2016 Volume 58 Issue 1 Pages 1-6
Objectives: The Japanese government launched a new occupational health policy called the Stress Check Program. This program mandates that all workplaces with 50 or more employees conduct the Stress Check Program for workers at least once a year. This article gives a brief overview and critical review of the program. Methods: We reviewed relevant laws, guidelines, and manuals, as well as the policy development process. The policy and the components of the program were compared using available scientific evidence and trends in the management of psychosocial factors at work according to the policies and guidelines of international bodies and European countries. Results: The process of program policy development was based on a discussion among employer and employee representatives, occupational health professionals, and mental health experts. Scientific evidence shows that mandated components of the program (i.e., feedback of stress survey results and physician's interview) may be ineffective. However, additional components recommended to employers, such as stress management skill provision and work environment improvement, in conjunction with the program may be effective in improving psychosocial stress at work. The Stress Check Program is unique compared with the global trend for psychosocial risk management because it focuses on the assessment of stress among individual workers. Conclusion: The new program may be effective in improving worker mental health by facilitating the psychosocial risk management approach in Japan. Concerns regarding the program include mass leakage of collected information, and possible disadvantages for workers labeled as having high stress.
(J Occup Health 2016; 58: 1–6)
The Japanese government launched a new occupational health policy called the Stress Check Program in order to screen for workers with high psychosocial stress in the workplace1). This program began with amendment of the Industrial Safety and Health Law in 2014, which became effective on Dec 1, 2015. The law mandates use of the Stress Check Program at least once per year in all workplaces in Japan with 50 or more employees. Employers shall not be informed the results of the Stress Check for individual employees without consent from these employees. Employers shall provide employees with a physician interview at their request. In this short review, we briefly describe this new program and critically review it from three viewpoints: (1) the policy development process, (2) relevant scientific evidence, and (3) global harmonization. We also discuss the impact and challenges of this program.
Relevant laws, guidelines, and manuals were reviewed to summarize the structure, procedure, and instruments of the Stress Check Program1). The process of policy development was reviewed based on published minutes, materials, and reports from a series of meetings and discussions relevant to the program. These meetings included the Committee on Health, Welfare and Labour of the Diet, the Health and Safety Division Committee meetings of the National Labour Policy Council, and ad hoc expert meetings focusing on the involvement of stakeholders in the process2,3). The effectiveness of the components of the program was critically evaluated with available scientific evidence in occupational health. From the perspective of global harmonization, the program was compared with the current trends in management of psychosocial factors at work according to guidelines set forth by the WHO4) and ILO5) as well as policies of selected European countries6–9).
The rationale for mandating the Stress Check Program is threefold1): (1) decreasing the risk of mental health problems in workers by increasing their awareness of their own stress through periodic surveys and feedback, (2) decreasing work-related stressors by analyzing group stress survey results and improving the work environment, and (3) preventing mental health problems by screening for high-risk workers and providing them with opportunities to have physician's interviews.
The new program requires an employer to (1) provide a survey of psychosocial stress for workers, (2) report to each individual worker his/her results, (3) arrange for an interview by a physician when requested to do so by a worker with high stress, (4) consider the opinions of the physician and improve working conditions for the worker, and (5) not take any action against the worker because he/she needs changes of his/her working conditions (see Fig. 1). In addition to these mandatory components of the program, employers are obligated to analyze the Stress Check data in relevant groups and to utilize the data to improve the psychosocial work environment. Furthermore, it is recommended that employers should provide information on stress coping and management and an opportunity for consultation with health professionals when workers receive the results of a Stress Check.
The flow of the Stress Check Program at the workplace based on the new legislation in Japan*. *Actors in parentheses.
Note: the translation was made by the authors, and that it is not an official translation.
The questionnaire used for the Stress Check Program assesses the following three components quantitatively (e.g., with a scale score): (1) psychological stressors (e.g., job demands), (2) psychological and physiological stress reactions (e.g., depression and anxiety), and (3) social support in the workplace (e.g., supervisor support). A workplace may choose its own survey. However, the Brief Job Stress Questionnaire (BJSQ) is recommended10); it is a questionnaire consisting of 57 items used to assess job stressors, psychological and physical stress reactions, and buffering factors, such as social support at work. A computer program is provided to create an individualized “stress profile” for workers. The manual of the program proposes criteria to define “high-stress” workers based on the BJSQ1). High-stress is defined as having the highest level of stress reaction (criteria A) or having a moderate level of stress reaction, along with having the highest job stressor (or lowest social support in the workplace) (criteria B). The criteria were developed based on expert consensus, and criterion B was included because the program is aimed at improving the psychosocial work environment as well as reducing psychosocial stress among high-stress workers.
Efforts to improve the psychosocial work environment are required in the Stress Check guidelines1). Employers need to have a physician (or other designated staff) analyze the Stress Check responses in sufficiently large groups (>10) and to consider the results in order to take relevant measures (e.g., decreasing work hours or demands). As of the date of enforcement of the amended law, no specification for the process has been given.
It is important to include all stakeholders in the development of a policy2,3). In 2010, the Minister of Health, Labour and Welfare released a program for screening of mental disorders in annual health examinations. The program was initially proposed for screening for workers with mental disorders in the workplace. However, an expert committee recommended developing a new program that would be separated from annual health examinations: a program primarily to monitor psychosocial stress of workers for the prevention of mental health problems at work. The National Labor Policy Council discussed this idea and submitted a proposal to revise the Law to the Minister, where union representatives to the Council took an active role in the development of this proposal. The proposed revision of the Law was submitted to the Diet for discussion, but was scrapped due to the dissolution of the House of Representative in 2012. The Labour Policy Council restarted the discussion of this program in June 2013. A series of hearings withexpert/professional associations were conducted between September and December 2013. Finally, the Labor Policy Council submitted a proposal to the Minister in December 2013 to amend the Law. The amendment was approved by the Diet in June 2014. At the same time, the Diet further concluded that the Stress Check Program should focus on the primary prevention of mental health problems, not the screening of mental disorders, and that this should be combined with improving the psychosocial work environment.
