790936

research-article2018
HPPXXX10.1177/1524839918790936Health Promotion PracticeMcQueen et al. / Perceptions of Health Coaching for Behavior Change

Perceptions of Health Coaching for Behavior

Change Among Medicaid and Commercially
Insured Adults
Amy McQueen, PhD1
Mathew Kreuter, PhD, MPH1
Molly Loughran, MSW, MPH1
Tess Thompson, PhD, MPH1
Tim Poor, BA1

Use of health coaching to help individuals make and Keywords: health education; health behavior change;
sustain changes in health behavior and disease man- health coaching; self-management
agement is increasing, and early evidence about its
effects is promising. However, few studies assess par-

H
ticipants’ preferences and expectations about health ealth coaching in the United States is used by
coaches, the use of the term health coach, and the health insurance plans, workplace wellness pro-
coaching relationship. To help inform the design of grams, primary care clinics, and community
future health coaching programs, we conducted quali- health centers to promote health behavior change.
tative interviews with 50 U.S. adults (25 with Medicaid, Health coaching combines health education with psy-
25 commercially insured) to assess their (1) sources of chosocial support and behavior modification tech-
health information; (2) familiarity with, preferences for, niques to meet patient-determined goals, often involving
and associations with 32 terms that could describe lifestyle behaviors such as diet, exercise, smoking ces-
“someone who uses experience and one-on-one com- sation, and stress management (Hill, Richardson, &
munication to help others change behaviors to improve Skouteris, 2015; Wolever et al., 2013). Studies of coach-
their health;” and (3) perceptions of how well different ing interventions have shown positive effects on behav-
terms apply across different health behaviors and for iors, including physical activity, nutrition, and weight
nonhealth concerns (e.g., financial, career). Results loss (Hill et al., 2015; Olsen & Nesbitt, 2010), as well as
showed wide variability in preferences for different improved medication adherence and health outcomes
coaching terms and mental models of coaching that among those with chronic diseases (Vale, 2003; Wolever
differed by insurance type. Commercially insured par- et al., 2010).
ticipants made a distinction between experts and sup-
porters as different categories of coaches. Medicaid
1
participants associated coach with sports and viewed Washington University in St. Louis, St. Louis, MO, USA
the term as less professional. All participants preferred
terms such as advisor and specialist, and all wanted
Authors’ Note: The research was conducted as part of collabora-
content experts who could also appreciate the broader tions with the Envolve Center for Health Behavior Change Research
context of their life. at Washington University School of Social Work. The authors wish
to thank all the participants and the Missouri Home State and
Louisiana Healthcare Connections health plans for their support
of this research. The authors also acknowledge contributions to
the research and reporting of results by Nikki Caito, Katie Childs,
Health Promotion Practice Rachel Garg, Jennifer Funaro, Lisa Gibson, and Karyn Quinn.
Month XXXX Vol. XX , No. (X) 1­–10 Address correspondence to Amy McQueen, Washington University
DOI: 10.1177/1524839918790936 in St. Louis, 4523 Clayton Avenue, Campus Box 8005, St. Louis,
© 2018 Society for Public Health Education MO 63110, USA; e-mail: amcqueen@wustl.edu.

