Physical and mental health of behavioural health certified peer specialists in four US states

Abstract

Background

Little is known about the health and healthcare needs of the behavioural health peer specialist workforce in the USA. This study explored the physical and mental health-related quality of life (QOL) of a US multistate cohort of certified peer specialists, and factors associated with health-related work absences among those employed in peer specialist positions.

Methods

Data come from 419 participants surveyed 18 months after state certification as part of a 2-year longitudinal cohort study of peer specialists in four US states. Measures included the Veterans RAND 12 Item Health Survey, the Epidemic-Pandemic Impacts Inventory and items from the National Health & Nutrition Examination Survey and Medical Expenditure Panel Survey. Multivariable hierarchical regression models predicted physical and mental health-related QOL and occurrence of work absences due to health.

Results

High rates (60%) of multiple physical health conditions characterise both those working in peer support positions and those not employed. Better physical health-related QOL was associated with younger age, not having multiple physical health conditions, not experiencing cost as a barrier to healthcare and not being enrolled in Medicaid or Medicare. Better mental health-related QOL was associated with older age, being Black/African-American, employment in peer support positions, moderate exercise, having a usual source of medical care and cost not being a barrier to care. Among those employed as peer specialists, health-related work absences were associated with physical and mental health QOL and other factors.

Conclusions

Certified peer specialists have high rates of physical comorbidities, and this affects their mental and physical health-related QOL and likelihood of working in peer support positions. Factors such as cost, having a regular source of healthcare, insurance coverage and demographic features are also associated with their QOL. These findings can inform efforts to attract and retain certified peer specialists in the behavioural health workforce.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Certified peer specialists are one of the fastest growing workforces in US behavioural healthcare, yet little is known about their health and healthcare utilisation. Given documented high rates of physical comorbidities among people with lived experience, this knowledge is needed to promote the health, job satisfaction and labour force participation of this important provider group.

WHAT THIS STUDY ADDS

• We found high rates of multiple physical health conditions among certified peer specialists, both those working in peer support positions and those not employed. Among those working as peer specialists, health-related work absences were associated with both physical and mental health quality of life.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• Results of this large-scale study support the need for further research on the health status and healthcare use of certified peer specialists, and suggest both clinical practices and employment policies that can better serve the needs of this growing sector of the behavioural health labour force.

Introduction

Peer specialists use their experience of recovery from mental health conditions, along with skills developed through training, to support others with psychiatric disorders. Certified peer specialists are one of the fastest growing workforces in US behavioural healthcare,¹ currently numbering over 100 000 individuals,² making them well-positioned to address the country’s severe and persistent shortage of behavioural healthcare providers.³ While research shows that people in certified peer specialist jobs earn less than those engaged in similar work,¹ they also express higher job satisfaction and lower professional burnout than people with mental health conditions employed in other types of jobs.⁴ Yet while high levels of physical comorbidities characterise people with serious mental health conditions,⁵ little is known about the health and healthcare experiences of the certified peer specialist workforce. A healthy peer workforce could result in higher productivity, enhanced job retention, lower healthcare costs and reduced work disability,⁶ as well as improved work experiences for those providing peer support,⁴ and greater opportunities for their integration into their employing organisations and the larger service delivery system.⁷

Studies of the general US workforce have shown that chronic physical conditions such as diabetes and hypertension have a major impact on work outcomes including attendance, productivity, job loss, early retirement, receipt of disability benefits and return to work.⁶ In particular, physical multimorbidity, defined as the presence of two or more chronic medical conditions,⁸ is associated with lower work productivity, higher absenteeism and greater likelihood of temporary or permanent leaves.⁶ Health risks such as lack of physical exercise, obesity and tobacco use are also associated with lower work productivity,⁹ while use of preventive healthcare such as medical screening and influenza inoculation is associated with reduced absenteeism, higher productivity and greater job satisfaction.¹⁰

Physical health-related quality of life (QOL) is a person’s perception of how their physical health and ability to function in different life areas influence their overall well-being and satisfaction with life.¹¹ Mental health-related QOL refers to a person’s view of their mental health and how it influences their physical, psychological, social, environmental functioning and ability to live a fulfilling life.¹² Both physical and mental health-related QOL are predictors of absenteeism,¹³ and health-related QOL may significantly explain the nature of work productivity loss as well as the duration of absenteeism.¹⁴

In a survey of 173 mental health peer specialists from 35 US states,¹⁵ substantial numbers identified functional barriers to working full time including poor physical and mental health. Certified peer specialists in the US also tend to have limited access to healthcare and preventive services because their positions are often part-time, low-wage, and without employer-sponsored benefits such as health insurance and sick leave.¹⁶ Despite these vulnerabilities, we could find no large-scale studies of health and healthcare needs of this growing workforce.

