at the practice level with Practice Managers to initiate the services and Nurses and GPs to refer to the service, as well as at the client level to engage clients and conduct the actual intervention.

This review Following the initial pilot phase, the Health Coaching Service has now been operational for more than 18 months, and over 50 clients have now taken part in Health Coaching. It is therefore timely to present a review focussing on intervention activities and initial outcomes. The Health Coaching Service has six measurable outcomes introduced in the NHSG document Health Behaviour Change in Keep Well: An Overview (NHS Grampian 2011). These are:

• Taken up by ‘vulnerable groups’ • Client and Practice satisfaction • Relevant goals set by clients • Improved confidence to make health behaviour changes • Access to other services offered • Perceived health behaviour change

Progress against these specific outcomes is reviewed in the discussion. This review explores more generally activities and initial outcomes relating to service uptake and service effectiveness at both practice and client levels . Questions asked in this review are: Health Coaching at the Practice Level

Activities

1) What is the implementation strategy? 2) What has been conducted to engage Practices? 3) What has been conducted to increase referrals? Initial Outcomes 4) How many practices have taken up the service? 5) How many practices have referred to the health coach? 6) What are practitioner views of uptake and effectiveness? Health Coaching at the Client Level Activities 7) What has been conducted to engage clients? 8) What has been conducted to maximise service effectiveness?

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Initial Outcomes 9) What is the uptake of the service? 10) What are the characteristics of clients attending the service? 11) Are the techniques being used as planned? 12) Do clients using the health coaching service make changes? 13) What are client views of service effectiveness? 14) What are health coach views of the service? This review aims to explain the service to interested readers, investigate uptake and effectiveness, share lessons learned and make recommendations for future. However, the small numbers involved and the lack of Randomised Controlled design mean this review is not powered to investigate effectiveness statistically- and is deliberately termed ‘interim review’ rather than ‘evaluation’. Furthermore, cost-effectiveness, long-term behaviour change and eventual physical health outcomes are all outwith the scope of this review. Instead, this review is a learning tool, for the Keep Well team in implementing the Health Coaching Service, and hopefully for other NHSG services. The data for this review are from a variety of sources:

- Client measures : self-reported behaviour and written feedback provided in the first and final sessions

- Health coach measures : written reports of session activities each week and monthly client attendance data

- Practice measures : practice record data (e.g. dates of birth) and practitioner feedback

- Keep Well programme measures : from the programme records (e.g. keep well status)

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Health Coaching at the Practice Level

Activities

1) What is the implementation strategy?

The Health Coaching Service was developed and piloted in the first practice, in this report called Practice A, in 2009-10, where it continues to run today. Since then, the ultimate implementation aim has been for all 29 Practices involved in NHS Grampian’s Keep Well Programme to have the opportunity to refer patients to the Health Coaching Service, with all 22 in Aberdeen City connected by the end of 2012. The implementation strategy chosen by the team focuses on incrementally increasing the service’s reach, matching health coaching capacity with expected uptake. A key aspect is around being flexible: contacting practices individually to engage them in the service, and arranging a bespoke model of referral and delivery depending on the practice’s preferences. This strategy was chosen given experience of success in organising Keep Well programme health checks in a flexible manner. Equally, activities to increase referral once the service was initiated have been bespoke, in response to arising opportunities or perceived need. These activities are briefly described below.

2) What has been conducted to engage Practices?

The initial engagement process has been similar in each Practice participating in Keep Well following an initial invitation to use health coaching as an additional intervention for the practice:

1) Informal discussion : Initial invitation or discussion about whether the health coaching service could form an additional intervention for the practice is made by the Keep Well Programme Manager (KWPM) informally, such as at more general Programme meetings.

2) Initial meeting : Depending on the response, the KWPM and Health Psychologist

in Training meet with Practice Manager (PM) to explain the service concept and development to date. Lately, explanation and promotion of the service has been aided by sharing written client feedback examples and the updated patient information leaflet.

3) Planning meeting : If the PM is interested in engaging with the service, the

referring staff, the KWPM and the available health coach meet to organise a 3 month pilot. Venue and booking process are decided. Depending on practice preferences, the venue can be at the practice, a nearby community clinic or other venue and booking can use practice systems, the community venue systems or be arranged centrally through the Keep Well Programme administrator.

4) Materials sent: Personalised practitioner health coach service information sheets

and patient health coach service information leaflets are sent to the Practice before the pilot begins, to support referral.

5) Review meeting : After the pilot phase, the KWPM, HPiT, health coach and key

staff meet to discuss progress and arrange further health coaching sessions

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3) What has been conducted to increase referrals?

Once delivery is initiated, other activities have focussed on supporting practitioners to make referrals to health coaching. Activities aimed to help busy practitioners to remember to refer and incorporate systems to make it as easy as possible:

• Supporting materials : - personalised practitioner health coach service information sheets with an

example ‘how to refer’ script - Health Coaching Service posters displayed in the practice - Patient health coach service information leaflets to help in explaining the

service, personalised with a label attached outlining how to make an appointment in that practice.

• Regular feedback: - periodic personalised written summaries of client numbers and their written

comments for practice managers - letters written by the health coach to the referrer for the patient records

summarising the outcome of the intervention for each patient seen • Face-to-face contact with Staff

- follow-up meetings with staff, reminding them of the service and how to refer

- experiential staff training sessions delivered by the current Health Psychologist in Training held in consecutive months in Practice Learning Time, in the form of ‘group health coaching’ to introduce the content and style of health coaching

• Opening up referrals to non Keep Well patients: - The practitioner health coach service information sheet specifies “you can

refer Keep Well or other patients who you think might be interested in making healthy changes to their lifestyle”. This was a strategy implemented following low initial uptake: it was seen as important to not initially be too selective in welcoming only ‘vulnerable groups’, to help the system become operational.

Initial Outcomes

4) How many practices have taken up the service?

1) Informal discussions : To date, these have taken place with 22 of the 29 practices participating in NHSG’s Keep Well Programme. This includes nearly all of the Aberdeen City practices and one practice in Aberdeenshire, where health coach capacity is now growing. All practices have responded positively to these discussions

2) Initial meeting : These have been held with 17 of these practices, where the PM either agreed to participate immediately or planned to discuss with the team. Many of these meetings were held recently since capacity is expanding with staff from NHSG’s healthpoint service (Aberdeen City) being trained as health coaches, bringing the total number of trained health coaches to 6. Therefore further planning meetings are expected shortly. 3+4) Planning meeting and materials sent : A pilot phase was planned with 9 practices and relevant materials sent. In ‘Practice I’ the pilot phase has just recently begun.

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5) Review meeting : At the review meeting, 6 of the 8 practices whose 3 month pilot period was completed decided to continue to use the service. The 2 practices not arranging further appointments have recently been offered healthpoint as another access point to health coaching.

5) How many practices have referred patients?

Of the 9 practices running a pilot, 6 practices have so far successfully referred at least one client to the health coach, although it is not possible to measure how many more clients may have been invited to attend by practitioners without attending. The practices which have not referred clients are the practice which has recently commenced their pilot (practice I), and the two practices (practices B and E) who have been offered healthpoint as their access point to health coaching. Referral volume is indicated below with practices coded A-I and listed in chronological order according to date of first pilot. Figure 1: Clients attending Health Coaching Service by practice

6) What are practitioner views of uptake and effectiveness?

Feedback was requested from all staff through contact with practice managers. 2 Practice nurses, 3 GPs, 2 Practice managers and 2 admin staff from practices A, D and H provided feedback for this review. Uptake In response to the question ‘In your view, what are the main things which determine how many patients are referred to the service?’ staff comments related both staff and patients’ views and behaviour. Explaining why referral might be limited, the nurse at Practice H pointed to lack of confidence, motivation and understanding in patients, and lack of understanding in staff.