1
 Although titles, training, and credentials of health
coaches vary (Ustjanauskas, Bredice, Nuhaily, Kath, &
Wells, 2016), there is some agreement about what they
do. The International Consortium for Health & Wellness
Coaching (ICHWC) conducted a job analysis that identi-
fied common tasks, knowledge, and skills to inform a
national standard for health coaches (ICHWC, 2017). In
general, ICHWC concluded that coaches do not diag-
nose or advise, but rather elicit goals and solutions from
clients. Coaches use strategies to motivate and hold
clients accountable to change behaviors in ways that are
appropriate to their life context (Wolever, Jordan,
Lawson, & Moore, 2016). The focus of these duties can
vary, with some coaches specializing in a particular
chronic disease or health behavior and others address-
ing wellness holistically. Although there is some con-
ceptual overlap between health coaching and patient
navigation, the latter has a specific focus on care coor-
dination within health care organizations, which can
also help increase particular health behaviors such as
timely adherence to screening and treatment (Ali-Faisal,
Colella, Medina-Jaudes, & Benz Scott, 2017).
The promising findings from health coaching
research have led to questions about the “active ingre-
dients” or mechanisms that drive their effects (Hudlicka,
2013; Willard-Grace et al., 2015) and prompted forma-
tive research such as qualitative interviews with
coaches to understand how they engage with clients
(Goldman, Ghorob, Eyre, & Bodenheimer, 2016) and
with physicians to understand the role of coaches in
their practice (Johnson, 2015) and the level of support
they receive (de la Riva et  al., 2016). Fewer studies
have interviewed potential recipients of coaching to
learn about their preferences for and expectations
about health coaches and the coaching relationship.
Although several studies have interviewed patients
after they completed coaching interventions for life-
style behaviors, the studies excluded individuals who
choose not to participate in coaching or who disen-
gaged during the study (Andersen, Andersen,
Muurholm, & Roessler, 2014; Lyden et  al., 2013;
O’Sullivan et  al., 2010). Because only a minority of
people who are invited or eligible to participate in a
coaching program actually start and complete one,
research is needed to understand the facilitators and
barriers to engaging in a coaching program.
This study was conducted to inform design deci-
sions and best practice implementation strategies for a
future health behavior change program using phone-
based and online health coaching to address lifestyle
behaviors (i.e., diet, exercise, smoking cessation, stress
management) among Medicaid beneficiaries in the
United States. This formative research was needed to
2  HEALTH PROMOTION PRACTICE / Month XXXX
better understand how coaching programs offered
through commercial health insurance plans and
employers may need to be adapted to better reach and
serve Medicaid beneficiaries. Specifically, we antici-
pated that Medicaid beneficiaries may have more
unmet basic needs (e.g., food, housing, unpaid bills)
that act as barriers to behavior change and may extend
beyond a coach’s expertise or scope of work. To explore
potential differences, we interviewed Medicaid benefi-
ciaries and individuals with commercial health insur-
ance to gain insights about (1) the sources of health
information and support currently used by members of
both groups, (2) their familiarity with different coach-
ing-related terms and associations with our definition
of a health coach, and (3) preferences for particular
terms and how those preferences may vary across
health behaviors and for nonhealth concerns such as
financial or career needs. The goal of this formative
research was not to test a priori hypotheses, but to
understand how people talked about different terms
and their expectations of programs we considered rel-
evant to “coaching.” The study was informed by schema
theory, which includes both relevant attributes of a
concept and the associations among those attributes
(Fiske & Taylor, 1991). Specifically, role schemas create
cognitive scaffolding for individuals to organize their
knowledge and expectations about individuals and
their behaviors depending on their social position and
their situational context.
>>
Method
Sample
Eligible participants were adults 18 years or older
who were able to complete a single, face-to-face inter-
view in English. Only one person per household could
participate. For practical (e.g., limited time and person-
nel resources) reasons, we recruited a convenience
sample of two groups. Commercially insured partici-
pants were recruited through a research volunteer reg-
istry and recruitment flyers posted in community
locations (i.e., university buildings, coffee shops, pub-
lic libraries, and a fire station). Medicaid beneficiaries
were recruited from Medicaid Managed Care Plans in
Missouri (Home State Health) and Louisiana (Louisiana
Healthcare Connections) who provided the research
team with contact information (Missouri) or onsite
referrals (Louisiana). Letters were mailed to Missouri
members, and research staff made telephone calls
within 1 to 2 weeks to schedule interviews, which were
completed in December 2016. Louisiana participants
were recruited and interviewed during a health fair at

