Sarah Hays-Coomer, Forbes columnist, author, and NBC-HWC wellness coach, describes the effects of Social Determinants of Health on the health and wellness coaching industry:
“I think the biggest challenge in the industry right now is access. Everyone could benefit from a health coach, but very few can afford private coaching. Once insurance coverage is in place and coaching options are more widely available, I think education will be increasingly important - educating the public and medical professionals on the health and fiscal benefits of universal access to health coaching. The Veterans Administration in the United States is doing great work right now to model and study those benefits.”
(Sarah Hays-Coomer - Forbes columnist, author, and NBC-HWC coach, Health Coaching Industry Report: At the front lines of Health, Your Coach, 2022, p.4)
Health coaches must become more geographically accessible. Health and Wellness Coaches work independently in private practice as sole practitioners. A survey of 243 NBHWC-certified coaches found that more than half wanted to enter private practice after training (Global Wellness Institute, Wellness Coaching Initiative White Paper, February 8, 2022, p. 30, taken from Babcock, 2020). Reports from the UKHCA and HCANZA professional associations suggest that approximately 80% of their members work in private practice. (Global Wellness Institute, Wellness Coaching Initiative White Paper, February 8, 2022, p. 30)
While private coaching satisfies many practitioners' independent, entrepreneurial spirit, it may also isolate them from interacting with more diverse populations. Seventy-two percent are primarily white women, compared to twenty-one percent of white men. (zippia.com) The average age of health coaches is 40+ years old, representing only fifty-two percent of the population. (zippia.com) We cannot change accessibility unless we change the face of health and wellness coaching and the industries’ training programs.
Defining the Social Determinants of Health (SDoH)
Social Determinants of Health (SDoH) propel health inequities. SDoH encompasses the conditions in the environment in which people are born, grow, live, learn, work, play, and age, including their health system. These factors occur within a country and between countries. The distribution of money, power, and resources at global, national, and local levels is often influenced by policy choices that drive SDoH parameters.
Image courtesy National Cancer Institute https://cancercontrol.cancer.gov/hdhe/about/background
Although awareness of Social Determinants of Health exists, applying the determinants is far more complex. The Local Health System Sustainability Project states that no global agreements exist on core SDoH-related competencies regarding per-service health workforce education, in-service training, or continued professional development. However, the project clearly defines competencies central to any wellness profession, mainly:
● Equity lens
● People-centered care
● Evidence-informed practice
● Personal growth
Individuals and groups of lower socioeconomic status are born, grow, live, work, and age in environments detrimental to their health. They have far greater chronic and acute illness risks and have shorter lives. Risk factors include substandard housing, pollution, food and job insecurity, low education levels, and lack of sanitation. Other elements creating insecurity are not as easy to see, such as violence, discrimination, social isolation, and chronic stress from harsh living conditions and circumstances. (Local Health System Sustainability Project, June 2022) One could add individual and intergenerational trauma to the extensive list of less obvious factors.
Epigenetics is the study of how your behaviors and environment cause changes that affect the way your genes work. More evidence in epigenetics shows that social and economic policies, power, resource allocation, and structural factors affect not only living conditions but, alarmingly, gene expression. (Local Health System Sustainability Project, June 2022) Social determinants of health affect a person’s current circumstances and determine cyclical and intergenerational lack of access to necessities.
Consider the following facts from the Kaiser Family Foundation:
Nonelderly AIAN (21%) and Hispanic (19%) people are twice as likely as Whites to be uninsured (2021)
In 2021-2022, the majority of Hispanics (62%), Blacks (58%), and AIAN adults (59% went without a flu vaccine compared to Whites (46%)
The AIAN population, Hispanics and Blacks, have more than a decade shorter life expectancy than Whites.
In 2021, Black and Hispanic children are more than twice as likely to be food insecure. (KFF, March 15, 2023)
The American Lung Association has published multiple studies demonstrating that those with lower SES are vulnerable to harm from air pollution.