Number of clients referred to health coaching by Practices A-I and year of pilot

05

101520253035

Practic

e A

Practic

e B

Practic

e C

Practic

e D

Practic

e E

Practic

e F

Practic

e G

Practic

e H

Practic

e I

Clie

nts

Pilot year: 2009 2010 2011 2011 2011 2011 2011 2012 2012

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Practice Manager D pointed out those activities which the practice has undertaken to maximise uptake which she felt have worked well:

Other staff in each practice provided helpful ideas to improve uptake, including improving flexibility of delivery (time, mode e.g. telephone, and format e.g. by group), enabling self-referral, improving selection of patients, and further support for staff in referring. Better integrating the health coach with the practice team was also mentioned, perhaps for relationship-building and to be a ‘reminding presence’. Overall, appointment times and formats, staff understanding and remembering to refer the ‘right’ patients, patient motivation, understanding and remembering to attend were therefore perceived as key factors determining uptake. Effectiveness Responding practitioners commented positively on the effectiveness of the service, using words like ‘beneficial’, ‘good’ or ‘useful’. Practitioners commented particularly that patients ‘appreciate’ the service, and that the one-to-one format is helpful.

“We phone patients the day before their appointment to remind them and (health coach) phones our secretary on a Monday to see if any patients are booked in. Useful that (health coach) did two health coaching sessions at the Practice Learning Time so we all had a better understanding of what is involved We give regular reminders to doctors about referring as they often forget about the service amongst all the other things to remember” Practice Manager, D

“Definitely continue with the health coaching, helpful for patients to have that added bit of help and support and some positivity to help them to achieve their goal” Admin Staff 1, D “I think the health coach services are beneficial to those patients who require motivation in order for them to achieve their goals. I believe that the "one to one" sessions help people remain positive and motivated." Nurse, H “Patients appreciate; helped patients target efforts; helped me with patients with whom you just don’t know where to start!” GP, D

“I feel maybe patients’ lack of understanding leads to them being reluctant to attend these sessions. The ‘unknown’ can be a scary situation for lots of patients. Also lack of motivation. Additionally I think staff’s understanding and knowledge of the sessions could be improved in order for them to promote the service effectively....including myself” Nurse, H

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At practice D, where the experiential health coaching practice learning time sessions had been conducted three months previously, one member of staff commented on specific goal setting and self-monitoring as specific components she felt were effective. This demonstrated an in-depth understanding of the service, suggesting that the staff sessions had been effective in improving staff knowledge of the service: Finally, one practice manager proposed that a review appointment would be useful to improve effectiveness of the service in the long-term. In conclusion, though this was a limited sample of staff solely from practices which had referred to health coaching, practitioner views on service effectiveness and client satisfaction were very positive. Administration staff were also making effort to remind practitioners to refer and even reminding patients to attend via telephone, which shows admirable commitment and is much appreciated by the Keep Well team. The main actions for the Keep Well team may be to offer further experiential staff training sessions, flexibility in appointment delivery, and a review or ‘update’ appointment to clients, in order to improve service uptake and effectiveness.

“Setting yourself a specific (SMART) goal to work on, making yourself ‘if-then’ plans to help be positive towards your goal, self-monitoring homework is a good way of keeping track of your achievements, either by drawing a chart or using a diary to keep a note of your progress“ Admin Staff 2, D

“I note that many stray back to their old ways - perhaps an update, say three and six months down the road would be worthwhile?“ Practice Manager, A

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Health Coaching at the Client Level

Activities

7) What has been conducted to engage clients?

Patient Information leaflet and posters Practitioners initially explain and promote the service to patients at their Keep Well health check or at another consultation, using the patient information leaflet. Initially, this was a small card (credit card size), but in early 2010 a more engaging and informative leaflet was designed, based on those used in a similar service in England (DH, 2004), on research findings about health communication, and NHSG Corporate Communications advice. After NHS Corporate Graphics Design finalised layout and printed a small number, pilot work was then undertaken to gain feedback from 15 patients and 10 staff. They held generally positive views of the leaflet, particularly the information included, style of writing and format. Their helpful ideas for improvement were adhered to, such as incorporating an image of ‘health coaching in action’. No suitable library pictures existed so a health coaching photography session with NHSG Medical Illustration team was undertaken. A larger print run of the improved version of the leaflet was completed in January 2012. Given the different booking processes in use, the ‘how to make an appointment’ information on each leaflet is customised for each practice by adding a printed label before distribution to the practice according to need. Posters have also been designed and printed by Corporate Graphics and placed in waiting rooms, with the advice to ‘ask at reception’. Evidence-based engagement strategies As well as providing an engaging and informative leaflet to explain the service, evidence-based techniques for engaging patients and reducing the likelihood of ‘non-attendance’ at booked appointments have been piloted. In previous research in primary care and other settings, two simple strategies have had large effects on reducing unattended appointments: (Cialdini, 2009; Martin et al. 2012):

• Asking clients to write out their own next appointment slips • Asking clients to verbally confirm that if they need to rearrange the appointment

they will call the practice beforehand

This is different to completing the appointment slip for the client or merely reminding them to call to cancel because in both cases, the client plays an active role which can enhance their sense of commitment to attend or call to cancel, reducing unexpected non-attendance. Telephone reminders Finally, in Practice D the administration team implemented a system of telephoning clients the day before their appointment to check that they are still able to attend.

8) What has been conducted to maximise service effectiveness?

Since the service was developed in 2009, changes have been made continuously to improve its effectiveness.

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Improvements to the intervention - Manuals and materials have recently been updated to improve their clarity of

explanation, accuracy (updating of contextual details) aesthetic quality, and usability in using the manuals on NHS computer systems.

- Data gathering has also been improved over time, including the post-session checklists which assess adherence to the framework and coaches’ views of the session, and the health behaviour check to record pre- and post-intervention health behaviour. Data is now recorded fully and systematically on a master log database.

- Feedback sheets were developed to gain clients’ views on the service from all clients after session 1, not only from those who complete the full four sessions, to gain an accurate picture of the service’s strengths and suggest areas of improvement.

Improvements at the health coach level

- The Health Coach Group was established in early 2011, for all health coaches to meet every 8 weeks. This is an opportunity for sharing practice, gaining others’ views and discussing service development.

- A supervision session with an expert health and clinical psychologist, (who also generally provides input at a strategic level such as devising the key service outcomes) including opportunity for ‘troubleshooting’ was held in July 2011 and was much appreciated by the health coaches.

- New health coaches are identified by the Keep Well programme manager based on their current and previous job experience(s) of working one-to-one with patients and their availability to be ‘seconded’ to the programme for an average of one morning per week. New health coaches are trained by those with experience, following a cascade model.

- The training framework has developed considerably, so that now a structured five session programme is followed, to train coaches in health behaviour change competencies (Dixon and Johnston 2010) which incorporates interactive activities, multimedia resources including opportunity to shadow a health coach with a client, brain friendly learning techniques and culminates in an observed ‘practice client’ session. Health Coaches must demonstrate sufficient competence in health coaching practice (conducting a session using the approach and techniques) before they are connected with one of the Keep Well practices to begin health coaching.

- Finally, there is opportunity for health coaches to develop their practice by having ‘refresher sessions’ with other coaches and shadowing their practice and developing a ‘buddy’ system.

Initial Outcomes 50 clients are included in this ‘client initial outcomes’ section of the review, from Practices A, C and D. Additional clients not included in this section are either actively participating, or data is not available making reviewing difficult. An additional 2 clients were inappropriate referrals and directed appropriately within 15 minutes, so are also not included.

