Challenges in acquiring support for employee treatment and work balance in small- and medium-sized enterprises in Japan during COVID-19

Abstract

Objectives: This study aims to elucidate a few of the challenges experienced by employees of small- and medium-sized enterprises (SMEs) in Japan while attempting to acquire support to strike a balance between medical treatment and work during the novel coronavirus disease 2019 (COVID-19) pandemic. Methods: This descriptive qualitative study was conducted from February to March 2022 on SMEs. Semi-structured online interviews were conducted with 11 SMEs. Data collection focused on two key areas: (1) changes and challenges in medical treatment and health support at work during the COVID-19 pandemic, and (2) ideas and strategies for coping with the crisis. This study was approved by the Research Ethics Committee of the Japanese Red Cross College of Nursing. Results: Thematic analysis produced five main themes: difficulties in access to health services, rapid spread in teleworking, necessity of various responses depending on the situation, anxiety, and no major changes. Conclusions: SMEs in Japan faced difficulties in implementing regular support to help employees balance between medical treatment and work during the COVID-19 pandemic. In contrast, the incorporation of information and communication technology to stem the spread of the COVID-19 infection has advanced to continue to work for employees with a high risk of infection.

Introduction

Small- and medium-sized enterprises (SMEs) play a major role worldwide by contributing a vast sum of money to the economic development of countries. The same is true for SMEs in Japan, who are the driving force behind manufacturing and key to revitalizing regional economies¹⁾. Significantly, 98.8% of companies in Japan are SMEs, and 74.7% of all employees work for SMEs²⁾. Therefore, developing measures to protect the safety and health of workers in SMEs will support not only workers and workplaces but also the economy of Japan as a whole. However, SMEs report higher rates of occupational accidents than those of large enterprises³⁾. Employee health in relation to maintaining a good work–life balance for managing or preventing disease and mental health problems is also important. A domestic survey conducted in Takahashi reported that the largest number of cases compensated by the industrial accident compensation insurance (IACI), which are related to brain and heart diseases, occurred in workplaces with 10–29 employees⁴⁾. Approximately half of IACI-compensated cases related to mental disorders, including karojisatsu (overwork-related suicide due to mental disorders), occurred in businesses with less than 50 workers^5,6). Despite this situation, small enterprises with less than 50 full-time workers are not obliged to appoint an occupational physician under the Industrial Safety and Health Act, and the lack of adequate industrial health services is an issue^7,8).The survey was instrumental in demonstrating the need for full access to health services to support employees in SMEs with performance, mental health, and managerial issues.

Support for employees undergoing health challenges is important for facilitating sustainable employment and quality of working life. The Japanese government published a guideline and action plan on support for workers with diseases to help them balance between sustainable medical treatment and work in 2016⁹⁾ and 2017¹⁰⁾. These systems were established such that even if employees develop a disease during employment, they can continue to receive medical treatment while working. According to these systems, employers should provide workers with cancer, stroke, or other physical diseases with appropriate employment considerations to balance work and medical treatment in collaboration with their attending physicians. However, the knowledge about and dissemination of these systems were insufficient. According to a previous survey, only 6% of workers and 15% of the management were aware of efforts to support the balance between medical treatment and work¹¹⁾. Another survey in 2021 found that 41.1% of enterprises exerted efforts toward these measures¹²⁾. However, this percentage is slightly lower than that of a previous survey (55.8% in 2018), and the proportion of enterprises who are exerting such efforts has declined with the decrease in the size of enterprises¹³⁾.

The novel coronavirus disease 2019 (COVID-19) pandemic suppressed socioeconomic activities and adversely impacted SMEs with a weak management foundation^14,15). Many SMEs experienced a significant impact on the safety and health of employees¹⁶⁾. However, no studies reported the influence of COVID-19 on support for balancing between medical treatment and work in SMEs. Therefore, this study aims to elucidate the changes and challenges in supporting the balance of medical treatment and work in SMEs during the COVID-19 pandemic.

