Melanoma is a form of skin cancer that can be prevented by limiting exposure to the sun. Among the Atlantic provinces of Canada, varying incidence rates of melanoma have been reported. The province of New Brunswick has melanoma incidence rates comparable to the national average, while in Nova Scotia and Prince Edward Island, the rates are above the national average, and in Newfoundland and Labrador, the rates are below. We conducted focus groups with participants in Atlantic Canada to understand the factors contributing to this difference. We found that Canadians living in Nova Scotia and Prince Edward Island—provinces with high melanoma incidence rates—were more likely to report using sun protection, more aware of the health risks of sun exposure, and more apt to follow the UV index. Despite this, they also received more sun exposure due to warmer temperatures and a tendency to engage in outdoor occupations and recreational activities. These findings suggest a sunscreen paradox, whereby individuals with higher levels of sun exposure also tend to use more but not an adequate quantity of sunscreen or other sun-protection measures, providing a false sense of security. Tailored sun protection campaigns must consider this sunscreen paradox and the unique norms of communities in Atlantic Canada and elsewhere in the world to design effective messaging.Globally, cutaneous melanoma (CM) incidence is increasing, with sun exposure identified as a key modifiable risk factor. The Atlantic provinces of Canada display varied CM incidence rates: New Brunswick aligns with the national average, while Nova Scotia and Prince Edward Island exceed it, and Newfoundland and Labrador fall below this benchmark. We investigated the relationship between sun exposure and CM in these provinces. Twenty-two focus groups encompassing 95 Atlantic Canada residents were conducted and transcribed. A thematic analysis was conducted in MAXQDA using the social–ecological model as a framework. Residents of high-CM incidence provinces demonstrated greater sun exposure awareness, consulting UV indices, and using sunscreen and sun-protective clothing. However, they received greater UV exposure due to warmer climates and outdoor work and cultural activities. Conversely, those in low-incidence provinces used sunscreen and sun-protective clothing less often, engaged in occupations and hobbies affording less sun exposure, and lived in cooler climates. Our data supports a possible “sunscreen paradox”, whereby increased sunscreen use is correlated with augmented sun exposure, leading to a deceptive sense of security. Public health initiatives in Atlantic Canada promoting sun safety must address this paradox while integrating community-specific behaviors and norms in order to develop tailored campaigns. Cutaneous melanoma (CM) is one of the most aggressive forms of skin cancer, with a propensity for metastasis and poor prognosis ,2. The eWithin the Canadian population, several sociodemographic variables have been associated with sun exposure rates and subsequent CM development, including geographic latitude, climate, vegetation, genetic predisposition, Fitzpatrick skin phototype, socioeconomic status, occupation, and behavioral habits ,10,11,12Given the geographic proximity and the sense of regional identity that has been well documented ,22,23, iThe social–ecological model—developed by Bronfenbrenner in the 1970s —has beenUp to now, large-scale qualitative studies have not examined behavioral drivers behind sun exposure and skin cancer awareness in Atlantic Canada. In this context, the objective of this study was to explore the individual, interpersonal, community, and societal factors influencing sun exposure habits perceived by individuals living in the provinces of Atlantic Canada. Using a consensual qualitative research design, we aimed to understand participants’ perspectives of sun exposure to serve as a foundation for the development of public health recommendations for CM prevention.The present study is part of a research program (SunFit Project) designed to: (a) explore adults’ perspectives regarding sun protection habits and CM and (b) develop tailored sun exposure recommendations to enhance behavior change regarding sun exposure practices leading to the prevention of CM. Using a patient and public involvement strategy, we designed a consensual qualitative research study . This tyThe SunFit cohort , which iThe McGill University Faculty of Medicine and Health Sciences Institutional Review Board provided ethical approval in May 2022 (Protocol # A05-B39-22A). Participants were offered monetary compensation of CAD 10–50 for their participation in this study. The data collected and the participants’ identities were securely saved in SP’s University-based iCloud.One virtual and 22 in-person focus groups were conducted between July and August 2022. We used this data collection technique because we were interested in open discussion and exchange of ideas among participants . The sumPrior to starting the focus groups, participants were asked to sign either an online or in-person informed consent form detailing the risks and benefits of participation and were given an opportunity to ask questions about this study.The discussions that took place during the focus groups were recorded and ten verbatim transcribed by AH and uploaded into MAXQDA software Version 2022 . The traA total of 13 focus groups from NS and 2 from PEI were included in the high-CM-incidence group consisting of 74 participants; 5 focus groups from NB were included in the average-incidence group consisting of 11 participants; and 2 focus groups from NL were included in the low-incidence group (6 participants). The mean age of participants was 65.0 in the low-incidence group, 70.0 in the average-incidence group, and 69.4 years in the high-incidence group. Demographic data on the participants are summarized in We analyzed reported behaviors regarding sun exposure, sun protection, and melanoma as perceived by participants and per the relationship to their social environment. More specifically, critical environmental factors discussed by participants, such as dominant industries and occupations (the mesosystem), recreational activities and regional traditions (the exosystem), and climate and geographic conditions (the macrosystem) were related to sun protection habits enacted and reported by individuals (the microsystem) .Across all groups, there was a range of behaviors from diligent and proactive sun protection to a more reactive approach based on expected sun exposure. However, the NS and PEI groups showed more regular habits of sunscreen use, possibly due to a higher awareness or due to environmental factors . For exa“I always have sunscreen in my purse in case I get caught out. You know, they were samples that were given to me, but I keep them here in case I end up at the beach unexpectedly and need to slap something on, right?”.Individuals from NB, on the other hand, seemed to be more proactive and consistent in their habits, often applying sun protection even for shorter outdoor activities. They also seem to show a slightly higher awareness of the UV index and its implications for sun protection. One participant shared, “Sometimes I even use SPF 60 because I burn so easily” .Meanwhile, individuals from NL displayed a more activity-dependent approach to sun protection, sometimes not considering less obviously risky activities as requiring sun protection.In addition to sunscreen, participants used sunglasses, sun-protective clothing, hats, and umbrellas. Sunglasses use was not discussed in any of the NL groups, but both the NS/PEI and NB groups demonstrated an understanding of the importance of wearing sunglasses for sun protection. However, the emphasis was slightly different in each group: NB participants seemed to stress more the quality and type of sunglasses in relation to their benefits for sun protection, while those from NS and PEI mentioned sunglasses usage more in relation to specific outdoor activities and personal health concerns. In this regard, a participant said: “And the other important thing is to wear the right sunglasses that will protect your eyes. You don’t want to buy these cheap colored glasses you need proper Polaroid lenses” .With respect to sun-protective clothing and hats, in NL, there was a general aversion to wearing hats, especially during the summer months, due to personal discomfort with having something on the head. Long-sleeved clothing was preferred instead. NS/PEI and NB, on the other hand, had a more consistent habit of using hats for sun protection, including wide-brimmed hats, baseball caps, and Tilly-like hats, regardless of the season or activity. They also endorsed wearing long-sleeved clothing. For instance, while discussing the use of a hat, a participant said: “No …I just don’t like anything on top of my head. I’ll wear it—sorry—in the wintertime if I’m going for a walk for warmth. But definitely not in the summertime” .Umbrellas were not discussed extensively among participants and were mentioned only in NS/PEI as a means of sun protection.Seeking shade was another form of sun protection described by participants. All three groups emphasized the importance of avoiding peak sun hours, typically between 10 AM and 2 to 3 PM, and scheduling outdoor activities outside of these times. However, the motivation for avoidance varied between groups. In NL, avoiding intense sun was motivated by not having to use sunscreen. With regards to this, one participant commented:“I’m not 100% about anything. I guess the thing that I’m most conscious of all the time, is what time of day it is. Because I know you don’t need to have sunscreen at 9:00 AM morning. You know, just the average times”.In NB and NS/PEI, however, avoiding heat was cited as a motivating factor for avoiding sun exposure. A participant noted: “I never look at the UV index but there are days I remember going outside and just feeling literally assaulted by the sun. It’s just so intense” .All groups shared an awareness and proactive behavior of seeking shade as a means of sun protection. In NS/PEI and NB, this was connected to a balance between enjoying the outdoors and safety and the recognition that seeking shade was related to a reduced risk of cancer. A participant noted:“I usually seek the shade myself, so if we do go to the beach or something like that, I try to pick up a shady spot, or I have a chair with an umbrella. I am even a little more cognizant of it to having gone through colon cancer, so I mean, funny how it takes something like that to wake you up and shake you up”.All groups seemed to show an intentional avoidance of sun tanning. However, in NS/PEI and NB, this was more commonly achieved with active avoidance, whereas in NL, participants did not seem to seek out sun tanning in the first place. A participant noted: “I just...I’ve always probably been fairly careful about the sun just I would never be sunbathing or anything like that” .Of note, while participants from all provinces shared past experiences including “sunburns”, the discussion around this was more extensive among people living in NB and NS/PEI, who described blistering, peeling skin, and feeling horribly sick. Sunburns in these groups were significant enough to discourage subsequent sun exposure, as stated in the following quote:“I remember as a teenager