Ongoing diversity training can yield happier, healthier workers

Cultural differences can cause physical, mental health problems

The issue of cultural diversity has had a front-of-mind status in much of corporate America for several years now, and many companies recognize the value of respecting the differences within an employee population. However, paying attention to those differences has a special significance for occupational health professionals. In fact, ignoring them can lead to myriad problems both for individual employees and for the worker population at large.

"The workplace has become more and more diverse and heterogeneous," asserts Donna L. Goldstein, EdD, a cross-cultural psychologist and managing director of Development Associates International in Hollywood, FL. "People have been used to making assumptions that everyone was like them, but now, in any workplace, you can have people from different parts of the world, with different values that can cause them to make very different choices and have very different priorities. If management does not understand that, they can make bad decisions."

Even the simplest decision can lead to greater stress for some employees, she notes. "Say you want to reward your employees, and you want to have an event on a Monday night," Goldstein poses. "If the employee is single, it might be a good thing; but if employees are married or single parents, or if they are Haitian, Caribbean, or Latin — where family is very important in their culture — it would not be a good thing to go out with fellow employees on a weeknight."

The employee is then caught in the middle; if he does not go, he may anger his boss. If he does go, he could anger his family. "So the situation causes stress one way or the other," Goldstein says. "In such a case, it might be more appropriate to go at lunchtime."

Goldstein’s reference to married couples or single parents points out an important consideration when it comes to diversity: The occupational health professional needs to be aware of employee differences that go beyond ethnicity.

"I look at populations at special risk in the workplace," says Pamela F. Levin, PhD, RN, associate professor at the college of nursing at Rush University in Chicago. Most programs in the workplace are centered around ethnicity, she asserts. "But culture is also age and gender."

"We need to have a broad definition to include socioeconomic factors as well," Levin continues. "Certain industries hire more low-income workers, who are less likely to have insurance. Also, they tend to work in more risky jobs. Diversity also brings in issues like disability and lifestyle [e.g., sexual preference]."

It’s also important, says Goldstein, for occ-health professionals to recognize the difference between cross-cultural considerations and diversity issues. "Diversity usually focuses on recognizing prejudice and discrimination, and developing strategies for understanding each other in a domestic setting," she explains. "Cross-cultural training is required outside of a domestic setting — for example, a hospital in Japan seeking to do work in Brazil."

The issue of diversity is much more than a theoretical problem for occ-med professionals; it plays out in real-world health problems every day. "There are a lot of people from different ethnic backgrounds who are afraid to use the health care system for a variety of reasons involving fears, including anything from losing their job for reporting that they hurt themselves to not being understood and in some way being discriminated against," says Lewis Schiffman, president of Atlanta Health Systems.

"Additionally, many of them are used to receiving services from health care systems that operate differently, and they don’t understand our system. So what is often easier for them, rather than feeling awkward or embarrassed, is to try to treat things on their own or with methods traditional to their own culture."

Such differences can cause both physical and mental health problems, says Levin. "Health practices and health beliefs vary across cultures, ethnicities, and ages," she observes. "For example, those workers who are in their 20s are quite different from baby boomers. For one thing, they grew up with managed care.

"With gender, we know that women use the health care system differently than men; they are more preventive-oriented," she continues. "Also, health services have been designed to appeal more to men, and although this is changing, it has not trickled down to the workplace yet. And men have a disproportionate number of injuries [compared to women]."

Workers from other cultures, Levin notes, may not know how to access or understand the health care system, including dealing with insurance issues. "Also, our health care system is predominantly Western in style," she says. "This raises issues such as CAM [complimentary alternative medicine], which is not often incorporated into a traditional occupational health assessment."

Mental health issues also can be significant, Levin notes. "There is no training outside the workplace in terms of how to respect people who are different from you. We teach self-esteem, but not how to respect others in the workplace, which will be very different from their smaller community at home," she says.

"If there is racial or ethnic tension or misunderstanding, it creates a much more stressful work environment," adds Schiffman. "This adversely affects everyone’s health and will also increase the number of injuries and workers’ comp claims."

"There is a lot of interesting evidence that turnover is more likely if workers do not feel accepted or part of a group," says Goldstein. "Employees who are gay, for example, may be made to feel uncomfortable if they are not allowed to have a picture of their sweetheart on their desk. You could expect their morale and productivity to go down, they will become more introverted, less willing to interact with their colleagues, and less likely to fulfill their potential as workers. The more open you can be with them, the more likely you will be to resolve their problems."

