Transcript Hello everyone,
my name is Kathleen Ryan and you're very welcome to our talk, 'Understanding How eHealth Coaches
Tailor Support For Weight Loss: Towards the Design of Person-Centered Coaching Systems'.
This work was completed in University College Cork, alongside Samantha Dockray and Conor
Linehan, and it was supported by the Irish Research Council and S3 Connected Health.
Obesity is a population-wide public health concern as it confers a higher risk of developing
chronic diseases, but may be mitigated for individuals as even modest weight loss can
have a beneficial impact on health. Weight loss interventions have typically included frequent
in-person contact with a health practitioner who provides individualized goals and strategies to
help people to change their behaviors. However, to achieve large-scale public health impact, the
geographical, accessibility and economic barriers of in-person interventions must be overcome.
Tailoring is one strategy to deliver content at scale in a personalized manner that has
been identified as being effective in weight loss interventions. The process of tailoring,
as outlined by Noar and Harrington, typically involves an assessment of individual
characteristics associated with a specific health outcome, gathered by a trained interventionist,
or self-administered. The information is processed by either the interventionist,
or an expert system that uses decision rules to select content from an expert-developed database.
More recently, context-aware systems for tailoring use wearables, sensors and smartphones that
enable passive data gathering to provide personal intervention to the individual, that is sensitive
to their changing internal and external states. This process produces personally-relevant
information, advice and behavior change techniques matched to the individual recipient.
However, in spite of their promise to deliver health behaviour change interventions at scale,
tailored systems do not attain the same level of effectiveness for weight loss as in person
interventions. To improve the design of tailored systems therefore it is essential to study in
detail the practice of human interventionists. One model of providing behaviour change interventions
that has gained momentum in recent years is health coaching. Health coaching is defined as
a patient-centered approach wherein patients at least partially determine their goals,
use self-discovery or active learning processes together with content and education to work
toward their goals, and self-monitor behaviors to increase accountability, all within the context
of an interpersonal relationship with a coach Recent evidence suggests that more explorations
of how technology can support the health coaching relationship are required, focusing on the ability
of coaches to tailor support to user needs, balanced with cost of resources and delivery.
Relative to inperson coaching, eHealth coaching is delivered by human health coaches via email,
web-based video coaching, apps, and smartphones; its key processes are data collection, analysis
of data and recommendations (i.e., sending the right message at the right time in the right
context for the individual), as well as data security. Compared to traditional in-person
coaching sessions, eHealth coaching sessions are more time-efficient, and more cost-efficient.
They've also been found to be more motivating and more engaging than more automated approaches.
As such, our research question was: how do eHealth coaches tailor support to
individuals to help them to lose weight? Nine eHealth coaches (3 women and 6 men)
were recruited through Facebook and Twitter. They were eligible to take part if they: supported
clients in behavioral weight loss, and if they reported using technologies to deliver coaching.
Indepth, hour-long, one-to-one interviews were conducted in-person or via videocall,
depending on what suited the participant. The research questions involved a discussion of the
specific aspects the health coach enacted over the course of their work. Reflexive Thematic analysis
(TA) was chosen as a method for systematically identifying, organizing and obtaining insights
into patterns of meaning across a data set.
We identified three themes in understanding how eHealth coaches tailor support to individuals seeking to lose weight.
The first theme was 'Understanding the client'. This involved an in-depth assessment of various
variables associated with weight loss, e.g., anthropometric measurements, diet,
level of physical activity, as well as other key health-related factors, including sleep
and stress. More importantly however, was the need to have an initial synchronous
conversation with the client, to ascertain their specific needs and goals in the coaching process,
their weight loss goals and personal information (including marital status, job, personal values,
number of children). This information shaped the nature of support that was provided, as well as
the content of the intervention (e.g., framing advice differently for clients who were parents).
It also determined the fit between the coach and client and whether the relationship would work.
The other aspect of this assessment was an ongoing egalitarian relationship built on mutual respect,
with regular two-way communication. It involved the coach being autonomy-supportive (providing
options, supporting client to find activities they enjoy). It went beyond offering content or
strategies for behaviour change, and included: asking open questions and active listening,
being an enthusiastic, passionate coach who instilled confidence in their weight loss approach,
as well as having normal conversations, (not just weight loss related ones) to build rapport.
Our second theme was 'Adapting support' and related to how health coaches adapted the
nature of their support and their manner of relating to the client,
based on their understanding of each individual. For example, to understand the
pace of learning and detail of educational content appropriate for each individual,
coaches gauged their client's need for information or the depth of knowledge required by the client.
The type of support changed over time, to allow the client to move from directional support
to promoting their independent thinking in navigating behaviour change.
Coaches also adopted different personas relative to the client in front of them,
moving from a more jokey style for example for certain clients to more sensitive and reassuring
in manner for others. Coaches also adapted their use of technology platforms for communication
and whether or not they use tracking tools - based on digital literacy of the individual.
Our final theme was 'Navigating challenges', and related to how eHealth coaches experienced
challenges in their practice, highlighting the burden of care in providing tailored support. For
example, some eHealth coaches' personal boundaries were eroded by the process of providing tailored
support. They discussed having an 'always on' mentality, as they were contactable over a range
of online platforms at any time and because they were so empathetic, they felt compelled to provide
support. Other challenges included high caseloads and pressure to attain weight loss outcomes for
clients, as well as angry or disrespectful clients or those with mental health issues,
requiring more complex care that the coach was not equipped with due to a lack of psychological
training. We have provided further detail on each of these themes in Summary Table 1 in the paper.
To conclude, tailoring as it is conducted by human health coaches is much more nuanced than theory
would suggest, therefore presenting a challenge to implement it in a purely automated way in systems design. In the article
we draw a distinction between a tailored vs a person-centred approach, highlighting
the concept of tailoring depth or degree of personalization. To move towards the goal of
person-centred coaching systems, in the article we contribute a detailed summary of how in-depth
tailoring occurs in the context of supporting clients to lose weight, which can be used,
adapted, and tested in the creation of future tailored systems to strive for enhanced engagement
and optimal health outcomes. A person-centred design must also consider reducing the burden of
tailoring on the health practitioner who is trying to deliver a personalized intervention. In the
article we present design guidance to cultivate the relationship between the coach and client to
produce optimal personalization, while maintaining personal and professional boundaries.
Thank you for your attention. I'm happy to take any questions now or feel free to contact me by
email or Twitter. For more details you can see the paper and the reference is on-screen. Thank you.