I love[d] the sun and I would go to the beach with my friends and put on sunscreen. One time I fell asleep in the sun, and I woke up and I had such a bad sunburn on my face, it blistered the next day and that was sort of the turning point for me”.Participants from all provinces expressed that the Atlantic provinces, compared with the rest of Canada, have a higher proportion of rural population and economies heavily reliant on natural resources, which often involves outdoor work. Fishing, farming, and construction were mentioned in all four provinces. In the low-incidence province (NL), however, fishing and construction appeared to be the dominant industries. In the average-incidence province (NB), there was a focus on occupations related to forestry including lumber and dockyards. In contrast, in NS and PEI, there was a focus on farming and commercial fishing, including lobster fishing.Working on the water, which was more common in the high-incidence provinces, was viewed as particularly risky due to the absence of shade and enhanced sunlight refraction in open water. In high-incidence provinces, the concept of a “farmer’s tan” was frequently mentioned and was linked to the perception that farmers and fishermen often neglect sun exposure.One participant from St. John’s, NL, recounted an observation of outdoor workers, highlighting the intense exposure they endure:“And there were all these construction workers outside and I was thinking man I should have like, got some water, cold, and just dropped it off. Cause they were looking so, so hot…And especially you think about, growing up, the fishermen out on the water. They often too, like their faces, and their arms, their neck, their heads were always very burnt or tanned”.As a result of the short summer days across Atlantic Canada, participants from all provinces felt a collective urge to make the most of sunny days and spend time outdoors. One participant from NL noted, “You can’t stay inside on a nice day, because you’ve been inside all winter”. . Yet another participant from NB said, “We have a very short summer here in New Brunswick, so we have to take advantage of it” . Finally, a participant from NS said, “I would rather be outside than in. The winters are long in Canada. We wanna be outside … we also wanna be safe” .Outdoor hobbies on the water and land were common in all groups, including boating, swimming, fishing, gardening, hiking, biking, golfing, visiting the beach, and attending festivals. Participants from NL described berry-picking and attending the St. John’s Regatta  as common outdoor hobbies. Cross-country skiing was also a popular winter sport specifically in NL and NB. In NB, there was also an emphasis on land activities, including soccer and baseball, lawn bowling, four-wheeling, and hunting. A participant shared, “New Brunswick is one of the most rural provinces in Canada and its forestry is the biggest industry. So, spending time in the woods might be higher than in other provinces” .Participants from high-incidence provinces seemed to perceive themselves as “outdoor people”. In fact, one participant even described feelings of guilt for not intentionally spending time outside: “And, and I think we’re a culture of people that like to be outside, you know, we enjoy, you know, boating and gardening and everything outside” . Also, another participant added: “I’m guilty of that, so cycling and hiking and playing outdoors in the summer, there will be times when I’ll be an hour or two in the sun” .Participants from all groups unanimously agreed that summers in Atlantic Canada were shorter compared with the rest of the country. However, participants perceived the climate in NL and NB as being cooler, with lower temperatures and shorter summers than NS and PEI. Based on these climatic conditions, they perceived their risk of skin cancer to be lower. One participant commented:“When growing up, I always thought that [in] NL we wouldn’t get skin cancer because we had so little sun. I think we have the least amount of sun of any province per year. With the fog, and it rains a lot”.There was also a tendency among both Newfoundlanders and New Brunswickers to consider their weather as being unpredictable, which reduced awareness of sun exposure risk. With regard to this idea, a participant commented, “The environment here is not certain, you don’t think of people getting sunburn. Because of the fog and you know …” and another added, “We are more likely to need a sweater at our beach than sunscreen” .There also seemed to be a difference in the perceived number of rainy days across Atlantic provinces . The phrTemperature and the UV index were discussed in the groups. Participants from NL identified that their winters are not as severe as they used to be. In NS, participants noted that temperatures remained elevated for longer hours during the day. Interestingly, there seemed to be greater consciousness about increasing UV levels among participants from the high-incidence groups and the consequent sun exposure risk this conferred. Participants from these groups also reported checking the UV index more often compared with the low-incidence groups, in which this was not mentioned at all. As an example, one participant from NS commented, “Come May/June I start to look at UV indexes and listen to them on the on the radio” .In the average-incidence group, there was also mention of checking UV indexes and an awareness that the UV index tended to be high in NB despite the fog, which was thought to contribute to sunburn or skin cancer. With respect to this idea, one participant noted, “Another thing people have to be aware of is that the UV comes through the fog. We have a lot of fog here. So, you cannot say because it is foggy you are not getting exposed” .Global warming/climate change emerged as a theme in conversations in all groups. In NB and NS/PEI, participants reported a rise in temperatures for longer durations over the years. One participant said: “We didn’t even ever get the days that we are getting now like over 30 or 35 for a couple of weeks. That didn’t happen it would normally be like a week tops” .However, participants from NL seemed to perceive that NL would be protected from the effects of global warming/climate change. One participant from St. John’s mentioned that while most regions were expected to see a rise in temperatures, NL was expected to see a decrease:“And a couple of years ago, I’m looking over to the side… People think I’m making it up. When they were talking about global warming and how the whole earth is becoming so warm, there’s one area in the whole world that’s going to be colder and is right around NL”.The depletion of the ozone layer over time, and the consequent increase in exposure to UV radiation, was also an idea that emerged in NL and NS/PEI. However, in NL, the discussion centered around the idea that the ozone layer was not a tremendous priority, and possibly an issue of the past, while in PEI and NS focus groups, in that context, it was also thought to be an ongoing and urgent issue. Accordingly, one participant from NL commented:“I haven’t thought about the ozone in forever, because it’s just not talked about in the same way, but when there was all this worry about the depleting ozone, it was like we’re all gonna end up with skin cancer because we don’t have that built-in exposure” barrier.In contrast, a participant from NS said:“Over the course of my life I’ve got some nasty sunburns, but we didn’t think of the sun as being something so dangerous, and you didn’t get sunburns as quickly as we do now because it wasn’t as much of a problem with the ozone layer”.Changes in the ozone layer did not emerge in discussions in NB.In the high-CM-incidence focus groups, as highlighted above, the idea emerged that Atlantic Canada had a much larger rural population than the rest of the country. Participants felt that the economies in rural areas tended to rely more on natural resources and would in turn have more outdoor work and activities, where people were less likely to use sun protection and have less awareness of the risks of sun exposure. One participant from NS shared:“One factor for Atlantic Canada … is that we have a much larger rural population than Canada as a whole… People in rural settings tend to be natural resource economy to a large extent. So farming, fishing, lumbering, what have you, but basically outdoor activity and physical work activity … so there’s likely more exposure and to some degree, probably less awareness as well”.In the average-incidence group, there was also the idea that NB’s rural settings confer more sun exposure. A participant said, “As a kid in Saint John and rural wise like you would get hot, you’d be laying on the beach in it would get hot and you want [to] cool [down]” . In the low-CM-incidence focus groups, there were no discussions around rural versus urban settings or the implications of sun exposure.In all provinces, participants reported an interest in a public health campaign tackling skin cancer risks. When asked to suggest potential approaches to reduce CM incidence, participants described interventions at the individual, interpersonal, community, and societal levels , which are summarized in When asked to provide examples of the content of messaging, participants from all groups discussed beauty, healthy living, weather, and global warming. Participants in the higher incidence groups opted for more scary, graphic approaches focused on negative health outcomes, including pictures of skin cancer and stories of cancer survivors. With respect to this idea, a participant from PEI said, “I wished I knew more. I was so happy when I do see pictures of tumors just so I know what to look for in my own body. But you know, that sort of education” .There has been a growing interest in understanding the knowledge, attitudes, and perceptions that influence sun exposure at both individual and systemic levels, which is a relationship that has not been extensively studied in Atlantic Canada. According to the social–ecological model (SEM), health behaviors are influenced by the interactions at the microsystem , mesosystem , exosystem (community), and macrosystem  levels . In accoAt the interpersonal level, high-incidence provinces had dominant industries involving outdoor work including farming and fishing, and working on the water was also perceived to involve higher sun exposure risk. At the community level, outdoor hobbies, although popular in all Atlantic provinces, appeared to be more integral to the self-identity of NS/PEI residents, which may suggest the presence of cultural forces to increase sun exposure. Finally, at the societal level, the high-incidence provinces experienced more favorable climate conditions, with more sunny days, higher temperatures, and fewer rain events, and had more rural geographies. Taken together, these findings suggest that while higher-incidence provinces have a greater awareness of the risks of sun exposure, and use more sun protection, they paradoxically experience greater levels of sun exposure.n = 75,614), in which 13.1% of beachgoers reported sunburn, with the highest sunburn rates occurring at beaches along the Eastern Seaboard [Our previous research demonstrated a higher incidence of skin cancer in NS and PEI compared with the rest of Canada and NB and a lower incidence in NL . This stSeaboard , an areaThe curious finding that high-CM-incidence provinces have high sunburn rates despite high sunscreen use rates resonates with the existing sun protection literature. One Norwegian study reported that sunscreen users experienced significantly more sunburns, took more sunbathing vacations, and were more likely to use indoor tanning devices . In a SwAcross all Atlantic provinces, there was a predominance of outdoor occupations. It is well established in the literature that professionals who are employed in outdoor occupations are exposed to higher levels of UV radiation  than thoHowever, participants from NL often listed construction as an occupation, and those from NB listed construction and forestry, whereas NS/PEI listed farming and occupations on the water, including commercial and lobster fishing. Daily levels of UV exposure have accordingly been observed to be high in farmers ,42, withWith respect to recreational activities, participants from NS/PEI more often discussed visiting beaches as a pastime, which represents a form of recreational sun exposure. In fact, in our recent work using quantitative survey data, recreational sun exposure was more frequently reported in PEI and NS . SeveralThe influence of climate on sun exposure behaviors and skin cancer incidence, as observed in our study, is supported by the existing literature. Globally, there is a recognized inverse relationship between CM incidence and geographic latitude, with areas further from the equator having lower incidence rates of melanoma . CorrespWe recently identified that higher general annual temperature , availability of green spaces, and the UVR index are the three main factors associated with CM risk in Canada . In 2018We used a consensual qualitative research study design to understand the factors contributing to high and low incidence of cutaneous melanoma within Atlantic Canada. To the best of our knowledge, this is the first study to analyze the experiences of communities in Atlantic Canada, which has an especially high burden of skin cancer. Our focus groups were conducted on the older population within Atlantic Canada who may have a higher risk of CM and also reflect the broader demographic of the Atlantic provinces. The analysis was conducted using a carefully constructed theoretical framework while maintaining openness and flexibility in interpreting the outcomes. One notable limitation of this study was the size of our sample, which consisted of 22 focus groups that largely represented participants from high-incidence provinces (15 interviews) with considerably less representation from the low-incidence province of NL (2 interviews). While this allowed us to better study the enacted behaviors of the high-CM-incidence group, it may have limited our ability to understand attitudes and behaviors in NL. We also used a snowball sampling strategy, which may have led to an overinclusion of individuals within the same networks or communities. Such homogeneity could lead to shared perspectives, thereby potentially narrowing the diversity of experiences and views captured. Consequently, these biases could impact the broader generalizability of our findings. We also acknowledge that the efficacy of sunscreen in real-world applications may be compromised if not applied appropriately, leading to suboptimal protection against sunburn. This potential inconsistency in the application was not explored in this study but might contribute to the observed sunscreen paradox.Individual behaviors are crucial determinants of solar UV exposure, including actions such as wearing protective clothing, sunglasses, and hats, utilizing sunscreen and seeking shade. Our findings underscore the need for comprehensive public education regarding the risks associated with sun exposure, the specific dangers posed by occupational and recreational exposures, and the appropriate use of sunscreen.The participants in this study demonstrated awareness of preventive measures for skin cancers. Interestingly, community members from the high-incidence group (NS and PEI) cited more societal-level factors contributing to CM risk and were interested in scarier messages focused on possible negative health outcomes. This is consistent with their greater awareness of skin cancer and their use of sun protection. Perhaps this higher awareness translates into the perception that skin cancer is a broader issue that requires system-level intervention and the participation of governments.Public health campaigns need to be carefully crafted, considering the unique cultural norms prevalent in areas of high-, average-, and low-CM-incidence regions. For the high- and average-incidence groups, it may be valuable to focus on a reduction in recreational sun exposure with the use of sun-protective clothing as opposed to mostly relying on sunscreen, which perpetuates the “sunscreen paradox”. Sun-protective UPF > 50 clothing has shown greater efficacy in preventing sunburns and providing reliable sun exposure . Based oFor the low-incidence group, it may be valuable to center efforts on educating the public on UV exposure risks in the absence of direct sunlight. Beyond individual behaviors, policy changes are needed to encourage the provision of public shade through government subsidies, employer-sponsored sunscreen/clothing and personal protective equipment, and removing tax from sun-protective items, making them more affordable to the public and particularly for outdoor workers . The devIn summary, our study found that the high incidence rate of CM observed in NS and PEI compared with NB  and NL  may be explained by four factors: (1) greater use of sunscreen, which confers a false sense of security, known as “the sunscreen paradox”, (2) a predominance of outdoor occupations involving higher sun-exposure levels, (3) a culture of engaging in outdoor hobbies/activities, and (4) warmer temperatures increasing UV exposure. Effective behavioral change interventions to address these gaps should be tailored to the unique social and cultural experiences of each group while also addressing systemic barriers that create broader access challenges across Atlantic Canada.


Agenda-setting is a central communicative task for professionals and a joint activity of all participants particularly at the onset of helping interactions such as coaching. Agreeing on goal(s) and assigning tasks alongside establishing a trustful bond prepare the ground for the success of the interaction. The professional agent initiates and sets the agenda as part of their professional role and responsibility, i.e., based on their professional epistemic and deontic authority. Concurrently, by orienting to clients’ epistemic authority and by yielding power, control, and agency to clients to co-manage the ensuing interaction, agenda-setting is the first opportunity for client-centeredness, which is a central characteristic and success factor for the working alliance in coaching.We take first steps in filling a research gap by providing a first analysis of the interactional unfolding of agenda-setting in coaching and by showcasing that and how agenda-setting as a joint activity of coach and client contributes to their working alliance. More precisely, we investigate agenda-management practices in five first sessions of business coaching to (1) document and analyze how the joint activity ‘agenda-setting’ is implemented via various (coach-initiated) social actions, (2) detail their contribution to establishing the working alliance, and (3) to interpret the emerging practices of agenda-management against the concept of ‘client-centeredness’. For the analysis, we draw on conceptual and methodological resources from interactional linguistics alongside linguistic pragmatics and conversation analysis.We found 117 instances of ‘agenda-setting’ in our data which can be assigned to the seven social actions “Delivering Agenda Information”, “Requesting Agenda Information”, “Requesting Agenda Agreement”, “Requesting Agenda Action”, “Suggesting Agenda Action”, “Offering Agenda Action” and “Proposing Agenda Action”.The social actions display that agenda-setting serves to establish a common ground regarding goals, tasks and the relational bond of coach and client, and (after this has been achieved) to negotiate future coaching actions. Thus, the joint activity of ‘doing’ agenda-setting can be shown to be ‘doing’ working alliance at the same time. Insights into the interactional trajectory of agenda management offer an important perspective on the concrete local actions of coach and client and on how the working alliance is discursively achieved , this uneraction , p. 173.eraction , p. 2 ar(a)chieving equal participation in an encounter with two or more participants is always a great challenge (…). While this is the case even in dyadic encounters that are permeated by strong expectations of equality (…), the situation is naturally even more challenging in encounters in which participants have distinct roles and hierarchical statuses (…).These distinct roles and hierarchical statuses in professional (helping) encounters such as coaching are tied to the participants’ differing epistemic and deontic authorities . CoachesQuestioning Sequences in CoachingAnalyses of the local interactional unfolding of agenda-setting are so far missing in (linguistic) coaching process research . The cur2.As outcome research across various professional contexts has convincingly illustrated, agreeing on goal(s) and task(s) alongside establishing a trustful bond between the participants prepare the ground for the overall success of the interaction. That is, setting and managing the agenda contributes to (initiating) the working alliance of coach and client, which in turn positively influences the overall success of the encounter. Agenda-setting thereby also represents the first and pivotal opportunity to locally act out client-centeredness . In what2.1.While building and managing relationships are part and parcel of all social interactions, in helping professions, the relationship between professionals and their patients/clients has proven central for the interactive construction of the process and for achieving the respective institutional tasks and goals e.g., . The conIn quantitative outcome research on psychotherapy, the therapeutic/working alliance represents an established and verified success factor e.g., : “The stThe significance of the working alliance for coaching success has more recently also been established in quantitative psychological outcome research . Despite2.2.Steering the conversation is an omnipresent activity of participants in talk-in-interaction. Communicative partners prospectively and retrospectively control or influence the overall organization of the ensuing conversation via, e.g., turn-taking and turn design, the thematic development via introducing new topics or shifting topics and, more generally, the overall progressivity of joint actions and activities  is prolific for medical encounters, especially in physician-patient consultations. Agenda-setting is defined as a communicative strategy that physicians use at the beginning of clinical visits to elicit patients’ topics or concerns, to propose their own topics and to organize a list of shared topics . Yet, esBeyond this relatively narrow reading of agenda-setting as collecting and prioritizing relevant concerns during the