a federally qualified health center in New Orleans in
October 2016. Interviews with Missouri participants
were conducted in private meeting rooms at the univer-
sity or a local federally qualified health center. Response
rates were not accurately recorded due to problems
estimating the denominators of commercially insured
participants exposed to study flyers, Home State mem-
bers who actually received a letter and phone call (60%
of phone numbers were incorrect), and Healthcare
Connections members who heard about the study dur-
ing the health fair. Participants did not have a relation-
ship with research team members prior to their
interview. All participants were told the study purpose
and the role of the research team, which was independ-
ent of their health plan.
Interviewers
To accommodate participants’ preferred interview
days and times, five research team members including
A. M., M. L., and T. P. were trained to conduct inter-
views. Ages, gender, and credentials varied across inter-
viewers; T. P. is a former reporter and current publications
editor in a research lab; two interviewers have graduate
degrees, and two interviewers were graduate students.
Interviewers were trained to use the semistructured
interview guide (Supplemental Appendix A available
in the online version of the article) to elicit the opinions
of participants. None of the interviewers had been a
health coach or involved in a health coaching program,
which further supported our participant-as-expert inter-
view style. The research team had few a priori expecta-
tions about term preferences and associations or
differences between groups. One exception was an early
assumption that Medicaid beneficiaries may be less
interested in having a health coach compared with com-
mercially insured participants due to greater concerns
about trust, intrusiveness, or time required.
Study Design
We conducted a cross-sectional observational study
using semistructured qualitative interviews to explore
the reactions of participants to, associations with, and
preferences for different terminologies used to refer to
“someone who uses experience and one-on-one commu-
nication to help others change behaviors to improve their
health.” Card sort exercises were used to process and
discuss 32 terms (Figure 1), each printed on a 4 × 6 inch
index card. Terms were generated by the research team
from sources, including scientific literature (e.g., naviga-
tor), commercial support services (e.g., geek squad),
interpersonal communication and support (e.g., friend;
McQueen et al. / Perceptions of Health Coaching for Behavior Change 3

parent), and relevant synonyms of each. Terms were not
limited to health-focused applications. The list was not
presumed to be exhaustive, and participants were encour-
aged to add terms using blank cards provided to them
(although only one did this, adding OB/GYN).
Procedure
After providing verbal informed consent, each par-
ticipant was interviewed face-to-face for 30 to 60 min-
utes. First, open-ended questions elicited participants’
usual sources for health information and support. Card
sort exercises were then used to assess the familiarity
of participants with different terms, their reactions, and
preferences. For example, participants were asked to
sort the cards into two piles: terms that were familiar
and unfamiliar to them when applied to health. Starting
over, participants then sorted the same cards into two
new piles of terms they liked or didn’t like, then
selected terms they preferred most. Throughout the
interview and card sort exercises, participants were
encouraged to reflect and elaborate on the characteris-
tics, qualifications, experience, services, and types of
personal interactions they associated with each term
being discussed. Participants also were asked how well
each term applied to someone who helps others with
more than one health behavior as well as nonhealth
issues, for example, career development, financial
planning, parenting, or civic engagement.
Participants completed a brief paper survey of demo-
graphic information using standard questions from
national surveys and received a $25 gift card to a local
grocery store (Missouri) or Walmart (Louisiana). Study
procedures and materials were approved by the institu-
tional review board at Washington University in St.
Louis ID 201509027 on December 22, 2015, and were
approved by the Louisiana Department of Health and
the participating health plans.
Analysis
All interviews were digitally recorded and profes-
sionally transcribed verbatim. Transcripts were
anonymized, checked for accuracy and completeness,
and formatted for Atlas.ti for coding. Transcripts were
stored on secure university servers, and access was
limited to the research team.
Traditional qualitative descriptive research methods
with grounded theory and phenomenological influ-
ences were used to iteratively code and analyze the
data (Charmaz, 1995; Weitz et al., 2011). Phenomenology
is a critical reflection on conscious experience where
the participant’s view is taken as fact (Goulding, 2005).
Figure 1  Preferred Terms by Insurance Type
Phenomenology focuses on the participant’s lived
experience and perspectives. The constant comparative
methods of grounded theory guided the coding and
analysis processes that were both deductive and induc-
tive (Miles, Huberman, & Saldana, 2014). A codebook
was developed by the first author a priori based on the
interview guide and initial research questions, and
emergent codes were added to the codebook by the
coders during the iterative coding process (Supplemental
Appendix B available in the online version of the arti-
cle). Because of differences in the timing of recruitment
efforts, we completed the coding and codebook for the
commercially insured sample, then applied the code-
book to the Medicaid sample and made few changes.
Two staff members were trained and supervised in cod-
ing each transcript independently. Discrepancies that
arose were resolved through group discussion to
achieve consensus (Padgett, 2012). During analysis, we
focused on individuals’ interpretations and meanings.
When primary coding had been completed for all tran-
scripts, reports for each code were reviewed and sum-
maries were created to address deductive research
questions.
In contrast, our interpretation of participants’ cogni-
tive representations or “mental models” of the 32 terms
emerged from the data. Specifically, many commer-
cially insured participants grouped some terms as
4  HEALTH PROMOTION PRACTICE / Month XXXX
experts and distinguished other groups of terms as
nonexperts. To construct mental models, we examined
the following information about each term: expert ver-
sus supporter, educational background, other terms
viewed as closely related, services provided, associated
characteristics of this person, relationship to client,
and specific behaviors or topics addressed. The
responses of Medicaid participants were examined for
the same information, but the mental model that
emerged was different. All results were discussed
among investigators, providing opportunities to chal-
lenge perceptions, explore potential negative and devi-
ant cases, and reduce the potential for confirmatory
bias (Esterberg, 2002; Pidgeon & Henwood, 1997).
Additional interviews were not sought once the data
became saturated per sample for our interview ques-
tions determined a priori, and no new themes or con-
tradictory evidence became evident. Saturation was
determined through discussions with interviewers,
coders, and research leads. Illustrative quotes were
selected for presentation and are accompanied by the
code assigned by the interviewer to the interview for
simple data tracking purposes. Specific codes are not
meaningful per se, but indicate the interviewers ini-
tials, sample (Medicaid Missouri, Medicaid Louisiana,
or Commercially insured), and a sequential numbering
per interviewer.

