2022 Volume 4 Issue 1 Article ID: 2022-0009-FS
Objectives: This study aimed to investigate the activities to support balancing treatment and the occupational life of employees provided by occupational health service organizations. We also aimed to collect suggestions from these organizations for improving support activities in enterprises. Methods: Questionnaires about support activities (status, required external support, collaborative external facilities) were sent to 121 occupational health service organizations in Japan in 2018. Completed questionnaires were collected from 76 organizations (Response rate: 63.0%). The organizations were categorized as small (fewer than 99 employees), medium (100–199 employees), and large (200 employees or more). Results: More than 20% of the organizations had already started to provide several kinds of support activities. There were no significant differences in the status of support activities by size of occupational health service organization. To promote support activities, the organizations required external support, like educational programs, for occupational health specialists (59.5%), staff in client enterprises or health insurers (50.0%), or managers in the organizations themselves (48.6%). The most common external facility for referral or cooperation was prefectural occupational health total support centers (40.0% for referral and 24.0% for cooperation). Conclusions: This study found that some occupational health service organizations have already started to provide support activities for their clients. To promote these support activities, more educational programs should be provided for occupational health specialists, managers within the organizations, and staff of their clients.
In recent years, there has been increasing global recognition of the need to promote the balancing of treatment and the occupational life of employees1). In February 2016, the “Guidelines for supporting treatment and work integration in the workplace” were published by the Ministry of Health, Labour and Welfare, Japan2). As a result of the revision of the Cancer Control Act in December 2016, enterprises in Japan are required to support the return to workplaces of employees with cancer3).
Occupational health service (OHS) activities for small-scale enterprises (SSEs) are often insufficient in many countries, as they have limited access to human, economic, and technical resources4). It has been reported that small-scale enterprises also have a limited budget for mental health activities5). Employees in SSEs are, therefore, often provided with lower quality OHS and sometimes have poorer health conditions than their counterparts in large-scale enterprises.
A study on work–life balance and treatment for illnesses and other conditions found that the number of enterprises applying flexible working arrangements for employees with work limitations related to illness was lower among smaller enterprises6). There has been a governmental report about support balancing treatment and the occupational life of employees in enterprises, focusing on enterprise size7), but most scientific studies have not focused on small enterprises8). If enterprises appoint an occupational physician (OP), this OP should play an important role in support activities9). However, the Industrial Safety and Health (ISH) Law in Japan10) stipulates that enterprises employing fewer than 50 employees are not required to appoint an OP. OHS organizations are the most common external OH specialists used by SSEs for consultations on mental health problems5). These organizations could, therefore, contribute to support activities in SSEs. However, to the best of our knowledge, there have been no reports on support activities by OHS organizations.
This study was initiated to investigate the support activities of OHS organizations and to collect suggestions from OHS organizations to improve support activities in enterprises. It was expected that the study would be useful for improving of the quality of support activities for enterprises in Japan.
This study was a questionnaire survey among organizations on the list of OHS organizations prepared by the National Federation of Industrial Health Organization (NFIHO), Tokyo, Japan. The NFIHO conducts continuous external quality control for member OHS organizations. The list is continually updated by the NFIHO, taking advantage of additional available information to improve effectiveness of communication with the OHS organizations. In 2018, the list contained the names and postal addresses of 121 OHS organizations.
To the best of our knowledge, no similar questionnaire surveys targeted at OHS organizations have previously been implemented. Therefore, the questionnaire for the study (in Japanese; see Appendix for details) was developed by the authors. Four experts developed the questionnaire (two university researchers who majored in occupational health and two OH practitioners who had more than 10 years of relevant professional experience; three of them had senior occupational health physician certification by Japan society for occupational health). They carefully evaluated whether the contents in the questionnaire were relevant to the context of support activities by OHS organizations and whether the questions were comprehensible.
Regarding reliability, our questionnaire tried to measure the support activities the OHS organizations provided but not the single concept. A test-retest procedure during a short period (e.g., 2 weeks) might indicate the reliability (reproducibility) of the questionnaire. However, considering the burden of participant OHS organizations, we measured the support activities at a single time point.