problem presentation phase in medical encounters, e.g., Overall, agenda-setting in helping interactions fulfills a principal organizational, thematic, as well as relational function for the ensuing professional encounter with special relevance at its beginning, i.e., during first sessions. It is the professionals’ responsibility to organize the encounter following a more or less predetermined structure , educational e.g.,  and more3.3.1.For the current study, we use five randomly selected first sessions from a recently collected corpus of work-related coaching processes from Germany and Switzerland. The coaching processes, both face-to-face and online, were carried out in German and were video- and audio-recorded by the coaches themselves. Coaches  are seasoned practitioners working in the realm of solution-oriented, systemic coaching; the clients  had either an academic or an organizational background. The sessions were transcribed according to (simplified) CA transcription conventions  in first sessions of coaching. To this end, we use conceptual and methodological resources from linguistic pragmatics, interactional linguistics, and conversation analysis. From linguistic pragmatics , we adop3.3.QueSCo project, authors 1 and 2 examined all five first sessions for the occurrence of agenda management by coaches and clients. Beyond the narrower category of agenda-setting questions, 127 instances of agenda management, 117 initiated by coaches and 10 initiated by clients, were identified and further processed. In an iterative process, seven categories were established according to the types of social actions implemented by coaches that ‘do agenda management’: “(t)he particular sense of action being put central here is the ascription or assignment of a ‘main job’ that the turn is performing. The sense of ‘main job’ or primary action intended here is what the response must deal with in order to count as an adequate next turn” , modality  and imperativity (is non-compliance an option or not?)” , interrogativity (are you asking me or telling me?), conditionality ” , p. 639 According to On the other hand, the question of agent and beneficiary of coaching agenda-related future action determined our categorization. More generally, it focused on the participants’ rights to direct future actions (based on their (upgraded) epistemic status) . In the (r)equests for action may range from orders and commands to suggestions and hints, depending most fundamentally on the extent that the first speaker may assume that the second speaker will perform the relevant action without being directly asked for it (…). Hence (…) we argue that such an interpretation is contingent on the recipient’s judgments about the speaker’s high deontic status relative to the recipient in the domain in question.Based on For each (sub-)category see  a represThe categorization of the instances into seven social actions was critically discussed with authors 3 and 4, who also substantially contributed to the detailed analysis of the chosen examples and the interpretation of the findings. The degree of detailedness is dependent on the overall analytic goal, i.e., to give a first overview of agenda-setting practices in coaching. While the overall approach in this paper is qualitative in nature, the raw frequencies of the social actions and their respective sub-types were considered for the purpose of interpretation.4.4.1.A central part of setting and managing the agenda in coaching is informing clients about the overall organization of the interaction, i.e., setting up the interaction frame of ‘coaching’ regarding its content(s) as well as its temporal and structural layout. The primary communicative practice in the context of framing coaching methodologically, procedurally, and temporally  are ‘infwould, which renders the information delivery more polite and pays tribute to the clients’ negative face needs by granting more freedom of action  and those which inform about coaches’ upcoming own actions (4.1.2). Delivering agenda information often entails information about time and place along with structuring devices to clarify what happens when. Coaches almost exclusively use declaratives, often phrased with first-person singular present tense forms. We find various uses of the indicative, but also conditional 4.1.1.I, but also a few first-person plural we pronouns in subject position. Most of these examples contain temporal or spatial deixis  and other structuring devices (to make a point here). When it comes to planning the future, the agenda moves also contain visual lexis . Examples often contain conditional forms to downgrade the coaches’ deontic claims. Example 1 illustrates this category.21 out of the 36 examples of “Delivering Agenda Information” in our corpus have a structuring function. In providing structural information for clients and making the procedure etc. transparent, these agenda moves promote a trustful bond between coach and client; they also prepare for an agreement on the tasks to be carried out. Except for one imperative, all information deliveries are realized as declaratives, featuring predominantly first-person singular Example 1: Delivering Agenda Information: Structuring content/session/process/coaching..h uhm hhh well we are we just (have just) finished circling around a bit uhm how what what your state of affairs looks .h like,” ll.1–3). The coach’s summary is characterized by various hesitation markers , audible breathing, a cut-off, self-repairs, and repetitions (“we are just (have just),” ll.1–2; “what what,” l.3), as well as modal particles  and rather unspecific vocabulary . Addressing their prior work serves as a preparation and accounting for the coach’s attempt to define the goal of the current session. The latter is introduced via a contrastive “but nevertheless” (l.3), implying—together with the hesitant summary of their prior actions, the focus on the here-and-now —that what they have been doing so far is insufficient regarding a goal definition. This leads the coach to formulate her wish to specify  today’s goal or, more precisely, “what we can .h do today” (l.4), with the modal verb “can” denoting ability combined with achievement. While the coach uses first-person plural “we” to refer to their prior actions and mutual goal, she uses first-person singular “i” and matching pronouns to introduce her piece of agenda-relevant information, i.e., her wish to specify the goal, and to account for it. She claims deontic authority with her information delivery statement but allows for the possibility of client disagreement in the use of mitigating particles and conjunctive mode with the modal “would” (l.3). In the following, the client responds with an acknowledgement token when the coach continues to summarize goal-relevant information from her notes.To arrive at a goal definition for this first session as a basis for working on the client’s issues in a narrow sense, the coach starts by summarizing what they have already done in the first couple of minutes of the session, i.e., that they have encircled the client’s concern more generally . Again, we find various temporal adverbs  in these declarative informing statements. The coaches position themselves as the agents of the action via first-person singular pronouns and active voice in all examples. Present tense indicative forms are used throughout. Often, the coaches minimize the impact of their actions on the overall activity with a bit, some, only, just, etc. We also frequently find hesitation markers, pauses, audible breathing as well as accounts whereby coaches might want to mitigate their explicit assumption of higher deontic stance: They often name aims  or give reasons  stressing the positive impact of taking notes for the clients and the process as such. Indeed, while information deliveries do not present instances in which the coaches’ deontic authority—as the persons in charge of the process and of the action—can be easily challenged, the professionals still account for their doings for the benefit of their clients.15 out of the 36 examples of “Delivering Agenda Information” belong to the category “Commenting on own action.” In the majority of cases, the coaches make their actions transparent by informing clients about the fact that they are (about to be) taking notes. This transparency regarding their actions is even mirrored in their choice of vocabulary (Example 2: Delivering Agenda Information: Commenting on own action.just” or by reducing the extent of her action by “a few” (l.2). She stresses the benefit of her action by referring to the coaching as a mutual process  and by producing an account, i.e., that she does not only want to be able to listen to the client, but also to get back to aspects . Using declarative statements in the present tense and indicative mode, the coach stresses her deontic authority to decide on such procedural next actions. At the same time, by referring to “our” (l.4) progress, the coach constructs her actions as beneficial for the process and, eventually, for the working alliance, too. While the coach explains her actions by drawing on her epistemic and deontic authority, she ensures transparency regarding the purpose and the addressee of these notes and thereby builds trust with the client. Besides some overlapping acknowledgement tokens , the client produces a positive receipt of this information once the coach has finished her turn (l.8).In Example 2, the coach informs the client that she will take notes. She modulates her comment in different ways, e.g., via the modal particle “4.2.In our corpus, agenda-relevant coaching information is not only delivered, but also requested by the coach. In their professional role, coaches have the deontic authority to ‘demand’ information in order to benefit from this knowledge. By requesting information, the coach, as beneficiary of a knowledge upgrade, seeks to gain some measure of access to the client’s (territory of) knowledge , thus poIn the context of “Requesting Agenda Information,” clients are expected to provide insights into their concern(s) and goal(s) of coaching and how they can be approached (11 examples) as well as their expectations concerning the coaches’ role and responsibility (three examples). In these agenda moves, clients are attributed a [K+] and coaches a [K-] status . While would. We frequently find first-person pronoun I used by the coach as well as second-person pronoun you addressing the client directly.Concerning the syntactic structure, interrogatives are found in the great majority of examples of requesting agenda information. This is in line with 4.2.1.wh-questions regarding goal or concern , we also find more topic-specific requests for information (What do you want to achieve with the coaching? Which of the two concerns would you prioritize? What would be useful for you?). The clients and their wishes are directly addressed in the majority of cases, which increases response relevance even further . These agenda moves showcase the client-centeredness of coaching: Knowledge about the concern lies in the clients’ epistemic domain, and hence coaches need clients’ collaboration when defining the goal. In the turns following the request proper or building on this common ground at later stages, the cooperation between coach and client in working toward clients’ goals is sometimes explicitly stressed via