WELLNESS has different meanings for different populations. The first step towards an effective wellness program is understanding what it means to your audience.
The Multicultural Wellness Wheel focuses on three pillars for optimal and lifelong well-being:
Supporting underserved communities and minimizing healthcare disparities via the following approaches:
By becoming aware of one’s own personal assumptions about human behavior, values, bias, stereotypes, and personal limitations. Practitioners learn who they are as “cultural beings” and how cultural socialization has shaped their worldview and their ability to work effectively with culturally diverse populations.
A culturally skilled practitioner is one who actively attempts to understand the worldview of their culturally different clients without negative judgments, and shows respect and appreciation for human differences.
A culturally skilled practitioner is mindful of actively developing and practicing culturally appropriate intervention strategies and working appropriately within diverse communities.
The Multicultural Wellness Wheel serves as a tool for sustained engagement and personal reflection, supports dialogue and discussions, and assists practitioners with individual, family, workplace, and community wellness initiatives related to their unique communities of practice.
The wheel fosters the building of healthy relationships across cultural differences within diverse communities of practice.
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:
- Be aware of their own cultural worldviews
- Possess knowledge of different cultural practices and worldviews
- Examine their own attitudes toward cultural differences
- Explore the attitudes of those they serve toward cultural differences
- 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."
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.
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.
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 http://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.
The Department of Health and Human Services Office for Civil Rights (OCR)1 has enforcement authority over federal conscience protection statutes and certain federal nondiscrimination laws that prohibit discrimination on the basis of religion in the following U.S. Department of Health and Human Services (HHS) programs and entities:
- Maternal and Child Health Services Block Grant
- Projects for Assistance in Transition from Homelessness
- Preventative Health and Health Services Block Grant
- Community Mental Health Services Block Grant
- Substance Abuse Prevention and Treatment Block Grant
- Programs funded under the Family Violence Prevention and Services Act
- Federally-funded public telecommunication entities
This past January, HHS formed a new Conscience and Religious Freedom Division in the Office for Civil Rights. If your organization or facility receives certain federal funding and you do not have controls in place to ensure that your organization or facility protects your providers’ conscience and religious freedom, or your patients’ or enrollees’ religious freedom, my advice is to “suit up”. In other words, check your policies, start your monitoring, and develop your training to avoid being the subject of the new and enthusiastic enforcement efforts.
The Conscience and Religious Freedom Division’s mission is to restore federal enforcement of U.S. laws that protect the rights of conscience and religious freedom. In its announcement, the HHS explicitly stated that the creation of the new division will allow HHS to have greater focus on conscience and religious freedom issues necessary to more "vigorously and effectively enforce existing laws protecting the rights of conscience and religious freedom." So, expect more enforcement of Conscience and Religious Freedom regulations.
OCR Director Roger Severino stated in the announcement, "[l]aws protecting religious freedom and conscience rights are just empty words on paper if they aren’t enforced. No one should be forced to choose between helping sick people and living by one’s deepest moral or religious convictions, and the new division will help guarantee that victims of unlawful discrimination find justice. For too long, governments big and small have treated conscience claims with hostility instead of protection, but change is coming and it begins here and now."
If you have refused (or want to refuse) to perform, accommodate, or assist with certain health care services on religious or moral grounds and (1) you are working in an organization or facility that receives certain federal funding, or (2) you are an entity that has been discriminated against by a federal government and any state or local government receiving federal financial assistance, there is now an entire new division that will be dedicated to hearing your complaints and enforcing your rights, when those rights have been violated under the conscience protections provisions of federal laws listed below.
If you are (1) an individual who feels you have been discriminated against in the delivery of services by an organization or facility that receives certain federal funding, or (2) an individual or entity that has been discriminated against on the basis of religion, you too have a division that will, according to the OCR, "vigorously and effectively enforce" the protection of your religious freedom under any of the laws listed below.
Federal statutes protect health care providers’ conscience rights and prohibit recipients of certain federal funds from discriminating against health care providers who refuse to participate in services based on moral objections or religious beliefs. Below are the statutes that provide Conscience Protections.
- The Church Amendments (42 U.S.C. § 300a-7 et seq.)
The Church Amendments protect the conscience rights of individuals and entities that object to performing or assisting in the performance of abortion or sterilization procedures if doing so would be contrary to the provider’s religious beliefs or moral convictions.
- Coats-Snowe (42 U.S.C. § 238(n))
Coats-Snowe prohibits the federal government and any state or local government receiving federal financial assistance from discriminating against any health care entity on the basis that the entity: 1) refuses to undergo training in the performance of induced abortions, to require or provide such training, to perform such abortions, or to provide referrals for such training or such abortions; 2) refuses to make arrangements for such activities or 3) attends (or attended) a post-graduate physician training program, or any other program of training in the health professions, that does not (or did not) perform induced abortions or require, provide or refer for training in the performance of induced abortions, or make arrangements for the provision of such training.
- The Weldon Amendment (Pub. L. No. 111-117, 123 Stat 3034)
The Weldon Amendment provides that "[n]one of the funds made available in this Act may be made available to a Federal agency or program, or to a state or local government, if such agency, program, or government subjects any institutional or individual health care entity to discrimination on the basis that the health care entity does not provide, pay for, provide coverage of, or refer for abortions."
