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Commentary: Singapore should look beyond doctors to reduce chronic disease

Knowing why and how we should lead a healthier lifestyle isn't enough when it comes to preventive health. Health coaches can support the ambitious goal of Healthier SG, say Tina Ng and Susan Tan from the Society of Behavioural Health, Singapore.

Commentary: Singapore should look beyond doctors to reduce chronic disease
The start of a new year is a great time to aim for healthier living, but how long we sustain those efforts is a different story. (Photo: iStock/Morsa Images)

SINGAPORE: Is one of your New Year resolutions to follow your doctor’s advice to eat more healthily and do more exercise? The start of the year is a great time to make a change, but how long we sustain those efforts is a different story.

Educating the public about why and how we should lead a healthy lifestyle is essential to health promotion - but it isn’t enough for healthy behaviours to last. 

The recent Healthier SG White Paper outlined a proactive, preventative approach to reducing the incidence of chronic disease in Singapore. Singaporeans can also choose to enrol with one family doctor and adopt a health plan. 

It aims to shift doctor-patient relationships from being transactional and episodic to ones based on familiarity and trust. Good doctor-patient relationships play a significant role in our healthcare experience and have been shown to influence health outcomes.

Better preventive care could reduce or delay treatment needs in the long run. For example, patients with pre-diabetes can avoid long-term medication or more drastic outcomes with lifestyle changes.

But this will add to doctors’ immediate workload, with some already voicing concerns on needing more time to care for complex cases enrolled with them.

This might not be sustainable, especially when we consider the increasing rates of physician burnout and our ageing population’s healthcare needs will only increase.

But are doctors - besides friends and family - the only ones who can help drive our healthier behaviours? 


Health coaches could be that overlooked but essential part of the equation, when we consider how other roles can support and supplement doctors.

In considering behavioural change, psychologists often cite self-determination theory, a well-established framework that says goals are more likely to be achieved when they are fuelled by internal motivation rather than external pressure or coercion. 

The fulfilment of three essential psychological needs is necessary for internal motivation to flourish: Autonomy (such as voluntarily deciding to quit smoking instead of feeling forced into it by a family member), competence (feeling confident in our ability to succeed) and relatedness (feels cared for and supported by those around us). 

Research indicates that when these core needs are fulfilled, we are driven by internal motivation and tend to persist in our behaviour. 

With this in mind, we can imagine tapping on non-medical professionals to help guide and motivate us to succeed in health-related but what are ultimately lifestyle changes. In some chronic conditions, lifestyle changes have the potential to reverse disease progression, not just manage it like with medication.

When health is more than the biomedical aspects of a disease, we should not ignore the social determinants of health. 


Instead of a one-way health advice that might go in one ear and out the other because it tends not to be person-centric, health coaching is more similar to talk therapy or counselling. Health coaches aim to build a sense of trust and rapport and understand the psychosocial, economic and familial context behind our health decisions. 

Together, health coaches can work with patients on how to create their own goals and action plans based on their unique set of preferences, values, barriers and prior experiences - effectively fulfilling the psychological needs to build intrinsic motivation.

For example, some patients with Type 2 diabetes may think bingeing on pineapple tarts is okay as long as they take their medicine. Health coaches can improve their health literacy by determining their understanding of the impact of pineapple tarts on daily calories count, carbohydrates count and blood sugar level, and help bridge any gaps or misinformation. 

Health coaches could partner them to monitor their blood sugar in a way that provides the patients sufficient knowledge to decide if bingeing on festive goodies, even if it is a once-a-year affair, may harm their blood sugar control in the long run. 

The patient could decide to eat a few pineapple tarts while reducing the overall carbohydrates intake and increasing physical activity for that day, without making this an everyday habit. Life need not be an all-or-nothing approach after all.

Chinese New Year goodies (Photo: iStock/ThamKC)

Evidence for health coaching’s positive effects has been demonstrated in research, including improved weight management, promoting physical activity, and better mental and physical health status for adults with chronic diseases coupled with medication adherence. 

Health coaching appears promising in its ability to sustain long-term behaviour change and should be more widely adopted in Singapore’s approach to health promotion and disease prevention, beyond their current presence in SportSG’s Active Health initiative. 

One way could be for general practitioners (GPs) to refer patients to a pool of health coaches who would serve as the bridge between patients and doctors. Health coaches could check in on patients more regularly than the months between medical check-ups and report back on progress. 


There is certainly interest in this approach to healthcare, as seen from the increasing numbers of health coaching courses being offered by a range of institutions, from Tan Tock Seng Hospital (TTSH), to Nanyang Technological University (NTU) and Singapore University of Social Sciences (SUSS). Since its launch in 2017, the Active Health initiative has also seen an uptake of more than 320,000 participants in its various health coaching programmes. 

To assure doctors and patients of the quality and competency of health coaches in Singapore, one hurdle to overcome will be to better define what it means to be a health coach. There is currently no certifying or professional body for health coaches.

We may tend to think of coaches in the sporting sense, who similarly guide us towards physical health and fitness goals. But there are subtle differences as health coaches also consider preventive health and chronic disease management and should be trained with this in mind.

An official Health Coaching Competency framework could outline the set of core competencies and thus training required - something the Society of Behavioural Health Singapore is commencing on. Key competencies should include communication skills such as motivational interviewing, behavioural change theory, nutrition and exercise physiology, as well as other basic medical knowledge and professional ethics.

This could be similar to how there are standards for doctors, nurses, dietitians and physiotherapists, though going further to licence and regulate health coaches would require further discussion on the impact. 

While developing communities of care can easily be done by drawing on the expertise of existing providers, we also believe that building competency for emerging and promising areas of practice such as health coaching can be a priority for our local health promotion efforts. We believe that such investments will indeed pave the way for a Healthier Singapore.

Susan Tan is the president of the Society of Behavioural Health, Singapore, and founder of ECI Consulting Holdings, a public health social enterprise. Tina Ng is a final year Psychology undergraduate from Singapore Management University, and an intern with the Society of Behavioural Health, Singapore. The Society of Behavioural Health, Singapore is an interdisciplinary society that aims to promote preventive health in Singapore.

Healthier SG - what will it take to fundamentally shift the way we look at healthcare in Singapore? Doctors give their take on CNA's Heart of the Matter:

Source: CNA/ch


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