the use of collaborative we in further requests for information   is often (yet not exclusively) found in the first parts of the first sessions and comprises 11 examples. Along with general initiatory requests via open  further , but we Example 3: Requesting Agenda Information: Defining content/goal.wh-questions, the professionals invite clients to define their concerns/goals in coaching or—as is the case here—to decide on the most important one.Example 3 features an agenda management move which is typical across many helping interactions  and, based on her epistemic authority, concludes that the issues constitute two separate (though interrelated) concerns (ll.1–2). Without being prompted, the client minimally agrees with this . The coach tentatively adds that the client becoming a mother soon might be another issue and finishes with a question tag seeking confirmation and thereby addressing the client’s epistemic authority (l.6). The client responds affirmatively . Thereafter, the coach—in an information-delivery sequence—sets the time frame as regards the current session  as well as the entire coaching process . In each case the coach uses the personal pronoun “we” (ll.13 + 16) stressing the joint activity. The client first provides a minimal acknowledgement (l.14), and then a clearly affirmative one in an overlapping manner (l.17). Against this common knowledge regarding the time frame and the two distinct concerns, the coach, again, requests agenda-relevant information via a polite wh-question (leaving the client freedom of decision) so that she can continue her agenda management. She addresses the client via the personal pronoun “you” and uses conditional “would” along with the verb “like” to learn about the client’s priority. She starts off with “which of the two concerns would you hh (0.7) like to” (ll.18–20), and the client immediately provides the verb “prioritize” (l.21) to collaboratively complete the coach’s turn, which shows her attentiveness:Prior, the coach asked the client to elaborate on her current situation and to name coaching-relevant topics. Among others, the client explains that maintaining her focus is a major problem. The coach—ratifies the client’s elaboration with “The joint production of an utterance, in which one speaker begins the utterance and another extends it, is a carefully orchestrated accomplishment requiring considerable attentiveness and skill from the second speaker; that is, the second speaker must be able to project when turn constructional units (…) are nearing completion and, at the same time, must be able to immediately build upon the utterance by adding an appropriate grammatical unit that semantically coheres with what has come before (…). These co-constructed utterances also have considerable social relevance, because they index a high degree of cooperation, solidarity and involvement between the participants (...). , p. 11yes,” l.22) and after an overlapping continuation yields her turn to the client to name the concern to be dealt with first . Agreement on goals, an essential component of the working alliance, has been reached for the current session.The coach thus actively invites and acknowledges the client’s expert status as regards her (prioritizing the) concern. By completing the coach’s turn, the client accepts this ‘invitation’ with confidence. The coach accepts this (“4.2.2.Three instances of requesting agenda information explicitly relate to the role and responsibilities as a coach and (in this function) they form a subtype of “Requesting Agenda Information.” This subtype (comprising interrogatives only) explicitly addresses relational issues and is primarily bond-related.Example 4: Requesting Agenda Information: Defining roles & responsibilities.what shall my role as a coach (0.2) in this process be,” ll.1–3). She formulates this as an open wh-question and directly addresses the client, attributing both epistemic and deontic authority to her. At the same time, the coach assumes deontic authority by asking the question at this particular point in the process  and by requesting very specific information  thereby putting pressure on the client to provide such details. The wh-question is embedded in a longer, multi-turn formulation of the client’s concern (not in the excerpt) and, at first, after a 0.2 s pause, the client only provides minimal acknowledgement . After another 1.3 s pause, which suggests interactional trouble (my role as a coach (0.2) in this process” (ll.1–3) via concretizing her role as offering help “what can i help (0.4) you with (.) concretely” (ll.7–9). While offering help accentuates that the client is in need of support and builds on the assumption that the coach can provide this help, inviting the client to specify the type of help implies that the client has an active share and responsibility in the outcome as well as sufficient knowledge regarding the kind of support needed to achieve it. This points at the traditional sharing of tasks in coaching: The coach is responsible for the process, the client is responsible for the content. That the coach intends to adjust her role (and interventions) in the coaching process to the client’s individual needs and expectations . After a 2.6 s delay, a hesitation marker  possibly indicating reflection and another pause of 2.1 s, the client starts to provide an answer, which covers different aspects. The structuring device “for one” (l.13) indicates a complex upcoming turn which will involve several components . Her response shows that she is not only prepared to formulate her needs, but also has some knowledge about coaching practices, i.e., that coaches ask questions  to help clients concretize their thoughts. Her uptake is phrased tentatively with various mitigating expressions , which can be interpreted as an awareness of the socially challenging situation to tell a professional expert what to do. It also possibly indicates a lack of clear procedural knowledge of what the coach can actually do. At the same time, via her suggestions the client assumes some deontic authority to mold the coach’s future actions.In example 4, the coach puts herself at the service of the client via using thematically open interrogatives. She thereby first requests general information about the client’s wishes regarding her role/responsibilities in the coaching process  measures is attributed to the clients in coaching. All of them are phrased using interrogative syntax; they are very uniform in that the coaches’ display of power does not align with their deontic authority as professional agent to, e.g., suggest a certain procedure at a particular moment in coaching. Instead, they attribute deontic authority to the clients to authorize these suggestions or reject them, i.e., procedural decisions are highly contingent on clients’ acceptance , p. 271.would (Would this be something for you? Would this be a good moment to come to an end?) as well as modal auxiliaries (May I note down X? May I just briefly share what I just thought?). The requests are mitigated  and contain temporal references indicating a short duration  and only minimal intrusion. Clients’ negative face needs are respected. Furthermore, we find some impersonal formulations (Can it be left like that for today?).In terms of linguistic features, we find the polite use of conditional Example 5: Requesting Agenda Agreement.would this very moment perhaps be an opportunity,” l.1) with reviewing what the client has already learned about herself and the topic at hand  found out about the topic,” ll.1–4); he mitigates his request using a conditional form and “perhaps.” Also, he constructs the implicitly announced intervention as useful by labeling it “an opportunity.” The polar interrogative question format does not, however, question whether reviewing previous work is a useful course of action; instead, the requested agreement  only concerns whether the client considers the present moment a good time to do a review . While the client is thus given the power to decide on the adequacy of the timing for the intervention (and is the agent of this decision), she is not given the power to decide on the intervention as such. Deciding on its appropriateness or adequacy remains in the coach’s epistemic and deontic domains. After a considerable pause of 2.2 s, the client first only produces the minimal agreement token “yes” (l.6), but—after another short pause—upgrades her agreement to a more enthusiastic stance “we can absolutely do that” (l.8), thereby granting the requested agreement, from which the coach benefits. Interestingly, while the coach directly addresses the client “you […] yourself” (ll.1–2), the client employs a collaborative “we” (l.8).In example 5, the coach elicits the client’s stance regarding the timing of a continuation of the session  wants the addressee (the client) to do something: These directives “involve some future event or task to be accomplished, orient to speakers’ rights and responsibilities, and make relevant some form of acceptance or compliance by the recipient or commitment to carry out the task (…)” , p. 2. T(r)equests for action may range from orders and commands to suggestions and hints, depending most fundamentally on the extent that the first speaker may assume that the second speaker will perform the relevant action without being directly asked for it. Declarative statements do not necessarily impose any action on the recipient. Hence (…) we argue that such an interpretation is contingent on the recipient’s judgments about the speaker’s high deontic status relative to the recipient in the domain in question.The three instances of “Requests for Action” do not contain imperatives, but two declaratives and one interrogative. In two of them, the coach asks her client to correct her if she has understood or summarized the client’s prior talk incorrectly, in the third one the coach requests the client to state her goal, thereby contributing to agenda-setting and working alliance alike.Example 6: Requesting Agenda Action.i had (.) another look at my notes .h ((clicks tongue)) and what struck me were .h,” ll.5–6). Before proceeding with the actual formulation (l.11ff.), though, the coach requests future agenda action from the client, asking her to correct her in case she got it wrong . She thereby displays a high entitlement to request such action from the client, using the imperative mode, only slightly mitigating her directive with the adverb “please” (l.9). At the same time, she attributes both the epistemic authority to the client regarding the content of the formulation (as pertaining to the client’s epistemic domain) and the deontic authority to take agentive action (of correcting) and potentially turn the summary down. The client acknowledges the request for action in providing a minimal acknowledgement token .As already explained in section 4.1.1, Example 6 first features a delivering agenda information move with which the coach tries to structure the thematic focus of the session. After this preparatory move, the coach introduces an upcoming highlighting formulation  of the cThis request for action, i.e., for correction, clearly bears on the relationship between coach and client in the sense of both having similar rights and responsibilities. While the coach’s formulation displays an updated epistemic stance regarding the client’s concerns, she concurrently