With the onset of the COVID-19 pandemic, the peer specialist workforce was increasingly called on to provide services and supports,¹⁷ yet these workers may be vulnerable to poor health outcomes due to greater risk of contracting COVID-19,¹⁸ coupled with higher rates of pre-existing health conditions and lower rates of health insurance access.¹⁸ Moreover, peer specialists working in peer support positions are likely to be exposed to health stressors similar to those experienced by healthcare workers and other first responders,¹⁹ which may result in poorer mental health and employment outcomes.

Given the foregoing factors, the purpose of this study was to examine peer specialists’ physical health-related QOL, mental health-related QOL and physical multimorbidity, and whether these varied by their employment as peer specialists versus not working. We also explored factors that were associated with being absent from work for health reasons among those working in peer specialist positions.

Methods

Study design and participants

Data are from a longitudinal study of career outcomes during the 2 years following state certification as a peer specialist in the US states of Texas, Pennsylvania, Oregon and North Carolina.⁴ Each state provided the researchers with contact information for its certified peer specialists. Inclusion criteria were age 18 or older, and peer specialist certification in calendar years 2019 or 2020. Eighteen months after joining the study, all 671 longitudinal cohort participants were invited to complete a special wave of questions focused on health, health risks and healthcare utilisation: 62% (419/671) consented to participate and 99% of those consenting (417/419) completed the wave. Compared with the original 671, the 417 did not differ significantly on background characteristics except for race: 21% (87/417) of health wave completers identified as Black/African-American compared with 24% (158/671) of the larger cohort, and 67% (281/417) of health wave completers identified as White compared with 64% of the larger cohort (428/671) (χ²=6.34 (df=2), p=0.042). Included in the current analysis (n=294) are those who were currently employed as peer specialists and those who were currently not working (n=79). Survey data were collected online using Qualtrics from November 2021 through May 2022, with 50% of surveys completed by January 2022 and 75% completed by February 2022. This coincides roughly with the second year and the early part of the third year of the COVID-19 pandemic.

Recruitment

Respondents were recruited from the larger cohort via a US Postal Service letter introducing the study and containing a US$5 unconditional cash incentive. Next, respondents received a personalised survey link to complete informed consent, followed by the survey itself. Follow-up efforts included multiple email, phone and text message reminders. Those who completed the survey received a US$10 electronic gift card.

Measures

Chronic physical health conditions were assessed using items from the National Health & Nutrition Examination Survey (NHANES) Medical Conditions Questionnaire,²⁰ which ask respondents whether they have ever been told by a physician or other healthcare provider that they have a particular medical condition. Conditions queried were those identified as priority health conditions by the Agency for Healthcare Research and Quality (AHRQ),²¹ due to their prevalence and/or expense, including high cholesterol; hypertension; lung diseases such as asthma, chronic bronchitis, emphysema or chronic obstructive pulmonary disease; diabetes; arthritis; heart conditions such as congestive heart failure, angina, heart attack/myocardial infarction, coronary heart disease; and cancer of any kind. Physical multimorbidity was defined, following prior research, as the presence of two or more physical health conditions.⁸

The two outcomes of physical health and mental health-related QOL were assessed by the Veterans RAND 12 Item Health Survey (VR-12),²² a widely used measure of health status and functioning that was developed from the Medical Outcomes Study (MOS) RAND SF-36 V.1.0.²³ The VR-12 is comprised of 12 items that measure physical and mental health status across eight domains: (1) self-rated general health; (2) physical functioning; (3) role limitations due to physical problems; (4) bodily pain; (5) role limitations due to emotional problems; (6) vitality; (7) mental health; and (8) social functioning. Two summary scores are computed representing a physical component score and a mental component score ranging from 0 to 100, with higher scores indicating better health status.²⁴

Two additional outcomes were measures of absence from work due to health-related reasons which were assessed with items from the Medical Expenditure Panel Survey’s (MEPS) Household Component Questionnaire.²⁵ The Disability Days section of the Questionnaire assesses the impact of any physical illness, injury or mental or emotional problem on respondents' attendance at work in the past 12 months, coded as ‘yes/no’ if the person was absent on one or more days and as the actual number of days of work that were missed.

