Business of Well-being

A Failure to Communicate: How Cultural Incompetence Leaves Many Wellness Programs Incomplete

According to the U.S. Bureau of Labor Statistics, by 2015 racial and ethnic minorities will comprise 41.5 percent of the work force (U.S. Bureau of Labor Statistics, 2008). Ensuring equal healthcare for all members of today's workforce is imperative, but to ensure its quality for tomorrow's workforce may prove to be even more demanding.

There are things that people need to take into account when working with a wide array of different people from different cultures. The first is to have respect for the people you deal with. To relate with different people, you need to be able to respect their traditions, norms, and other traits.

Increased incidence of heart disease, diabetes, cancer, and obesity among Blacks and Hispanics specifically is associated with an increased number of missed workdays due to illness, as well as lower overall household earnings (Government Accountability Office, 2007). Heart disease, hypertension, diabetes, cancer, musculoskeletal problems and asthma are all among the costliest conditions to employers, in terms of both direct and indirect costs.

Indirect costs associated with unscheduled absences, and productivity losses associated with family and personal health problems, cost U.S. employers $225.8 billion annually now. These are typically not the kind of numbers or trends that you would expect at a time when the term 'wellness' is thrown around as often as pigskin on Sundays. A recent survey conducted by the Society for Human Resource Management shows that more employers than ever are trying to encourage their employees to be healthier which is great news.

That survey found that 77 percent of employers offer wellness resource information in 2012, compared to 72 percent in 2008. Furthermore, 61 percent of companies said they now offer wellness programs compared to 58 percent four years earlier. In fact, the 2012 Kaiser Family Foundation and Health Research and Educational Trust annual survey of employer health benefits found that 63 percent of companies with three or more employees that offered health benefits also offered at least one wellness program.

Some typical components or pieces of wellness programs are health-risk assessments and screenings for high blood pressure and cholesterol. Some companies offer behavior modification programs, such as tobacco cessation, weight management, and exercise combined with health education.

This includes everything from classes to referrals to online sites for health advice. At the least, companies present changes in the work environment or provision of special benefits to encourage exercise and healthy food choices, such as subsidized health club memberships.

Now for the Down Side

If programs fail to take into account racial and ethnic differences among their intended populations, employers miss opportunities to maximize the return on their investment of millions of dollars in the health and well-being of their employees whether they are providing disease-management and wellness programs or not.

It's imperative to understand what and how to offer programs that respond to the needs and cultural preferences of members of a diverse workforce. It's no surprise that while more and more companies offer wellness opportunities, slow return on investment and impatience leave many employers running the risk of undermining the long-term success of their own programs.

The cost of sponsoring health insurance for their employees is the top concern for large and small employers, and racial and ethnic minority entrepreneurs are no exception. These populations have diverse health needs and many experience different treatments when they seek healthcare. Health disparities are differences in disease burden, disability and mortality in a defined population.

Populations affected by disparities include racial and ethnic minorities, people who live in diverse geographic locations, women, older people, and people with disabilities. Most businesses nowadays recognize the benefits of prevention and the incorporation of wellness and health promotion programs yet there still exists strong resistance to investing in cultural competence as these entities search for evidence that supports a potential for quality improvement and cost savings.

The potential rewards that come from reducing health disparities has not generally been a criterion for selecting health providers or plans. Low-cost and high-quality healthcare coverage should mean increased profits, higher wages, and the ability to attract and retain skilled employees. There is a disconnection, though, between minority employees and the systems put into place to keep them healthy and productive in the workplace.

Many minority employees get caught under the umbrella of wellness programs that never speak directly to their needs, in their language. Cultural competence refers to the attributes of an organization that describes the set of congruent behaviors, attitudes, skills, policies, and procedures that are promoted and endorsed to enable all levels of the organization to work effectively and efficiently with persons and communities of all cultural backgrounds (Adapted from Cross et al, 1989).

The term has largely been used in reference to discrepancies in healthcare and how it's provided, but a thorough understanding and implementation of cultural competency also has to be an integral part of any company's wellness programming, regardless of size. An important element of cultural competence in the workplace will be the capacity in which all employees are empowered to overcome even their own health illiteracy to sustain health, regardless of race or color or economic status.

According to the American Medical Association, poor health literacy is "a stronger predictor of a person's health than age, income, employment status, education level, and race. The issues are complex, and achieving success will require an active strategy, rather than a reactive approach. Waiting until health problems created by disparities occur and ignoring healthcare disparities and their impact on the workforce, rather than addressing them in advance, will be costly to the employer and less than ideal for the employee.

Participating in employee wellness programming minus cultural competency among the employers and those healthcare providers and/or vendors leaves already high risk employees with a lower quality of health.Receiving lower quality healthcare that results from disparities not only compromises the physical and emotional well-being of minority Americans, but it also likely jeopardizes their productivity and viability in the workplace.

Minority workers are put at greater risk for increased absenteeism and presenteeism, and opportunities for professional growth and promotion are diminished. Employers, with few examples thus far, largely remain unaware of the problem and do not understand what role they might play in ameliorating it. Health insurers, such as Kaiser Permanente, Aetna, and BlueCross BlueShield of Florida, have been proactive in their development of initiatives regarding cultural competence.

Kaiser Permanente has had long-standing efforts that range from educational monographs in cultural competence to full-fledged "Centers of Excellence in Cultural Competence" targeting specific populations and should be commended for those efforts. For the sake of saving jobs and a few lives, hopefully other business will follow suit.