positions the client as having the epistemic authority over this domain by explicitly inviting correction. As such, the agenda move bears both on the goal-component of the working alliance given that the participants need to agree on what they should be working on as well as on the bond-component of the working alliance, i.e., on establishing a stable relationship where critique is possible. Still, the right to exert influence on the professional agent via a possible correction  presents a delicate interactional moment: explicit corrections are indeed dispreferred social actions that are generally avoided , p. 217.4.5.now, at this point [in time] in the next session) or a period of time  which is usually used to argue for the feasibility of the suggested action. With concern-oriented suggestions, clients are invited to reflect on their goal, aspects of their personality, strengths and weaknesses, or on what has been discussed so far. Instances of “Suggesting Agenda Action” build on mutually upgraded knowledge as regards clients’ concerns/goals, i.e., are found during later stages of first sessions. The negotiation of these suggestions promotes a possible agreement between coach and client on the goal(s) and tasks of the coaching.We now turn to ‘suggestions’ as another kind of directive and controlling social action. you can do X or, somewhat more directive, I would ask you to do X. We also find no-agent constructions in the passive voice (a look would have to be taken at X). In a few cases, the coach prefaces the suggestion with an explicit attribution of deontic authority to the client by emphasizing volition (if you feel like (doing X), if you like (we can do X)). In addition to examples showcasing the verb suggest (I would like to suggest X) or the noun suggestion (my suggestion would be X), we find verbs expressing intention, willingness or wish, often featuring conditional would (perhaps you would like to do X). We also find some examples in which the coaches, in a pre-sequence (if you permit) or their agreement (if you want to) before uttering the actual suggestion. Yet other examples are more straightforward and emerge locally without any preparatory moves. Following the actual suggestions, we find various cases of accounting, where coaches stress the benefits for the clients and their goals in coaching .The coaches mostly phrase their suggestions as declaratives in the form of sequence , ask foryou decide, you can ask people, your task would be to do X), we also find suggestions that draw on first-person plural pronouns . The coaches’ suggestions often feature mitigating devices  and hesitation markers, pauses and breathing, which render their turns rather tentative in nature. As such, coaches—while having the relevant (knowledge and) power as professional experts of appropriate next steps– mostly do not publicly display a stance congruent with their (epistemic and) deontic status as professionals  as to listen to what they say. The first part of the task is phrased as a possibility for a client action (“you”) involving the modal verb “may” (l.6) and comprises several alternatives as to whom the client might ask, leaving it open for the client to decide exactly who would be most appropriate for the exercise (“people who are close to you or be it colleagues be it (.) your husband or the [like],” ll.7–8). The coach minimizes the costs of the suggested task for the client (just” and “for the fun of it” (l.8). In this same minimizing sense, she emphasizes that the client’s actual task would be to “in a [sense] .h to listen attentively hhh” (l.10) to her friends and family. In spite of this, the coach leaves it up to the client to decide whether this ‘easy homework’ will be completed or not: she designs her utterance using the conditional, thus stressing the optional nature of the suggested task. The client reacts with overlapping acknowledgement tokens (ll.9 + 11) and a positive polar interjection . The coach then precises how the client’s asking could be “simply” done, providing candidate questions as explanations (l.15ff.). She “takes on the client’s voice thus speaking as if she were paraphrasing or quoting the client’s message” . Regarding their contribution to establishing the working alliance between coach and client, all instances of this social action type are either task- or bond-focused.Another nine instances of agenda management were classified as “Offering Agenda Action.” Just as with suggestions (chapter 4.4), the client is the one who benefits from the named action; yet, unlike with suggestions or requests, the coach is the agent of the offer. This makes offers commissive actions: The coaches commit themselves to carrying out the future action in question, which refers to “the transfer of an object or a service” , p. 249.I for the coach as the (future) agent. And all but one example feature characteristics of mitigation in the sense of pauses or audible breathing, conditional mode, auxiliaries would, may or adverbials such as a few, a bit, perhaps. While offers are preferred actions compared to requests . The client adds that she feels depressed and like not having a life of her own (ll.7 + 9). In reaction to this, the coach offers to take action, i.e., to give some tips regarding time management (ll.11 + 13). Before the actual offer, the coach starts her turn with affiliative laughter, then breathes in, pauses and hesitates, and uses the acknowledgement token “okay” and adversative “but” (l.11) to introduce a measure against such feelings expressed by the client. Giving tips implies expertise and epistemic authority and underlines an asymmetric and hierarchical relationship. However, the coach downplays her authority and orients toward the client by asking for permission , mitigating her offer  and by using hesitation markers. Only thereafter the coach starts naming her tips. There is, however, no pause which would give the client the chance to grant permission. However, since the client has provided agreement in overlap, the coach can build on this positive uptake and elaborates different recommendations such as to reserve slots for herself in her work schedule and to accept that there are days when it is not possible to stick to a scheduled plan.In Example 8 the client explains that she has problems with her work-life balance (ll.1–9). The coach affiliates with the client and voices understanding for her situation , the proposals are all framed as options, respecting the negative face of coach and client alike. Moreover, they are all metapragmatic statements of proposed future actions in that these instances realize the ‘discourse on coaching,’ not the ‘coaching discourse’  coaches frame possible next agenda steps as open for discussion and explicitly involve the client in the decision , thereby mitigating a potential face threat and enhancing the clients’ freedom of action. While proposing next agenda steps bears on the task-component of the working alliance, the fact that these moves create transparency and commitment on the side of the client promotes the bond between the interactants.Our corpus features six examples which were classified as proposals, i.e., as “Proposing Agenda Action.” These instances are characterized by coach and client both being agents and beneficiaries of the proposed future action, which is documented in the use of the first-person plural pronoun scourse’ , p. 290.Example 9: Proposing Agenda Action.then,” referring to the future action. While making such a proposal documents the coach’s deontic authority, integrating the client in the agenda management by phrasing the proposal as possibility , by employing the first-person plural pronoun “we” and the verb “agree […] on” (l.7) stresses agenda management as joint activity in which client’s deontic authority is upgraded. The coach also mitigates the effort or time investment by adding “briefly” (l.7), which will make the proposal more easily acceptable for the client. The client provides continuers  during the coach’s turn though prior to the proposal. However, she does not immediately provide a positive uptake regarding the proposal itself. After some pausing, the coach offers further explanations what ‘agreeing on’ means (ll.13–16) emphasizing that the proposed has to fit the client. Thereafter, the client agrees .In Example 9 the coach offers some additional material on time management tools which the client can read and try out. This serves as a basis for agreeing on whether the tools fit for the client. The proposal (l.7) contains the temporal adverb “5.The interactional trajectory of agenda-setting in first sessions of dyadic business coaching is closely linked to the domains of knowledge and power of the participants and how these bear on the participants’, i.e., on coaches’ and clients’ momentary relationship , p. 187,The distribution of epistemic authority concerning procedure and content showcases the ‘division of labor’ as claimed in coaching practice literature e.g., , p. 9, vAs such, the social actions found in the data promote and underlie the working alliance in coaching and do not only ‘do’ agenda-setting, but they also ‘do’ working alliance: Agreeing on the goal(s) of the coaching , assigning task(s) to reach these goals , and establishing a bond between coach and client .5.1.n = 36), coaches inform clients about possible content of their coaching interaction or about the temporal framing of the session or the process. Moreover, coaches also inform clients what they themselves are/will be doing in the sessions. As outlined by opaque.” Thus, “Structuring content/session/process/coaching” (n = 21) builds on coaches’ epistemic authority as professional coaching experts and enables an upgrade of clients’ epistemic status with respect to how coaching will proceed, i.e., it reduces the opaqueness of coaching by creating a thematic and procedural common ground. In “Commenting on own action” (n = 15), coaches inform clients about the rationale of a certain action, primarily of them taking notes during the session. This meta-pragmatic framing strategy creates transparency for the clients and pays tribute to their entitlement to know the motivation for coaches’ actions. Moreover, in sight of the triadic constellation of (most) coachings (n = 36) belong to the social category of “Delivering Agenda Information” can be interpreted as a form of client-centeredness in its reading of democratizing the professional—client relationship.In more detail, in “Delivering Agenda Information”  and also what coaches should specifically be doing for them . Such concern and goal elicitation via, e.g., wh-questions represents a core agenda move discussed in existing literature on other helping formats, too (chapter 2.1) and represents, following Silverman’s argument . With this social action, coaches seek agreement from clients with respect to the  adequacy of taking next procedural steps or actions suggested by the coaches. Unlike for the other subtypes, where clients enter coaching with a pre-existing relative epistemic advantage, clients’ [K+] status here is contingent upon their upgraded epistemic status with respect to the locally ensuing interaction with the coaches. Although coaches here attribute the rights, responsibilities and also the obligations to know to the clients, the procedure to be evaluated is introduced by them in the first place on the