Health Coaching Has Differential Effects on Veterans with Limited Health Literacy and Numeracy: a Secondary Analysis of ACTIVATE

  • Sarah S. NouriEmail author
  • Laura J. Damschroder
  • Maren K. Olsen
  • Jennifer M. Gierisch
  • Angela Fagerlin
  • Linda L. Sanders
  • Felicia McCant
  • Eugene Z. Oddone
Original Research



Health coaching is an effective behavior change strategy. Understanding if there is a differential impact of health coaching on patients with low health literacy has not been well investigated.


To determine whether a telephone coaching intervention would result in similar improvements in enrollment in prevention programs and patient activation among Veterans with low versus high health literacy (specifically, reading literacy and numeracy).


Secondary analysis of a randomized controlled trial.


Four hundred seventeen Veterans with at least one modifiable risk factor: current smoker, BMI ≥ 30, or < 150 min of moderate physical activity weekly.


A single-item assessment of health literacy and a subjective numeracy scale were assessed at baseline. A logistic regression and general linear longitudinal models were used to examine the differential impact of the intervention compared to control on enrollment in prevention programs and changes in patient activation measures (PAM) scores among patients with low versus high health literacy.


The coaching intervention resulted in higher enrollment in prevention programs and improvements in PAM scores compared to usual care regardless of baseline health literacy. The coaching intervention had a greater effect on the probability of enrollment in prevention programs for patients with low numeracy (intervention vs control difference of 0.31, 95% CI 0.18, 0.45) as compared to those with high numeracy (0.13, 95% CI − 0.01, 0.27); the low compared to high differential effect was clinically, but not statistically significant (0.18, 95% CI − 0.01, 0.38; p = 0.07). Among patients with high numeracy, the intervention group had greater increases in PAM as compared to the control group at 6 months (mean difference in improvement 4.8; 95% CI 1.7, 7.9; p = 0.003). This led to a clinically and statistically significant differential intervention effect for low vs high numeracy (− 4.6; 95% CI − 9.1, − 0.15; p = 0.04).


We suggest that health coaching may be particularly beneficial in behavior change strategies in populations with low numeracy when interpretation of health risk information is part of the intervention.


telephone coaching health risk assessment health literacy health numeracy 



We are grateful to the leadership and staff of the VA’s National Center of Health Promotion and Disease Prevention (NCP) for the constant support throughout this project, including Dr. Jane Kim, Chief Consultant (NCP) and Ms. Kathleen Pitman. We also acknowledge the dedication and professionalism of our two health coaches, Ms. Karen Juntilla and Ms. Courtney White-Clark.

Funding Information

This project was funded by the Department of Veterans Affairs, Health Services Research and Development Service (CRE 12-288) and by a fellowship training grant by the National Research Service Award (NRSA) T32HP19025.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they do not have a conflict of interest.


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Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • Sarah S. Nouri
    • 1
    Email author
  • Laura J. Damschroder
    • 2
  • Maren K. Olsen
    • 3
    • 4
    • 5
  • Jennifer M. Gierisch
    • 2
    • 4
  • Angela Fagerlin
    • 6
    • 7
  • Linda L. Sanders
    • 3
    • 4
  • Felicia McCant
    • 4
  • Eugene Z. Oddone
    • 3
    • 4
  1. 1.Division of General Internal Medicine, Department of Medicine University of CaliforniaSan FranciscoUSA
  2. 2.VA Center for Clinical Management ResearchVA Ann Arbor Healthcare SystemAnn ArborUSA
  3. 3.Division of General Internal Medicine, Department of MedicineDuke University Medical CenterDurhamUSA
  4. 4.Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT)Durham VA Health Care SystemDurhamUSA
  5. 5.Department of Biostatistics and BioinformaticsDuke UniversityDurhamUSA
  6. 6.Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS 2.0) Center for InnovationSalt Lake CityUSA
  7. 7.Department of Population Health SciencesUniversity of UtahSalt Lake CityUSA

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