Among the numerous issues surrounding health care in America is one that is acknowledged but not well-understood, non-compliance. There have been a number of studies in the health care industry that point out that many individuals cannot or will not follow through with agreed upon treatment plans including continuing drug prescriptions and following doctors recommendations. As with all human behavior issues, the reasons are varied and complex. The purpose of this paper is to explore possible remedies for this difficult problem. We think part of the solution is in applying methodologies from other disciplines that are focused on assisting the individual to make the changes necessary to improve their health, methodologies such as "coaching."

Coaching, to motivate, influence, compel or persuade, has long been used to change executive and employee behavior in corporations. Executives, whose success depends on their ability to persuade and influence both internal and external audiences, must be able to communicate effectively. The goal of these coaching programs is to develop effective skills in persuasive internal and external communications; to assess personal style and hone presentation skills that result in strategic, precise, persuasive, and motivating messages; and to explore a variety of best practices, ranging from the development of a communications strategy to the actual delivery of a message.

Using these corporate coaching programs as a model, another kind of coaching has evolved to meet the needs of those who are attempting to make more healthful lifestyle choices. This kind of coaching is known by many names [healthy lifestyle coaching, motivational interviewing, co-active coaching]. The goal of this kind of coaching is to help people develop more healthful lifestyles and to make and act on decisions either to prevent or to better manage chronic diseases and conditions such as cardiovascular disease, diabetes or obesity.

Healthy lifestyle coaching is designed to help people either prevent or effectively manage lifestyle risks and chronic conditions. To that end, for example, the Minnesota Department of Health has published Healthy Minnesotans: Public Health Improvement Goals 2004 [1998]. This document defines and makes explicit the goals that Minnesotans need to adapt in order to develop a healthier lifestyle. The document provides 3 areas of opportunity as well as the 18 identified public health improvement goals. The report points out that what we do collectively, in our communities and personally, will move us as individuals, as communities and as a state toward a healthier future. Among the Minnesota Public Health Improvement Goals are 2 that relate directly to the issue of helping patients improve their health by understanding and complying with proper treatment:

• Reduce the behavioral and environmental health risks that are primary contributors to unintentional injury;
• Promote early detection and improved management of non-infectious disease and chronic conditions;

Stages of Change and the Transtheoretical Model
What do we know about the stages of change and how people change their lifestyles? The Transtheoretical Model, developed by Prochaska and his colleagues, is an extremely powerful model that tells us a great deal about how people prepare to change their lifestyles and how they can change successfully. Prochaska and his colleagues have used these stages of change to examine such lifestyle changes as smoking cessation, exercise and supplements to prevent osteoporosis, exercise adoption, diet change, quitting cocaine, weight control, high-fat diets, adolescent delinquent behaviors, safer sex, condom use, sunscreen use, radon gas exposure, exercise acquisition, mammography screening, physicians' preventive practices with smokers, substance abuse, psychotherapy and much more [Prochaska et. al., 1994; Rosen, 2000; Smith, Subich and Kalodner, 1995; Morera et. al. , 1998; Nezami et. al., 2003; Adams and White, 2003; Haggerty and Goodman, 2003; Goldberg, Hoffman and Anel, 2003; Goldberg, Hoffman and Anel, 2002; Spencer et. al., 2002; Froelicher and Kozuki, 2002; Burbank, Reiber, Padula and Nigg, 2002; Konkle-Parker, 2001; Enguidanos, 2001; Sutton, 2001; Cole, 2001; Patten, Vollman and Thurston, 2000; Zimmerman, Olsen and Bosworth, 2000, Burbank, Padula and Nigg, 2000] . This powerful model has also generated thousands of other research projects and publications, a measure of how truly robust this model is.

