The growing gap of health and wealth inequity in the United States calls for renewed focus and new strategies to improve health outcomes for the poorest among us. At the same time, the ongoing economic and financial downturn has placed significant burden upon state and local public health departments and community agencies that aim to reduce health disparities among underserved populations.1
According to the US Census Bureau, the number of poor increased by 3.7 million from 2008 to 2009, with one-third of those being children. Addressing the socioeconomic determinants of health is critical for slowing current trends.2 However, what is often left out of public discourse is the recognition that lifestyle improvement is a two-step of personal responsibility along with sociocultural support. While communities need to provide cost-effective means for providing health services, accessing those services remains the responsibility of individuals or families who are ultimately the ones who muster the motivation and inner resources to make positive changes. That is where a health coach may prove most valuable.
Health coaching is a rapidly growing nonclinical health profession that offers an accessible, client-centered, holistic approach to changing attitudes, behavior, and lifestyles habits of individuals for improved health and well-being. The coach builds a trusting alliance with clients, helping them evoke their own goals from within, discover inner strengths and capacities, build action plans, and monitor progress.
Insurance reimbursement for health coaching is not universally available at this time, although employers are beginning to offer health plans (eg, Kaiser, Aetna, United) that feature two or three sessions with a telephonic health coach. Aside from the employee who may receive sessions with a health coach through an employer-sponsored health plan, health coaching is customarily an out-of-pocket expense. Those who take advantage of coaching services are usually educated, higher-income individuals who choose to enter into a contract with a health coach just as they would with a personal fitness trainer.
For the underserved, minorities, the unemployed, and the poor, not only is there an absence of financial or social incentives but it is often assumed that there is a diminished capacity for making healthful changes due to a lack of resources to fall back on as well as the need to cope with hardship and basic survival needs. Therefore, despite the fact that health coaching occupies the most affordable rung of the healthcare ladder, it remains largely inaccessible for low-income or poverty-level individuals and families who suffer a disproportionate number of health disparities.
The lower the socioeconomic status in terms of income, education, and occupation, the poorer the state of health. The disadvantaged suffer an increase in chronic stress (higher allostatic load), higher blood pressure, and unhealthy body mass index and may even suffer more DNA damage as indicated by shorter DNA telomere length.3 Socioeconomic status shapes social norms and the physical environment by exposing people to more toxins and limiting access to health-care and health insurance. Low socioeconomic status directly affects behavior that affects health and illness.
The most vulnerable are often criticized for an over-dependency on social programs such as Medicaid and the Special Supplemental Nutrition Program for Women, Infants, and Children, although after the welfare reforms of the Clinton era, research shows that the majority of recipients have part-time employment. Still, proposed draconian budget cuts in upcoming federal, state, and local public health budgets will affect the poorest, most vulnerable families.4
A RADICALLY DIFFERENT CONVERSATION
The premise for this project, Health Coaching for the Underserved, was somewhat audacious: What if a poor man or woman on the street were talked to about improving his or her lot in life just as an executive coach would talk to chief executive officers about pursuing their strategic plans? The tone and character of the conversation might be respectful and regard the client as capable, resourceful, and whole. The social conditioning of healthcare personnel to regard the person as someone needing to be treated, cured, or “fixed” would be bypassed. Coaches are trained to think that the optimal solutions for whatever problems exist are usually within the clients themselves. Contrary to medical models, the coach would follow the client’s agenda, even if that seemed questionable to the coach—again, a counterintuitive approach for healthcare personnel. Coaching conversations support the client discovering his or her own values, purpose, and goals.
Not only does this entail a shift, it comprises a radically different, day-to-day experience for the poor as they attempt to access care and receive health services. When this project was posed to the first four homeless men by the researcher/author, their reactions were filled with disbelief and sarcasm. One homeless man responded, “You’re gonna coach me like I’m a rich guy? Like I’m the man? Yeah, right.”
No prior data were available regarding how the coach ing conversation, composed of powerfully evocative questions, might influence homeless, underserved minorities or low-income individuals of diverse race, gender identification, ethnicity, and immigrant status. Research shows that public attitudes toward low-income and welfare recipients may have improved since 2003, yet the primary social interactions that the homeless and vulnerable have with health and social service authorities remains top-down in delivery and directive in tone, with expert-driven dispensation of health information. This style often fails to evoke from the individual any intrinsic motivation or life-changing, health-enhancing behavior.
In the best of cases, public health and social service workers are trained in motivational interviewing (MI) techniques, which bring a nonjudgmental atmosphere to the client-practitioner relationship.5 Barriers to resistance are recognized and not confronted but “rolled with” in a way that keeps the conversation going and the client fairly engaged until the possibility for change can be manifested.6,7 For the populations discussed in this case report, a coaching methodology with MI techniques was employed in the one-on-one sessions. It proved particularly useful in coaching individuals diagnosed with mental health problems and substance abuse. MI has a solid record of effectiveness for individuals struggling with addictions.