Patient activation was a primary outcome of the PROTECTS study. Patient activation refers to a patient’s understanding of their own role in the health-care process and their level of knowledge, skill and confidence in managing their own health.
Patients were recruited into the PROTECTS trial on the basis of a having a moderate score (level 2 or 3) on the PAM. A PAM level of 2 or 3 reflects that a patient has some understanding of his or her own role in the management of their long-term condition and is somewhat motivated to make changes to their lifestyle, but requires some support to do so.
Patients in PROTECTS talked about how the health coaches had supported them to increase their knowledge, skill and confidence in managing their health. Many patients described how the health
Areas addressed during coaching n
Behavioural activation 46 Cognitive restructuring 23 Problem-solving 24 Diet 79 Smoking 9 Exercise 70 Alcohol 9 Social prescribing 31
TABLE 58 Areas addressed during coaching by coach
Health coach Average number of areas addresseda
coaches had helped them to seek help from their GP as well as other support available from within their local community:
. . . with [health coach] I’ve got enough confidence to go to my doctor and say I’m not happy, which I suppose a lot of people aren’t, they’ll just accept it or sulk. I have a whinge if I don’t think I’m getting a, you know–well, if I don’t think I’m being treated fairly.
PROTECTS 4, M67y
The health coaches frequently advised participants to return to their GP for a review of their medication and, with their support, participants described taking action earlier that they would have done before, and feeling more confident to do so:
I’d been . . . I changed tablet, depression tablets, and my daughter, and everyone, was saying to me, you’re not yourself, [patient name], but of course when you’re . . . when you’ve got depression you’re really inside yourself. It’s like a glass, you just . . . you know, even though you know it there’s nothing you can do about it. So it was with her [health coach] persuasion and telling me to get back to the doctor straightaway it was because of her. I think I would have gone on for months and months longer if she hadn’t.
PROTECTS 6, F69
One of the ways in which health coaches were able to activate patients was by increasing their knowledge of healthy eating. Many patients talked about how they had changed their diet as a result of the intervention:
She did tell me she said that I’m eating the right stuff, the lettuce and that and she said don’t eat . . . don’t drink the orange juice because two little oranges are better than one orange juice sort of thing. I thought‘alright then I’ll eat accordingly’.
PROTECTS 9, F73
The dietary advice patients received was described as useful and different from health care that they had received in the past, whe they did not remember diet being discussed:
It was different health advice than I’ve received in the past. Because nobody had ever discussed diet with me before, so, you know, that was useful.
PROTECTS 15, M85
Some talked about the knowledge around diet and their health having resulted in weight loss and how this had affected their mood and quality of life:
They [health coaches] taught me about my health, how to be more healthy, and I told them that I was going to lose weight, and they said‘well, that is very, very good’, and she advised me on the benefits of healthy . . . which obviously has worked because I’ve lost all this weight . . . I’m happy now, honestly. I can do things . . . I can even get in and out the car which used to be hard for me. And the kids, we have the grandkids all weekend and I can play with them.
PROTECTS 18, F70
In some cases patients also talked about the changes they had made having an impact on their health outcomes, such as reduced cholesterol:
But yeah, I was genuinely surprised that just with a little bit of effort; you can make a big change can’t you? And so when my cholesterol had come down .2 I said to the doctor,‘well I have been really, really trying,’and I’m desperately trying, . . .
PROTECTS 5, F68
level rather than restricted to the participant themselves. It may be therefore that the health coaching intervention had spill-over effects.
Although most accounts were positive, on occasion patients were reluctant to change some of their dietary habits, especially if they saw a particular food as a treat, although they were happy to swap other food items:
But the thing is I won’t go off me butter, I like me butter me, I like butter and it makes no difference what you’re telling me I’ll still eat the butter. She said,‘go on this low fat.’I said,‘no I’m sorry love I’m stopping on me butter. I don’t get many treats in life.’.
PROTECTS 9, F73
As well as advice on diet, there were also examples of health coaches encouraging patients to take opportunities to increase their exercise within their daily routine, such as walking to the next bus stop instead of standing and waiting for the bus:
This business of walking further along, if I walk down Lancaster Road and I don’t see any buses and a bus is coming when I get there, I’ll get on it, but if I don’t see a bus when I get to the bus stop I will walk to the next one. Invariably it passes me, in which case I get there and I don’t see another one so I walk to the next one, but I find that I’m running . . . I’m not walking any further. And another thing, I do get up in the morning and I’ll do my hoovering and I’ll prepare the tea and I’ll do my washing and I’ll do . . . but if I sit down in the afternoon I could doze off, so I’ll do something. I’ll write a letter or I’ll do my ironing.
PROTECTS 8, F73y
This was the case for patients who had also reported experiencing significant symptoms of low mood and had previously found it hard to get out:
And it’s like I say, even if, you know, I’m not going to do anything special. I’ll jump on a bus and go for a ride and things like that rather than sit and mope. I find now that I don’t want to sit in now. Well I’ve got into a habit now of doing things instead of sitting there. So what she said to me has gone in, you know, because I do feel as if I want to do things now which I didn’t do before.
PROTECTS 10, F74y
One lady with low mood whose mobility was limited and used a scooter outside her home was encouraged by the health coaches to move from passive to a slightly more active form of exercise. She ultimately hoped to return to a healthy hips and hearts class run locally:
Well [health coach] sent me her information [on armchair exercises]. You know what they do, and it’s the same thing. Yeah, I’ve got the elastic bands and . . . Yes, I do that now, and I’ve got this [vibration plate exerciser] as well, this is good.
PROTECTS 6, F69
Patients also talked about how the health coaches had increased their knowledge about their own
medication and they gave examples of how they had improved their skills in managing their own medication regimes. One man with diabetes mellitus talked about sugar levels being very high and how the health coach had identified he was taking his diabetic medication at the wrong time of day:
Anyway, but with the help of that lady from Hope Hospital, Salford Royal, that rang me, I was taking them at the wrong time on the . . . I was taking them, one, one, one, something like that, after meals. She said, no, two in the morning after your breakfast, and then two after your tea . . . And what else was it? I’ve always liked fruit and veg, well, yeah, I do. And she said, if you do have anything, like
fruit, make sure you have it immediately after your meal, because if you leave it till the afternoon, like you say with a biscuit, it spikes up again . . .
PROTECTS 11, M86
Participants described the techniques that the health coaches used to engage them and increase their level of activation:
I told her what I did and some days you do what you think is right but it turns out it isn’t, so then I think,‘oh, blow everything, why do I bother?’. For a couple of days and then I think,‘no, come on, pull yourself together’. So I spoke to her about that and she didn’t say,‘well, you should stick to what you’re trying to do instead of thinking,“oh, blow it all” ’she just said,‘as long as you go back to it’. So, as I say, there was nothing dictatorial about it, you’ve got to do this and you’ve got to do that, but the support was there.
PROTECTS 12, F80
When patients talked about experiencing barriers to behaviour change the health coaches suggested alternatives to support them in achieving the change. They also encouraged them to set realistic and achievable goals and used problem-solving techniques to help them overcome challenges:
I said, I don’t like eating fruit in cold weather, I know it’s silly, but I eat loads of fruits in summer time, but she suggested ways of doing things, like fruits salads, and so on, and so forth. Then, about walking, she said,‘well, set yourself a small goal’, because, of course, [grandson] can walk now, and he walks with his mum and his dad with the dogs. He was my real catalyst for keep walking, but I had a spell, when I had painful knees, and all sorts, and I just didn’t. So, I started back doing that again, and realised how much better it makes you feel . . .