The stages of change are pre contemplation [person not contemplating change and may be totally unaware of the need to make the change], contemplation [person is aware and is contemplating making the change, e.g. concerned about the health impacts of smoking], preparation [person is making the preparations needed to make the change, e.g. setting a date to quit, enrolling in a smoking cessation program, speaking with the family physician], action [person is taking action to actively make the lifestyle change a part of her or his life] and maintenance [person has successfully made the change and is able to maintain the changed lifestyle] [Prochaska et. al., 1994]. In one quick assessment of the stage of change, it is simple to ask the person to place herself or himself on a scale of 0-10, where 0 = not at all motivated to make this lifestyle change and 10 = very motivated to make this change.

Some research points out that these stages are well documented for many different conditions in U.S. populations, but that much more research needs to be done for non-U.S. populations and for special populations, such as the elderly, teenagers, diverse racial and ethnic populations, rural populations, those who are illiterate, functionally illiterate or marginally literate. For example, in research by Burbank et. al. [2000; 2002], researchers looked at changing health behaviors of older adults. These researchers found that changing lifelong unhealthy habits can have a positive effect on health for older adults. The Transtheoretical Model of behavior change proposes that people move through a series of five stages and use a variety of processes as they attempt to change a behavior. Among the most important outcomes of this research is evidence that tailoring interventions to an individual's stage of change is most effective in promoting behavior change. These researchers also suggest specific stage-based strategies for nurses to use with both individuals and groups of older adults.

Family physicians have also begun using the Transtheoretical Model or stages of change approach to help patients change their behavior [Goldberg et. al., 2002; Goldberg et. al., 2002; Zimmerman et. al. 2000]. Helping patients change behavior is an important role for family physicians, especially in addressing lifestyle modification for disease prevention, long-term disease management, and addictions. Many family physicians in the past have often focused on patient non-compliance and patient failure at motivation. However, it is now believed that understanding patient readiness to make change, appreciating barriers to change and helping patients anticipate relapse can improve patient satisfaction and lower physician frustration during the long change process. For example, we now know that people who are trying to stop smoking may backslide and smoke again an average of seven times before stopping for good. It is important for both physicians as well as for patients who are trying to stop smoking to know this so that neither becomes discourages with these "failures", which are actually just steps along the way progressing toward a smoke-free lifestyle and a major healthy lifestyle change.

Health Coaching and Healthy Lifestyle Coaching
We know that healthcare actually exists on a continuum ranging from simply identifying risk factors through health risk assessments (HRA) to triaging of injuries and illness to intensive care such as emergency room and hospital stays and finally, a return to good health or disease containment/management. In a fully integrated healthcare system, people need and should have access to a great deal of support and guidance in managing the transitions across this continuum. Healthy lifestyle coaching can be a very helpful tool. One form of this coaching which may be effective is called "Motivational Interviewing".

Motivational Interviewing
Motivational interviewing is a person-centered, directive method of communication used for enhancing intrinsic motivation to change by helping a person resolve her or his ambivalence to change [Resnicow et. al., 2002; Miller and Rollnick, 2002]. Motivational interviewing is used in many different settings and for many different lifestyle changes. These include addictions, such as alcohol, drugs and smoking; adopting healthy behaviors, such as physical activity/exercise and fruit/vegetable consumption; and treatment adherence for chronic illnesses and conditions. Motivational interviewing has also been used to encourage contraceptive use among adolescents at high-risk for early childbearing.

We know that generally speaking the usual ways of helping people make lifestyle changes do not work. For example, advice, especially if it is unwelcome advice, can often elicit resistance. In addition, knowing what to do is only weakly correlated with actually adopting a new behavior. Also, people vary in the motivation to change and it has been discovered that the style of helping must match the motivation of the person. This requires knowing what stage of change the person is stuck in order to be of assistance in helping them progress to make healthful lifestyle changes.

The usual approach to helping people adopt change involves confrontation, education and authority. Motivational interviewing, by contrast, involves collaboration, evocation and autonomy. I tend to think of these differences as the difference between quantitative vs. qualitative research, or the difference between male ways of knowing vs. female ways of knowing.

There is a special spirit of motivational interviewing. This involves a belief in the innate capacity of individuals to naturally evolve in a healthful direction under conditions of acceptance and support, where people use their own positive, creative energy and insight to discover the best solutions for themselves. Motivational interviewing [or MI] uses good listening and counseling skills, with unconditional positive regard, genuineness and empathy.