- The Affordable Care Act (Pub. L. No. 111-148 as amended by Pub. L. No. 111-152)
The Affordable Care Act includes new health care provider conscience protections related to the Health Insurance Exchange program. Section 1303(b)(4) of the Affordable Care Act provides that "No qualified health plan offered through an Exchange may discriminate against any individual health care provider or health care facility because of its unwillingness to provide, pay for, provide coverage of, or refer for abortions."
Section 1553 of the Affordable Care Act states that the Federal Government and any state or local government or health care provider that receives federal financial assistance under this Act (or an amendment made by this Act) or any health plan created under this Act (or an amendment made by this Act) may not discriminate against an individual or institutional health care entity because the entity does not provide any health care item or service that causes, or assists in causing, the death of any individual, such as by assisted suicide, euthanasia, or mercy killing.
OCR enforces these laws and regulations that protect conscience and prohibit coercion of providers to perform, accommodate, or assist with services that conflict with such providers’ religious or moral beliefs in HHS funded or controlled programs and activities. Examples of services that a provider may refuse to perform on religious or moral grounds are things like abortion and assisted suicide.
Healthcare providers may file a complaint under the Federal Health Care Provider Conscience Protection Statutes if they believe that they have experienced discrimination because they:
- Objected to, participated in, or refused to participate in specific medical procedures, including abortion and sterilization, and related training and research activities
- Were coerced into performing procedures that are against their religious or moral beliefs
- Refused to provide health care items or services for the purpose of causing, or assisting in causing, the death of an individual, such as by assisted suicide or euthanasia
(Source - https://www.hhs.gov/conscience/conscience-protections/index.html)
OCR also enforces the following laws and regulations that protect the free exercise of religion and prohibit discrimination in in HHS funded or controlled programs and activities.
- Section 508 of the Social Security Act (42 USC § 708)
Section 508 of the Social Security Act prohibits discrimination on the basis of age, race, color, national origin, disability, sex, or religion in the Maternal and Child Health Services Block Grant.
- Section 533 of the Public Health Service Act (42 USC § 290cc-33)
Section 533 of the Public Health Service Act prohibits discrimination on the basis of age, race, color, national origin, disability, sex, or religion in Projects for Assistance in Transition from Homelessness.
- Section 1908 of the Public Health Service Act (42 USC §300w-7)
Section 1908 of the Public Health Service Act prohibits discrimination on the basis of age, race, color, national origin, disability, sex, or religion in programs, services, and activities funded by Preventative Health and Health Services Block Grants.
- Section 1947 of the Public Health Service Act (42 USC § 300x-57)
Section 1947 of the Public Health Service Act prohibits discrimination on the basis of age, race, color, national origin, disability, sex, or religion in programs, services, and activities funded by Community Mental Health Services Block Grant and Substance Abuse Prevention and Treatment Block Grants.
- The Family Violence Prevention and Services Act (42 USC § 10406)
The Family Violence Prevention and Services Act prohibits discrimination on the basis of race, color, national origin, disability, sex, or religion in programs, services, and activities funded under this Act.
- The Communications Act of 1934 (47 USC § 398)
The Communications Act of 1934 prohibits employment discrimination on the basis of age, race, color, religion, national origin, or sex by federally-funded public telecommunication entities.
(Source - https://www.hhs.gov/conscience/religious-freedom/index.html)
The Conscience and Religious Freedom Division in the Office for Civil Rights is a division worth watching. Its enforcement activity will not go without challenge. Religion is a very passionate subject and civil rights is serious business. Challenges will likely come if the exercise of those freedoms is viewed as discriminatory by those who are denied a service by a provider because it is against the providers’ religious or moral beliefs.
Personal conflicts may arise when the religious belief being protected defies the sense of right and wrong of individual regulators charged with enforcing the statutes. Question of “sincere” religious beliefs and convictions may be wrongly assessed from the worldview of the adjudicator and not from the cultural prospective of the one invoking the conscience and religious freedom right.
If regulators lack the multicultural competency necessary to navigate the emotions, beliefs and culture of the complainant, they could render outcomes inconsistent with the stated goal of protecting religious and conscience freedoms. Protecting religious and conscience freedoms may support a fundamental and constitutional right, but it is a hard thing to enforce because there is usually immense passion and unwavering conviction on opposing sides. Just look at the case that highlighted a clash between gay rights and claims of religious freedom when a Colorado baker refused to make a wedding cake for a gay couple2. This issue went all the way to the United States Supreme Court. It takes a lot of passion and conviction, among other things, to get to the Supreme Court.
Regardless of where you fall on issues related to conscience and religious freedom, if you are responsible for overseeing your organization’s compliance with the applicable federal laws, it is time to access your risks and update your policies, because the Conscience and Religious Freedom Division in the Office for Civil Rights has officially been launched.
To file a complaint with the OCR based on a violation of civil rights, conscience or religious freedom, or health information privacy, visit HHS.gov.
1OCR is the law enforcement agency within HHS that enforces federal laws protecting civil rights and conscience in health and human services, and the security and privacy of people’s health information.
2Masterpiece Cakeshop, Ltd. v. Colorado Civil Rights Commission.