Methods

Study design and participants

The study adopted a descriptive qualitative research design because it was considered most appropriate for describing the views of workers in SMEs on health support provided during the COVID-19 pandemic¹⁷⁾. The participants were recruited from 22 SMEs that published examples of their efforts to support the balance between work and treatment on the “Chiryo to shigoto no ryoritsu shien nabi (Work–Treatment Balance Support Navi)” website created by the Ministry of Health, Labour and Welfare¹⁸⁾. This portal website included more than 90 good examples of various sizes of industries and enterprises out of which we selected and invited 22 enterprises with less than 300 employees to participate in the research. A total of 11 SMEs agreed to participate in the study after obtaining informed consent. Interviewees were selected from each SMEs as the person in charge of employee health through company initiatives.

Data collection methods

The researchers conducted in-depth semi-structured interviews using an interview guide. This type of interview is useful for exploring complex behaviors, opinions, and collecting information from a diverse range of experiences¹⁹⁾. Interview data were collected once per person, and each interview lasted for approximately 1 hour. Basic information about the participants and their workplaces was collected during the interviews using a fact sheet. The interview guide consisted of two key questions. The first pertained to the changes and challenges faced by SMEs during the COVID-19 pandemic, especially in terms of support for balancing medical treatment and work. The second referred to ideas and strategies for coping with the crisis. The interviews were conducted online using the videoconferencing software Zoom (Zoom Video Communications, Inc., San Francisco, CA, USA), from February to March 2022. Interview data was recorded using an integrated chip recorder with the consent of the participants. The researchers took handwritten notes.

Data analysis

The study conducted data analysis using descriptive qualitative methods²⁰⁾. Verbatim transcripts of the interviews were carefully reviewed. According to the research objectives, the study extracted a code representing what the participants said, and the main codes were categorized. While finding commonalities, the level of abstraction was increased in comparing based on the differences and similarities of codes, and categories and subcategories were extracted. In the process of analyses, three concurrent flows of activity, such as data condensation, data display, and occlusion drawing/verification, were conducted, as suggested by Miles and Huberman²⁰⁾.

Guba and Lincoln’s criteria were applied to ensure trustworthiness: (a) credibility: method and investigator triangulation were conducted, such as multiple qualitative data collection (interview transcripts, quotations, and researcher notes) and data analysis by two different researchers; (b) transferability: thick description of the participants and the research process were provided; (c) dependability and confirmability: the records of the research path were kept throughout the study as an audit trail; and (d) reflexivity: reflexive notes were recorded in data collection and analysis²¹⁾.

Ethical considerations

The Research Ethics Committee of the Japanese Red Cross College of Nursing approved the study (2021-065). The participants were informed about the objective, purpose, methods, and ethical considerations of the study in writing and verbally. The participants provided informed written consent.

Results

Characteristics of the participants

Table 1 presents the characteristics of the companies and interviewees. Construction and manufacturing companies accounted for 50% of the organizations interviewed, and half of them had less than 50 employees. Approximately 60% of the participants had contracts with occupational physicians.

Table 1. Company profile and characteristics of the participants

		A	B	C	D	E	F	G	H	I	J	K
Company profile
Industry		Construction	Transportation	Construction	Finance and insurance	Manufacturing	Education	Construction	Others	Manufacturing	Others	Construction
Years of establishment		52	48	69	48	15	65	64	69	99	93	33
Head office location		Hokuriku	Shikoku	Hokuriku	Tohoku	Tokai	Kyushu	Kyushu	Chugoku	Shikoku	Kyushu	Chugoku
Employees		42	64	200	20	15	15	125	249	232	48	46
Number of employees on sick leave (last 5 years)		0	1	5	3	2	2	2	2	5	0	1
Contracts with an occupational physician		Yes	No	Yes	No	Yes	No	Yes	Yes	Yes	Yes	No
Coordinatora in your company		No	No	Yes	Yes	No	No	Yes	Yes	No	Yes	No
Interview time (min)		29	53	52	35	31	59	59	32	48	44	40
Participants	Position	Person in charge of personnel and labor affairs	Managerial executive	Person in charge of personnel and labor affairs	Managerial executive	Person in charge of personnel and labor affairs	Managerial executive	Person in charge of personnel and labor affairs	Person in charge of personnel and labor affairs	Person in charge of personnel and labor affairs	Person in charge of personnel and labor affairs	Person in charge of personnel and labor affairs
	Years of experiences	26	23	38	20	5	13.5	15	18	14	22	8
	Age	50s	50s	50s	40s	50s	50s	50s	40s	50s	40s	30s
	Gender	Male	Male	Male	Female	Female	Male	Female	Female	Female	Male	Female

