The phrase social and cultural determinants of health has entered the lexicon of medical and social service providers and is often mentioned alongside health disparities. Since the early 90s, public health researchers have been suggesting that a person’s socioeconomic characteristics, including race, ethnicity, socioeconomic status, gender and age, largely influence one’s health (Link and Phelan, 1995). These characteristics determine our place in the social structure and consequently, the resources or lack thereof to protect and manage our physical and mental health. In addition to resources, cultural beliefs and ideas about our lives and health are also associated with these determinants. Health disparities, systemic differences in health care and health outcomes among populations, have been attributed largely to the interaction between available resources and aspects of one’s culture. The realization that policies, programs and services must also attend to the social and cultural determinants to achieve health equity is now a commonplace to our collective understanding of health. However, best practices for identifying and addressing these determinants remain under discussion and are being evaluated for effectiveness as we aspire to decrease disparities.
The professionalization of the role of youth and family peer advocates: Over the past three decades, there has also been a growing appreciation for the role of peer advocates in providing resources, supportive services and enhancing the health of different communities and especially of persons with behavioral health conditions. Peers provide advocacy, empowerment, coaching and services coordination in many clinical settings and in the community, and successfully engage in services socially disenfranchised, often stigmatized, groups. Many peer advocates have direct, lived experience in navigating health and social services systems and communicating with service providers and can translate their experiences into skills and insights that help those they serve.
Building on this unique skillset of peers, several statewide trainings and credentialing programs have emerged to support them in the workforce. As a result, peer advocates increasingly are being hired as full-time paid employees, especially in the field of mental health. Under the auspices of Children and Family Treatment and Support Services in the state of New York, services provided by credentialed family and youth peer advocates will become billable under Medicaid, as of July 1, 2019 and January 1, 2020 respectively. Although this recognition of the critical role of peer advocates in providing services has been long overdue, rendering their services billable enhances their integration into the workplace and denotes their professional value in the healthcare system.
A novel component of the Wraparound Training of peer advocates in New York State: The New York State (NYS) Office of Mental Health (OMH) has been training in and implementing Wraparound with providers serving youth with serious emotional disturbances and their families. This training, offered by the Wraparound Training & Implementation Institute of NYS OMH and funded by a SAMHSA Systems of Care expansion grant, creates a framework for comprehensive, holistic and family-driven service delivery. One of the distinctive features of New York State’s Wraparound program is the formation of a provider triad: a care manager, a family peer advocate, and a youth peer advocate. This triad ensures a team approach to services and is designed to effectively weave the skills and perspectives of all three providers aiming to more effectively address the family and youth needs.
As part of this program, the Wraparound Training & Implementation Institute, in partnership with C-CASE (Center for Research on Cultural and Structural Equity in Behavioral Health) at the Nathan Kline Institute, has incorporated a novel and theoretically-guided social and cultural competency training tailored specifically for peers. Guided by the health lifestyle model, peer advocates are trained in using the family story to identify the social and cultural factors that shape a family’s available opportunities to address health-related matters and the health-related choices the make (Cockerham, 2013). This model suggests that the interplay between opportunities and choices generates lasting dispositions or orientations towards health, which include the tendency to access or avoid mental health services, to seek or not seek community supports, or to adhere or not to adhere to recommended treatment. These tendencies are defined as health habitus and they sponsor our health behaviors. Over time, and with repetition of the same behaviors, a health lifestyle is formed.
The training team’s decision to integrate this health habitus-driven model into the peer advocates’ training stemmed from the following three advantages. First, the model provides a clear depiction and understanding of how our tendencies to manage our health in particular ways are shaped by social and cultural determinants. This realization deflects the stigma and blame from a family or youth that chooses to address their behavioral health needs in their own way. This view is also consistent with the Wraparound principles of family voice and choice, cultural (and structural) competency and individualized strategies (Walker, Bruns, VanDenBerg et al. 2004). Second, the model also reveals how the parents’ and caregivers’ health habitus contributes to the youth’s orientation towards their health, and this can inform the team-based support and services offered to the family. Finally, the health habitus model recognizes that there is a lasting effect of one’s long term opportunities, or lack thereof to address their health. This perspective is invaluable in developing a care plan and supports the Wraparound principles of unconditional, persistent and outcomes-based provision of services.