>>
Results
Participant Characteristics
We interviewed 50 adults: 25 commercially insured;
25 Medicaid (16 from Missouri, 9 from Louisiana). The
ages of participants ranged from 18 to 62 years (M = 38,
SD = 10.5). Most were women (72%), and either Black
(56%) or White (38%). Most (74%) were employed full-
time or part-time, and their educational backgrounds
varied from high school (20%), to some college (28%),
to bachelors or advanced degrees (38%). Ten percent of
participants described themselves as being in poor or
fair health. Most (78%) had looked for health informa-
tion online in the past 12 months. Participants reported
being active an average of 3 days a week (SD = 1.8),
eating an average of 2.7 servings of fruits and vegeta-
bles per day (SD = 1.2), and 14% smoked some days or
every day. Thirty percent of participants were over-
weight, and 40% were obese.
Sources for Health Information and Support
In both samples, the top three sources of health
information were the Internet (e.g., WebMD, Google),
doctors or clinics, and family members or friends—ide-
ally people with health-related experience or previous
training (e.g., nursing).
Thirteen of the 25 commercially insured partici-
pants reported prior exposure to coaching: seven had
some prior experience with a health coach, two had
experience with a personal trainer, and four were
familiar with the practice through friends or coworkers.
Spontaneous examples included Weight Watchers
coaches, personal trainers, disease support groups, and
web- or telephone-based health coaching programs.
Only one of the 25 Medicaid participants reported
some prior experience with coaching. Most Medicaid
participants (n = 15) thought of health care providers
when considering the definition we provided. Nine
additional participants described helpful individuals
such as social workers, health educators, counselors,
housing authority advocates, nutritionists or dieticians,
wellness professionals, and school-based staff who
helped families receiving state assistance such as food
stamps.
How Terms Related to Our Definition of a Health
Coach
Preferences for different terms are presented by
participant health insurance type in Figure 1. Both
groups preferred the terms specialist and advisor. For
commercially insured participants, the term coach
McQueen et al. / Perceptions of Health Coaching for Behavior Change 5