Note: ^a Coordinator of health promotion and employment support

A total of 23 employees had taken a sick leave within the past 5 years in 11 SMEs. Malignancies were the most common diseases (n=7, 30.4%) followed by mental health disorders (n=5, 21.7%). Other health issues include connective tissue diseases, musculoskeletal disorders, and infectious diseases (n=2 for each, 8.7%).

Six SMEs reported on the content of support for the balance between medical treatment and work, which included the introduction of a flexible work style system (ie, trial and short/staggered work, telecommuting, and paid leave by the hour). Five SMEs promoted in-house initiatives by receiving support from the prefectural Occupational Health Support Center. Out of all SMEs, four contracted compensations through private insurance (Group Long-Term Disability and cancer insurance), three formulated and announced internal policies regarding support for work–treatment balance, two established consultation desks and persons-in-charge of support, and two secured replacement personnel (part-time workers and extension of retirement age).

Changes and challenges in medical treatment and health support at work during COVID-19 pandemic

The study identified a total of five categories and 11 subcategories. The five categories were difficulties in access to health services, rapid spread in teleworking, necessity of various responses depending on the situation, anxiety, and no major changes (Table 2).

Table 2. Changes and challenges to the support for treatment-work balance

Category	Sub-category	Responses/ideas
Difficulties in access to health services	Refraining from going to the hospital (n=5) Difficulties in visiting and accessing hospital due to restrictions (n=4)	Devise for continuing medical treatment and ensuring opportunities to have annual health checkups Conduct online interviews and telephone calls with inpatient employees Assign a qualified coordinator of the health promotion and employment support as a point of contact
Rapid spread in teleworking	Reducing various risks by using teleworking when returning to work (n=6) Having progressed teleworking rapidly (n=6)	Improve the sharing of information to prevent lack of communication during teleworking Keep frequent opportunity for interview with employees
Necessity of various responses depending on the situation	Changing necessary measures and information according to each region (n=7) Having to change responses according to individual workers’ health conditions (n=10)	Decide an information disclosure policy in accordance with administrative policy of COVID-19 Conduct information collection and sharing considering each regional infection situation Pay particular attention to prevent infection for sick employee
Anxiety	Having various anxiety among many workers (n=6) Occurrence of unexpected accidents because of workers felt tensed (n=2) Being afraid of discrimination because of COVID-19 (n=3)	Recommend vaccinations for employees actively Prepare antigen test kit in the workplace Follow up carefully in case of COVID-19
No major changes	No major changes for support provided (n=4) Remaining unchanged health output and outcomes (n=4)	N/A

COVID-19, novel coronavirus disease 2019.

( ) number of the SMEs

First, we described each of the five categories and the narrative data. Subsequently, we presented the types of measures taken for each of the four categories, excluding the category, no major changes.

Difficulties in access to health services

This category comprises two subcategories. First, employees who require regular hospital visits refrained from going to the hospital due to fear of infection. Another aspect was the difficulty of direct contact with doctors and inpatients due to restrictions on visiting medical institutions due to COVID-19.

With the spread of COVID-19, employees with chronic diseases that require regular hospital visits refrained from seeing a doctor for fear of infection risk. The types of diseases among these employees included lifestyle-related ones with a high risk of severe infection, such as diabetes and dyslipidemia, as well as cancer patients like leukemia, who were taking drugs that suppress their immune systems, making them susceptible to infectious diseases.

Specific details of difficulty in accessing hospitals included cases in which clusters occurred in the hospitals, medical institutions were temporarily closed, clinics were closed, and face-to-face contact with inpatients were restricted for preventing spread of infection.