9) What is the uptake of the service?

Appointment uptake Formal attendance records have been collected since July 2011 in Practices A,C and D. In this time there were:

• 330 appointments available • 114 of 330 appointments booked

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• 91 of 114 booked appointments attended • 23 of 114 booked appointments missed

Therefore, 35% of available slots were booked, and clients attended 80% of the appointments they had booked. Other appointments were cancelled or rescheduled by clients prior to the health coaching session but since this often took place without the health coach’s knowledge it could not be reliably reported on. The bar chart below shows the distribution of appointments available, booked, attended and not attended (DNAs) in the three sites. Figure 2: Appointments available, booked, attended and not attended by clients in three sites since July 2011

The graph below shows uptake of the service by the 50 health coaching clients included in the review over time, as measured by the month of their first appointment. It is clear that the majority of the 50 clients were seen in the last year, with appointment uptake rising sharply in recent months. This coincides with the onset of heightened engagement activities, as discussed in the previous section. Figure 3: Uptake of the service by 50 health coachi ng clients over time

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Sessions attended Clients can attend the health coaching service for up to four appointments. However, in the case where the client requests further sessions, up to six appointments may be offered. 117 sessions were attended in total by the 50 clients. As displayed in the pie chart (figure 4) clients differed in how many appointments they attended. 27 clients (54%) returned for a follow-up appointment, and 16 (32%) attended four sessions or more. Figure 4: Number of Health Coaching Sessions attend ed by clients in this review

10) What are the characteristics of clients attending the service?

Demographics and ‘case complexity’ The table below shows typical client characteristics. 20 of the clients seen (40%) had a keep well read code, suggesting that they were amongst those for which the service was designed. In fact, anecdotal evidence suggests that many without a keep well read code also had characteristics typical of ‘vulnerable groups’ that the directorate’s activities would hope to target, such as clients with few formal qualifications, in a manual occupation or unemployed, or of migrant status. ‘Case complexity’ are themed groupings of the notes by the health coach relating to a session taking longer than usual, or perceived to be slightly challenging. This was in 30 cases (60%). Since case complexity was not formally measured, it may be that the figures are actually under-estimates. The five clients with incorrect expectations all were happy to continue the session. The average client was therefore female, in her forties, perhaps from the Keep Well programme population, and presenting as ‘complex’ in some way.

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Table 1: Client characteristics: sex, age, keep wel l status and indication of ‘case complexity’ from health coach notes Characteristic Description Figure

Sex Number male (%) 17 (34%) Age Mean age (range) 48 (20–67)

Keep Well status Number keep well read code (%) 20 (40%) Case complexity

-Mental Health Condition -Physical Health Condition -Unsure which behaviour to choose -Incorrect expectations of the service

10 8 7 5

Typical Health Behaviour 48 clients completed a health behaviour check at the beginning of the intervention to whom the following figures relate. The average client attending the service drinks alcohol and is moderately active, with a daily diet fairly low in fruit and vegetables. Table 2: Typical health behaviour of clients - heal th behaviour check at session 1 Behaviour Description Figure

Smoking

-Number who smoke (%) -Mean per day smokers (range) -Previous attempted quit? (% smokers) -Mean number of quit attempts (range)

13 (27%) 23 (1-50) 12 (92%) 4 (1-10)

Alcohol -Number who drink alcohol (%) -Mean approx units per week amongst drinkers1 (mean in whole sample) -Number of clients exceeding recommended weekly intake (%)

33 (69%) 18 (9) 11 (23%)

Activity -Number who engage in at least some moderate or vigorous activity each week -Number moderately active -Number vigorous active -Mean minutes moderately active /week (hours) in sample 2 -Mean minutes vigorously active / week in sample

44 41 11 197 34

Eating -Number who eat fruit each day -Mean times per week in sample -Number who eat veg each day -Mean times per week in sample -Number who eat fried food each day -Mean times fried food eaten/week in sample -Number eat high fat dairy food each day -Mean times that high fat dairy foods consumed per week in sample

18 4 18 5 3 2 16 4

1 Glasses of wine were assumed to be 175ml unless stated at 12.5%, if 250ml, assumed to be 3 units. Pints of lager/beer were assumed to be 5% abv unless stated. Cider was assumed to be 6.5%abv unless stated. Measures of spirits were assumed to be 25ml bar measures (40%abv) unless stated. Bottles of beer were assumed to be 330ml at 4.5% abv unless stated. 2 Mean of 47 people: Excludes one ‘outlying’ person who reported being moderately active for 24,480 mins per week

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Health coaching clients were compared to a large sample of the Scottish population, the Scottish Health Survey (Scottish Government 2010) in terms of the proportion who are current smokers, and the proportion who exceed the recommended weekly alcohol intake. Health Coaching clients seem fairly similar to the survey population. Diet and activity figures were not comparable because of measurement differences. Figure 4: Percent of Health Coach Sample smoking an d exceeding recommended alcohol intake guidelines compared to Scottish Heal th Survey 2010 sample

Typical perceived health The final question measured perceived health, which has been shown to be one of the best predictors of health outcomes (e.g. Idler and Kasl 1991). The pie chart below shows that at the beginning of the intervention the majority of clients felt they had fair health, where the choice was between 5 ratings: ‘excellent’, ‘very good’, ‘good’, ‘fair’ and ‘poor’3. The 5 ratings in the Scottish Health Survey were labelled differently (‘very good’, ‘good’, ‘fair’, ‘bad’, or ‘very bad’), but it was note-worthy that only 7% of the Scottish sample chose one of the lowest two categories, compared to over half (58%) of Health Coaching Service clients. Health Coaching Service clients tended to perceive their health as limited at the beginning of the intervention. 3 Those who chose a rating in between were assigned the higher category for the purpose of this review

0

5

10

15

20

25

30

% current smokers % exceed recommendedweekly alcohol intake

Health Coach Sample

Scottish Health Survey 2010sample

Per

cent

of s

ampl

e

20

Figure 5: Distribution of perceived health scores i n first Health Coaching session

Client behavioural choice In their first session, 31 clients (62%) chose to discuss diet, 9 clients (18%) discussed exercise, 7 clients (14%) discussed smoking and 3 clients (6%) discussed alcohol. 6 clients (12%) who set a dietary goal in the first session then set a physical activity goal later in a later session.

11) Are the techniques being used as planned?

As described in the introduction, health coaching sessions follow a structured format of several main activities, or techniques (see appendix 2: The Health Coaching framework in action for explanation of each technique). Interventions can only be evaluated if the facilitators adhere closely to the planned activities, known as intervention fidelity. Therefore it is important to ascertain whether health coaches and clients are actually carrying out the techniques as planned – this is recorded by health coaches in the post-session checklists. Though not a behaviour change technique, offering accesses to other services is one of the agreed service outcomes so is included in the list.

• Decision balance : All 50 clients completed a decision balance to weigh up pros and cons of staying the same and changing.

• Overall goal setting : All clients decided to set an overall goal. For 36 clients (72%) this was to lose weight, whilst other overall goals were to get more sleep or reduce stress.

• Action planning: In their first session, 46 clients (92%) set a specific goal. Examples were:

-‘take the stairs three of four working days’ -‘To have only one cigarette with friend when we meet, on Tuesday 7.30pm’

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-‘swap alcohol for soft drinks this Friday and Saturday’ -‘have a piece of fruit at 2pm every day this week’ The remaining four clients chose to self-monitor their behaviour and identify a

change the following week. Three of these clients returned and set a specific goal the following week, so that in all 49 clients (98%) set at least one specific goal. According to a recent expert definition of action planning, with the support of the health coach, these goals were specific enough to be considered good use of the action planning behaviour change technique4

• Self-monitoring: The use of self-monitoring was explained by all coaches, who

provided clients with a diary. Whether clients completed the diary was not recorded on the checklist, but anecdotal evidence suggests about two thirds of the 27 clients who returned for session two brought a completed diary.