basis of their professional epistemic and deontic authority. Still, clients are authorized to influence and participate in decisions regarding the thematic and interactional trajectories of the coaching encounter as a form of client-centeredness. Agreement on goals and tasks as essential components of the working alliance require eliciting the ‘reason for visit’ in the first place alongside the negotiation of adequate steps.In terms of frequency, “Requesting Agenda Agreement” is even slightly more common than “Requesting Agenda Information” (Agenda-setting is not only an information- and agreement-oriented joint activity for establishing a trustful bond (predominantly via creating transparency for clients) and successfully working on clients’ goals , but also includes (first) intervening steps to work on what has been agreed on. Action-oriented agenda moves bridge the gap between the definitional phases  and more generally on their professional stock of knowledge. Suggestions resemble requests in that they are directive speech acts and in that the addressees (the clients) are the agents of the future action, yet, with suggestions, the clients are also the beneficiaries of that action . Due to this difference, suggestions are less dispreferred than requests: Clients ‘work on their own account’ rather than for the coaches’ benefit. Given that clients enter coaching and the asymmetrical and hierarchical relationship with their coaches with a willingness to change , p. xix,5.6.I) at the service of their clients, who will benefit from actions such as sending material or giving tips. While offers generally exist in three formats  agenda action, but they also both benefit from it. The proposed actions in our corpus all relate to organizational issues regarding the ensuing coaching work on clients’ concerns and add to the transparency of what coach and client can do together and when or how they can do it. While transparency—against the background of the overall opaqueness of coaching  and how it is further processed by the participants in second and third positions . With 11The original contributions presented in the study are included in the article/Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.SJ and E-MG examined the corpus for the occurrence of agenda management by coaches and clients and assigned them to the social actions. The categorization was critically discussed with MF and FD, who also substantially contributed to the detailed analysis of the chosen examples and the discussion and interpretation of the findings emerging from the categorization. E-MG was mainly responsible for the theoretical background and the discussion, while SJ was mainly responsible for the analyses. MF and FD took special care of examples and references. SJ produced the final edited manuscript. All authors contributed to the article and approved the submitted version.


Individuals living with hypermobile Ehlers-Danlos syndrome (hEDS) and Hypermobility Spectrum Disorders (HSD) have reported feeling discredited and unsupported by healthcare professionals. However, the level of knowledge about hEDS/HSD among maternity staff remains unknown. Informed by patient and public involvement, this research aimed to investigate maternity staff’s knowledge and confidence in supporting people with hEDS/HSD, examine people with hEDS/HSD’s experiences of perinatal care, and co-create tools to help maternity staff support people childbearing with hEDS/HSD. Two online mixed-methods international surveys were completed by childbearing people with hEDS/HSD (N = 955) and maternity staff (N = 307). This was followed by the co-creation of three tools with 17 co-creators and a design team. Two main qualitative themes were identified through thematic analysis: (1) a need for recognition of hEDS/HSD in perinatal care and (2) the delivery of appropriate individualised perinatal care. Quantitatively, people with hEDS/HSD perceived maternity professionals to have a low level of knowledge about the conditions. Respectively, maternity staff reported low levels of confidence in supporting people with hEDS/HSD. The co-created tools provide applicable outputs for both education and practice and include an i-learn module hosted by the Royal College of Midwives, a tool for perinatal records, and infomercials. Standards of maternal and newborn health  and intrAlthough hEDS/HSD were previously understood to be rare, more recent evidence suggests these conditions may be more common. In a study of healthcare records, 1 in 500 people were found to have a diagnosis of either EDS or Joint Hypermobility Syndrome (JHS) on their medical records , where iThis research implements a mixed-methods approach , combiniwww.sallypezaro.wordpress.com) over professional social media accounts. It openly asked members of the public to answer questions about topics and tools important and relevant to childbearing and hEDS/HSD to inform what questions should be included in the surveys (part 2) and potential tools to be co-created (part 3) . Some had been cared for by knowledgeable specialists or professionals who actively sought to develop their understanding: “Midwife was not aware of hEDS prior to my treatment, but took the time to research and shared valuable insight with me” . Few professionals perceived that hEDS/HSD awareness had recently grown: “In my hospital, EDS is a new word; people are now mentioning it, but a year ago it was unheard of” . However, professionals also reported that misconceptions towards hEDS/HSD were held by colleagues: “Many people I have spoken to seem to believe that hypermobility would be an advantage in labour and fail to acknowledge the added pain or tissue damage that could be caused” . Taken together, professionals frequently described wanting more knowledge of hEDS/HSD, including about symptoms and care management: “More awareness of the condition and associated complications” .Many women reported that professionals often had limited awareness and knowledge of hEDS/HSD: “Participants with hEDS/HSD quantitatively reported that they perceived the professionals to have a somewhat low level of knowledge about hEDS/HSD, with maternity support workers, midwives, and obstetric nurses perceived as mainly ‘not at all knowledgeable’ . PhysiotWhen asked, 36% of staff did not consider themselves to be knowledgeable on hEDS/HSD. Out of those that did consider themselves to have knowledge of hEDS/HSD, the main sources of knowledge were professional (N = 136) and personal (N = 106) experience, followed by reading research (N = 75) and seeing it in the media (N = 48). Very few gained their source of knowledge from university courses (N = 9) or other types of training (N = 22).“I tried to research EDS in pregnancy, and material was hard to come by” . Both participant groups also wanted an increase in evidence-based guidelines to inform appropriate care: “We need more information that will allow the discontinuation of rapidly dissolving sutures in women with EDS” and the potential link “with severe vaginal prolapse postpartum” . Professionals wanted a range of resources, including professional guidelines, toolkits, online courses, and posters, though resources should be based on research, “a study published to provide the advice that I can pass on to the planning/expectant mother” . It was important that resources were “easily accessible”, including in multiple languages, and that professionals had capacity in their roles to learn that “information is no good if we do not have enough time to access/absorb or implement it” .Both childbearing women and professionals identified a current lack of relevant training resources: “professional articles”, “access to hEDS/HSD patients and caregivers”, and “incorporating into existing resources like the Altered Health Module”. One participant highlighted the importance of the “involvement of all major stakeholders” in the development of resources. This information was fed into part 3 of the co-creation workshops.Quantitively, when asked what resources professionals would find most useful, the main seven, starting with the highest ranked, were: clinical guidance (N = 254); online course (N = 232); clinical decision-making tree (N = 180); maternity toolkit (N = 143); infographic (N = 130); leaflet (N = 127); and online information sources like webinars, blogs, Twitter feeds, and online health learning boards (N = 97). Other suggestions across four participants included “read it later” now that the survey had raised their awareness. For those who had read the care considerations before survey participation (N = 35), they commented that they found it useful for developing a “better care plan”, “discussing it with women to empower them to be the experts and be heard”, “sharing with peers”, being “aware of the implications of this condition”, and increasing “knowledge” and “confidence” to support and create “individual plans” with people with hEDS/HSD. One participant was concerned that the care considerations focused on “risk” and “lack of individuality”, which “puts pressure on midwives to refer all women on to a high-risk pathway regardless of the woman’s past experiences. It will put fear into midwives when women with hEDS ask for support to birth outside of a consultant-led unit”. These comments highlight the impact some research in the field has already achieved and may have in the future.Although the request for clinical guidance was the highest, most had not read the published care considerations available   in the last trimester of pregnancy and then became very symptomatic in the year after my child was born” . Therefore, some with hEDS/HSD suggested that professionals are well-positioned to identify hEDS/HSD in those undiagnosed: “I saw a number of physios, etc., and not one realised I was hypermobile despite being bed bound for a lot of my 2nd and 3rd trimesters” . Some professionals also estimated that they had unknowingly cared for those with hEDS/HSD: “I have probably looked after women with this condition and was not aware that this was the cause of their symptoms” .The experiences of participants with hEDS/HSD were impacted by whether they had been diagnosed with hEDS/HSD prior to pregnancy or not. Some felt that a diagnosis would have improved appropriate care: “Overall, most professionals  highlighted quantitatively that they had heard of some form of hEDS/HSD, EDS Type III, EDS-Hypermobility Type, or Joint Hypermobility Syndrome, with 15% not having heard of any of the listed conditions and 19% having heard of all of them. When asked how many pregnancies they thought were associated with hEDS/HSD each year, most thought it was rare, with either 1 in 20,000 (31%) or 1 in 5000 (42%). 