was frequently selected as a preferred term. Fewer
Medicaid members selected the term.
Although the mental models we developed varied by
insurance type, they had several similarities. First, all
participants thought of medical providers as the pri-
mary specialists who would address serious health
concerns. Everyone saw specialists as focused on one
specific issue, and most agreed that different specialists
would be needed to address different health conditions
or life concerns (e.g., financial, child care, job). Although
personal experience was valued, when pressed, most
participants prioritized an expert’s experience helping
others change behavior as more important than having
faced the same issue themselves (e.g., having a former
smoker as a quit smoking coach; Table 1).
Second, all participants valued family members and
friends as lay supporters of their health and nonhealth
needs. Participants immediately thought of people they
had close relationships with when discussing terms
such as parent, friend, and partner, and thus these
were not viewed as useful terms to describe profes-
sional health coaches with whom they did not have
such relationships.
Third, some terms consistently elicited strong
impressions or associations that may not be helpful for
engaging people in certain health coaching programs.
For example, trainer was always associated with per-
sonal trainers who focus on exercise. Geek was not a
desirable term and was always associated with comput-
ers and tech support. Coach and cheerleader were
almost always associated with sports, which led to
mixed reactions regarding the appeal of the terms
among participants. Elders were viewed as senior mem-
bers of a family or church, which also led to mixed
reactions.
Commercially insured participants made a strong
distinction between experts and lay supporters, and
neither were perceived to be emotionally or personally
involved with the client, but rather acting in paid posi-
tions to serve clients. Commercially insured partici-
pants also articulated when advanced educational
degrees or other credentials would be needed (e.g., for
mental health services), and when specific training or
experience would suffice (e.g., for proper use of exer-
cise equipment). Participants said they would want an
expert if they had a serious health concern, but were
willing to see a nonexpert for “preventive health or
general health information” (TPC6). Several responses
suggested that lived experience was especially valued
for nonexpert sources. For example, one said, “the phy-
sician or expert can give you the medical knowledge of
it, but to see and hear a person who’s really had it
makes you feel better” (AMC02). It’s the nonexpert who
 Table 1
Quotes Illustrating Benefits of Specialized Versus Holistic Coaches

Views on Coaches’ Personal Experience

  “Getting advice from somebody who’s been down the road is probably a more useful thing than somebody who just
has read a lot. . . . somebody with some personal experience of some kind, either by observation or personally lived
it.” (NCC8)
  “. . . it really has to be somebody that’s been through it and actually understands and knows the struggle of trying to
get off of that habit to something else. Somebody that has never done it, you don’t really know what their struggle
feels like.” (MLMM4)
  “Training would be good. It’s even better whenever they have—if you’re talking to someone about managing diabetes
or something, they have struggled with that before and they’ve overcome it. Then that’s a really good person, in my
opinion, to ask.” (TPMM2)
Preferences for referrals to other specialists when needed
  “This is what I am specialist in. I’m not a specialist in that, but I can refer you to somebody who is a specialist.”
(NCC7)
  “I think a person should never exceed their boundaries without enough knowledge. If there’s somebody out there
who’s got more knowledge, I think that person should possibly refer them to that person just because it’s out of their
realm or out of their specialty . . .” (NCC7)
  “A health care worker may not be able to advise me on day-to-day things because they may not have gone through
that. They may not have that experience and not know the answer.” (AMML1)
  “I think it would probably help them understand better, but it might feel intrusive . . . Like why are you asking me
about my marriage when we’re talking about my health?” (AMC1)
Positive view of a holistic coach
  “I think that person could be the same person, because some of this is about time management, isn’t it? Whether we
exercise, or how we eat is really about how do we establish some life balance.” (NCC8)
Positive view of a team of providers and coaches
  “. . . because they’d give me a lot of different options, but having more than one in different areas, you get a whole
lot more opinions.” (MLMM4)
  “You definitely need a group of different peoples, as everybody can bring something different to the table.” (NCML7)

can show you “what recovery [from surgery] looks
like” (TPC5). Some participants thought having an ini-
tial counselor or consultant who would get to know
you and refer you to the best person to address your
problem would improve participant engagement and
trust (NCC1).
Distinct characteristics and expectations were
ascribed to each term. For example, participants felt
that an advisor provides information, resources, and
referrals in their domain of expertise, but not necessar-
ily solutions to a problem. A supporter was not viewed
as an expert, but was assumed to be a good listener and
encouraging rather than providing advice. Neither
advisors nor supporters were associated with having a
close personal relationship with the client like a men-
tor or ally would. Participants expected to ask ques-
tions of consultants who would provide direction and
advice, whereas participants would delegate tasks to
(subservient) assistants who were not expected to be a
source of new information or resources.
Figure 2 illustrates commercially insured partici-
pants’ mental model of terms associated with these two
types of care (experts vs. supporters). The vertical
organization distinguishes a consumer-focused affilia-
tion versus a personal relationship. The ordering of
terms in the figure was based on participants’ collec-
tive comments about each term. Terms that were men-
tioned together or that shared similar characteristics
are shown more closely together, even overlapping.
Supplemental Table S1 (available in the online version
of the article) provides sample quotes showing how
terms were related.
Compared with commercially insured participants,
Medicaid participants classified many more of the
terms as experts compared with the commercially
insured participants, but they were not specific about
what credentials they should have. Anyone in a posi-
tion providing support to the participant was perceived
to have valuable expertise through training or experi-
ence. Although many participants described family