• Identifying barriers and facilitators: 26/27 (96%) of the clients who attended their second session identified at least one barrier to achieving their specific goal and found a way to overcome it. 25/27 clients (93%) identified and planned to use at least one facilitator to help achieve their specific goal.

• Rewards: 15/20 (75%) of clients attending session 3 identified and planned at least one reward for achieving their specific goal. The remaining clients discussed with their family and friends after session 3, and recorded their reward in session 4.

• Offering access to other services: 23 recommendations were made for 16 clients to attend local services. These services were healthpoint, the Healthy Helpings programme, the client’s GP, the Smoking Advice Service, Dietetics and Pharmacies. It is impossible to know if all of these recommendations were taken up, but it is known that at least 2 clients attended Healthy Helpings following Health Coaching.

All in all, it seems that there is high intervention fidelity: health coaches are offering the techniques in the framework to the client as well as offering access to other services, and for the most part, clients choose to complete these activities.

12) Do clients using the health coaching service make changes?

The main aims of the intervention are to support the patient to begin to think about change, enhancing motivation, and if they would like, furnish confidence in making sustainable steps towards health improvement, using behaviour change techniques. Therefore improvements in motivation, confidence and health-related behaviour may be expected. Motivation is not formally measured, but the fact that following completing a decision balance, all clients in the review decided to set a specific goal or monitor behaviour suggests that the intervention was effective in supporting the clients to think carefully about the pros and cons of change and then crucially move towards action. Written feedback (see ‘client views’ section) also suggests the intervention had a motivating effect.

4 Action planning is defined as ‘detailed planning of performance of the behaviour (must include at

least one of context, frequency, duration and intensity). Context may be environmental (physical

or social) or internal (physical, emotional or cognitive’ From Michie et al. (2011); Michie et al. (in

preparation).

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Measures of confidence, health behaviour, and perceived health taken in the first and fourth sessions, and notes of other health-related changes provide further indication of change over the course of the intervention. Confidence Client confidence to improve their health behaviour was high: both after their first session (mean 8.6/10, lowest 7) and final session (mean 9.26/10, lowest 8) all ratings were above the midpoint of 5/10. The difference between the two means also indicate that client confidence may increase over the intervention, although no measure of confidence was taken before the intervention began. It is also difficult to track changes in individuals’ confidence, as the first session feedback form was developed relatively recently, and to maximise clients’ freedom to give their honest and open views there was no requirement for clients to add their name to their feedback sheets. There were three cases in which comparison was possible, with ratings following session 1 and session 4 displayed in table 3: Table 3: Client confidence to improve health behavi our following session 1 and 4

End Session 1

confidence /10

End Session 4

confidence /10

Change?

Client 1 10 10 No change Client 2 8 8 No change Client 3 10 8 -2 Confidence was high at both points measured with not much change: it would have been interesting to measure confidence before the intervention rather than after session 1. Client 3’s confidence decreased slightly between session 1 and 4: perhaps for this client, their view had become more realistic as a result of experiencing making behaviour changes. Health Behaviour Goal achievement If a client reports achieving the specific behavioural goal they set, this indicates that a positive health behaviour change has been made, suggesting the intervention has been effective in changing behaviour. 21 of 27 clients (78%) of clients who attended their second appointment reported fully achieving or even going beyond their specific goal from session 1. The remaining 6 clients all achieved a specific goal in subsequent weeks, so that all 27 clients attending 2 or more sessions improved their health behaviour. Overall 55/67 (82%) specific goals set between two attended appointments were achieved or exceeded. However, this is an approximate figure because the data relies on self-report by clients, and noting down by health coaches, and further goals may well have been achieved where the client did not return to share this with the health coach. Behaviour in the first and final session This section compares self-reported health behaviour of the 16 clients who completed health behaviour checks in their first and final session. 8 of these clients’ goals had focussed exclusively on diet, 2 on exercise, 4 on diet and exercise (on different sessions), whilst 1 client focussed on alcohol reduction and 1 on smoking reduction. Group means and frequencies in first and final session for these clients are reported in appendix 3: table comparing client health behaviour in session 1 and final session .

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The table 4 below, however, reports number and direction of changes made, in the 5 ordinal measures most sensitive to the changes the team are interested in. Table 4 shows that In all 5 measures, more of the 16 clients made healthy changes (e.g. reduction in cigarettes smoked last week) than unhealthy changes (e.g. increase in cigarettes smoked last week). The difference in number of healthy vs. unhealthy changes for the 5 measures did not reach statistical significance according to the Sign test, which may have been due to the small sample size. The majority of clients’ physical activity levels (frequency and duration) increased over the course of the intervention: 6 clients’ goals related to exercise but 9 clients’ exercise frequency increased. This is encouraging and indicates that effects of the intervention may be widespread. On the other hand, the majority of goals were set around diet so a greater number of changes were expected than seen in table 4. However, the measure ‘number of days on which fruit consumed’ was not very sensitive: portions consumed per day was not recorded so many reported the maximum ‘7’ to begin with, and goals often focussed on reducing high sugar/fat snacking, which was not measured, rather than on fruit consumption. The check has recently been improved in these respects. Only one of the 16 clients was a smoker, and she made a positive change in reducing cigarettes smoked per week. Alcohol seemed more mixed, with some clients increasing and others decreasing intake, though this seemed particularly changes to fluctuations in weekly schedule, such week 1 or 4 coinciding with a holiday from work and thus normal routine. In summary, there are limitations in conclusions that can be drawn from ‘snapshot’ self-reported behaviour using measures chosen originally for ease over accuracy, but it seemed many clients’ health behaviour changed positively between the first and final session. Furthermore, whilst for simplicity magnitude of individual behaviour change is not reported, this was sometimes dramatic: one client whose alcohol intake had been in excess of 60 units per week managed to halve his consumption by his final session. Table 4: Changes in key health behaviour variables between first and final session (n=16)

Health behaviour last week:

Change towards health

Change away from

health

No change

Smoking

(Cigarettes smoked)5

1

0

15

Alcohol

(Units of alcohol consumed)

4

3

9

Physical activity

(Minutes of moderate activity)

(Number of times exercised)6

7

9

4

3

5

4

Diet

(Number of days consumed fruit)

4

0

12

5 Note that only one client smoked at the beginning of the intervention, hence the high number of ‘no changes’ 6 This includes both moderate and vigorous activity

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Perceived health Client ratings of their health also tended to improve from first to final session of health coaching. There were significantly more positive ratings than negative ratings according to a Sign test [Z=-2.38, p=.02]. This is clear in table 5 and figure 6, which show changes in perceived health and the number of clients rating their overall health in the different categories in the first and final session respectively. Perhaps social desirability in responding explains why some clients rated their health more positively in the final session. However, given the strength of perceived health as a predictor of later health, even small changes may have big health effects, and it is very encouraging that a relatively brief behavioural intervention may cause changes in feelings about health more generally. Table 5: Changes in perceived health between first and final session (n=16)

Change towards health

Change away from

health

No change

Perceived health

(Poor, fair, good, very good, excellent)

9

1

6

Figure 6: Frequency of perceived health ratings in first compared to final session Other health-related changes Other physiological changes were reported by clients and recorded in the post-session checklist:

• Weight loss (three clients lost more than 7 pounds) • Reduced blood pressure • Increased fitness – feeling energetic and being able to walk faster or further • Changes in shape and being able to fit into more clothes • Reduction in indigestion and heartburn

16 clients' health ratings in first and final health coaching session

012345678

Poor Fair Good Verygood

Excellent

Num

ber o

f clie

nts

1st session

Final session

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• Breathing improvements from reduced cigarette consumption It is highly encouraging that a relatively low intensity behavioural intervention supported clients to make changes which had noticeable physical health effects.