Components of the Health Habitus Integration training: The Health Habitus Integration training consists of five components: (1) a didactic phase familiarizing trainees with the model and its significance; (2) a practice activity where trainees write about their own health habitus; (3) a didactic phase on conducting an in-depth interview designed to elicit the family’s and the youth’s health habitus accompanied by practicing one’s interviewing skills; (4) a practice activity where trainees organize the information about the family and the youth’s health habitus into a note, that can be enriched and revised as peer advocates increase their rapport with and understanding of the family and the youth through multiple meetings; and (5) a discussion phase on potential strategies for integrating the health habitus information into the peer advocates’ one-on-one meetings with the family and the youth, but also in the triad’s meeting with the care manager and both peer advocates.
The integration of the health habitus information in the peer advocates’ interactions with the family, the youth and their team members has the potential to: strengthen the family and the youth’s engagement in care, strengthen self-advocacy and empowerment, contribute to the identification of community and natural supports, and to the development and implementation of a family-centered strengths-based plan. The training is offered by expert facilitators and consists of six hours. Four to five weeks after the day of the training, a one-hour booster session is provided through webinar that focuses on discussing a family’s health habitus note and strategies for integrating the information in the note into the peer advocates’ family meetings.
Preliminary evidence on the training utility: Based on baseline and follow-up evaluation surveys, the implementation team has found that most trainees, over 90%, perceived the health habitus training to be useful. As one peer advocate said, “Health Habitus can help me during the intake and subsequent contacts to learn the family story and engage them.” Writing one’s own health habitus was identified as the most beneficial component. As another peer advocate explained, “Writing my own health habits was very helpful in looking at my own barriers and influences. It helps me empathize with barriers others come up against.” Further, the training enhances the trainees’ humility and understanding of the families they serve: “Gives the opportunity to look at the family in a non-judgmental way by looking at choices and opportunities,” as a third peer advocate suggested.
Conclusion and looking forward: The health habitus integration training of peer advocates throughout New York State and the evident opportunities to also train care managers is one strategy for integrating the social and cultural determinants of health into the perspective and practice of teams that work with families and youth with behavioral health conditions. Adding the health habitus integration training into the peer advocates’ repertoire of skills builds professional competency and supports efforts to reduce social and cultural barriers that contribute to health disparities.
Thank you to our peer advocate coaches, Daphnne Brown, Ashley Rivera and Bianca Logan, for their insights and contribution to the health habitus integration training.
Helen-Maria Lekas, PhD, is Research Scientist and Co-Director; and Crystal Fuller Lewis, PhD, is Research Scientist and Director at the Center for Research on Cultural and Structural Equity (C-CASE), Division of Social Solutions and Services at the Nathan Kline Institute for Psychiatric Research. Joanne Trinkle, MSW, is Project Co-Director, New York State System of Care Pilot, at the Division of Integrated Community Services for Children and Families.
Cockerham W.C. (2013) Bourdieu and an Update of Health Lifestyle Theory. In: Cockerham W. (eds) Medical Sociology on the Move. Springer, Dordrecht.
Link BG, Phelan JC (1995). Social conditions and fundamental causes of disease. Journal of Health and Social Behavior, 35, (Extra Issue): 80-94.
Walker, J.S., Bruns, E.J., VanDenBerg, J.D., Rast, J., Osher, T.W., Miles, P., Adams, J., & National Wraparound Initiative Advisory Group (2004). Phases and activities of the wraparound process. Portland, OR: National Wraparound Initiative, Research and Training Center on Family Support and Children’s Mental Health, Portland State University.