6  HEALTH PROMOTION PRACTICE / Month XXXX


Figure 2  Mental Model of Coaching Terms for Commercially
Insured Sample
and friends as their first source for health-related infor-
mation and support, unless that person also had health
training (e.g., nursing), participants did not character-
ize them as experts. Several terms were viewed as less
professional (e.g., mate, geek, coach, whiz).
Figure 3 illustrates the mental model among partici-
pants with Medicaid. These participants distinguished
between terms based on the role or service they per-
ceived would be provided to clients. For example, a
leader takes charge and trainer helps clients reach their
goals. Mentors are guides; they provide information
and motivation, and act as role models because they
have “already traveled down that road” (TPMM2) as
the client (i.e., they have personal experience). Mentors
McQueen et al. / Perceptions of Health Coaching for Behavior Change 7

Figure 3  Mental Model of Coaching Terms for Medicaid
Sample
are more experienced and can teach clients what they
know and may develop a personal connection to the
client—like a peer, friend, or elder. Assistant and
helper were viewed as having a subordinate role to the
experts and may or may not have direct interaction
with the client.
Preferences Across Health Behaviors and Nonhealth
Concerns
Interviewers asked participants whether someone
assisting with health and lifestyle behaviors (e.g., diet,
exercise) would be capable of addressing more than
one behavior and whether the same person would also
be capable of helping clients with nonhealth concerns
(e.g., finances, child care, employment).
Many participants viewed diet, exercise, and weight
loss as related behaviors that might all need to be
addressed by a weight loss expert, but participants
often prioritized diet or exercise, which elicited differ-
ent associated terms and characteristics for who would
help with each behavior (e.g., nutrition counselor vs.
personal trainer). Some participants wanted a team of
experts that worked together to address different needs,
which discounted a more holistic approach (Table 1).
Some participants thought experts would be knowl-
edgeable enough to offer advice on other behaviors or
nonhealth concerns outside their area of expertise, but
that a different type of specialist should be consulted if
more help was needed to address serious concerns.
Participants expected coaches to make referrals when
clients required help outside their area of expertise
(Table 1). One participant thought a health coach might
seem intrusive if they tried to address nonhealth issues,
such as marital discord.
Most participants made connections between health
and nonhealth issues, particularly those that result in
increased stress (Supplemental Table S2 available in
the online version of the article). Participants discussed
many nonhealth aspects of life that could affect health
behaviors and health outcomes by creating competing
priorities. For example, participants described how
relieving financial needs would improve their health,
and how nonhealth challenges in life affected their
access to and use of health care. Several participants
talked about caregiving responsibilities as barriers to a
healthy lifestyle. Participants felt that coaches who
could address broader life stress(ors) would have a
positive impact on the health of their clients. Thus,
many participants saw an advantage to having a health
coach who took into account their life context.
>>
Discussion
This formative research identified the rich associa-
tions and expectations participants have for 32 differ-
ent terms that could be used to describe someone who
helps others change their behaviors to improve their
health. Findings indicate that different labels affect cli-
ent expectations, and that while some perceptions were
more universal across participants, others varied in
meaningful ways between Medicaid and commercially
insured participants.
Regardless of insurance type, participants saw value
in having a health coach—by any name—as long as the
coach developed good rapport with the client and was
an expert in their topic area. Participants had a general
sense of what they needed to do to improve their health
(e.g., lose weight) and were comfortable finding infor-
mation on their own using the Internet or talking to
others. However, participants believed they would ben-
efit from the expertise of a coach.
Understanding participants’ perceptions of differ-
ent terms and potential functions can inform the
development of client-centered health coaching pro-
grams, and promote them in ways that make them
8  HEALTH PROMOTION PRACTICE / Month XXXX
attractive to different audiences. Some terms had
strong associations that would appear to preclude
other uses. For example, trainers are universally asso-
ciated with exercise, and many clients would see them
as a poor fit for addressing other behaviors or non-
health concerns. No one wanted help from a geek
unless it involved computer tech support. Although
most participants liked the term coach, participants
with Medicaid insurance were less likely to prefer it.
This is likely due, at least in part, to what they reported
as its strong association with sports and a view that the
term seemed less professional than other terms (e.g.,
specialist or advisor). An assistant was not perceived
to be an expert who would provide new knowledge,
but rather could help with delegated tasks such as
looking up recipes or exercises.
All participants valued specialists for their expertise
in a defined area. Most people agreed that the expert or
specialist had the final say on an issue and would not
need to refer a client elsewhere unless it was to address
an issue outside the expert’s area of focus. More par-
ticipants with commercial insurance focused on the
advanced education and training as the credentials for
“expertise.” For a small subset of participants who val-
ued the convenience of a one-stop shop for addressing
life’s challenges, the idea of a holistic life coach to
address all health and nonhealth needs was appealing.
More common, however, was a preference for a team of
experts with complementary areas of experience.
>>
Limitations and Future Directions
Qualitative results are not meant to generalize back
to the population, but provide a richer understanding of
how people think about the concept of health coaching.
To properly assess quantitative differences in the prefer-
ences for specific terms would require standardized
surveys or interviews of representative samples.
Similarly, this research was designed to inform future
health coaching programs delivered in the United
States, and our research team and study participants
were native English-speakers, which may limit the gen-
eralizability of results. Even though findings may gener-
alize to similar programs in other countries, the
perceptions of specific terms will likely vary across
cultures and languages. The order and context for dis-
cussing each term varied across interviews based on the
responses of participants. Of note, participants spent
more time discussing liked and preferred terms than
disliked terms. The differences between the mental
models of Medicaid and commercially insured partici-
pants may be due to subsample differences in socioeco-
nomic status, abilities to verbalize perceptions, and