Access to healthcare, including insurance type, usual source of care and cost, also was assessed with items from the MEPS.²⁵ Respondents’ ability to access routine or preventive medical care since the pandemic onset was assessed with the Epidemic-Pandemic Impacts Inventory.²⁶ Participants were also asked to report their COVID-19 vaccination status, coded as 1=not vaccinated and 0=1 or more vaccines received.

Statistical analysis

Participant demographics, health, COVID-19 experiences and peer support employment status were characterised using descriptive, χ² and t-test statistics. Missing data were minimal (see table 1) and accommodated by available case analysis using all observations. Multivariable sequential hierarchical regression models entered groups of variables in three steps representing: (1) demographic factors; (2) health behaviours and risks; and (3) healthcare barriers/facilitators, predicting first physical health-related QOL, and next mental health-related QOL. Finally, among those employed in peer support positions, multivariable analysis was used to examine physical and mental health-related QOL as predictors of any disability days from work (logistic regression) and number of disability days from work (negative binomial regression). Non-collinearity of variables in the multivariable linear models was assessed by variance inflation factors which were all found to be in the acceptable range of <2.0.²⁷

Table 1. Demographics, health, health risks and access to services of certified peer specialists in total, those employed in peer support positions and those not employed.

	Certified peer specialists total (n=294)		Certified peer specialists employed in peer support positions (n=215)		Certified peer specialists not employed (n=79)		P value†
	%*	N	%*	N	%*	n
Male	31%	89	30%	64	32%	25	0.810
Race							0.103
White	72%	199	76%	155	63%	44
Black/African-American	25%	69	22%	46	33%	23
Other non-white	3%	7	2%	4	4%	3
Hispanic/Latinx	11%	32	11%	24	10%	8	0.804
Social security disability income	18%	52	15%	32	25%	20	0.038
Supplemental security income	4%	12	2%	5	9%	7	0.012
Education							0.910
Less than high school	<1%	1	<1%	1	0%	0
HS/GED	14%	39	14%	29	13%	10
Some college	39%	113	39%	82	40%	31
Associate's degree	18%	51	17%	35	21%	16
Bachelor’s degree	21%	59	21%	43	21%	16
Graduate/professional degree	9%	25	10%	20	6%	5
Household income							<0.001
<US$12 000	9%	25	3%	6	25%	19
US$12 000–US$24 999	27%	75	25%	50	33%	25
US$25 000–US$39 999	31%	85	33%	66	25%	19
US$40 000–US$69 999	21%	57	23%	47	13%	10
US$70 000–US$149 000	12%	34	15%	31	4%	3
US$150 000 or greater	1%	2	1%	2	0%	0
Two or more physical conditions	60%	176	57%	123	67%	53	0.126
High cholesterol	50%	144	49%	102	54%	42	0.426
Hypertension	49%	141	48%	101	51%	40	0.631
Arthritis	42%	121	40%	84	47%	37	0.256
Lung disease‡	25%	73	25%	52	27%	21	0.708
Diabetes	19%	56	18%	38	23%	18	0.342
Heart disease	11%	32	12%	25	9%	7	0.482
Cancer	10%	29	9%	18	14%	11	0.166
Currently smoke or vape	37%	10	34%	72	45%	35	0.104
Exercises moderately	30%	86	30%	63	30%	23	0.914
Not vaccinated for COVID-19	13%	37	10%	20	22%	17	0.006
Delay care due to COVID-19	32%	93	29%	62	40%	31	0.076
Cost (copay, out of pocket) as barrier to care	19%	57	20%	42	19%	15	0.916
Has usual source of care/provider	88%	259	90%	194	82%	65	0.062
No health insurance, past 12 months	7%	21	4%	9	15%	12	0.001
Medicare, past 12 months	28%	82	22%	46	46%	36	<0.001
Medicaid, past 12 months	20%	59	16%	34	32%	25	0.002
Employer-sponsored private insurance, past 12 months	43%	125	53%	112	17%	13	<0.001

