Dialing In: Effect of Telephonic Wellness Coaching on Weight Loss | Page 1
Published Online: February 25, 2014
Min Tao, PhD; Krishna Rangarajan, MS; Michael L. Paustian, PhD, MS; Elizabeth A. Wasilevich, PhD, MPH; and Darline K. El Reda, DrPH, MPH
Obesity poses a substantial threat to the US health and healthcare system.1 Among adults, higher morbidity in association with being overweight or obese has been observed for hypertension,2-4 type 2 diabetes,5-8 coronary heart disease, stroke, respiratory problems, and some types of cancers.9-16 Epidemiologic studies have shown that mortality increases with body mass index (BMI) values above 30.17-19 Consequently, obesity has conferred a significant economic burden for the nation.20 A wide variety of programs have been developed to address the obesity issue in the United States, including wellness coaching programs.
In wellness coaching programs, wellness coaches assist individuals to establish and work toward health-promoting goals using techniques such as motivational interviewing.21 Telephonic wellness coaching offers the personalized focus and discussion, while avoiding common barriers for on-site consultations such as inadequate transportation or lack of childcare. Telephonic coaching programs have been used to address a variety of health behaviors including smoking, nutrition, and weight.22-25
Evidence for the effectiveness of telephonic coaching on weight loss is limited, with only a few studies having demonstrated a small but positive effect.24,26,27 Previous published studies have largely not provided details on participant or intervention factors that may mediate the outcomes of such coaching programs. The goals of this study are to estimate the effect of telephonic coaching on weight loss in a large, commercially insured population and to evaluate how a participant’s initial stage of change, motivation level, and intensity of coaching program received impact weight loss among wellness coaching participants.
Telephonic Wellness Coaching Program
This study assesses a health plan-administered telephonic wellness coaching program that consists of 4 telephone calls designed to help participants reduce risk factors through health education and behaviorchange counseling. During the initial telephone contact, health coaches review the top 3 risk factors identified on each participant's health assessment questionnaire. Health coaches also assess each participant's readiness to change, level of motivation to change, and perceived barriers to adopt healthy lifestyle behaviors.
Initial stage of change is determined by asking participants how ready they are to make changes to improve their health on a scale of 1 to 10. If participants respond with a score between 1 and 4 and show characteristics of not considering change, feeling no control, or believing consequences not to be serious, the health coach will classify them as precontemplation. If participants respond with a score between 5 and 7 and have considered the benefits and costs of their health behaviors as well as proposed changes in behaviors, the health coach will classify them as contemplation. For participants who respond with a score between 8 and 10, having experimented with small changes will lead to classification as being in the preparation stage; having demonstrated definitive actions to change will lead to classification as being in the action stage; and having definitive actions over an extended time period will lead to classification as being in the maintenance stage.
After the assessment, health coaches work with each participant to create an action plan that includes personalized health-related goals, actions the person will take, strategies for coping with perceived barriers, and identification of who might support them with their efforts. The action plan is mailed to the program participants. During subsequent calls, the health coach discusses progress, barriers and action items with the participant. The length of each phone call ranges between 10 and 20 minutes.
The health coaches that deliver the intervention can be registered nurses, registered dietitians, exercise physiologists or health educators. Several approaches are taken to ensure quality and consistency of interventions being delivered. First, health coaches are required to have a bachelor's or master's degree with additional training in motivational interviewing and certification such as Chronic Condition Professionals from the Health Sciences Institute. Second, health coaches receive ongoing trainings which utilize cognitive behavioral therapy modules. The trainings include classroom training, 1-on-1 instruction, and mentoring by an established coach. Third, fidelity to the program is assessed through randomly recorded phone conversations between health coaches and participants to ensure that the delivery of the program is consistent across health coaches and follows established policies and procedures.
Employers purchase the wellness coaching program benefit for their employees from the health plan. The eligible employees are required to complete an annual health assessment questionnaire at the beginning of each benefit year in order to receive program-related incentives provided by employer groups. The incentives vary across employers from lower office visit and prescription co-pays to gift cards. Health assessment questionnaire respondents are first prioritized for case management or disease management. Disease management is a nurse-administered, telephonic program that targets patients with 1 of 5 chronic diseases: asthma, ischemic heart disease, chronic obstructive pulmonary disease, diabetes, or chronic heart failure, and focuses on chronic disease selfmanagement. Case management is a nurse-administered, telephonic program that targets patients with complex medical needs and focuses on coordination of care. The prioritizing processes for disease management and case management are separate from the health assessment. For respondents who neither need disease management nor case management but have 3 or more risk factors identified via questionnaire, these respondents will receive outbound calls from an engagement specialist to enroll them in the wellness coaching intervention. Individuals who have few risk factors identified via questionnaire do not receive outreach to participate in the wellness coaching program, but are encouraged to use the health plan’s online health tools to maintain good health.
Health Assessment Questionnaires
During the course of the study period, there was a change in the health risk assessment questionnaire administered by the health plan. The University of Michigan Health Risk Appraisal (HRA) was used through May 200928; afterward the StayWell Health Media Health Assessment (HA) was used.29 This change in health assessment questionnaires reflects a business decision of the health plan and not of the authors, who conducted the evaluation retrospectively. The HRA consists of 47 questions while the HA consists of 150 questions. Common health risks assessed by the 2 questionnaires include body weight, existing medical conditions, physical activity, nutrition, alcohol, smoking, stress, safety belt use, skin protection, absenteeism at work, perceived health, and overall life satisfaction. On each instrument, respondents also report their race/ethnicity, gender, level of education, and motivation to lose weight. Although both questionnaires assess similar health risks, the wording of the questions and answers differ markedly. For example, the HRA asks “Do you have heart problems? (Never/Have Currently/In the Past)” while the corresponding HA question is worded as “Have you been diagnosed with coronary heart disease? (Yes/No).” For this evaluation, we only used questions from the 2 questionnaires that could be reconciled to allow consistent measurement over time.
As shown in the Figure, 40,222 individuals responded to 2 questionnaires at least 6 months apart from 2008 to 2010 for our pre-post evaluation. The average time between baseline (T1) and follow-up (T2) questionnaires was 385 days (approximately 1.05 years) with a standard deviation of 70 days. BMI was calculated from responses to height and weight questions on these surveys. Overweight was defined as a BMI between 25 kg/m2 and 29.9 kg/m2 and obesity was defined as a BMI of 30 kg/m2 or greater. Among respondents, 16,178 (40%) were considered overweight or obese at baseline. Of the overweight and obese respondents, 5653 (35%) were referred for a wellness care management (WCM) program during the study period between baseline and follow-up; 8922 (55%) did not receive any referral during the study period, and 1603 (10%) received a referral, but outside of the period, and thus were excluded from the analysis. Two percent (2%) of the adults who reported a more than 2-inch difference in their height across the 2 time periods were excluded from study population due to potential data quality concern. Respondents with complete data on weight, height, age, gender, race/ethnicity, level of education, motivation to lose weight, smoking status, and comorbidities were used for the analysis. The final study population was divided into 3 groups. The intervention group consisted of obese or overweight respondents targeted for the telephonic wellness coaching program (N = 1448, including 1050 participants and 398 nonparticipants). The 2 comparison groups were overweight or obese respondents: (1) not targeted for any telephonic WCM program (N = 7586) and (2) not targeted for telephonic wellness coaching, but targeted for other WCM programs, primarily disease management (N = 1270).
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