Small differences, big issues

Even seemingly small cultural differences can have a large impact on how employees interact with you and with the health care system, says Goldstein. "Even things like the perception of mental and physical illnesses are significant," she notes. "In some cultures, it’s OK to say you are going to a psychiatrist; in others, it’s taboo to admit weakness. In some, you may not believe you are sick because of germs, but because of some sort of spirit. If you have a different perception of what makes you ill, you will have a different perception of what will heal you."

This, Goldstein says, impacts how the health care professional will treat the employee. "You must be cognizant of the fact, for example, that while you may want to just give them medicine, they may also go for spiritual [treatment]," she explains. A similar problem can arise with a death in the family, she notes. "In some cultures, it is a terrible thing. In others, they believe you are going to a better place," Goldstein says. "So, how do you comfort a co-worker?"

Even such simple things as how close we stand to each other can become large issues, says Goldstein. "In a number of instances, cultural miscommunication is seen as sexual harassment," she explains. "In some cultures, people touch each other when they talk, but the British, for example, stand particularly far apart and almost never touch except when they shake hands. Mexicans, however, touch maybe 70%-80% of the time. Then, overlay [these differences with] the appropriate concern in the U.S. for sexual harassment, and you can have a lot of miscommunication."

The same may be true with nonverbal communication, such as eye contact. "In some cultures, it is considered a sign of respect for authority to not make eye contact," Goldstein explains. "But if a worker did that to an American boss, that boss might think he was lying."

Winning strategies

Despite the daunting list of challenges presented by employee differences, there are a number of techniques occupational health professionals can use to address these differences. "The first thing is, finding out about the cultural norms of the group or groups you work with and what their traditional beliefs are in health care," Schiffman recommends. "Second, learn a few words of their language. Making an effort to communicate with them in their language, even if you are not fluent, demonstrates respect and is perceived as a desire to create alignment.

"Third, make a lot of eye contact and try to observe their nonverbal responses. Many health care providers will focus more on the interpreter rather than the patient, and this is often perceived as disrespectful and builds distrust."

Levin agrees. "It’s on the very basic level of the health professional that you treat everyone with respect," she says. "Ask what it is that they do in terms of helping for their health. If you have that dynamic of equal respect, you don’t have to know everything about all the different cultures."

Also, be aware that while cultural sensitivity may make you cognizant of general trends. "When you get down to the individual level they may not represent that population at all," says Levin. "They may have a Spanish surname, but they may have grown up in America and do not identify with Hispanic culture at all."

It’s also important to take a look at the tools used within the health center, she adds. "Do your health and history forms take into account issues broad enough to capture the diverse health issues of the population?" she says.

Diversity training needed

Goldstein recommends using a Cross-Cultural Adaptability Inventory. Basically, this indicates how well workers are likely to do with people different than themselves. "If the score is low in flexibility and openness, you might have to have a [training] series," she says, noting that she’s had employees complain about things as seemingly minor as the smell of curry in the break room.

Unfortunately, says Goldstein, the emphasis on diversity training seems to have waned. "A lot companies are saying, We’ve already done that,’" she complains. "They’ve had a day or two of training, and they think they’re done." However, this is an ongoing process, Goldstein says, partly because our definition of diversity continues to evolve, and partly because employee populations themselves continue to evolve. "What if 10 years ago, 5% of your workers were Hispanic, and now it’s 40%? What if you now have a boss who’s gay?" she poses.

Any training that occurs must be strongly supported by management, adds Levin. "Unless you evaluate your people on those behaviors or skills, there is no repercussion," she asserts.

While it is true that in most companies the human resources manager hires the diversity trainer, the role of the occupational health professional is no less critical, says Schiffman. "I would encourage the occupational health professional to be an advocate and an educator, to teach all people to make better use of the health care system," he says. "It should be brought up as an organizational health and performance issue for any number of reasons. If people are reluctant to come in for care in a timely manner, it increases the risk for more costly claims — and that impacts everybody."

Even if the human resources department has instated a diversity training program, says Goldstein, it may be up to the occ-health professional to remind them there is an ongoing need for such training. "I would think it should be done once a year," she recommends.

Finally, says Levin, even if the organization at large is not proactively dealing with diversity, that doesn’t mean you can’t make changes within your department. "You certainly can, although it will be more challenging if the environment outside your department is that different," she says. "On the other hand, the occupational health professional can also be instrumental in changing an organizational culture."

For more information, contact:

Donna L. Goldstein, EdD, Managing Director, Development Associates International, Hollywood, FL. Telephone: (954) 893-0123.

Pamela F. Levin, PhD, RN, Associate Professor, College of Nursing, Rush University, 600 S. Paulina St., Suite 1080, Chicago, IL 60612. Telephone: (312) 942-8842. E-mail:

Lewis Schiffman, Atlanta Health Systems, Atlanta. Telephone: (404) 636-9437. E-mail: Web site: