**2. Coaching as a supportive tool in integrative primary healthcare of post-COVID-19 and ME/CFS patients**

Assuming that an integrative approach positively affects the treatment of chronic multimorbid conditions, this research aimed to identify opportunities to improve the health status of post-COVID-19 and ME/CFS patients by involving a professional coach in healthcare teamwork.

The theoretical foundation of coaching is based on psychological concepts [46]. Several types of models and theories form the basis of behavioral change in coaching. Those most frequently referred to in the literature include the Transtheoretical Model of Change (TTM), the Theory of Planned Behavior (TPB), Social Cognitive Theory (SCT), the Information-Motivation-Behavioral-Skills Model (IMB), Self-Determination Theory (SDT), Health Action Process Approach (HAPA), and Social Learning Theory (SLT) [47]. Each theory is distinct; however, coaching recognizes that individuals intrinsically learn in different ways, and thus the process could involve one or a combination of models or theories which may complement one another [46]. Practical coaching intends to facilitate, support, challenge, and guide a change to achieve a goal [48].

Regarding the coaching experience in healthcare during the COVID-19 pandemic, literature resources identified that COVID-19-specific tele-coaching effectively supported the risk-reduction behavior of patients with heart failure [49] and improved diabetes patients' health behavior [50], as well as coaching promoted medical staff well-being during COVID-19 [51] and demonstrated a positive effect on medical students' well-being [52]. On the whole, there are insufficient studies on the use of coaching in ME/CFS and post-COVID-19 patients.

To evaluate the complementary opportunities provided by coaching in post-COVID-19 in ME/CFS patients' healthcare, the longitude case study was performed in a primary care institution, in Latvia. The professional team consisted of a general practitioner, infectiologist, and coach. The coaching sessions were led by a certified coach of the Erickson Coaching International. Patient-centeredness, patient-determined goals, use of a self-discovery process, accountability, and consistent coaching relationship represent the key elements of coaching. Erickson coaching expands the coaching over and above these elements by strict focus at the solution (i.e. client's determined goal) not only throughout the individual coaching conversation but also throughout the entire coaching relationship (solution-focused Erickson coaching) [53].

Four patients, two ME/CFS and two post-COVID-19 patients with symptoms persistent for more than 6 months prior to diagnosis "Long-COVID-19," were invited to participate in this study. "Portraits" of the patients prepared by the supervising physicians are available in **Figure 2**. Virtual coaching sessions were held for each patient once a week for 4 weeks, in March and April 2022 (two additional sessions were conducted for Patient 2, by her request).

The work steps were devoted to the assessment of patients' HRQoL before and after the coaching course. In order to obtain comparable data for evaluation of the potential impact of the coaching process, HRQoL was assessed using the EuroQol-5D-5L measure (certified translation: EQ-5D-5L Latvian) as the patient-reported outcomes (PROs). The EuroQol EQ-5D-5L assesses HRQoL across five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression [54], and it was mentioned in previous research [12, 33–35]. Prior to the coaching course, patients were asked to assess their health across five dimensions, before the illness and at the present time. Accordingly, after the last coaching session, the patients had reassessed their health status.

#### **Figure 2.**

*"Portraits" of Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and post-COVID-19 patients in the study.*

The results of the PROs are shown in **Figure 3** (each dimension of health was scored from 1 (extreme problems) to 5 (no problems)). Descriptive and analytical statistical methods were utilized for the analysis of the obtained data.

#### **Figure 3.**

*Patient-reported health-related quality of life, as measured by the EuroQol-5D-5L framework (1—extreme problems, 2—severe problems, 3—moderate problems, 4—slight problems, and 5—no problems), in myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and post-COVID-19 patients: prior illness, prior coaching course, and after 4 weeks coaching course (Patient 2—after 6 weeks).*

The results (**Figure 3**) show that Patient 1 (ME/CFS) and Patient 3 (post-COVID-19) demonstrated full-health HRQoL prior to illness, but Patient 2 (ME/CFS) and Patient 4 (post-COVID-19) had the pain and discomfort also before making the

#### *The Advantages of an Integrative Approach in the Primary Healthcare of Post-COVID-19… DOI: http://dx.doi.org/10.5772/intechopen.106013*

diagnosis. Self-care ability was less affected by the illness—by two points in sum for all patients; usual activities were more affected—by five points in sum for all patients; mobility was affected harder—by six points in sum for all patients; anxiety/depression was activated—by six points in sum for all patients; and pain/discomfort was most accelerated—by seven points in sum for all patients. After the coaching course, PROs demonstrate a stronger impact on pain/discomfort reduction—by eight points in sum for all patients, and on anxiety/depression—by four points in sum for all patients; while mobility was improved—by five points in sum for all patient, usual activities by three points in sum for all patient, and self-care ability—by two points in sum for all patient (self-care ability was less affected by illness).