	mean±SD	mean±SD	mean±SD	P value§
Age, years	47±12	48±12	48±14	0.640
Physical HRQOL, 0–100	43.7±11.7	44.9±10.2	40.5±14.7	0.018
Mental HRQOL, 0–100	40.8±12.7	42.5±11.5	36.2±14.5	<0.001
HRQOL domains, 0–100
General health	53.2±23.8	54.8±22.2	49.0±27.3	0.094
Physical functioning	67.2±34.8	70.8±31.8	57.1±40.3	0.008
Bodily pain	66.1±31.1	70.1±27.6	55.2±32.0	0.002
Role-physical	69.0±28.4	73.2±24.7	67.6±34.4	<0.001
Role-emotional	67.5±26.3	72.0±22.3	55.2±32.0	<0.001
Vitality	41.8±25.6	42.8±25.3	39.2±26.4	0.311
Mental health	55.0±22.7	57.5±21.4	48.1±24.9	0.002
Social functioning	60.1±29.5	65.3±26.4	46.0±32.9	<0.001

^*Excluding missing values.

^†P value from χ2 test.

^‡Asthma, chronic bronchitis, emphysema or COPD.

^§P value from t-test.

COPD, chronic obstructive pulmonary disease; HRQOL, health-related quality of life; HS/GED, high school diploma or general equivalency diploma.

Results

Table 1 shows the demographic, health, health risk and service use characteristics of all respondents, those working in peer support positions, and those not employed as well as unadjusted significant differences. Less than one-third of the total group was male (31%), and their average age was 47±12 years. The majority were White (72%), one quarter (25%) were Black/African-American and 3% reported other/non-white race; 11% reported Hispanic/Latinx ethnicity. There were no significant differences by sex, race, ethnicity or education. Compared with those who were not employed, those working in peer support jobs had significantly higher incomes. Those working in peer support positions were significantly less likely than their non-working counterparts to be receiving Supplemental Security Income or Social Security Disability Income. High proportions (>50%) of both groups reported physical multimorbidity, with more than half reporting high cholesterol, over 40% reporting hypertension, over 40% reporting arthritis, 25% or more reporting chronic lung disease and notable proportions reporting diabetes, heart disease and cancer, with no significant differences by employment status. Despite the high prevalence of physical multimorbidity for both groups, those working in peer support positions had significantly higher physical health-related QOL and significantly higher mental health-related QOL compared with those not employed. Also compared with those who were not working, those employed in peer support positions reported significantly better health on the dimensions of physical functioning, bodily pain, physical role functioning, emotional role functioning, mental health and social functioning.

Regarding COVID-19 experiences, compared with certified peer specialists who were not working, those holding peer support positions were significantly more likely to report being vaccinated for COVID-19. They were also more likely to have had health insurance in the last 12 months, less likely to be enrolled in Medicaid or Medicare, and more likely to have been covered by employer-sponsored health insurance in the past 12 months. (We confirmed that the 13 non-working respondents who reported having employer-sponsored health insurance at the time of the survey had worked at some point after joining the larger study.)

Results of the first multivariable analysis predicting physical health-related QOL are presented in table 2. In the first step examining demographic characteristics, greater household income was significantly associated with higher health-related QOL but not in later steps. Older age was significantly associated with poorer health-related QOL in this and subsequent model steps. All other variables were non-significant. In the second step examining health risks and behaviours, moderate exercise was significantly associated with better health-related QOL but fell to marginally significant (p=0.059) in the final step. Physical multimorbidity was negatively associated with health-related QOL and remained significant in the final step. In step 3 examining healthcare use and service barriers/facilitators, cost as a barrier to care was negatively associated with health-related QOL. Healthcare coverage through Medicare and Medicaid in the past 12 months was also negatively associated with health-related QOL. Thus, in the final step of the analysis, better physical health-related QOL was associated with younger age, not having multiple chronic physical health conditions, not experiencing cost as a barrier to care and not having public health insurance coverage.