The questionnaire included characteristics of the OHS organization (number of employees, medical doctors, nurses, client enterprises, and health examinations implemented per year), status of support activities, external support required to promote the support activities, staff awareness of the guidelines separated by profession, handling of requests for advice about support activities from client enterprises, and others. The questionnaire was designed to be answered by OH specialists, such as occupational physicians or occupational health nurses. When answering some of the questions, these specialists were expected to need to ask other staff in the organization for information. Because barriers to support balancing treatment and occupational life might include the financial burden of the support activities on SSEs, as well as the lack of knowledge about the support activities of staff in OHS organizations and relevant members in client enterprises or health insurers, the authors included several questions about educational programs of support activities. Ten OHS organizations agreed to face-to-face interviews, and the authors visited these organizations to carry out interviews using the questionnaire from January to February 2018. The authors ascertained understandability of the questionnaire through face-to-face interviews. The same questionnaires were sent by mail to the remaining 111 of 121 OHS organizations in the middle of January 2018. Completed questionnaires were collected from 66 OHS organizations (response rate: 60.0%) at the beginning of March 2018. Usable answers were obtained from 76 OHS organizations (63.0% of the total). The analyses used all 76 effective answers. To investigate the difference in support activities by size of OHS organization, the organizations were categorized into three groups by number of employees (under 100, 100–199, and 200 or more employees) and were analyzed using the Chi-square test. One OHS organization gave no answer about organization size. We considered OHS organizations with fewer than 100 employees as small (n=26), those with 100–199 employees as medium (n=24), and those with more than 200 employees as large (n=25).
The data were analyzed using STATA 16.1 (StataCorp, College Station, TX, USA). We used the Chi-square test, the Mann–Whitney U-test, and the Kruskal–Wallis test for statistical analyses, and the significance level of p<0.05 was selected.
The research procedures were developed and approved in the study group supported by Ministry of Health, Labour and Welfare (Industrial Disease Clinical Research Grants: Grant number 170401-02). As mentioned above, the questionnaires were sent by mail to OHS organizations listed by the National Federation of Industrial Health Organization. Participants were informed in advance that their participation was voluntary, and that all information provided would be handled confidentially. Only those who consented to participate answered the questionnaire. The questionnaire was anonymous and self-administrated. No respondent could be identified.
Of the 76 OHS organizations that completed the questionnaire, the modal organization size class was those employing from 100 to 199 employees (32.0%) (Table 1). The median number of client enterprises was 2,625, and the organizations delivered a median of 110,000 health examinations per year. The median number of occupational physicians they required under the Industrial Safety and Health Law10) was four.
| Elements | Total number of answers | Number of answers for each choice | %a | AM ± ASD | Median | |
|---|---|---|---|---|---|---|
| Number of employees | Less than 50 | 75 | 13 | (17.3) | ||
| From 50 to 99 | 13 | (17.3) | ||||
| From 100 to 199 | 24 | (32.0) | ||||
| From 200 to 299 | 11 | (14.7) | ||||
| From 300 to 399 | 8 | (10.7) | ||||
| From 400 to 499 | 1 | ( 1.3) | ||||
| From 500 to 599 | 0 | ( 0.0) | ||||
| 600 and over | 5 | ( 6.7) | ||||
| Number of customer enterprises | 70 | ― | ― | 5789.9 ± 10911.4 | 2625 | |
| Number of health examinations per year | 73 | ― | ― | 160702.6 ± 160251.6 | 110000 | |
| Number of physicians | 74 | ― | ― | 11.2 ± 13.0 | 6 | |
| Number of occupational physicians | 73 | ― | ― | 6.8 ± 7.3 | 4 | |
| Number of nurses | 73 | ― | ― | 95.3 ± 553.0 | 19 | |
AM, arithmetic mean; ASD, arithmetic standard deviation.