At the same time, the person herself or himself needs to be willing to believe that the behavior is important; to be able to have confidence that she or he can make the change, and be ready to make the change a priority in her or his life. Most people are ambivalent about changing their behavior, and say, "Yes, but……". Their approach [avoidance conflict] is common and involves such statement as "I want to stop smoking, but if I stop, then I won't be able to…….". Ambivalence is one of the things that keep people stuck and unable to make lifestyle changes, even when they may wish to.

There are a number of tools that are needed in order to do MI, such as getting permission to discuss the lifestyle change with the individual; the use of open-ended questions; reflective listening; eliciting self-motivational statements; assessing on a scale of 1-10 the importance/confidence the person has to make the change; menus vs. single solution [this is elaborated further on in this article], and summarizing. To accomplish these items there are generally six techniques needed:

• Getting Permission: Have agreement from the individual to proceed.
• When Offering Information or Advice: Suggest strategies or information, not forced.
• Asking Open-Ended Questions: delve deeper into intentions and state of mind.
• Using Reflective Listening: The heart of the MI approach is to use the rule of thumb that there needs to be 5 reflective statements for every question.
• Using the Levels of Reflective Listening Pt 1: Here the therapist restates using the client's same word or words. There are a number of reflective listening phrases such as "It sounds as though you are unsure about….."; "It has been difficult for you to……"; "You have been feeling discouraged about……."; "You are embarrassed that….."; "You are not happy about……."; and "You believe that others view you negatively because……".
• Using Levels of Reflective Listening Pt 2: This involves content ["You see a connection between your inactivity and being overweight and getting diabetes."]; feelings ["You are scared that if you do not do something about your weight now you will end up like everyone else in your family with diabetes."]; and meaning ["Your children are important to you and you want them to be healthy and learn from your example."]. For motivational interviewing to be effective it is important for the therapist or counselor to elicit "change talk" from the person seeking to change because in this way, people become more committed to doing what they actually say they want do. The therapist facilitates these client statements by stressing the advantages of the behavior change, the disadvantages of the status quo, optimism about being able to change and by reinforcing the client's intentions to change. The counselor also uses an importance/confidence ruler to gauge the person's desire to make the lifestyle change [e.g. on a scale of 1-10, how confident are you that you will make this change?].

The counselor also explores ambivalence being felt by the person. During this phase, the therapist responds to change talk by reflecting and elaborating, by affirming the intention, and by summarizing what the person is saying. It is also important to develop and point out the discrepancy between current behavior and the client's core values. The therapist can also offer menu vs. single solutions, by saying, "Here are some things that have worked for other people…….which of these do you think might work for you?" or "Controlling your weight may involve several different strategies, such as…….which of these do you think are most important for you to work on?".

It is important to focus on the client's statements regarding such issues as problem recognition and reasons for making the desired lifestyle change. If the client seems ambivalent, the counselor summarizes both the pros and cons of the behavior change and stresses optimism and confidence that the change can be made. The therapist also asks for feedback from the client about the summary by saying, "What have I missed?"

There are a number of important markers to indicate to both the therapist and the client that this has been a productive MI encounter:

• The client does most of the work;
• The client accepts the possibility of change;
• The client accepts the responsibility for making the change;
• There is an upward slope of commitment language within and/or between sessions; and,
• The sessions should feel more like "dancing" and not like "wrestling" with the client.

Throughout the course of motivational interviewing the therapist shows respect and empathy for the client. The therapist does more listening than talking. The counselor recognizes and honors the client's autonomy. The counselor recognizes that the solutions reside within the client and the solutions depend on the client's motivation, behavior, values and goals [Resnicow et. al., 2002].