Table 2. Characteristics associated with physical health-related quality of life (n=294) among certified peer specialists employed in peer support positions and not employed.

Characteristics	Physical health-related quality of life (MOS-VR-12 PCS)
	Model 1		Model 2		Model 3
	B	SE	B	SE	B	SE
Age, years	−0.26***	0.05	−0.14**	0.05	-0.15**	0.05
Male (vs female)	2.24	1.31	1.41	1.25	1.03	1.23
Latinx (vs non-Latinx)	1.12	1.88	1.02	1.79	0.98	1.76
Black/African-American (vs White)	0.34	1.38	0.68	1.31	0.36	1.28
Other non-white (vs White)	−4.27	2.66	−2.95	2.54	-2.05	2.51
Education level	0.48	0.47	0.45	0.45	0.45	0.44
Household income level	1.23*	0.49	0.67	0.47	0.09	0.49
Not employed (vs employed as certified peer specialist)	−2.59	1.49	−1.98	1.42	-1.20	1.42
Currently smoke or vape (vs not)			−0.60	1.17	0.10	1.16
Exercises moderately (vs less)			2.60*	1.22	2.28	1.20
Not vaccinated for COVID-19 (vs vaccinated)			−1.13	1.68	-1.14	1.65
Two+ chronic conditions (vs one or none)			−7.36***	1.23	-6.56***	1.22
Delay care due to COVID-19 concerns (vs not)					-1.53	1.16
Cost as barrier (vs not)					-3.75	1.41
Has usual source of care (vs no usual source)					0.03	1.80
No health insurance					1.16	2.11
Medicare, past 12 months					-3.31*	1.35
Medicaid, past 12 months					-3.79**	1.41
Model fit statistics	Adjusted R square=0.10 ANOVA p<0.001		Adjusted R square=0.19 ANOVA p<0.001		Adjusted R square=0.23 ANOVA p<0.001

*p<0.05, two-sided. **p<0.01, two-sided. ***p<0.001, two-sided.

ANOVA, analysis of variance; B, unstandardised beta; b, unstandardised beta; MOS, Medical Outcomes Study; PCS, physical component score; VR-12, Veterans RAND 12-Item Health Survey.

In the first step of the model predicting mental health-related QOL (table 3), older individuals, those who identified as Black/African-American, and those employed in peer support positions had significantly better mental health QOL, and these remained significant through subsequent steps. Also in step 1, males had better mental health QOL, but this became non-significant in later steps. In step 2 examining health risks and behaviours, moderate exercise was associated with better mental health QOL, and this remained significant in the final step. In the third step examining healthcare use and access, having a usual source of care was associated with significantly better mental health-related QOL, while cost as a barrier was significantly related to poorer mental health-related QOL. Thus, in the final step of the analysis, better mental health QOL was associated with being older, Black/African-American, being employed in a peer support position, engaging in moderate exercise, having a usual source of medical care and not experiencing cost as a barrier to healthcare.

Table 3. Characteristics associated with mental health-related quality of life (n=294) among certified peer specialists employed in peer support positions and not employed.

Characteristics	Mental health-related quality of life (MOS-VR-12 MCS)
	Model 1		Model 2		Model 3
	B	SE	B	SE	B	SE
Age, years	0.24***	0.05	0.28***	0.06	0.25***	0.06
Male	3.14*	1.44	2.28	1.44	2.23	1.42
Latinx	2.27	2.07	2.83	2.06	3.24	2.03
Black/African-American	3.93*	1.52	3.93**	1.50	3.85*	1.48
Other non-white	0.93	2.93	2.35	2.92	3.98	2.89
Education level	−0.55	0.52	−0.52	0.51	−0.70	0.51
Household income level	0.98	0.54	0.97	0.54	0.76	0.57
Not employed vs employed in peer support job	−5.25**	1.64	−5.52***	1.63	−4.88**	1.63
Currently smoke or vape			0.45	1.35	1.20	1.34
Exercises moderately			4.65***	1.40	4.55**	1.38
Not vaccinated for COVID-19			2.46	1.93	1.76	1.90
Two+ chronic conditions			−0.52	1.41	−0.50	1.40
Delay care due to COVID-19					−2.12	1.34
Cost as barrier					−4.07*	1.62
Has usual source of care					5.99**	2.07
No health insurance					3.38	2.43
Medicare, past 12 months					−0.46	1.55
Medicaid, past 12 months					−0.52	1.63
Model fit statistics	Adjusted R square=0.13 ANOVA p<0.001		Adjusted R square=0.15 ANOVA p<0.001		Adjusted R square=0.19 ANOVA p<0.001