13) What are client views of service effectiveness?

18 clients returned the main feedback form after their final session, including all 16 who completed 4 or more sessions. 21 clients completed the more recently developed shorter review form after session 1 (this represents all clients seen since the form was developed). a) Numerical feedback Clients reported how helpful they had found the first session or the service as a whole from 1 (not at all helpful) to 10 (completely helpful). After session 1, client mean rating was 9.1/10 (lowest=6) and after the final session it was 9.7/10 (lowest=8). After their final session, clients also reported their satisfaction numerically from 1 (not at all satisfied) to 10 (very satisfied). The mean rating was 9.7/10 (lowest=8). Ratings of client satisfaction and how helpful the service was are displayed in figure 7: Figure 7: Clients views of satisfaction and service helpfulness after health coaching service Although ratings were generally high, helpfulness ratings after session 1 predicted whether the client returned: the 5 clients who rated the first session 6,7 or 8 helpful did not return for session 2 whereas 7 of the 14 who rated it 9 or 10 helpful returned. b) Written feedback Written feedback on the service has been overwhelmingly positive. Themes have been taken with examples included in the speech bubbles. Firstly, most comments included the view that the service was helpful and stimulating , i.e. made people reflect.

“Very helpful and challenging. Longed for someone to help in this area” Female “Very thought provoking” Female “Because of my visits to you, you have opened up something that makes me think sensibly. It’s speaking about it, speaking about it to you” Female

Client views of 'satisfaction with service' and 'service helpfulness' after final health coachi ng session

0

5

10

15

1 2 3 4 5 6 7 8 9 10

Rating 1 (lowest) - 10 (highest)

Nu

mb

er o

f cl

ient

s /1

8

Satisfaction

Helpfulness

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Furthermore, health coaching seemed to strengthen both motivation and confidence . Asking clients about the ‘best parts’ of health coaching revealed which were the specific activities that were helpful. Most of the techniques were mentioned in some form by clients. Nearly all clients referred to the client-led approach/style of health coaching. They particularly appreciated non-judgment in combination with the counselling approach

Motivation “Focussed my attention to change my lifestyle” Male “It made me want to prepare meals and plan my shopping trips” Female “(I’m) fully motivated to change the way my life is” Male Confidence “It made me feel good about myself for trying” Female “I can make changes in my life” Female

The decision balance “Remembering the reasons why you are trying to change” Male

Specific goal setting “SMART goals–keep simple and achievable and focused” Female

Self-monitoring “Keeping notes, diary…a better understanding of my previous eating habits” Female

Identifying barriers “Barriers – aware and how to deal” Female

Identifying rewards “Rewards for reaching goals” Female “Rewarding success” Male

Relapse prevention “Don’t fall back into bad habits” Female

Non-judgment “No preaching, common sense approach” Female “Not being treated like a child that didn’t know better…speaking to someone who understands and does not try to belittle you” Female “I did not feel that it was dictating towards me at all” Female Counselling approach “Making you see things from a different perspective” Female “Someone taking the time to ask questions and make me think” Female

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Comments for improving the service were nearly always to offer further appointments. One client wished for improvements in the interviewing room used in the Practice. On the whole then, client feedback was positive and clients reported that completing the specific activities in partnership with a skilled, non-judgmental health coach helped increase their confidence and motivation around health behaviour change. Offering follow-up sessions and improved surroundings may improve client satisfaction and service effectiveness.

14) What is the health coach perspective of the service?

No review would be complete without the views of the intervention facilitators: the trained health coaches. To gather their opinions, as well as those of the Keep Well Practice Manager, a semi-structured discussion was held in a recent health coach group meeting. Initial perceptions of delivery Health coaches considered the model worked on two levels: macro being the health coach manual and approach; and micro level being about what happens in each of the 4 sessions. They were aware of the importance of delivering the model reliably to ensure the consistency required to assess the contribution of the intervention in supporting clients to change their behaviour. Managing this was a skill which led to discussion about the coach’s ability to balance fidelity to the core components of the model, with a sensitivity to areas of patient need. They valued the facility of the Health Coach group to ensure a sharing of experience and the development of a clearly articulated common approach to this fundamental challenge. Peer discussion also helped to support and share ways of flexible working with clients to add to the legitimate repertoire of the coach. In relation to the structure of the intervention, one coach usefully summed it up: Coaches were clear that GP practice staff also play a critical role. They require sufficient understanding of the intervention, its potential and actual impact, to be able to effectively engage clients in the first instance and refer them to the service. Two coaches commented on this:

Improving the service “Extend time as it is very useful to have ongoing counselling to ensure I keep on track” Female “More time together later on in the year to see if things were actually working out the way I have planned them” Female “Better interviewing conditions. Bare, empty, cold, uninviting surroundings. No ambience at all” Female

“I really believe in the structure of it: (the health coach model) you lose the whole ball game if you don’t follow the structure” Health Coach, A

“If the practice is aware of what the service is about and are keen, and promoting it as something positive, then that’s helpful” Health Coach, C “For practice staff, it’s also promoting the unknown – they don’t know if it’s effective or not because it’s a new service” Health Coach, F

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The interim review is clearly an important additional milestone in capturing feedback and ensuring that practice staff have an increasingly strong basis from which to promote the intervention, other than simply how the new service ‘aims’ to support patients. Perceptions of client experiences Health coaches considered that one of the most important contributions of the intervention was the structure it provides for clients to make their own changes. They recognised that whereas clients who were experienced in ‘self-regulation’ and ‘planning’ and with fewer ‘difficult circumstances’ may find health coaching very ‘accessible’, those who may have a more chaotic lifestyle and are unused to applying structured approaches to their thoughts, feelings and behaviours may find it difficult. Nevertheless for some: Perceptions of being a health coach Finally, the group spoke very positively about their role and identity as health coaches, including the techniques and skills which they saw as applicable to other professional roles. Some coaches also distinguished the health coach experience from what they regarded as their more traditional roles outside of the Health Coaching Service.

“It can be eye-opening and life changing, because they realise their barriers. Knowing how to plan and set a goal can make a huge difference, for some people it can be life changing” Health Coach, A “Taking an interest in somebody, and demonstrating support for their change – it may be years since they’ve really looked at themselves, and it’s time just for them” Health Coach, C “It won’t work where people have little motivation, who maybe have been ‘sent’ along by their nurse” Health Coach, G “Some people want to come back after completing four sessions to focus on one of the other behaviours” Health Coach, D “Being able to facilitate and link people to other services is also a really important aspect. People are getting to be aware of other services too. There is facilitation in such a way that the person is supported by that” Keep Well Programme Manager

“Being a health coach is rewarding. Compared to traditional experiences as an ‘advisor’, health coaching is eye opening - it’s more empowering to use these techniques. It’s a bit of a relief not to tell people (clients) what to do anymore -they never did what you suggested anyway!” Health Coach, A “Knowing health coaching is a good skill to have for future work: it is another ‘arrow to your quiver’, so to speak” Health Coach, F

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Discussion

Progress against key outcomes This review has provided an overview of the health coaching service intervention, including activities and outcomes relating to its implementation in primary care settings in NHS Grampian. The findings can be summarised by relating progress back to the key outcomes of the service, introduced in Health Behaviour Change in Keep Well: An Overview (NHS Grampian 2011).

- Taken up by ‘vulnerable groups’ : The service was designed for people from geographically deprived areas of NHS Grampian (the programme commenced in Aberdeen City) following their Keep Well health check. In this review, 40% of clients seen were those identified by the Keep Well programme. This is the minority because the team have encouraged practitioners to also refer appropriate non-keep well patients. As well as a strategy to initially implement the service, this was because there maybe many experiencing health inequity who do not have a ‘keep well read code’ on their records. Indeed, anecdotal evidence suggested that many who were not identified by the Keep Well programme have social risk factors for poor health outcomes, such as unemployment, mental health issues, or immigrant status. Therefore, the Health Coaching Service is likely to be providing support to ‘vulnerable groups’. As mentioned, take-up in itself has been a major challenge, which is discussed later.

- Client and Practice satisfaction : Feedback has been provided from nearly all

clients and from a range of practitioners from three practices. Clients and practice staff seem highly satisfied with the service, finding the content and approach helpful. For practitioners who refer, health coaching means extra time and support, to add to that provided in a usual length consultation. Clients feel that health coaches value their experiences and choices: this is empowering, and in one or two cases, perhaps even unusual amongst their health service encounters.

- Relevant goals set by clients: All clients in the review decided to set a health-

relevant goal. This suggests the service successfully motivates clients to aim to make a change to one (or more) of the key behaviours for maintaining health: increasing exercise, improving diet, cutting down on alcohol or stopping smoking.

- Improved confidence to make health behaviour change s: All client ratings of

confidence to make health behaviour changes following either one or four sessions of health coaching were above the midpoint on a scale of 1-10, and on average, confidence ratings were higher following session 4 than session 1. Information about confidence before attending health coaching would be useful to further examine whether confidence improves with experience of setting and achieving behavioural goals over the intervention. Written client feedback would suggest this is the case.

- Perceived health behaviour change: Despite the shortcomings of self-reported

‘snapshot’ data collection, there seems evidence of improvements in client self-reported health behaviour between the first and fourth sessions, especially in relation to increases in physical activity. Furthermore, clients reported achieving 86% of all specific behavioural goals set, which in itself is strong evidence of perceived health behaviour change. There was also evidence of other health-related changes, such as statistically significant positive shifts in perceived health, and anecdotal evidence of physiological changes such as weight loss. It is difficult to know whether the 23 (46%) clients who attended just one session made health behaviour changes.

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- Access to other services offered: In keeping with the Keep Well programme, the

Health Coaching Service also aims to connect clients to local services following or additionally to health coaching. 23 recommendations were reported to have been made for 16 clients to attend 6 different services. Furthermore, connect with the NHSG healthpoint service, with two staff now trained as health coaches to conduct health coaching with clients at the Aberdeen Indoor Market healthpoint, which is a venue with a great array of health resources, is an exciting opportunity for increasing access to other information and services.

Challenges As explored throughout this report, uptake of the service has been the main challenge for the implementation of the Health Coaching Service. In each practice, referral volume has been relatively low, especially in the initial few months of a practice using the service. Of course, there are practice factors external to the service which affect likely referral volume, such as volume of Keep Well health checks conducted: if this is high, there will naturally be more opportunities to suggest the service to Keep Well patients. This relates to many other practice factors external to the programme. Yet anecdotally, it seems GPs (who do not usually carry out health checks) are most likely to refer to the service. There may be more work to do to explain and promote the service to the nursing staff, especially as further practices are connected to a health coach in line with the implementation strategy over the coming months. Practices which chose an ‘in-practice’ system (i.e. the practice organises the health coaching service booking system, and sessions are held on-site) were more likely to refer to health coaching. Choosing this system may reflect available space, available administration time or a more general practice interest in the service. Practice D has been especially dedicated, devoting administration time to telephoning clients to remind them to attend, and reminding GPs to refer during weekly meetings. Possibly the actual presence of the health coach at the practice is also a powerful reinforcing factor. For the client, booking an appointment at the practice reception on leaving the surgery and attending health coaching at the surgery is usually more accessible than calling an unknown number to make an appointment at another location. The sharp increase in referrals in the last year coincided with the advent of many of the strategies to increase uptake, suggesting they are having a positive effect, although of course causation is difficult to determine. Certainly, there was more face-to-face contact between the Keep Well team and staff in practices with higher volume: in Practice A, frequent meetings have been held with practice staff with client feedback presented, and in Practice D staff experienced two group sessions of health coaching in successive the PLT training sessions, including setting a behavioural goal and monitoring their progress over a month. These face-to-face activities, as well the more general strategy to create flexible models to suit the practice (with consequences like needing to affix a personalised label for ‘how to make an appointment’ for each patient information leaflet) are time and resource intensive for the Keep Well programme team. Presently, there is no dedicated administration support for the health coaching service. However, with the extension of the Keep Well Programme in 2012 into other vulnerable groups such as the prison population, it is likely that flexible models of delivery will still be needed. In terms of strategies to increase client attendance, the updated client information leaflet is appreciated by both clients and staff. Telephone reminders to clients, whether for the first or final session, seem useful. Anecdotally, on the weeks when the administrator at Practice D has had time to telephone clients beforehand, attendance is approximately

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doubled. More work may be needed to determine why many clients do not return for session 2, when feedback after session 1 seems almost universally positive. It may be that some clients find one session sufficient support, or perhaps for some, not having achieved their set goal may cause fear of disappointing the health coach if they returned, however much the client is reassured in this respect by the health coach beforehand.

Recommendations Several ideas for improving the service, particularly in relation to its uptake, are proposed. These include ideas from the practitioner feedback, from the Keep Well Programme team, and from ideas used to good effect in other services, including in other NHS Boards. The current Health Psychologist in Training is also carrying out a systematic review of behaviour change interventions for low-income groups, to find out which techniques are used to engage people to participate – the findings may add to these recommendations. Improving support to practitioners to refer

• Knowledge and understanding: Practitioners indicated in their feedback that their understanding and knowledge of the service could be enhanced. Staff in Practice D found the experiential health coaching sessions helpful on three counts: for increasing their understanding of the service and thus enhancing ability to refer, for some extra ideas for assisting their patients in lifestyle change during routine consultations, and even to support them personally in making lifestyle changes. Perhaps as an official ‘launch’ for the Health Coaching Service, successive lunchtime events could be held in a convenient venue for practitioners to experience health coaching for themselves. Practitioners could also collect patient information leaflets and practitioner information sheets at this time. This review has also provided further insight into the ‘typical client’ attending health coaching. Sharing this with practitioners may enable them to better identify patients who are interested in attending the service.

• Simplifying the process: Presently, several different booking and appointment models exist, which can be confusing for practitioners, and certainly is time consuming for the Keep Well team who need to make tailored materials for each practice. If all practices had a practice-based booking system and health coach hosted on-site, this may be simpler for clients, health coaches, the Keep Well team and referring practitioners. However, a ‘one size fits all’ model is probably not feasible, especially given the extension of the Keep Well Programme into very different settings such as the two local prisons. Now that two health coaches are trained to deliver in the healthpoint, located in Aberdeen Indoor Market many practices in Aberdeen City will at least be using one ‘healthpoint’ model of booking and attending.

• Cues to help referring: Referring must be quick, easy and memorable. One idea to

increase this is to habitually offer health coaching to every person who comes for their health check, so that health coaching almost becomes an additional stage of the health check. Making attending health coaching a default choice or norm is likely to have a powerful effect (e.g. Dolan et al. 2010) and is a strategy implemented in a similar project in NHS Ayrshire and Arran. The Keep Well health check template could also incorporate a reminder, such as an electronic button ‘refer to health coaching?’ with instructions, as happens on the template with other service like the Smoking Advice Service. Reminders to practitioners made by the Practice Manager at staff meetings are evidently very helpful too.