“It was just after the outbreak of COVID-19, so even though we were sometimes able to talk on the phone, it was a time when not only company staff but also family members could not visit the hospital. I heard that due to COVID-19, he could not visit the hospital frequently for rehabilitation. We heard that he wanted to return to work; therefore, we asked him to obtain a medical certificate from his doctor. However, it was very difficult to get in touch with the hospital and doctor, saying that they were busy dealing with COVID-19 patients and that it was difficult to respond to the phone.” (Company G)

In case of difficulties in accessing medical institutions, such as sick employees refusing to go to the hospital for fear of getting infected, persons-in-charge in SMEs provided advices to them by receiving 2-month medicine. In other cases of difficulties of visiting hospitalized employees because of visiting restrictions of hospitals, they conducted online interviews or telephone calls with inpatients and used coordinators of health and employment support.

Rapid spread in teleworking

Four of the SMEs indicated the use of teleworking, which has spread rapidly during the COVID-19 pandemic. However, SMEs that introduced telework prior to COVID-19 were few. Initially, they introduced teleworking due to COVID-19 for other reasons and not for supporting the balance between medical treatment and work. For example, Company G introduced telework for parents who needed to take care of small children at home due to the closure of elementary and nursery schools at the time. In Companies K and J, work from home was prioritized for pregnant women and employees with chronic diseases. A few SMEs established a work-at-home system for employees with close contact with patients with COVID-19 and were required to undergo home quarantine. SMEs and occupations that can introduce telework were utilized in the case of returning to work, because the infection risk can be reduced by decreasing commuting and contact opportunities at the workplace.

“There are several people in our company who have chronic diseases, but we have asked them to switch to telework because they are at a high risk of becoming seriously ill if infected. We prepared the network equipment and set up a teleworking system. Employees who have diseases are now able to work full-time instead of working short hours by using telework, and she is happy too.” (Company D)

For teleworking workers with diseases, Company D mentioned that they attempted to hold morning meetings even if the workers were remote and frequently shared information to prevent a lack of communication due to teleworking. Moreover, they conducted an interview, including personnel evaluation once every 3 months, to check the physical condition of the employees.

Necessity of various responses depending on the situation

This category consists of two subcategories: changing necessary measures and information according to each region and having to change responses according to individual workers’ health conditions. For companies with branch offices across the country and with employees that work across prefectures, the SMEs faced many challenges and difficulties in responding to COVID-19, in which the number of people with the infection and measures for preventing the spread of the infection differed across regions. For example, in large urban areas, such as Tokyo and Osaka, a state of emergency was declared due to the rapid increase in the number of people with infection, and socioeconomic activities were suppressed. Therefore, SMEs had to consider measures to prevent the spread of the infection, including restrictions on coming to work, social movement, and business trips beyond the home prefecture, while also considering regional characteristics. The need to disseminate information according to each situation also emerged.

Taking such measures was also important according to the circumstances of individual employees. Companies A and C cited that particular attention was paid to prevention of infection, such as job assignment and the elimination of direct contact with external customers for their sick employees in the case of COVID-19 spread.

“The company has branch offices throughout the country. Since each municipality has different rules for responding to COVID-19, we first collected information on the response of each local government and shared the collected information throughout the company. For example, employees with cancer are asked to take particular care such as wearing appropriate masks and thorough hand disinfection. We also strongly recommend that you quit smoking.” (Company C)

Company F decided on an information disclosure policy in accordance with the administrative policy regarding COVID-19, because it is necessary for infection measures according to region and individual. Moreover, Company C conducted information collection and sharing to consider each regional situation with changes in the infection phase.

Anxiety

This category comprises three subcategories: severe anxiety among many workers, unexpected accidents, and being afraid of discrimination due to COVID-19. Vague anxiety about COVID-19 was observed in the workplace and among workers. In Company B, which transports packages to various regions, the atmosphere of business partners became tense overall, and unexpected accidents occurred in unusual situations, such as when workers felt overwhelmed or tense during the COVID-19 emergency. Typically, employees would be able to easily explain to business partners that they would like to wait and that they would take time, but they were overwhelmed by the general atmosphere and were unable to do so.