*p<0.05, two-sided. **p<0.01, two-sided. ***p<0.001, two-sided.

ANOVA, analysis of variance; B, unstandardised beta; MCS, mental component score; MOS, Medical Outcomes Study; VR-12, Veterans RAND 12 Item Health Survey.

Next, among those employed in peer support positions, we examined associations between physical and mental health-related QOL and absences from work due to health-related reasons in the past 12 months, controlling for the same covariates as in prior models. Almost three-quarters (72.2%, 153/212) had absences from work due to health in the past year, with a mean±SD of 14.0±34 days. In multivariable analyses controlling for factors examined in previous models (table 4), better mental health QOL was associated with lesser likelihood of any absences from work due to health in the past 12 months, as was being Black/African-American. Those with two or more chronic physical conditions and those who reported delaying care due to COVID-19 were significantly more likely than others to report any absences from work due to health. Turning next to the actual number of days absent from work due to health, those with higher physical and mental health-related QOL reported fewer days absent from work, as did those with higher education, while all other variables were non-significant.

Table 4. Characteristics associated with health-related absences from work (disability days) among certified peer specialists employed in peer support positions (n=215).

	Any disability days				Number of disability days (including zero)
	OR	95% CI, LL	95% CI, UL	P value	IRR	95% CI, LL	95% CI, UL	P value
Physical HRQOL	1.00	0.96	1.04	0.964	0.97	0.94	0.99	0.028
Mental HRQOL	0.96	0.93	0.99	0.037	0.96	0.94	0.98	<0.001
Age, years	0.96	0.92	1.00	0.067	1.00	0.97	1.03	0.937
Male	1.51	0.61	3.73	0.372	1.28	0.71	2.32	0.414
Latinx	0.94	0.28	3.08	0.912	1.35	0.62	2.90	0.450
Black	0.40	0.16	0.99	0.047	1.27	0.66	2.43	0.470
Other non-white	0.52	0.06	4.87	0.569	2.97	0.52	16.92	0.210
Education level	0.83	0.61	1.14	0.250	0.81	0.66	0.98	0.034
Household income level	1.19	0.82	1.74	0.357	1.05	0.82	1.35	0.682
Currently smoke or vape	1.22	0.53	2.79	0.638	0.94	0.56	1.58	0.812
Exercises moderately	1.07	0.46	2.50	0.871	1.53	0.82	2.86	0.178
Not vaccinated for COVID-19	1.80	0.44	7.39	0.412	0.95	0.43	2.12	0.907
Two+ chronic conditions	2.95	1.16	7.48	0.023	1.19	0.65	2.19	0.668
Delay care due to COVID-19	4.05	1.45	11.28	0.007	1.46	0.85	2.49	0.168
Cost as barrier	1.47	0.43	4.99	0.540	0.94	0.48	1.84	0.858
Reports usual source of care	1.29	0.33	4.97	0.713	1.91	0.76	4.79	0.167
No health insurance	0.63	0.09	4.22	0.631	0.64	0.18	2.31	0.500
Medicare, past 12 months	1.59	0.56	4.56	0.385	1.15	0.61	2.19	0.668
Medicaid, past 12 months	0.82	0.28	2.42	0.717	1.98	0.91	4.32	0.085
Model fit statistics	Nagelkerke R Square=0.25 χ2 p=0.014				Deviance value/df=2.16 Likelihood Ratio χ2 p<0.001

P=two-sided p value.

95%CI LL, 95% CI lower limit; 95%CI UL, 95% CI upper limit; HRQOL, health-related quality of life; IRR, incidence rate ratio.