22% thought it was 1 in 500, with only a small percentage thinking it was more common at 1 in 20 (4%) or 1 in 3 (1%).The second theme was focused on the delivery of care for childbearing people with hEDS/HSD, with sub-themes on listening and believing what people with hEDS/HSD are saying to professionals, co-ordinating care for these multi-system conditions better across multiple professionals and disciplines, and as a result, improving care and reducing the potentially traumatic experiences that people with hEDS/HSD can have.I gave birth in the car park on my own because they did not believe I was in labour” . A lack of trust in these personal bodily experiences sometimes led to increased risks, complications, or traumas, including pain: “I was still not believed when I said the epidural was not working… I then told them correctly which ones [toes] they touched” . Some professionals also highlighted the value of learning from people with hEDS/HSD when co-creating guidelines and care plans, particularly because of the diverse nature of hEDS/HSD: “EDS presents differently in every woman; communication is key. It is essential to believe women when they report unusual symptoms and not to fob them off because it does not fit in a box” . Relatedly, women frequently described having to advocate for themselves amidst a lack of professional understanding of hEDS/HSD. Professionals who had hEDS/HSD themselves often felt better placed to advocate for EDS-informed care: “I am a registered nurse. I was well researched and advocated for the care I needed” .Collaborative and individual-led care were considered crucial for good perinatal care. Many with hEDS/HSD felt that staff had dismissed their symptoms or not believed their labour progression: “Overall, quantitative GSPEQ scores  for chilThe OB [obstetrician] who was a geneticist was a strong advocate for me. She made all the difference with my medical team” . However, some participants received care during birth that was not delivered according to care plans: “My notes about EDS and my birth plan written by the doctors were ignored and led to complications” . Professionals, often because of a lack of confidence in their understanding, wanted referral pathways to specialists or hEDS/HSD-informed professionals: “Good signposting when women present with conditions that are outside of our sphere of competence and knowledge” . Similarly, those childbearing with hEDS/HSD described that other professionals should have been involved in their care, for example, physiotherapy: “I wish that discharge included a referral for physical therapy”  and mental health teams, “the maternity carers were completely focused on the baby and not my mental health (due to the immense pain I was in)” . Restrictions on some health systems were noted. For example, insurance-based systems could limit exploration of health issues beyond pregnancy: “My insurance was for pregnancy only, so they were unable to address my care even if they wanted to” .Care coordination across professionals and disciplines ensured that information about an individual’s hEDS/HSD was effectively communicated to inform care. Professionals knowledgeable about hEDS/HSD often played an important role: “Quantitatively, the professionals most frequently rated feeling “not at all” confident in relation to providing effective care, identifying symptoms, referring, and forming a care plan. Most often, professionals were only “slightly” confident that other colleagues were providing good care . = 1.12, p = 0.33) in experience of care in relation to whether people with hEDS/HSD first conceived before diagnosis , after , or in the same year . Additionally, there was no significant difference  a need to educate professionals supporting perinatal care about hEDS/HSD; (2) a need to support shared decision-making between childbearing people with hEDS/HSD and professionals; and (3) a need to raise awareness more generally in the public about hEDS/HSD and childbearing. Although the need for guidelines had also been highlighted, it was acknowledged that published care considerations already existed, so it was more important to raise awareness and educate people about their existence and main messages. A key challenge was identified as wanting to raise the profile by emphasising the importance that professionals understand hEDS/HSD and childbearing, while also not wanting to put people off childbearing with hEDS/HSD. Linked to this was the challenge of explaining hEDS/HSD care considerations as a whole and in a simple, publicly accessible way, while also highlighting the different potential presentations and considerations of supporting people with hEDS/HSD. For example, some people do not respond to local anaesthesia, while others do.Three tools were decided following discussion. The first was in response to the highest-voted educational tool in the PPI poll, an online learning module, and would address the first identified need of helping professionals learn how to support childbearing people with hEDS/HSD. This could be developed as an accredited and professional i-learn module through the Royal College of Midwives. A prototype short learning course was co-designed with learning objectives, information to be provided, key resources, and signposting. The second agreed output was to address the need for shared decision-making by developing a one-page, freely downloadable tool for perinatal records. A prototype was co-designed to include key information about hEDS/HSD, considerations that maternity professionals and people with hEDS/HSD may want to consider together, and a section to write about aspects unique to that childbearing person and how support could be tailored for them. It features a direct picture from the co-created annotations in Big Blue Button, where one co-creator wrote, “Parents and staff making decisions together”, and other co-creators drew ticks, heart shapes, and ”yes!” around it. The third agreed-upon output was to address the final need of raising public awareness by creating a freely accessible infomercial about hEDS/HSD and childbearing. The idea was co-designed for a person with hEDS/HSD to speak about their experience, a midwife to talk about key care considerations, and then to show them making shared decisions together. BenClarkDesign was commissioned to create the infomercial as part of a team including an animator, voiceover actress, and videographer (see acknowledgement for details).www.hEDStogether.com research dissemination website. Positive feedback was provided in the co-refine sessions, with co-creators providing annotations directly to the software as well as discussing their thoughts. It was agreed that the tool for perinatal records  would feOverall, a major qualitative theme identified was the need for recognition of hEDS/HSD in perinatal care through building professional knowledge of hEDS/HSD, developing evidence-based guidelines and accessible training resources, and improving diagnosis for people with hEDS/HSD. Women with hEDS/HSD quantitatively reported that they perceived professionals supporting their perinatal period to have a low level of knowledge about hEDS/HSD with no significant difference in care regardless of diagnosis before, during, or after conception. This is understandable in a context where professionals also reported that they do not feel confident or knowledgeable about the conditions, providing effective care, identifying symptoms, referring, and forming a care plan. Most professionals still consider hEDS/HSD to be rare , even though it is now estimated to affect 1 in 20 births . In the Qualitatively, the second major theme was around delivering appropriate and individualised perinatal care. The sub-theme relating to a need to be listened to and believed corroborates research across other healthcare provision ,13,14, wThere were concerns expressed in both the survey and co-creation that when raising awareness among professionals, the emphasis could focus too much on the risks of the conditions. It was considered important that the co-created outputs and public messaging were not aimed at putting people off childbearing and did not provide the impression that all people with hEDS/HSD are the same and that all should be considered high-risk pregnancies because this is not the case. Although higher risks have been identified with a need for monitoring in cases of a need for higher-risk consultant-led care , in somePeople with hEDS/HSD should not be discouraged from birthing their babies vaginally . BirthinThese were large international surveys representing a range of diagnoses related to hEDS/HSD and professions. A high number of people took part, especially in the PPI activities and particularly people with hEDS/HSD, as hundreds participated from the first tweet (<24 h). This highlights a distinct appetite for these conditions to be researched and supported in healthcare. The inclusion of a range of countries provided a depth of experience, often highlighting key similarities in issues such as the need to feel listened to and coordinate maternity care to improve experiences. However, differences in healthcare provision also need to be considered within this context; for example, issues with insurance coverage do not apply across all included countries. Additionally, this was a self-report questionnaire with the potential for sampling bias from those that wish to have their voices and opinions heard about hEDS/HSD, both as people who have had children and perinatal staff. A third of childbearing people with hEDS/HSD reported a negative experience overall, a third neither negative nor positive, and a third experienced positive care. It is worth noting that some participants reported in their qualitative comments that they found this question difficult to answer because they have experienced variation across their care, either within the same pregnancy or across different pregnancies. In this self-report questionnaire, sampling bias presents a limitation. For example, healthcare professionals with experience with hEDS/HSD personally or professionally may have been more likely to complete the questions. The recruitment approach aimed to mitigate this by sharing the questionnaire broadly and clarifying that no knowledge or experience of the conditions was necessary to take part. Similarly, one limitation was the relatively low number of participants from some professional groups in the study , and so the results from these groups cannot be extrapolated to the wider profession’s population. This study used a mixed-methods questionnaire, with qualitative responses used to illustrate and provide completeness to quantitative data. In this way, it is recognised that participant interviews were not implemented to gain in-depth insight from each participant, and the aim of this survey was instead focused on reaching a broader population following previous interview research . The usePatient and public involvement was important to this research from the beginning, informing focus, design, and outputs. The international vision for PPI identified key PPI barriers, which have been successfully addressed within this research . For exaThe three co-created tools provide highly applicable outputs for use in both education and practice and could help to raise the profile of the current published care considerations ,33. HoweThis mixed-methods research is the first to examine professionals’ knowledge and confidence to support childbearing people with hEDS/HSD and is complementary to a large international survey examining the experiences of childbearing with hEDS/HSD. Not only was the research informed by PPI to ensure the focus was meaningful, but solutions to the identified problems were then co-created to provide applicable outputs to education and practice. The online CPD module is hosted officially by the Royal College of Midwives’ i-learn platform for its members, and the tool for perinatal records and infomercials is freely and publicly accessible to support shared decision-making and raise awareness.