Addressing disparities through a quality improvement framework is not only promising but it should also be viewed as good medicine and good business. By addressing health disparities, employers send the message that they are committed to ensuring that their employees and dependents receive high-quality healthcare, thus improving their health, productivity and quality of life.

After all, health promotion is the process of enabling people to increase control over the detriments of health and thereby improve their health," (World Health Organization, 1998). Cultural competency and health disparities are terms that have been long associated with healthcare but more so lately, it can be applied to that piece of the wellness programming pie that comes up missing or falling short.

It is not a cure-all but clearly aids in aiding in diversity, which encourages the process of including the perspectives of under-represented, non-dominant groups in organizations to ensure they have a voice (Orbe & Spellers, 2005). Disparities are the result of many factors and that cultural competence alone cannot fix the whole problem. Some of the disparate stats:

  • Cancer is the second leading cause of death for most racial and ethnic minorities. African American men are more than twice as likely to die from prostate cancer as whites, and Hispanic women are more than 1.5 times as likely to be diagnosed with cervical cancer.
  • African Americans, American Indians and Alaska Natives are twice as likely to have diabetes as white individuals; diabetes rates among Hispanics are 1.5 times higher than those for whites.

According to recent statistics from the Agency for Healthcare Research and Quality, only 12 percent of the 228 million adults in the United States have the skills to manage their own healthcare proficiently. These "skills" refer to a person's ability to obtain and use health information to make appropriate healthcare decisions that affect our home and work lives.

More than 40 percent of the U.S. population is currently living with one or more chronic conditions, and management of these conditions accounts for 75 percent of all personal medical care spending in this country and undoubtedly will increase without improvements in cultural competence in our workplaces.

Without improving cultural competency, the inability of minority wellness program participants to effectively communicate with healthcare providers and vendors is likely to worsen. The Culturally and Linguistically Appropriate Services (CLAS) standards project is often referred to as an effective blueprint for improving the cultural competence of our healthcare system.

Services such as bilingual staff or interpreters for non-English or ESL employees may help reduce the racial and ethnic health disparities as employers improve health and wellness opportunities. Poorer health outcomes may result when sociocultural differences between employees and providers, like language are not reconciled in the clinical encounter. This can lead to:

  • Increased likelihood of mistakes in collecting medical histories,
  • Decreased use of preventative services,
  • Increased use of diagnostic testing, and
  • Increased risk of drug complications affecting work or home life.

Further Recommendations

Health insurers could market cultural competence initiatives to employers as a method of expanding their member market share Finally, the "multilevel" nature of providing a culturally competent solution to increasing employee healthcare costs includes having diversity in leadership and in the provider and vendor network; systemic capacities, such as multilingual services like interpreters and 'healthy' literature are valuable components.

It cannot be understated, the importance of data collection, and quality measurement (including employee satisfaction and compliance); and cultural awareness training for healthcare provider, staff, and other vendors.

Some Questions Every Company with Wellness Offerings Should ask of Themselves

  1. Do we have familiarity with the Institute of Medicine's or others describing racial and ethnic disparities among the insured?
  2. What are our company's disease management programs? Do they include culturally targeted components? If so, briefly describe the cultural component of the program.
  3. How do our communication materials specifically address cultural health concerns?
  4. Do we collect racial and ethnic data? How does our health plan collect racial and ethnic data for the purpose of targeting culturally sensitive programs or initiatives?
  5. Does our plan address disparities within our network? If so, what culturally sensitive practices have our providers and health vendors incorporated?
  6. How do I describe the minority makeup of your physician network (African American, Asian/Pacific Islander, Hispanic, Native American) in terms of percentages?
  7. What additional efforts is our health plan or wellness program involved in to reduce disparities in deliverables?
  8. How can we incorporate third party vendors like Health and Wellness Coaches into our programming? What's the best way to incorporate them(onsite, online, telephonically)?

What Does a Culturally Competent Organization Look Like?

  1. It will be diverse by every definition. Remember that diversity doesn't just mean ethnic differences. Education, expertise, and even certain kinds of illness represent differences that can make a difference in employee experience.
  2. It will differentiate between 'book knowledge' and people sense. Education about ethnic diversity can be helpful, but the capacity to respect each employee, their strengths, and their needs will always be equally, if not more, important as we move to a more diverse workforce.
  3. 3. All levels of employees feel necessary. Support for professional advancement of employees, a form of respect in itself, also helps to build a diverse staff and may help keep some employees.

About the Author

Rod Sims is a speaker, writer, and health and wellness expert. He is the owner of BillboardzWellness360 and a member of the National Partnership for Action.


1. U.S. Bureau of Labor Statistics, 2008

2. Government Accountability Office, 2007

3. Kristen Suthers, PhD, MPH, Evaluating the Economic Causes and Consequences of Racial and Ethnic Health Disparities

4. National Business Group on Health. (2003). Why Companies are Making Health Disparities Their Business: The Business Case and Practical Strategies. Report prepared for the U.S. Department of Health and Human Services. Contract #: 02T025025.

5. Hewitt Associates, “Wellness and Beyond: Employers Examine Ways to Improve Employee Health and Productivity Costs,” August 2008.

6. Kaiser Family Foundation and Health Research and Educational Trust, “Employer Health Benefits: Annual Survey 2011,” September 27, 2011.


8. Joseph R. Betancourt, Alexander R. Green, J. Emilio Carriilo, and Elyse R. Park, FROM THE FIELD Cultural Competence And Health Care Disparities: Key Perspectives And Trends

9. Agency for Healthcare Research and Quality

10. World Health Organization, 1998

11. Orbe & Spellers, 2005



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