Discussion

This study sheds light on an under-studied yet critically important topic, namely, the health and healthcare access of those certified as behavioural health peer specialists. When comparing our findings to research regarding physical and mental health-related QOL in the general US population, we see that the mean physical health-related QOL score in our cohort of 40.8±12.7 falls below that of the general population mean at 45.2±10.0,²⁸ and the mean mental health QOL score in our cohort of 43.7±11.7 falls below that of the general population mean of 46.6±11.1.²⁸ Our cohort also had greater time lost from work than the general population, with 72.2% having any absences from work due to health in the past year compared with 13.9% in the general population, and an average of 14.0 days lost from work due to health compared with 3.5 days in the general population.²⁹

The importance of both mental health-related and physical health-related QOL to peer support work among certified peer specialists is clearly illustrated by our findings. Approximately 18 months after receiving their state’s peer specialist certification, those employed in peer support positions had significantly better mental health quality of life than those who were not working. Among employed peer specialists, those with higher physical and mental health-related QOL had significantly fewer health-related days absent from work than those with lower physical and mental health-related QOL. Notably, those with higher levels of mental health QOL were less likely to have any health-related absences from work during a time with unprecedented workforce shortages during a global health pandemic. The positive impact of peer support work on peer specialists’ sense of mental well-being, along with work absence rates no higher than non-peer mental health workers, has also been found by other researchers.³⁰

Our findings confirm those of other studies indicating the reliance of the behavioural health field on peer support services during the COVID-19 pandemic,³¹ and join others in suggesting that this may have conferred advantages on a growing peer workforce. For example, a survey of 1280 peer support specialists in May through June 2020¹⁷ found that 91% had not lost their jobs due to COVID-19 and that 73% reported having new job tasks including resource coordination and virtual service delivery. They also reported receiving high levels of supervisory and organisational support. Another study of 375 peer support specialists during Spring and Summer 2021³² found that they reported moderate to high levels of positive feelings and fulfilment from helping others, and low levels of secondary traumatic stress. Our study found that those employed in jobs delivering peer support were significantly more likely to report being vaccinated compared with their non-working counterparts, which may have been due to the fact that many healthcare and social service facilities required COVID-19 vaccination to continue working with patients.³³ Those working in peer support were also more likely to have health insurance coverage over the preceding year than their non-working counterparts, which has also been found in prior research.³⁴

At the same time, our findings confirm those of others in documenting health and other challenges faced by this workforce. High proportions of cooccurring chronic physical conditions were found in addition to mental health disorders: 57% of those employed in peer support jobs and 67% of non-working individuals reported two or more such conditions, referred to in the literature as physical multimorbidity. Around half reported being diagnosed by a medical provider with high cholesterol and hypertension, two-fifths reported arthritis, and proportions of lung disease, diabetes, heart disease and cancer were notably higher than those reported in the general population.⁵ Moreover, those with physical multimorbidity had significantly lower physical health-related QOL, controlling for all other factors. Multimorbidity was also associated with a greater likelihood of health-related absences from work. Clearly, the need to cope with comorbid medical and mental health disorders plays a key role in retaining employment following certification as a peer specialist. This suggests the importance of employer-sponsored health and wellness programmes for workers, generous policies regarding sick leave and the need for accommodations allowing workers to attend medical and mental health appointments.

In addition, those who reported delaying routine or preventive medical care due to the pandemic were more likely to have health-related absences from work than those not delaying care. If, as some have argued, the pandemic’s impact was disproportionately borne by people with lived experience,¹⁸ those providing behavioural health peer support may have experienced a magnified pandemic impact, as has been shown for other populations of peer supporters in medicine and emergency response.³⁵

Related to high rates of physical multimorbidity is access to and quality of healthcare. Those who reported that cost was a barrier to obtaining healthcare reported lower physical health QOL and lower mental health-related QOL even controlling for other factors including physical multimorbidity. This is important because studies of this same cohort reveal that workers in peer support positions earn low wages, report low financial well-being and are at risk of financial hardship.³⁶ Thus, they may have been poorly equipped financially to bear the economic burden of dealing with high healthcare needs. Also part of the constellation of healthcare access concerns was having a usual source of care. Those with this important facilitator had significantly better mental health-related QOL, suggesting the important interplay of mental health and physical healthcare. This is also seen in the finding that those with better physical and mental health QOL had fewer days absent from work due to ill health, supporting the notion that providing employer-sponsored healthcare accrues financial benefits to organisations due to lower worker absenteeism.³⁷