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Improving client uptake

• Self-referral: Practitioners indicated that self-referral could help increase uptake of the service. This is already possible, with leaflets and posters currently distributed in the waiting rooms. However, advertisement of the service in the local press or on local community radio station SHMU could encourage wider self-referral. Self-referral has been a successful model for another service run by a Health Psychologist in NHS Grampian for people with Diabetes Mellitus.

• Flexibility of appointments: Practitioners and clients have indicated that a wider range of appointments at different times during the week, opportunity to have a telephone session instead of attending in person, and attending in a group might be useful to support clients to attend the health coaching service, and return for the next appointment. Perhaps appointments on a Saturday could be offered at one location such as at the healthpoint, and those who cannot attend during the week could be recommended to this session. These ideas of course have their advantages and disadvantages, which now must be discussed further.

• Reminder telephone calls: Telephone calls by Practice administration staff to

remind clients of their appointment time have been helpful in Practice D.

• Further testing of strategies to reduce non-attenda nce: The psychological strategies to increase client commitment to return, such as clients writing their own next appointment slips, has only been piloted in Practice D. A more rigorous test in several practices to find out if these are effective would be very useful.

Improving effectiveness

• Review appointment: As recommended by the Practice Manager at Practice A, a review appointment some time following the final session may be a useful addition to the service. Simply assessing whether the first four sessions effected changes in the longer-term, as well as offering support for behaviour change maintenance, would be helpful. Steps towards this suggestion have been taken, with plans in place to telephone previous clients at Practice A and invite them for a review appointment in the next two months.

• Data collection: There were several areas in this report where conclusions were limited by data collection restrictions. Improving systems for recording service uptake, confidence before the intervention, official records of factors suggesting ‘deprivation’ such as unemployment, and improved records of health behaviour in particular could help demonstrate the effectiveness of the service. The dietary information recorded has in fact been recently reviewed and improved.

• Community health coaching: In the Health Trainer Initiative in England, (which

was one source used to develop this intervention) community members rather than NHSG staff members are employed and trained as health coaches. This is more in alignment with the community-led activities of the Asset Approach to health improvement. These ‘community champions’ may be better able to reach the ‘hard-to-reach’, and may be very effective in taking a coaching role. More recently, a similar model was implemented successfully in a prison setting in South Staffordshire PCT in England with prisoners taking part in training and providing health coaching to fellow prisoners. This kind of shift in delivery model, at least for some settings, may be ambitious but exciting and rewarding, providing a sustainable model with high uptake and effectiveness.

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Conclusion This review has enabled the Keep Well programme team to share intervention activities and initial outcomes relating to uptake and effectiveness. The experience with the ‘first 50’ clients suggests that the Health Coaching Service is making good progress against its outcomes, notably that clients and practitioners are satisfied and that clients are managing to set and achieve health-related goals, thus improving their health behaviour. The service draws upon and strengthens clients’ assets for change, such as their learning from previous experiences, their motivation and confidence. The Keep Well Health Coaching Service may be a good example of the Asset Approach in practice (e.g. Glasgow Centre for Population Health, 2011). At both practice and client levels, the review presented several ideas for improvement, especially regarding service uptake. Now the Keep Well programme team must use its own assets, including reflection and learning, collaboration and partnership working, enthusiasm and commitment to the intervention, and input from the third trainee health psychologist beginning in Autumn 2012, to build on what has been achieved so far.

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Appendix 1: Health Coaching Service Content and Delivery

Method Content The health coaching model is grounded in the psychological science of behaviour change. Health coaching is based within the social-cognitive framework (Abraham, Sheeran, & Johnston, 1998; Bandura, 1998) which was one of the main approaches discussed in the National Institute for Health and Clinical Excellence guidance (NICE 2007). Social cognitive models which have been shown to explain health-related behaviour include the Health Belief Model (Janz & Becker, 1984), Protection Motivation Theory (Rogers, 1975), Social-Cognitive Theory (Bandura, 1986), Theory of Planned Behaviour (Ajzen, 1991) and Self-Regulation Theory (Carver & Scheier, 1998). Other similar interventions such as the Health Trainer Initiative in England (Department of Health 2004) were also influencial in the development of the Health Coaching framework. In particular, these models can tell us when people are most likely to change. People tend to make a change when they have strong intention (or motivation), self-efficacy (or confidence), and skills in self-regulation to translate their motivation into behavioural performances (Sniehotta, Scholz, & Schwarzer, 2005). Like other interventions which have effectively changed behaviour, clinical variables or overall wellbeing (Abraham, Kelly, West, & Michie, 2009; Sarafino, 2002), the NHSG health coaching model therefore focuses on supporting people to build their confidence, motivation and behaviour change skills. The models can also tell us which psychological tools or procedures people use to build their confidence, motivation and skills, and achieve behaviour change. Everyone is capable of using these tools in a systematic way to achieve behaviour change. These ‘behaviour change techniques’ have recently been identified based, on reviews and expert consensus, in the Health Behaviour Change Competency Framework (Dixon and Johnston 2010). Examples include specific goal setting, keeping a record of the behaviour (self-monitoring), and provision of feedback. These techniques have been demonstrated to be effective in many interventions and reviews of interventions (e.g. Dombrowski et al. 2012; Michie et al. 2009). Therefore health coaching introduces and assists people, through a structured approach, to use the tools systematically to achieve their own goals. Delivery Method One-to-one interventions which are patient-led and goal focussed are often known as ‘health coaching’ interventions. Though different interventions have different theoretical underpinnings, this delivery method has been shown to be acceptable in primary care (Bodenheimer & Laing, 2007), hospital (Vale et al., 2003), and community (Holland et al., 2005) settings. Importantly, there is good evidence of health behaviour change and positive health outcomes following health coaching interventions (Lindner, Menzies, Kelly, Taylor, & Shearer, 2003). Health Coaching interventions vary in session number; four was chosen as a balance between typically low intensity interventions in public health and the higher intensity interventions typically found within psychological services.

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Appendix 2: The Health Coaching Framework in action As previously mentioned, the Health Coaching Framework was developed in 2009 by the Health Psychologist in Training and includes a number of activities to be undertaken by the client and health coach over the four sessions, with some, e.g. action planning, undertaken in each session. The focus is on strengthening the client’s resources, or assets, for change, such as motivation and confidence. Key activities are: 1) Decision balance : Generating alternative courses of action around either making a change or staying the same, and weighing up the pros and cons of each can be a useful technique to help the client decide whether and what to change, therefore building motivation and focusing attention. 2) Overall goal setting : For those clients who decide that they wish to make a change, an overall goal (often a concrete reason for change) is an important source of motivation for the client, and sets out their motivation to attend the service. 3) Action planning (specific goal setting): Specific goals detail the elements of how a health behaviour change can be achieved, and outline one step towards achieving the overall goal. This helps the client to move beyond motivation into taking action. The more specific (detailing where, when and how) the goal is, the more likely it is to be performed. In the Health Coaching Service, clients are supported to set SMART goals – i.e. ones which are Specific, Measurable, Achievable, Relevant, and Timed (to be performed until next week). 4) Self-monitoring : This is introduced once action planning is completed. Recording behaviour to measure progress, such as in a diary, motivates people when they are succeeding, and is informative when they are not, so that future action planning can take into account of times when achieving the goal is more difficult. 5) Identifying barriers and facilitators : In the second session, the client and health coach spend time identifying the behaviours (theirs or others’), emotions, thoughts and situations which influence whether the goal is achieved or not. Strategies are planned to overcome unhelpful factors and involve helpful factors. This increases the likelihood of changes being made. 6) Identifying rewards : In the third and fourth sessions, identifying something of value, e.g. a visit to the cinema, which can be used a consequence of achieving the goal can be useful to increase and sustain motivation 7) Relapse prevention : In the fourth session, the client and health coach discuss the process of change over the long term, including that lapses are common and discuss how to plan for potentially tricky events as well as how to quickly get back on track after a slip. This increases the likelihood that changes can be sustained. 8) Offering access to other services : An important part of the keep well programme more widely is to connect patients with other local health or community services if appropriate. Health Coaches therefore have supporting materials and information for other services to share if appropriate. An intervention’s effectiveness cannot be tested unless health coaches are adhering to the framework. This intervention fidelity is reported on in page 19-20.