Motivational interviewing has been successfully used in alcohol and substance abuse counseling [Smith, Shepherd, and Hodgson, 1998; Compton, Monahan, and Simmons-Cody, 1999; Miller and Moyers, 2002; Carroll et. al. 2002; Solomon and Fioritti, 2002; Miller, 1996; Sellman et. al. 2001; Cisler et. al., 1998]; for helping patients adhere to and better manage treatment regimens for those with chronic illnesses [Konkle-Parker, 2001]; manage innovative health programs [Gingiss, 1993; Emmons and Rollnick, 2001]; to work with teenagers in encouraging them to use contraceptives when they are at high risk for early childbearing [Cowley, Farley and Beamis, 2002]; and as motivational intervention in prenatal clinics [Handmaker and Wilbourne, 2001]. Motivational interviewing has also been used in cardiac coaching to produce better health, to enhance the patient's quality of life and to produce savings to the healthcare system [Kazel, 1998].

Other Forms of Motivational Interviewing and Coaching Models
Co-active coaching is another term for MI. Co-active coaching is not so much a kind of therapy as it is a professional relationship between two people: the coach assists another person in making some major life decisions and setting and meeting goals that will lead to desired changes. This kind of coaching, as in MI, is client-centered counseling that uses visualization and other tools to help clients clarify their values and establish goals. It has shown great promise in helping those with HIV/AIDS make life changes [Anonymous, 2001].

Another term is lifestyle coaching [Cantwell and Rothenberg, 2000]. Lifestyle coaching is used to help clients change and better manage their health habits. Lifestyle coaching has been used in a broad range of areas, from eating habits to stress reduction to overall health and fitness levels.

Finally, simple personal counseling from health care providers can have a significant impact on individual change as well as compliance. A study by Watson and Gallois [1998] found a very positive correlation between use of mentoring techniques by health care professionals and improved health outcomes for patients. More recently, a study [Grable et. al., 2003] found that a single, three-minute physician intervention produces a tobacco cessation rate of about 10 percent at 1 year; four or more person-to-person sessions approximately double that rate. Intervention by two or more healthcare providers (e.g. physician, nurse, pharmacist) or with more than three formats (e.g. individual session, telephone counseling, self-help materials) can raise the cessation rate to about 23.4%. Hospital interventions consisting of physician advice, nurse counseling, and follow-up phone calls have demonstrated tobacco cessation rates comparable to those of intense outpatient programs [Grable et. al., 2003].

Conclusions
It is estimated that as much as 50% of healthcare expenses in the United States may be due to personal lifestyle choices that are detrimental and unhealthful. Such things as heart disease, diabetes, cancer and many other major killers may result, at least in part if not whole, from lifestyle decisions we all make over a long period of time. Although most of us understand the implications of lifestyle choices and chronic diseases, the ability to adopt or modify our behaviors in such a way that we improve health outcomes is not nearly as simple or easy. As with virtually all questions related to the health care in this country, answers are neither simple, easy nor quick. In that spirit, we feel that Motivational Interviewing, co-active coaching, lifestyle coaching……no matter what you call it……may be one effective way to help Americans of all ages, races, ethnic groups, genders and socioeconomic classes to make more healthful lifestyle decisions. This would be a way to prevent or modify health risks, to enhance one's quality of life and to sharply reduce healthcare costs for all Americans. It is certainly one proven way to try to modify our many health risks.

Bibliography
Adams, J. and White, M. [2003]. Are activity promotion interventions based on the Transtheoretical model effective? A critical review. Br J Sports Med. 2003 April 37(2):106-14.

Anonymous [August 2001]. Co-Active Coaching could help HIV patients. AIDS Alert, August 2001,v. 16, 105. Burbank, P. M.; Padula, C. A.; and Nigg, C. R. [2000] Changing health behaviors of older adults. J Gerontol Nurse. 2000 Mar; 26 (3): 26-33; quiz 52-3.

Burbank, P. M.; Reibe, D.; Padula, C. A.; and Nigg, C. [2002] Exercise and older adults: changing behavior with the Transtheoretical Model. Orthop Nurs. 2002 Jul-Aug; 21 (4): 51-61; quiz 61-3.