When asked about the status of support activities they provided (Table 2), one of the 76 OHS organizations gave no answer. An analysis of the remaining 75 organizations showed that more than 20% had already started to provide consultations on balancing treatment and occupational life for health managers or individual employees. About 40% of the OHS organizations were planning to provide these support activities in the future. There was no significant difference in the status of support activities by size of OHS organization (Chi-square test, data not shown).
| Elements | Status | No. of activities provided by OHS organizations | (%a) |
|---|---|---|---|
| Lectures on support balancing treatment and occupational life | Currently providing | 9 | (12.0) |
| Plan to provide in future | 34 | (45.3) | |
| No plan to provide in future | 32 | (42.7) | |
| Support for establishment of system for support balancing treatment and occupational life | Currently providing | 9 | (12.0) |
| Plan to provide in future | 31 | (41.3) | |
| No plan to provide in future | 35 | (46.7) | |
| Consultation on support balancing treatment and occupational life for health managers | Currently providing | 16 | (21.3) |
| Plan to provide in future | 32 | (42.7) | |
| No plan to provide in future | 27 | (36.0) | |
| Consultation on support balancing treatment and occupational life for individual employees | Currently providing | 16 | (21.3) |
| Plan to provide in future | 28 | (37.3) | |
| No plan to provide in future | 31 | (41.3) | |
| Information delivery on support balancing treatment and occupational life | Currently providing | 4 | ( 5.3) |
| Plan to provide in future | 35 | (46.7) | |
| No plan to provide in future | 36 | (48.0) |
n=75
When asked about external support required to promote their support activities (multiple answers allowed), two of the 76 organizations gave no answer. The most common external support required was educational programs for OH specialists in OHS organizations, followed by educational programs for relevant members in client enterprises or health insurers, educational programs for managers in OHS organizations, and information on support activities and support facilities for examinees with findings from health check-ups or cancer screening (Table 3). From a detailed observation about advice required from external facilities about support activities, OHS organizations were most likely to seek advice from prefectural occupational health total support centers (n=17, 23.0% of 74 OHS organizations), centers for the promotion of health and employment support of industrial accident compensation hospitals (n=12, 16.2%), counselling and support centers of hospitals (n=12, 16.2%), support organizations for people with higher brain dysfunction (n=11, 14.9%), counselling and support centers for intractable diseases (n=11, 14.9%), and support coordinators for juvenile dementia (n=11, 14.9%). There were no significant differences in external support required to promote support activities by size of OHS organization (Chi-square test, Table 3).
| Elements of external support | Size of organization | Chi-square test | Total (n=74) | ||||||
|---|---|---|---|---|---|---|---|---|---|
| Small (n=26) | Medium (n=24) | Large (n=24) | |||||||
| Cases | (%)a | Cases | (%)a | Cases | (%)a | p-valueb | Cases | (%) | |
| Educational programs for OH specialists in OHS organizations | 15 | 57.7 | 12 | 50.0 | 17 | 70.8 | .331 | 44 | 59.5 |
| Educational programs for relevant members in clinet enterprises or health insurers | 11 | 42.3 | 13 | 54.2 | 13 | 54.2 | .622 | 37 | 50.0 |
| Educational programs for managers in OHS organizations | 12 | 46.2 | 13 | 54.2 | 11 | 45.8 | .805 | 36 | 48.6 |
| Information on support activities and support facilities for examinees with findings from health check-ups or cancer screening | 10 | 38.5 | 11 | 45.8 | 13 | 54.2 | .538 | 34 | 45.9 |
| Information about administrative systems and support facilities for OH specialists in OHS organizations | 8 | 30.8 | 10 | 41.7 | 11 | 45.8 | .527 | 29 | 39.2 |
| Advice on support activities from external support facilities | 7 | 26.9 | 8 | 33.3 | 11 | 45.8 | .366 | 26 | 35.1 |
| Cooperation with medical staff in hospitals | 3 | 11.5 | 8 | 33.3 | 9 | 37.5 | .083 | 20 | 27.0 |
In total, 61 organizations responded about awareness of the guidelines2) by profession. Overall, 10.1% of OH specialists understood the guidelines fully and 25.9% partially, 28.7% knew of it by name, and 35.2% had no awareness. Among account managers 4.0% understood the guidelines fully and 14.8% partially, 27.6% knew it by name, and 53.6% had no awareness. There was a significant difference between the percentage of OH specialists and account managers who understood the guidelines fully (10.1% vs. 4.0%, p<0.01, Mann–Whitney U-test). However, there was no significant difference by size of OHS organization in proportions of OH specialists and account managers who were aware of the guidelines (Kruskal–Wallis test, Table 4).