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Appendix 3 : Table comparing client health behaviour in

session 1 and final session

Measure

First session

Final session

Number of smokers 1 1 Number of cigarettes per day 5 0 Number of cigarettes per week

35 1

How many times stopped smoking?

1 2

Last time stopped smoking? 14 years ago 2 weeks ago Currently drink alcohol? 11 12 Mean units alcohol per week (whole sample)

7 6

Mean minutes moderate activity per week (whole sample)

223 192

Mean minutes vigorous activity per week (whole sample)

55 63

Mean days eating fruit per week

5 6

Mean days eating vegetables per week

6 6

Mean days eating fried food per week

2 1

Mean days consuming high fat dairy per week

3 3

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Appendix 4: References

1. Abraham, C., and Gardner, B. (2009). What psychological and behavior changes are

initiated by ‘expert patient’ training and what training techniques are most helpful?

Psychology and Health, 24(10), 1153-1165.

2. Abraham, C., Kelly, P., West, R., & Michie, S. (2009). The UK national institute for health

and clinical excellence public health guidance on behaviour change: A brief introduction.

Psychology, Health & Medicine, 14(1), 1-14.

3. Abraham, C., Sheeran, P., & Johnston, M. (1998). From health beliefs to self-regulation:

Theoretical advances in the psychology of action control. Psychology and Health, 13(4),

569-591. Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and

Human Decision, 50, 179-211.

4. Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory.

Englewood Cliffs, NJ: Prentice-Hall.

5. Bodenheimer, T., & Laing, B. Y. (2007). The teamlet model of primary care. Annals of

Family Medicine, 5(5), 457-461.

6. Carver, C. S., & Scheier, M. F. (1998). On the self-regulation of behaviour. New York:

Camebridge University Press.

7. Cialdini, RB. (2009). Influence: Science and Practice (5th dn) Boston: Allyn and Bacon

8. Department of Health (2004). Choosing health: Making healthy choices easier. London:

Crown Copyright.

9. Dixon, D., & Johnston, M. (2010). Health behaviour change competency framework:

Competencies to deliver interventions to change lifestyle behaviours that affect health.

Edinburgh: NHS Health Scotland. Retrieved from:

http://www.healthscotland.com/documents/4877.aspx

10. Dolan, P., Hallsworth, M., Halpern, D., King, D., Vlaev, I. (2010). Mindspace: Influencing

behaviour through public policy. Institute for Government and the Cabinet Office: London.

11. Dombrowski SU, Sniehotta FF, Avenell A, Johnston M, MacLennan G, & Araujo-Soares V.

(2012).Identifying active ingredients in complex behavioural interventions for obese adults

with obesity-related co-morbidities or additional risk factors for co-morbidities: a systematic

review. Health Psychology Review, 6, 1: 7-32.

12. Glasgow Centre for Population Health (2011). Asset based approaches for health

improvement: Redressing the balance. Glasgow Centre for Population Health: Glasgow.

13. Holland, S. K., Greenberg, J., Tidwell, L., Malone, J., Mullan, J., & Newcomer, R. (2005).

Community-based health coaching, exercise, and health service utilization. Journal of Aging

& Health, 17(6), 697-716.

14. Idler,E., and Stanislay, K. (1991). Health Perceptions and Survival: Do Global Evaluations

of Health Status Really Predict Mortality? Journal of Gerontology: Social sciences, 46 (2):

S55-65.

15. Janz, N. K., & Becker, M. H. (1984). The health belief model: A decade later. Health

Education Quarterly, 11(1), 1-47.

38

16. Lindner, H., Menzies, D., Kelly, J., Taylor, S., & Shearer, M. (2003). Coaching for behaviour

change in chronic disease: A review of the literature and the implications for coaching as a

self-management intervention. Australian Journal of Primary Health, 9(3), 177 - 185.

17. Martin, S.J., Bassi, S., and Dunbar-Rees, R. (2012). Commitments, norms and custard

creams: A social influence approach to reducing did not attends (DNAs). Journal of

Research in Social Medicine, 105: 101-4.

18. Michie, S., Abraham, C., Whittington, C., and McAteer, J. (2009). Effective techniques in

healthy eating and physical activity interventions: a meta regression. Health Psychology, 28

(6), 690-701.

19. Michie, S., Abraham, C., Eccles, M., Francis, J., Hardeman, W., Johnston, M. (2011).

Strengthening evaluation and implementation by specifying components of behaviour

change interventions: a study protocol. Implementation Science, 6, 10.

20. Michie, S., Richardson, M., Johnston, M., Abraham, C., Francis, J., Hardeman, W., Eccles,

M. (In preparation). Consensus development of an 84-item taxonomy of behaviour change

techniques (Working title).

21. Miller, W.R. and Rollnick, S. 2002. Motivational Interviewing: Preparing People to Change.

New York: Guilford Press.

22. National Institute for Health and Clinical Excellence. (2007). Behaviour change at

population, community and individual levels. London: NICE. Accessed from

http://www.nice.org.uk/nicemedia/pdf/PH006guidance.pdf

23. NHS Grampian (2011). Health Behaviour Change in Keep Well: An Overview. Accessed

from: http://www.hi-netgrampian.org/hinet/file/6919/KWHealthBehaviourChange.doc

24. Rogers, R. W. (1975). A protection motivation theory of fear appeals and attitude change.

Journal of Psychology: Interdisciplinary and Applied, 91(1), 93-114.

25. Sarafino, E. P. (2002). Health psychology: Biopsychosocial interactions (4th ed.). New

York: John Wiley & Sons.

26. Scottish Executive (2005). Delivering for health. Edinburgh: Scottish Executive. Accessed

at: http://www.scotland.gov.uk/Publications/2005/11/02102635/26389

27. Scottish Government (2007). Better health better care: Action plan. Edinburgh: Scottish

Government. Accessed at: http://www.scotland.gov.uk/Publications/2007/12/11103453/0

28. Scottish Government (2007). Equally well: Report of the ministerial task force on health

inequalities. Edinburgh: Scottish Government. Accessed at:

http://scotland.gov.uk/Publications/2008/06/25104032/16

29. Scottish Government (2010). The Scottish Health Survey. Edinburgh: Scottish Government.

Accessed at: http://www.scotland.gov.uk/Topics/Statistics/Browse/Health/scottish-health-

survey

30. Sniehotta, F. F., Scholz, U., & Schwarzer, R. (2005). Bridging the intention-behaviour gap:

Planning, self-efficacy, and action control in the adoption and maintenance of physical

exercise. Psychology & Health, 20, 143-160.

31. Vale, M. J., Jelinek, M. V., Best, J. D., Dart, A. M., Grigg, L. E., Hare, D. L., et al. (2003).

Coaching patients on achieving cardiovascular health (COACH): A multicenter randomized

trial in patients with coronary heart disease. Archives of Internal Medicine, 163(22), 2775-

2783.