The interviewees reported that employees spent their working lives with a vague fear of infection. Company H said that the employees with chronic illnesses were afraid of COVID-19. Evidently, if an employee was infected with COVID-19, the risk of advancing in severity was high. In this case, they were afraid that being infected would cause trouble for the company. Moreover, the results of a stress check demonstrated that many employees experienced anxiety in Company J.

“Last year’s stress check resulted in a high-stress reaction regarding ‘anxiety.’ I consulted an occupational physician regarding these results. The occupational physician told us that all workplaces had the same tendency in the stress check this time. I felt that the results of the stress check were also affected by COVID-19.” (Company J)

In the case of anxiety about COVID-19 in employees and the workplace, many company responses actively recommend vaccination, prepare antigen test kits, and establish a support system for workers infected with COVID-19.

No major changes

The previous four categories described the impacts of and changes due to COVID-19, but the final category denotes that the COVID-19 pandemic did not influence the support for the balance between medical treatment and work in SMEs. The participating companies took various measures to strike a balance between medical treatment and work, such as formulating internal rules and building support systems, even prior to the COVID-19 crisis. These measures and responses have been in place since COVID-19, and they have not disappeared with the increase in the number of infected cases. Companies A and E cited that no major changes were made in the contents of support they provided. Alternatively, Company F, which is an educational support service company, established flexibility shift systems, such as “taking a break whenever they wanted to,” prior to COVID-19. In these shift systems, substitute personnel are always secured to perform the tasks of employees who are absent due to illness or personal matters. By operating this system, Company F said it left them without damage or changes in their business plan even if there were sudden absences due to COVID-19.

“I think overall awareness and initiatives such as health checkup rates remain unchanged. Whether people become more conscious of their health varies from person to person. People who care about their health are very careful, but there are people who do not care. It is important that it is always necessary to send a top management message that we want to cherish the health of each employee.” (Company A)

Discussion

This study explored a few challenges in supporting the balance between medical treatment and work in SMEs during the COVID-19 pandemic. Although we discussed different recruitment strategies, we decided to recruit participants via a good practice website. Hence, the results were subject to selection bias because the interviewees were companies that prioritized employees’ health and well-being prior to the COVID-19 pandemic. In addition, the results focus on companies that have already introduced support to balance medical treatment and work.

As a result of the interview survey, persons-in-charge in SMEs experienced difficulties and challenges in maintaining a sense of distance from medical institutions, such as refraining from visiting medical institutions due to difficulty in accessing them and lacking opportunities to meet attending physicians when they return to work. Even SMEs that had good cooperation with medical institutions by utilizing external resources and internal staff, such as coordinators of health promotion and employment support, access to medical institutions is clearly difficult due to COVID-19, which influences the provision of support for the balance between medical treatment and work. Okawara et al. reported that approximately 4% of workers experienced interrupted medical care during the COVID-19 pandemic²²⁾. Interruption of medical care can adversely influence the management of chronic diseases and delay the detection and treatment of new diseases²³⁾. To promote support for the balance between medical treatment and work, ensuring regular hospital visits is important for workers with diseases⁹⁾, and cooperating and exchanging information with medical institutions are necessary for companies when employees return to the workplace^24,25,26). However, SMEs already have various limitations, such as time, cost, and resources, for promoting occupational health before the COVID-19 pandemic⁸⁾. Therefore, SMEs tended to experience substantial anxiety and stress, including concerns related to finances, the long-term viability of their business, and the unwillingness of employees to return to work, because of their vulnerable economic basis compared with large-sized enterprises²⁷⁾. These issues became more pronounced among SMEs during the COVID-19 pandemic.

