To our knowledge, the “Health Coaching” project is the first multidimensional, patient-centred and systematic approach to foster GPs’ counselling about health relevant behaviour. The high participation rate at baseline and the above-average adherence rates throughout the 4-step counselling process are strong indicators of acceptance and feasibility of our approach, as are the high ratings related to these topics from the patients’ and GPs’ questionnaires and interviews. For GPs, 1–2 starting sessions and 2–3 complementary (Step 2–4) sessions per week should present an acceptable supplementary workload in their practices, and the counselling times (8 to 22 minutes) still meet the criteria of a short intervention and cost-effectiveness.
We were encouraged by the patients’ high self-ratings of motivation and readiness to change at baseline. The Health Coaching programme appears to have met patients’ needs, traditionally unmet and undervalued, with respect to discussing health promotion topics with their GPs. The fact that the ratings of importance, self-confidence (to reach the goal), and readiness to change increased during counselling underlines the efficacy of our approach, although selection bias might limit the validity of these findings (see below).
The use of colours in our pictorial tool provided patients with an important reference point regarding the severity of risk. In this colour coding, the colour red denotes urgency (even danger) and the necessity to discontinue the behaviour, whereas the green colour denotes “no risk” [17]. This coding system relies on what most of us learn early in our childhood: the symbolism of traffic light colours. In the meantime, many risk calculators are using colour-coded tables or output categories [18]; consequently, this method of communication has become familiar. Patients seem to feel a need to compare themselves to an average value (or population) [19], and the result may improve their motivation to change, or, equally important, when they report being in the healthy (green) range, this can help them to sustain existing or recently acquired beneficial habits.
The main finding is an improvement in self-rated health behaviour by at least one of two possible levels in half of the participants in the Health Coaching programme; those showing no behavioural improvement reported some benefit as well. This benefit translates into an increase in awareness, perceived self-confidence, and readiness to take responsibility. In comparison to other preventive interventions, the “number needed to treat” (NNT) in our intervention to achieve a successful change of health behaviour, is low. In order to change behaviour successfully in one patient, we had to invite six patients to participate (one in three participants completed the four counselling steps, and one in two completers changed their behaviour successfully). The positive effects observed in the participants who did not complete the programme or in participants who did not report improvement are additional positive outcomes; this further improves the effort to benefit ratio.
Although acceptance and feasibility were high, research is needed to elucidate barriers among patients and GPs against the use of programmes similar to our’s, and to identify factors that may promote and facilitate this sort of approach. We suggest exploratory studies with focus groups, and interviewing techniques focusing on these factors. More studies with a randomised controlled design and a longer follow-up period are needed to establish objective and clinically relevant outcomes. Finally, the cost effectiveness of the Health Coaching programme will have to be investigated, by means of health services research, for example, on how biomedical or surgical interventions can be avoided by successful health behaviour changes in response to counselling.
In sum, our programme is innovative and atient-centred. It appeared to be well accepted by patients and GPs, and highly feasible in a primary care setting. To publicise this approach and programme among GPs, several issues need to be addressed. These include the smooth integration into busy office schedules and doctors’ workload, as well as the introduction of appropriate reimbursement for the counselling sessions. Sharing counselling activities with other health professionals, e.g. practice staff, may be one way to facilitate this. The extension of health behaviour change competencies is necessary at various levels: in the education of physicians (undergraduate and postgraduate training, as well as in continuous medical education); in practice-based research; in medical associations, in order to recognise these skills as basic medical competencies; and in the support of health policymakers at the legislative, executive, and regulatory levels. Finally, extending our Health Coaching programme to other healthcare professionals, including non academic professionals, is a promising option in order to promote its effects. Feasibility studies to explore this topic and access to it are necessary [20].
Limitations
Our feasibility and acceptability study was run in one region of Switzerland, with a relatively small number of GPs; therefore, the results have limited generalisability. Most outcomes were self-reports rather than clinical outcomes, as we did not have the intention nor the means to conduct a randomised controlled trial to measure the clinical effects of the intervention, but, rather, to test our approach and its acceptance and feasibility.
We cannot exclude selection bias owing to the way in which GPs and patients were recruited: GPs with a higher motivation for counselling activities in health behaviour may have been more inclined to accept the invitation, and patients willing to participate may have been more motivated to start counselling and undertake activities to change their behaviour than those who declined. The unexpectedly high rates of motivation (preparation stage of the TTM model) for a change at baseline may be an indicator of a possible bias. However, the fact that only 9% of invited patients declined participation minimises this possible bias, and the proportion of invited patients who highly appreciated a discussion about their health behaviour with their GPs (three out of four) was not significantly different from an average European general practice population [21]. Without a randomised controlled study, it is difficult to estimate the size of this selection bias, and the main focus of our study was the feasibility and acceptance.
In regard to the pictorial risk communication tool, it was not our intention to validate the tool independently of the counselling effect. A full validation would require a randomised controlled design and a separation of communication tool and counselling as interventions. Regardless, we included patient ratings and GPs’ comments about the pictorial tool in the evaluation.