| Awareness of the Guideline | OH specialists | Account managers | ||||||
|---|---|---|---|---|---|---|---|---|
| Size of the organizations | Kruskal–Wallis test | Size of the organizations | Kruskal–Wallis test | |||||
| Small (n=21) | Medium (n=20) | Large (n=20) | Small (n=21) | Medium (n=20) | Large (n=20) | |||
| % | % | % | p-valuea | % | % | % | p-valuea | |
| Fully | 8.9 | 13.2 | 8.0 | .590 | 5.2 | 4.5 | 2.3 | .897 |
| Partially | 27.8 | 25.4 | 23.6 | .784 | 18.3 | 12.8 | 13.0 | .355 |
| By name | 27.6 | 26.7 | 34.6 | .633 | 28.7 | 31.3 | 22.8 | .441 |
| No awareness | 35.3 | 34.8 | 33.8 | .961 | 47.9 | 51.5 | 61.9 | .387 |
Eleven of the 76 OHS organizations (14.7%) had provided consultations on support activities for their client enterprises. Ten of those activities were consultations on fitness for work in individual cases. When the client enterprises asked for advice about support activities from the OHS organizations (multiple answers allowed), the responses of the OHS organizations were to:
1. Decline (n=25, 24.5%; percentage of 102 answers),
2. Refer them to external facilities (n=33, 32.4%),
3. Cooperate with external facilities (n=24, 23.5%),
4. Provide support themselves (n=14, 13.7%), and
5. Others (n=6, 5.9%).
The details of referrals to external facilities and cooperation with external facilities are shown in Table 5. The most common external facility for both referrals and cooperation were prefectural occupational health total support centers, followed by centers for the promotion of health and employment support of industrial accident compensation hospitals. OHS organizations were significantly more likely to refer to prefectural occupational health total support centers than cooperate with them (40.0% vs. 24.0%, Chi-square test, p<0.05). There was no significant difference between referrals and cooperation for other external facilities, or between the three sizes of OHS organization in the ratio of referrals and cooperation with each type of external facility (Chi-square test, data not shown).
| External facility | Referral | Cooperation | Chi-square test | |||
|---|---|---|---|---|---|---|
| Cases | (%)a | Cases | (%)a | p-valueb | ||
| 1 | Prefectural occupational health total support centers | 30 | (40) | 18 | (24) | .036 |
| 2 | Centers for the promotion of health and employment support of industrial accident compensation hospitals | 5 | ( 7) | 9 | (12) | .262 |
| 3 | Counselling and support centers at hospitals | 4 | ( 5) | 7 | ( 9) | .347 |
| 4 | Counselling and support centers for intractable diseases | 3 | ( 4) | 7 | ( 9) | .190 |
| 5 | Support organizations for people with higher brain dysfunction | 3 | ( 4) | 7 | ( 9) | .190 |
| 6 | Support coordinator for juvenile dementia | 2 | ( 3) | 6 | ( 8) | .146 |
| 7 | Vocational rehabilitation centers for people with disabilities | 0 | ( 0) | 3 | ( 4) | .080 |
| 8 | Job placement offices | 3 | ( 4) | 3 | ( 4) | 1.000 |
| 9 | Job placement support offices for people with disabilities, intractable diseases, and other diseases | 1 | ( 1) | 0 | ( 0) | .316 |
| 10 | Labor and social security attorneys | 2 | ( 3) | 2 | ( 3) | 1.000 |
| 11 | Career development facilitators | 2 | ( 3) | 1 | ( 1) | .600 |
| 12 | Occupational health service organizations | 0 | ( 0) | 0 | ( 0) | NA |
| 13 | Labor unions | 1 | ( 1) | 2 | ( 3) | .600 |
| 14 | Labor bureaus, labor standards inspection offices | 7 | ( 9) | 3 | ( 4) | .190 |
| 15 | Prefectural medical associations, regional medical associations | 1 | ( 1) | 1 | ( 1) | 1.000 |
NA, not assessable because of insufficient data.
