Multicultural Competency in Wellness

If your worksite wellness program were to be measured against multicultural competency standards, would it meet, exceed, or fall short of those standards? As you will see, ensuring that your program considers the attributes and demographics that make up culture is mandated by a number of federal laws, renders a greater return on your investment, and serves the public good. When I speak of multicultural competency as it relates to worksite wellness, I am looking at the competency of those who design and implement the program as well as the program’s overall effectiveness in serving people of different cultures. Multicultural competency requires the individuals designing or implementing the program to:

1. Be aware of their own cultural worldviews
2. Possess knowledge of different cultural practices and worldviews
3. Examine their own attitudes toward cultural differences
4. Explore the attitudes of those they serve toward cultural differences
5. Have the interpersonal skills necessary to communicate and effectively interact with people across cultures

Many people confuse “diversity” with “multicultural competency.” They mistakenly use the terms interchangeably. While diversity is a good starting point, diversity does not equal multicultural competency. Nor do you achieve diversity by varying your team considering race alone. Cultural competency encompasses more than race. Culture includes such things as religion, gender, socioeconomic status, geographic location, language, sexual orientation, and education. Having a diverse group of people at the table is an excellent way to learn about other cultures; it is a way to begin to meet the second requirement on the list above (to possess knowledge of different cultural practices and worldviews).

Multicultural competency is a skill that must be learned. The answer as to whether your team has multicultural competency skills will largely turn on the answer to the following question: has your team had multicultural competency training? If the answer is no, then your team is probably lacking some element of multicultural competency.

To determine if your program measures up, I say the proof is in the pudding. It’s not just about your intentions; it’s also about results. Evaluate your program to see its effectiveness across cultural lines and whether it is in compliance with laws designed to eliminate discrimination and promote inclusion in wellness programs.

Why Should Worksite Wellness Programs Focus on Multicultural Competency?

Why should you care if your program measures up by Multicultural Competency standards? Simply put, because the law says you must and because you should!

Why Should Your Worksite Wellness Programs Focus on Multicultural Competency? Because They Should

You should be concerned about the effectiveness of your wellness program across cultures for the good of it – the social good, as a good business practice, and because programs that lack multicultural competency simply “ain’t good.”

Social Good
The CDC predicts that worksite wellness programs will become part of a national public health strategy to address an increase in chronic diseases that could cost the U.S. healthcare system an estimated $4.2 trillion annually by 2023. Chronic diseases linked to health disparities are connected to, among other things, variances in cultural health norms, healthcare literacy, and provider delivery systems, as well as the provider’s culture and multicultural competency. Worksite wellness programs can only achieve a notable impact on national public health by reducing chronic diseases if those programs effectively reach groups that are most impacted by chronic disease. Multicultural competency is a core ingredient in reaching those suffering with chronic diseases.

Smart Business Decision
According to the March 2011 Thomson Reuters Workforce Wellness Index, unhealthy behaviors of employees in the U.S. cost employers an average of $670 per employee annually. The Society for Human Resource Management (SHRM) states that there is evidence indicating that healthier lifestyles among employees are a plus for employers, because “[e]mployees who pursue healthful behaviors have fewer illnesses and injuries than other workers, and they recover from illnesses and injuries faster.”¹  Wellness programs that encourage healthy behavior can therefore reduce sick days and workplace injuries.

Racial and ethnic health disparities add another layer to the correlation of employee health and business productivity. Many employers are generally unaware of racial and ethnic health disparities as a business issue.²   It is important to recognize that many chronic diseases related to health disparities, such as hypertension, diabetes, cancer, cardiovascular disease, and obesity, greatly effect productivity and absenteeism. It follows that reducing or better managing of chronic diseases improves productivity and absenteeism. Since ethnic minorities and the poor have higher incidences of chronic diseases, reaching these populations (which is achieved with culturally competent programs and coaches) is critical to improving productivity numbers and reducing absentee numbers.

Lastly, studies have shown that effective wellness programs reduce the cost of insurance. Therefore, not only is there social good in positively impacting people’s wellbeing and reducing the stress on the U.S. healthcare system, there is a good business case for effective wellness programs that speak to a cross section of the population. A multiculturally competent wellness program will only serve to increase productivity while further reducing insurance cost and other expenses related to absenteeism. The business case is simply that it will improve the bottom line.

Standardized Programs Don’t Work
Racial and ethnic minorities comprise approximately 1/3 of the U.S. population and are projected to equal 54% by 2050.³  Plus, as described above the workforce today is diverse in ways that go beyond race and ethnicity (religion, age, sexual orientation, creed, geographic, etc.). Differences affect health norms, access to care, environmental health factors, desired providers, and wellness journey preference. A program that fails to factor in culture will fail to meet the preferences and needs of large segments of the workforce, likely resulting in less program participation or less than optimum results.

Why Should Your Worksite Wellness Programs Focus on Multicultural Competency? Because They Must

Worksite wellness programs must comply with numerous federal laws requiring that employers recognize disparities as well as genetics and physical and mental limitations when designing programs to avoid discriminatory behavior and impact.

Patient Protection and Affordable Care Act
The Patient Protection and Affordable Care Act promotes and funds prevention and wellness in the interest of public health. The Affordable Care Act explicitly sets out to reduce health disparities and improve the health of racially and ethnically diverse populations.

The Act was passed by Congress and then signed into law by President Obama on March 23, 2010. It is comprised of the Affordable Health Care for America Act, the Patient Protection Act, and the healthcare-related sections of the Health Care and Education Reconciliation Act and the Student Aid and Fiscal Responsibility Act. It also amends several other federal laws, such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Employee Retirement Income Security Act (ERISA) of 1974, and the Health and Public Services Act. Additionally, it reauthorizes The Indian Health Care Improvement Act (ICHIA).