African American populations suffer substantially from particle pollution mortality nationwide.
Medicare recipients have markedly increased mortality risks from fine particle pollution.
A 2016 study of lower SES New Jersey residents showed higher mortality risks from particle pollution exposure. (American Lung Association, 2023)
We accept customary traditions and institutionalized power, and they are internalized to a great degree. Yet what is the social, physical, and emotional cost of the structures created? Importantly, what can the health coaching field do to create greater opportunities for their patients to overcome SDoH?
First of all, health and wellness training programs must emphasize outreach and training methods that serve the underserved instead of those who are white and privileged.
Consider the following case study:
The American Medical Association recently evaluated the Union Health Center’s health coaching team based in Manhattan. (O’Reilly, 2017) The study highlights several ways coaches on multidisciplinary teams operate to support the individual, not individualism.
In a diverse lower SES population and Type2 diabetics, health coaches played a long-term role in educating patients about care, prevention, and mindset. Health coaches clarified which aspects are under their patient’s control and which are not. They worked as a team with primary care physicians, specialists, and mental health professionals.
Second, health coaches offered proximity through flexible scheduling, face-to face-meetings, or phone appointments when patients could not travel to a clinical setting. Patients can schedule appointments for six months to a year depending on their needs. If conditions worsened, visits increased. They filled gaps in patient education through visits when PCP was less available.
Third, coaches follow standardized tracking procedures and thoroughly document visits. It allows other practitioners to see if the coach is helping patients meet their goals and makes their interactions visible to a medical team. Consistent tracking enables coaches to start where they left off with a patient.
Coaches were bilingual and spoke Spanish, French-Creole, or Chinese in the patient’s preferred language.
Last but certainly not least, coaches used evidence-based communication skills and motivational techniques. They utilized specific methods like the ask-tell-ask approach or the “teach back” method to ensure the patient had heard their words by repeating the concepts. Then, the coach taught back by clarifying any misunderstanding. (O’Reilly, 2017) Individualism may pervade the healthcare system, but coaching can provide a way out.
An Inclusion Health and Wellness Coaching Certificate will give you the tools and knowledge to serve more diverse and marginalized populations based on the following:
Let’s look at more ways health and wellness coaches can help alleviate gaps in care:
Consider how the underinsured and uninsured will access health coaching in your local area.
Encourage colleagues to pursue diversity, equity, inclusion, and trauma-informed health coach training programs.
Support expanding the diversity of coaching programs in the coaching industry. BIPOC, especially those with lower socioeconomic statuses, often do not find a provider in their neighborhood. For instance, mental health providers who do not take health insurance may not set up a practice in neighborhoods where people cannot pay their out-of-pocket fees. Health coaches, similarly, provide services in wealthier areas. It means that low-income neighborhoods suffer from disadvantages brought on by structural racism and residential segregation.
Offer sliding scale fees.
Spread awareness of free and low-cost services in your local area. Help patients connect to them and promote low-cost wellness resources.
Encourage screening tools if working in a healthcare system that helps patients of all sizes, socioeconomic levels, BIPOC, and LGBTQ+ communities find the required resources.
Reach out to families, neighbors, friends, and other members of their communities to discuss wellness issues, utilizing language that avoids stigmatizing while encouraging conversations about mental and physical health and spiritual well-being.
Using the SDoH data on wellness needs to identify populations that need help, reach out to community members to develop organizational priorities, and expand programs.
Health coaches are positioned to become the leaders of not only prevention but inclusive healthcare. They can be the change so desperately needed to manage chronic illness.
American Lung Association 2023, “Key Findings: The State of the Air” https://www.lung.org/research/sota/key-findings#:~:text=The%20%E2%80%9CState%20of%20the%20Air,of%20ozone%20or%20particle%20pollution.
Hill, Latoya, Nambi Ndugga, Samantha Artiga, “Key Data on Health and Health Care by Race and Ethnicity,” Kaiser Family Foundation (KFF), March 15, 2023.