prior experiences with a health coach. The mental mod-
els also may be affected by the indirect elicitation meth-
ods we used. By design, our sampling approach included
many people without prior experience with a health
coach; however, the far greater proportion of Medicaid
participants without prior exposure may have biased
our comparison. Future studies may benefit by stratify-
ing participants by prior coaching experience per sam-
ple. Knowledge of members’ prior experience with
coaching also might inform how organizations design
and market their own coaching programs.
Results suggest that regardless of insurance type,
participants may respond well to terms such as health
specialist or advisor, but that Medicaid beneficiaries
without prior exposure to coaching programs may not
respond as positively initially to the term health coach.
It is possible that with greater exposure to the term
health coach and coaching programs that Medicaid
participants would come to understand and value the
term more. However, familiarity alone is not the only
answer; positive messaging about how such an indi-
vidual could help clients also may be needed. Dislike
for the term geek was because of ubiquitous familiarity
with geek squads who provide computer support.
Although some terms were clearly disliked by all par-
ticipants (i.e., guru), it is unlikely that any one term
will evoke only positive reactions and associations
among everyone. Further audience segmentation
research could help identify specific services and per-
sonal characteristics that are most highly valued by
different participants considering a health coaching
program in the United States or abroad.
Previous studies have attempted to identify which
aspects of the counseling or coaching relationship con-
tribute to successful behavior change (Greif, 2010; Hill
et  al., 2015; Wolever et  al., 2013). More research is
needed from the client perspective to understand what
factors influence initial and continued engagement
with health coaches. Many insurance companies and
employers commit significant resources to providing
health coaching programs, but only a small proportion
of members or employees enroll, limiting program
effectiveness and population health benefits (Carpenter,
Lovejoy, Lange, Hapgood, & Zbikowski, 2014; Dillon
et al., 2016).
Supplemental Material
The Supplemental Material is available in the online version of
the article at http://journals.sagepub.com/home/hpp.
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