Older age was associated with poorer health-related QOL but better mental health-related QOL. Interestingly, research on health-related and mental health-related QOL among older adults suggests that both are improved when people have higher health and general literacy, physical health promoting behaviour, perceived emotional and informational support and fewer comorbidities.³⁸ It is possible that certification and employment as a peer specialist offers the same advantages through job-related education and training, physical activity associated with job performance, supervisory and organisational support, and emotional benefits derived from helping others.

Study respondents who identified as Black/African-American showed noteworthy resilience in the form of significantly lower likelihood of health-related absences from work, and significantly higher mental health-related QOL. This may indicate the protective factor of culture in dealing with peer support work and pandemic stressors. Individuals from Black and other diverse communities may have more established coping strategies that enable them to be psychologically resilient in the face of COVID-19. For example, higher self-esteem was found to buffer the impact of pandemic stressors, racism and discrimination in one study of African-American adults,³⁹ and protective factors in Black intimate partner relationships moderated the impact of the pandemic in another study.⁴⁰ Similarly, a national sample of 5000 US survey respondents found that those identifying as Black had significantly better mental health and were significantly more resilient and optimistic about the pandemic than white respondents.⁴¹ These studies and our findings suggest that connections to family, religious communities and racial-ethnic identity integration may buffer pandemic impacts and promote mental health and well-being. This possible buffering effect was also observed in an earlier study of the cohort, which found that Black/African-American certified peer specialists reported lower work-life burnout than White certified peer specialists.⁴

Also noteworthy is the finding that moderate exercise was significantly associated with better mental health QOL and marginally significant in the model predicting physical health QOL. The importance of self-care for behavioural health peer supporters has been previously noted in qualitative studies, especially during the pandemic.⁴² The results of our multivariable analysis provide the most rigorous evidence thus far of the need for self-care for this growing workforce.

Limitations

Data come from respondent self-report, which could be subject to positive response bias or inaccurate recall. Our respondents were not randomly selected or nationally representative of all certified peer specialists, although they are a large and geographically dispersed group. The cross-sectional observational design of the study does not support causal inference, and the specific physical health conditions we selected for our survey may have influenced our findings regarding the prevalence of physical multimorbidity. Finally, those who consented to participate in the health wave were more likely to be White and less likely to be African-American, which may limit the generalisability of our results.

Clinical implications

Our study’s results have important implications for the clinical support of certified peer specialists. Our finding of high proportions of cooccurring chronic physical conditions and physical multimorbidity suggests that chronic illness treatment and chronic disease self-management strategies should be encouraged by this workforce’s primary care and behavioural health providers.⁴³ Our finding that lower physical health-related and mental health-related QOL were related to cost as a barrier to healthcare supports the importance of providers referring their patients to co-pay assistance programmes, prescribing generic medications, facilitating use of pharmaceutical patient support programmes and openly discussing the pros and cons of low-value, marginally beneficial medical services.⁴⁴ Our finding that having a usual source of healthcare was associated with better mental health-related QOL supports the use of patient retention strategies such as good communication, flexible payment options and personalised patient experiences.⁴⁵ Finally, our finding of resilience on the part of racially diverse peer specialists suggests that mental health professionals should consider using culturally sensitive treatment modalities and encourage culturally congruent coping strategies.⁴⁶

Conclusion

Study results point to the inextricably interlinked effects of physical and mental health among certified peer specialists and their need to deal with multiple physical health conditions in order to work in peer support positions. Without adequate workplace supports and employer-sponsored benefits, they may leave peer support jobs for other types of positions or exit the workforce altogether, and some have predicted a shortage of peer service providers in the coming years.⁴⁷ To ensure the delivery of effective peer support services, management of healthcare organisations and policymakers can use the findings of this and future studies to design work conditions and policies that support the well-being of this important behavioural health workforce and retain them in peer support positions.

Data availability statement

Data are available upon reasonable request.