Nineteen OHS organizations proposed the opinions regarding the support activities by the OHS organization in question 7. Nearly half of them emphasized the importance of the consultation on support balancing treatment and occupational life for individual employees (9 organizations) and lectures on support balancing treatment and occupational life (6 organizations). Importance of information provision to client enterprises by account managers (4 organizations) and supporting client enterprises as part of the “Health and productivity management” introduced by Ministry of Economy, Trade and Industry (3 organizations) were presented as well.
This study has identified several major points concerning provision of support activities for balancing treatment and the occupational life of employees by external OHS organizations in Japan. More than 20% of the OHS organizations had already started to provide several kinds of support activities. The level of awareness about the guidelines for health and employment support in enterprises differed between OH specialists and account managers. The most common external facility used for both referrals and cooperation was a prefectural occupational health total support center. To promote their support activities, the OHS organizations required external support, like educational programs, for OH specialists, relevant members in client enterprises or health insurers, and managers in OHS organizations.
To our knowledge, there have been no previous studies about support activities by OHS organizations in Japan. However, studies have reported that fewer smaller enterprises apply flexible working arrangements, including hourly paid leave, shorter working hours, discretionary work, flextime, and working from home, for employees with work limitations related to illness10).
In this study, the third most common type of support required to promote support activities (following educational programs for OH specialists in OHS organizations and relevant members in client enterprises or health insurers) was educational programs for managers in OHS organizations. Among small OHS organizations, these educational programs were ranked second. In a questionnaire survey in Japan and the Netherlands11), OPs in both countries unanimously considered that employers are the key people for improving OHS, especially in SSEs. In a review on preventive occupational health and safety in SSE, Hasle and Limborg12) found that the owners were the dominant actors in relation to any health and safety changes made in SSEs. In this study, 34.6% of OHS organizations had fewer than 99 employees, so they are defined as small- and middle-sized healthcare corporations in Japan13). Many OH specialists might, therefore, consider that their managers are the key people to develop support activities by OHS organizations. We recommend that the NFIHO, which conducts continuous external quality control for its member OHS organizations, should take the initiative to promote the education of managers in OHS organizations.
When asked about external support required to promote their support activities (Table 3), 38.5% of OHS organizations cited information on support activities and facilities for examinees with findings from health check-ups or cancer screening. Three OHS organizations commented that “information should be provided to all examinees from health check-ups or cancer screening” in the optional comments column. However, providing information on support activities and facilities before any definite diagnosis might make examinees anxious. Kanagawa occupational health total support center has developed an information card and poster on support activities and facilities for cancer patients in the university hospitals in Kanagawa Prefecture, Japan. A similar card and posters for all examinees at health check-ups or cancer screening should be considered.
There was a significant difference in awareness of the guidelines between OH specialists and account managers. Board members of OHS organizations usually include both OH specialists like OPs and account managers. The annual report of the NFIHO in 2014 indicated that there were 243 internal and 222 external board members, excluding medical doctors, in 124 OHS organizations. Boards could be key in developing support activities among OHS organizations. If some account managers are promoted to the board, their knowledge about support activities could affect future choices by OHS organizations.
There was no significant difference by size of OHS organization in the proportion of each type of professions’ awareness of the guidelines (Table 4). It has been proposed that the OHS organizations should offer team support from OPs, OH nurses, and other OH specialists for SSEs14). The majority of enterprises with fewer than 50 employees do not appoint an OP from an OHS organization but might ask advice on OH issues from account managers in these organizations. Four of 19 respondents to the open-ended question (question 7) proposed the importance of information provision to client enterprises by account managers. The account managers could be key in delivering support activities for SSEs from OHS organizations. Suka et al. reported that awareness of the guidelines by employers and employees was lower in smaller enterprises10). They highlighted the necessity of a support system for small enterprises. However, we found no differences by organization size and suggest that broad education about the guideline should be offered to all OHS organizations, regardless of size.
The responses of the question about awareness of the guidelines were collected as the recollection of the OH specialists who answered the questionnaire. Therefore, these results are considered as an analysis of individual respondents’ opinion about the situation of their OHS organizations.