Cantwell, S. and Rothenberg, B. [2000]. The benefits of lifestyle coaching. IDEA Personal Trainer, July 2000,v. 11, 24.

Carroll, K. M.; Farentinos, C.; Ball, S. A.; Crits-Christoph, P.; Libby, B.; Morgenstern, J.; Obert, J. L.; Polcin, D.; Woody, G. E. [2002] J Subst Abuse Treat. 2002, Sept. 23 (2):73-80.

Cisler, R.; Holder, D.; Longabaugh, R.; Stout, R. L.; Zweben, A. [1998]. Actual and estimated replication costs for alcohol treatment modalities: case study from project MATCH. Journal of Studies on Alcohol, Sept. 1998 v. 59 n. 5, 503 (10).

Cole, T. K. [2001]. Smoking cessation in the hospitalized patient using the Transtheoretical Model of behavior change. Heart Lung. 2001 Mar-Apr; 30 (2): 148-58.

Compton, P.; Monahan, G.; Simmons-Cody, H. [1999] Motivational interviewing: an effective brief intervention for alcohol and drug abuse patients. Nurse Pract. 1999 Nov; 24(11): 27-8, 31-4, 37-8 passim; quiz 48-9.

Cowley, C. B.; Farley, T.; and Beamis, K. [2002] "Well, maybe I'll try the pill for just a few months"….Brief motivational and narrative-based interventions to encourage contraceptive use among adolescents at high risk for early childbearing. Families, Systems and Health, Summer 2002 v. 20, 183 (220).

Emmons, K. M. and Rollnick, S. [2001] Motivational interviewing in health care settings: opportunities and limitations. Am J Prev Med 2001 Jan; 20(1): 68-74.

Enguindanos, S. [2001]. Integrating behavior change theory into geriatric case management practice. Home Health Care Serv. Q. 2001; 20 (1): 67-83.

Froelicher, E. S. and Kozuki, Y. [2002] Theoretical applications of smoking cessation interventions to individuals with medical conditions: women's initiative for nonsmoking [WINS] part III. Int J Nurse Stud. 2002 Jan; 39 (1): 1-15.

Gingiss, P. L. [1993] Peer coaching: building collegial support for using innovative health programs. J Sch Health 1993 Feb; 63(2): 79-85.

Goldberg, D.; Hoffman, A.; and Anel, D. [2002]. Understanding people who smoke and how they change: a foundation for smoking cessation in primary care, part 1. Dis Mon. 2002 Jun; 48(6): 385-439.

Goldberg, D.; Hoffman, A.; and Anel, D. [2002]. Understanding people who smoke and how they change: a foundation for smoking cessation in primary care, part 2. Dis Mon. 2002 Jul; 48(7): 445-85.

Grable, J.C.; and Termullo, S. [August 2003] Smoking cessation from office to bedside. Postgraduate Medicine, August 2003, vol. 114, no. 2, 45.

Haggerty, L. A., and Goodman, L. A. [2003] Stages of change-based nursing interventions for victims of interpersonal violence. J Obstet Gynecol Neonatal Nurs. 2003 Jan-Feb; 32 (1): 68-75.

Handmaker, H. S. and Wilbourne, P. [2001] Motivational interventions in prenatal clinics. Alcohol Research and Health, Fall 2001 v. 25, 219 (11).

Kazel, R. [1998]. Cardiac coaching produces better health, savings. Business Insurance, Oct. 19, 1998.

Konkle-Parker, D. J. [2001] A motivational intervention to improve adherence to treatment of chronic disease. J Am Acad Nurse Pract 2001 Feb; 13 (2): 61-8.

Miller, W. R. [1996] Motivational interviewing: research, practice, and puzzles. Addict Behav 1996 Nov-Dec; 21(6): 835-42.

Miller, J. H.; Moyers, T. [2002] Motivational interviewing in substance abuse: applications for occupational medicine. Occup Med. 2002 Jan-Mar; 17(1): 51-65, iv.