Additionally, the overall health self-assessment was performed by the VAS. Prior to the coaching, patients were asked to rate their health on a scale from 0 to 100 (where 0 means the worst health patient can imagine, and 100 means the best health patient can imagine), before the illness and at the present time. Accordingly, after the last coaching session, the patients had reassessed their health status. The results of the PROs by the VAS are shown in **Figure 4**.

#### **Figure 4.**

*Patient-reported health-related quality of life, as measured by the Visual Analogue Scale (0—the worst health patient can imagine, and 100—the best health patient can imagine), in myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and post-COVID-19 patients: prior illness, prior to the coaching course, and after 4 weeks coaching course (Patient 2—after 6 weeks).*

PROs by the VAS (**Figure 4**) show that all patients reported a significant reduction in overall health status due to illness: Patient 1 (ME/CFS)—by 40%, Patient 2 (ME/CFS) and Patient 3 (post-COVID-19)—by 20%, and Patient 4 (post-COVID-19)—by 15%. After the coaching period, all patients demonstrated an improvement in overall health status by more than half: Patient 1 and Patient 2—by 30%, Patient 3—by 20%, and Patient 4—by 10%. Remarkably that ME/CFS patients reported greater improvement in overall health, and Patient 2 reported a higher score of overall health after the coaching course than it was before the diagnosis of illness.

In order to obtain more information on the health status of patients during the study, the physicians supervising these patients were also asked to assess patients' health state, prior to the coaching course and after the course. The assessment was performed by the VAS with a rating on a scale from 0 to 100 (where 0 means the worst health state of the patient, and 100 means the best health state of the patient). Three dimensions of health were defined for evaluation: overall health, emotional health, and cognitive health. The results of the assessment of the patients' health provided by the physicians are shown in **Figure 5**. Significant improvement was indicated in all dimensions of health in each patient. Remarkable that the physicians indicated a lower initial rate of the health states for ME/CFS patients in comparison with the health status of post-COVID-19 patients. Notably that the improvement also is greater in ME/CFS patients. Overall health state assessment after the coaching period is correlated with the results of PROs performed by VAS (**Figure 4**) (except for Patient 2 data in which patient's self-assessment is higher—probably by the fact that Patient 2 performed the last self-assessment after two additional weeks of coaching). The stabilization between all dimensions of health was a common tendency for all patients (**Figure 5**).

#### **Figure 5.**

*Evaluation of the patient's overall health status, emotional health, and cognitive health, measured by the Visual Analogue Scale (0—the worst health state of the patient, and 100—the best possible health state of the patient), in myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and post-COVID-19 patients: prior to the coaching course, and after 4 weeks coaching course.*

Overall results of the study demonstrate significant improvement in the health state of ME/CFS and post-COVID-19 patients, particularly, in overall health, emotional stability, and cognitive functionality. However, this case study has limitations, such as the following: data are not statistically significant for extrapolation to the whole population of patients; there are no sufficient data for comparison with data in other countries on coaching approach in healthcare of post-COVID-19 and ME/CFS patients; during the coaching period, patients continued to receive the standard treatment; therefore, coaching could be considered as a complementary tool in an integrative approach, but not as a monomethod. The strength of this research is focused on the great additional opportunity to resolve the problems arising in chronic diseases management, by affective collaboration and integrative approach, particularly, in primary healthcare.

*The Advantages of an Integrative Approach in the Primary Healthcare of Post-COVID-19… DOI: http://dx.doi.org/10.5772/intechopen.106013*

This study can encourage the further investigation of coaching potential in healthcare, to receive more evidence on the effectiveness of this approach. Additionally, more sensitive evaluation instruments could be considered and would facilitate patients' self-assessment of such symptoms as anxiety, depression, fatigue, sleep disruption, and posttraumatic stress. At the same time, patients should be supported by teaching to work with the PROs tools in the process of health self-assessment. Eventually, in the scope of managerial and system level of integrative healthcare, it should be considered that the financing of the integrative approach can face the challenges in countries with strictly limited budget allocation for healthcare and social issues.