To promote their support activities, 23.0% of OHS organizations wished to seek advice from prefectural occupational health total support centers. These centers were also the most common facility cited for either referrals or cooperation when client enterprises asked OHS organizations for advice about support activities (Table 5). These centers were established in all 47 prefectures in 2003 to assist OPs, occupational health nurses, other OH specialists and organizations in the field of OH. The centers offer over-the-counter and on-site consultations, training for OH professionals, OH information provision (e.g., via websites, e-mails, and newsletters), public relations activities (e.g., seminars for employers), and OH research15). They have offered a consultation service for OH specialists for more than 15 years, and OH specialists in OHS organizations might find it easier to ask for advice from them than other external facilities. The centers also have provided facilitators to promote the balancing treatment and the occupational life of employees since 201715). One of the roles of these facilitators is to accommodate the balancing of treatment and the occupational life of individual employees without charge. OH specialists might consider they could entrust case management to these organizations, which may explain the higher levels of referrals than cooperation in this study. Because importance of the cooperation with centers for the promotion of health and employment support of industrial accident compensation hospitals and labor and social security attorneys was also emphasized in the guidelines2), OH specialists in OHS organizations should promote the cooperation with these external resources.
This study had several limitations. First, although the contents of the questionnaire for the study were carefully devised by experienced OH specialists, reliability and validity of the questionnaire were not fully verified. Repeated measurements combining verification with objective data, such as personnel information in the follow up studies, could strengthen our findings and the metrics of the questionnaire. Further investigations, including inductive as well as deductive methods, should be considered to understand the comprehensive promoters and barriers other than the educational programs for OH specialists in OHS organizations. Second, information about awareness of the guidelines for health and employment support in enterprises was provided by representatives of the OHS organizations. For accurate data, a further survey should be implemented among all OH specialists and account managers. Third, this study was conducted in 2018. The government has since launched a public information campaign, and awareness levels may have increased. The awareness level in this study should, therefore, be regarded as a baseline, at a point when support activities had only just begun. This kind of survey should be repeated to see the trajectory. Fourth, all OHS organization hired at least one OP, so we were unable to use any stratified analysis by the presence or absence of OPs. Fifth, the quality of the occupational health services of OHS organizations that are members of NFIHO may be higher than other OHS providers, so these results might be an overestimate. Sixth, the mixed-mode survey using a mail survey and face-to-face interviews with the same questionnaire in this study could lead to differences in the quality of responses. Although all organization answered closed questions in the same manner, the 10 OHS organizations that agreed to interviews provided a more detailed description in open-ended questions like question 7.
In conclusion, the questionnaire survey shows that many OHS organizations had already started to provide several kinds of support activities, and nearly half were planning to provide some support activities in the future. This included small OHS organizations. The most common provider of external support was prefectural occupational health total support centers. To promote their support activities, OHS organizations required external support, like educational programs for OH specialists, relevant members in client enterprises or health insurers, and managers in OHS organizations.
The authors acknowledge the OH specialists of OHS organizations for providing us with the information needed to conduct the study. We also thank Professor Masayuki Ikeda for assistance with statistical analysis that improved the manuscript, and Mister Tasuku Tadano the representative director of the National Federation of Industrial Health Organization, for support to implement the questionnaire survey of OHS organizations. The authors are also grateful to the administration and staff of the Kyoto Industrial Health Association and the Kitasato University for their support of this work. We thank Melissa Leffler, MBA, from Edanz (https://jp.edanz.com/ac) for editing a draft of this manuscript.
This work was supported by Ministry of Health, Labour and Welfare (Industrial Disease Clinical Research Grants: Grant Numbers 170401-02 and 200201-01).
The authors declare that they have no conflict of interests.
J.M. and H.E. conceived the ideas; J.M. and Y.N. collected the data; J.M. and F.O. analyzed the data; J.M. led the writing, and A.T. reviewed the manuscript and helped to draft the manuscript; All authors approved the final manuscript.
This article contains supplementary material (Appendix), which is available in the online version (doi: 10.1539/eohp.2022-0009-FS)