The Act prohibits discrimination in wellness programs that are group health plans. It is very prescriptive as to standards and requirements that must be met to avoid discrimination in these wellness programs.

The Age Discrimination in Employment Act of 1967 (ADEA)
The Age Discrimination in Employment Act of 1967 protects people who are 40 or older from discrimination because of their ages with respect to any term, condition, or privilege of employment, including hiring, firing, promotion, layoff, compensation, benefits, job assignments, and training.

An example of a practice that could cause issues with ADEA is if the wellness program has a mandatory program that requires employees to meet a certain health standard which does not consider the age of the employee.

Americans with Disabilities Act (ADA) and The Rehabilitation Act of 1973
Title I of the ADA is a federal civil rights law that prohibits an employer from discriminating against an individual with a disability in connection with, among other things, employee compensation and benefits. Title I of the ADA also generally restricts employers from obtaining medical information from applicants and employees. Additionally, Title I of the ADA prohibits employers from denying employees access to wellness programs on the basis of disability and requires employers to provide reasonable accommodations (adjustments or modifications) that allow employees with disabilities to participate in wellness programs and also to keep any medical information gathered as part of the wellness program confidential.

Note: The ADA does not, however, prohibit employers from inquiring about employees’ health or doing medical examinations as part of a voluntary employee health program as defined by the ADA. For guidance on designing a wellness program that is ADA compliant, read “Are You Up-to-Date on ADA and Wellness Programs Compliance? – EEOC’s Final Rule on Employer Wellness Programs and the Americans with Disabilities Act.”

The Rehabilitation Act of 1973 makes it illegal to discriminate against a qualified person with a disability in federal agencies, in programs that receive federal financial assistance, or in any federal employment, including the employment practices of federal contractors. It also requires that employers covered by the Act make reasonably accommodations for the known physical or mental limitations of an otherwise qualified individual with a disability unless doing so would impose an undue hardship on the operation of the employer’s business.

An example of how a program could violate the ADA or the Rehabilitation Act is when an employer has a program that rewards employees for taking so many steps a day or walking a certain number of miles a week. An employee with a disability that limits his or her ability to walk could not be participate and therefore cannot earn an award in the program (the additional compensation). To remain in good standing, the program would need to provide alternative methods for the disabled employees to earn the additional compensation.

Title VII of the Civil Rights Act of 1964 (Title VII)
Title VII makes it illegal to discriminate against someone on the basis of race, color, religion, national origin, or sex. It generally applies to employers with 15 or more employees, including federal, state, and local governments. It considers disparate impacts. Disparate impact is when your practices or program adversely affect one group of people with a protected characteristic more than another although rules are neutral. Certain races are at risk of drastically higher rates of high blood pressure, high cholesterol, and diabetes. Tethering premium savings to what the program has defined as a “healthy level” of these measurements could be seen as discriminatory under Title VII.

The Act also requires that employers reasonably accommodate applicants’ and employees’ sincerely held religious practices, unless doing so would impose an undue hardship on the operation of the employer’s business. A violation on religious grounds could arise if an employer requires employees to submit to a health screening to qualify for savings on their premiums and an employee refuses to submit to the screening based on religious beliefs.

The Genetic Information Nondiscrimination Act of 2008 (GINA)
GINA is a federal law that forbids discrimination on the basis of genetic information in health insurance and any aspect of employment. It has two parts, Title I and Title II. Title I prohibits discrimination based on genetic information by health insurers and group health plans. Title II prohibits discrimination based on genetic information in employment. Genetic information includes information about an individual’s genetic tests and the genetic tests of an individual’s family members, as well as information about any disease, disorder, or condition of an individual’s family members (i.e. an individual’s family medical history). For guidance on designing a wellness program that is GINA compliant, read “Are You Up-to-Date on GINA and Wellness Programs Compliance? – EEOC’s Final Rule on Employer Wellness Programs and GINA.”

Health Insurance Portability and Accountability Act of 1996 (HIPAA)
The Health Insurance Portability and Accountability Act (HIPAA) was first enacted to address the problem of the uninsured. HIPAA includes provisions that limit exclusions for preexisting conditions under group health plans. It prohibits group health plans and health insurance issuers from discriminating against enrollees and beneficiaries with respect to eligibility, benefits, and premiums based on a health factor, with some limited exceptions.

A wellness program that is a part of an employer-based health plan could face problems under HIPAA if the wellness program is not “reasonably designed” to promote health or prevent disease, or if the full reward is not available to all similarly situated individuals.

State Laws
Be sure to look at your state laws as well the federal laws mentioned about. For example, some state laws prohibit an employer from penalizing an employee from engaging in lawful conduct outside of work⁴ including smoking⁵, drinking, and eating fast food. Restrictions related to smoking may not comply with those state regulations.

¹ https://www.shrm.org/ResourcesAndTools/hr-topics/benefits/Pages/DecliningHealth.aspx

² Employer Survey on Racial and Ethnic Disparities: Final Results. The National Business Group on Health. July 30, 20083

³ US Census Bureau. (August 14, 2008). “An older and more diverse nation by midcentury.” Retrieved May 13, 2014, from https://www.census.gov/newsroom/releases/archives/population/cb08-123.html)

⁴ Examples of states that protect employees from being fired for legal off-duty activity include California, Colorado, New York, North Carolina, and North Dakota.

⁵ There are a host of states that specifically protect tobacco use, including Connecticut, the District of Columbia, Illinois, Indiana, Kentucky, Louisiana, Maine, Minnesota, Mississippi, Missouri, Montana, Nevada, New Hampshire, New Jersey, New Mexico, Oklahoma, Oregon, Rhode Island, South Carolina, South Dakota, Tennessee, Virginia, West Virginia, Wisconsin, and Wyoming.