The growing gap of health and wealth inequality in the United States calls for renewed focus and fresh strategies in improving health outcomes for the poorest among us. At the same time, the ongoing economic and financial downturn has placed a 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 impoverished citizens 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 the current trends.2 However, what is often left out of public discourse is the recognition that lifestyle improvement is a two-step process of personal responsibility and sociocultural support. While communities need to provide a cost-effective means of 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 to be most valuable.
Health coaching is a rapidly growing nonclinical health profession that offers an accessible, client-centric approach to changing attitudes, behavior, and lifestyles habits of individuals holistically for improved health. The coach builds a trusting alliance with clients, helping them complete their goals, discover inner strengths, 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 (e.g. 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 healthy changes due to a lack of resources to fall back on. Therefore, despite the fact that health coaching occupies the most affordable rung of the healthcare ladder, it remains largely inaccessible for low-income individuals who suffer a disproportionate number of health disparities.
In terms of income, education, and occupation, the lower the socioeconomic status the poorer the state of health. The disadvantaged suffer an increase in chronic stress (higher allostatic load), high blood pressure, and unhealthy body mass index, and they 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 healthcare and health insurance. Low socioeconomic status directly affects behavior that affects health and illness.
The most vulnerable are often criticized for an over-dependence 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 at least part-time employment. Still, the 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 was talked to about improving his or her lot in life just as an executive coach would talk to CEOs about pursuing their strategic plans?” The tone 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, as a result, be bypassed. Coaches are trained to think that the optimal solutions for whatever problems exist are fully within the reach of 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 in discovering his or her own personal 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 and receive healthcare. When this project was posed to the first four homeless men by the researcher, their reactions were filled with disbelief and sarcasm. One homeless man responded with, “You’re gonna coach me like I’m a rich guy? Like I’m the man? Yeah, right.”
No prior data was available regarding how the coaching conversation, composed of powerfully evocative questions, might influence the homeless, underserved minorities or low-income individuals of every race, gender identification, ethnicity, and immigrant status. Research shows that the public attitude toward low-income and welfare recipients may have improved since 2003, yet the primary social interactions that the homeless and vulnerable have with healthcare and social service authorities remains rock bottom in delivery. 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 that 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 during the one-on-one sessions. It proved particularly useful in coaching individuals diagnosed with mental health problems and substance abuse. MI also has a solid record of effectiveness for individuals struggling with addictions.