Miller, W. R. and Rollnick, S. [2002]. Motivational interviewing: preparing people for change (2nd ed.) New York, New York, US: Guilford Press. (2002)

Minnesota Department of Health [September 1998]. Healthy Minnesotans: Public Health Improvement Goals 2004 [Minnesota Department of Health, Division of Community Health Services, 121 East 7th Place, Box 64975, Saint Paul, Minnesota 55164-0975].

Morera, O. F.; Johnson, T. P.; Parsons, J.; Warnecke, R. B.; Freels, S.; Crittenden, K. S.; and Flay, B. R. [1998] The measure of stage of readiness to change: some psychometric considerations. Psychological Assessment. June 1998 V. 10, No. 2, 182-186.

Nezami, E.; Sussman, S., and Pentz, M. A. [2003] Motivation in tobacco use cessation research. Jan; 38 (1):25-50.

Patten, S.; Vollman, A.; and Thurston, W. [2000]. The utility of the Transtheoretical Model of behavior change for HIV risk reduction in injection drug users. J Assoc Nurses AIDS Care. 2000 Jan-Feb.; 11 (1): 57-66.

Prochaska, J. O.; Velicer, W. F.; Rossi, J. S.; Goldstein, M. G.; Marcus, B. H.; Rakowski, W.; Fiore, C.; Harlow, L. L.; Redding, C. A.; Rosenbloom, D.; Rossi, S. R. [1994] Stages of Change and Decisional Balance for 12 Problem Behaviors. Health Psychology January 1994 Vol. 13, No. 1, 39-46.

Resnicow, K.; DiIorio, C.; Soet, J. E.; Borrelli, B.; Hecht, J.; and Ernst, D. [2002] Motivational interviewing in health promotion: it sounds like something is changing. Health Psychology 2002, Vol. 21, No. 5, 444-451.

Rosen, C. S. [2000]. Is the sequencing of change processes by stage consistent across health problems: A Meta Analysis. Health Psychology November 2000 vol. 19, No. 6, 593-604.

Sellman, J. D.; Sullivan, P. F.; Dore, G. M.; Adamson, S. J.; MacEwan, I. [2001] A randomized controlled trial of motivational enhancement therapy (MET) for mild to moderate alcohol dependence. Journal of Studies on Alcohol, May 2001 v. 62, 389.

Smith, A. J.; Shepherd, J. P.; Hodgson, R. J. [1998] Brief interventions for patients with alcohol-related trauma. Br J Oral Maxillofac Surg. 1998 Dec; 36(6): 408-15.

Smith, K. J.; Subich, L. M.; and Kalodner, C. [1995]. The Transtheoretical Model's stages and processes of change and their relation to premature termination. Journal of Counseling Psychology January 1995 Vol. 42, No. 1, 34-39.

Solomon, J. and Fioritti, A. [2002] Motivational intervention as applied to systems change: the case of dual diagnosis. Subst Use Misuse. 2002; 37(14): 1833-51.

Spencer, L.; Pagell, F.; Hallion, M. E.; and Adams, T. B. [2002]. Applying the Transtheoretical Model to tobacco cessation and prevention: a review of literature. Am J Health Promot. 2002 Sep-Oct; 17 (1): 7-71.

Sutton, S. [2001]. Back to the drawing board? A review of applications of the Transtheoretical Model to substance abuse. Addiction. 2001 Jan; 96 (1): 175-86.

Triad [October 2001]. Impact Evaluation Report on the Coaching.com Intervention for [Client Company] October 2001. Study designed and completed by Triad, 2040 Raybrook SE, Suite 207, Grand Rapids, Michigan 49546 (616-956-6850).

Watson, B. and Gallois, C. [1998] Nurturing communications by health professionals towards patients: a communication accommodation theory approach. Health Communications, vol. 10, pp. 343-355.

Zimmerman, G. L.; Olsen, C.G.; and Bosworth, M. F. [2000]. A "stages of change" approach to helping patients change behavior. Am Fam Physician. 2000 Mar 1; 61(5): 1409-16.