Previous research indicated that 79.9% of companies that undertook the support of the balance between treatment and work experienced difficulties and issues¹³⁾. Out of these, 13.2% of companies cited difficulty in coordinating with the primary care physicians of workers¹³⁾. Compared with large companies that employ full-time occupational physicians and health nurses, the results suggested that barriers for the balance between treatment and work due to difficulty in accessing medical institutions in SMEs are an urgent issue. Therefore, the interviewed companies have devised measures, such as recommending online or telephone medical consultations and coordinating with persons-in-charge of personnel and labor affairs. In particular, employing full-time occupational health specialists is rare for SMEs. Thus, ensuring coordinators of health promotion and employment support and utilizing them as contact persons for cooperation with medical institutions and external resources are important initiatives^16,27). It might be needed to particularly support SMEs for continuous employment due to various impacts of the COVID-19 pandemic.

In addition to these issues, certain situations influenced support for the balance between treatment and work, such as vague anxiety regarding COVID-19. The International Labor Organization indicated that work arrangements and conditions are considerably changing due to the COVID-19 crisis, introducing new psychosocial challenges to the health and well-being of workers²⁸⁾. As suggested by recent studies, employment, regardless of company size, provided a better outcome for mental health situations compared with unemployment during the COVID-19 pandemic^29,30).

In contrast, cases emerged in which even employees with high risks of infection or serious illness could continue to work due to the spread of teleworking. For occupations conducting telework off site, the risk of infection can be reduced through decreased commuting and contact opportunities at work³⁰⁾. Another possibility is that the burden of commuting and working full-time can be reduced. Although scholars pointed out many advantages of teleworking during the COVID-19 pandemic³¹⁾, certain disadvantages were also observed, such as increased stress due to mismatch between telecommuting preference and frequency²⁹⁾, reduced social support³²⁾, and increased alcohol consumption³³⁾. Therefore, taking advantage of the benefits of teleworking is necessary to support the balance between treatment and work, while also identifying any difficulties with new work arrangements, gaining opportunities for communication, and ensuring that regular lifestyle habits are not hindered.

About half of companies cited that no change occurred in the support for the balance between treatment and work at SMEs during COVID-19. These results suggested that employers’ perceptions of prioritizing employee health remained unchanged during the COVID-19 pandemic. Alternatively, prioritizing employee health might become even more important with the spread of COVID-19. Previous research showed that employees working in companies with several COVID-19 measures have maintained their mental health situations³⁴⁾. Employers’ policies and attitudes toward employee health might increase safety and health culture in the workplace. Therefore, it was suggested that SMEs that focused on promoting employee’s health before the COVID-19 pandemic, all employees, including sick employees, could continue to work safely and healthy in the workplace.

This study has several strengths and limitations. The results may be due to selection bias because participants were selected from good practice websites for companies introduced to support work–treatment balance. Moreover, we understand the fact that qualitative research is not aimed at representative sample sizes. However, the sample in the present study could present bias, because it did not consider the industry type. Therefore, the practical utilization of the results to reflect individuality is likely limited and needs to be verified in future studies. Further research may be needed on various occupational groups, such as retail, wholesale, and medical and welfare. However, the interview data are rich in information based on experiences, particularly with regard to the diverse perceptions of the interviewees, and significantly contribute to the current discussion.

Conclusions

This study presented the challenges in supporting the balance between medical treatment and work in SMEs during the COVID-19 pandemic using a qualitative research approach. Some SMEs responded that no change occurred in the health support for employees during COVID-19. Conversely, they experienced certain difficulties in access to hospitals and the prevalence of anxiety in the workplace. In contrast, even employees with a high risk of infection or serious illness could continue to work in certain cases due to the spread of teleworking. The results suggest that SMEs that supported the employee health system prior to the COVID-19 pandemic are working to support it while adapting to the spread of infection and incorporating information and communication technologies, which has advanced due to COVID-19.

Acknowledgments

The authors would like to thank the participants. This work was supported by JSPS KAKENHI (Grant Number 21H03275).

Author contributions

EY designed the study and drafted the manuscript. HA collected and analyzed the data in collaboration with the EY. NN, MS, MI, SS, and MT supervised and peer-critically reviewed the results of the analyzed data. All authors have read and approved the final manuscript.

Data profile

Qualitative data are not available for sharing because they include personal information

Conflict of interest

The authors declare that there are no conflicts of interest.

Sources of funding

This work was supported by JSPS KAKENHI (Grant Number 21H03275).

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