During the development process, professional societies were keen to respond to proposed ideas for the program. Most of these societies expressed concerns regarding screening of mental health disorders in the workplace. For instance, a task force of the Japan Society for Occupational Health (JSOH) stated that there was no clear need to mandate the program. The program should instead facilitate improvements in the psychosocial work environment. An association of seven psychiatry-related societies claimed that there was not enough scientific evidence regarding the effectiveness of screening of mental disorders in the workplace and that there were not enough experts. These voices were heard by the Labour Policy Council in the discussion. The President of the JSOH was also invited to speak at the Health and Labour Committee, House of Representatives, in June 2014. Thus, the development process included multiple stakeholders, such as employer representatives, union representatives, occupational health professionals, and mental health specialists. However, opinions from international leaders have not been heard in regard to this program.
The following two of the three components of the Stress Check Program are mandated: (1) decreasing the risk of worker mental health problems through periodic surveys and feedback of stress to workers, and (2) prevention of mental health problems by screening of high-risk workers and giving them a chance to have a physician's interview. However, there is only weak evidence available for the effectiveness of these two components. A previous randomized controlled trial (RCT) reported that feedback of stress survey results to workers was ineffective in reducing psychosocial stress11). A different RCT reported that online screening and personalized feedback on impaired work function and mental health were not effective in improving mental health or other behavioral outcomes among workers. However, only a small proportion of the intervention group received a subsequent psychoeducation for mental health12). There is no convincing evidence, or even expert consensus, indicating that a non-psychiatrist physician's interview and advice are effective in preventing mental health problems among workers. This would most likely depend on the skills and experiences of the physician in charge. Thus, it is not clear if these two mandated components of the program are effective.
On the other hand, there is a lot of evidence based on RCTs and other controlled trials for a semi-mandated action in improving psychosocial work environment, which also includes education and training of managers. At least one RCT showed that improving the psychosocial work environment was effective in reducing psychological distress among workers when it was combined with a worker participatory approach13). Other controlled trials reported similar findings as well. Several RCTs indicated that education and training of managers was effective in reducing stress among their subordinates14).
A recommended action in the program is providing stress management skills to workers with high stress, which has been known to be effective in reducing depression and anxiety among workers (c.f., meta-analysis by van der Kilink et al.15)). On the other hand, only one RCT reported that screening and early treatment of depression in the workplace was effective in reducing depression symptoms, or retaining work performance among depressed workers16). However, the program used in this RCT included many services provided by trained social workers and other experts. The U.S. Preventive Services Task Force does not recommend routine screening of depressive disorder for patients at a clinic when there is no support from a mental health expert17, 18).
The Stress Check Program newly introduced in occupational health in Japan is a unique approach to worker mental health. International bodies such as the WHO and ILO have proposed risk assessment and management of psychosocial factors at work as a major strategy for improving worker mental health4, 5). European countries such as the United Kingdom6) and the Netherlands7) use this approach, and the Psychosocial Risk Management Excellence Framework (PRIMA-EF) proposed a cross-European standard for psychosocial risk assessment and management at work8, 9). This approach focuses on the psychosocial work environment, but not on psychosocial stress among individual workers. As part of psychosocial risk assessment at work, the psychosocial work environment and psychological distress of workers may be assessed using a questionnaire. However, in Europe, such a survey is often conduced anonymously, and its report includes only summarized group-based indicators (such as averages) based on the survey. Psychosocial risk assessment can also be done with other methods, such as site visits, direct observation, and interviews with workers. The uniqueness of the Stress Check Program in Japan is that it focuses on psychosocial stress of individual workers. This focus surely came from the initial intention of screening of mental disorders in the workplace. It is also attributable to the fact that health examinations are provided to individual workers in Japan, which is also unique in the world. It may further reflect a culture of paternalism of the occupational health system in Japan, in which employers are expected to protect employees' health and welfare like their father19).
The Stress Check Program is the first mandated policy in the history of mental health in workplaces in Japan. However, the mandated components lack scientific evidence indicating that they are effective. Other components that are either required or recommended, such as work environment improvement and the provision of stress management skills to workers with high stress, may be effective in reducing psychosocial stress among workers. While the program is an individual-oriented approach in principle, it may facilitate the psychosocial risk management approach to improve the psychosocial work environment, which is a current global standard approach in occupational health.
There is some uncertainty concerning the program's effectiveness in promoting worker mental health. First, no specified procedures are defined for some of the components of the program. In particular, improvement of the work environment, which is one of the evidence-based measures in this program, is not adequately detailed. However, the PRIMA-EF standard provides a clear description of psychosocial risk management procedure8, 9). The cooperation of workers is essential to make the program effective, but there is no obligation described in the law indicating that workers have to take part in the program. Workers would not participate in the program if there were a risk of leakage of their responses to a stress check questionnaire. It is known that massive leaks of private information collected by companies occur frequently in our information-based society. It has been pointed out that some workers may be treated in a disadvantaged way by a thoughtless employer because of the worker's responses in the stress check questionnaire. Close monitoring and evaluation of the Stress Check Program is needed.
The Stress Check Program newly introduced in occupational health in Japan may be effective in improving worker mental health if it is combined with evidence-based approaches for the prevention of stress. Close nationwide monitoring of the Program is needed to evaluate its impact on worker mental health and address remaining concerns about it.
Acknowledgments: This article was prepared with support from a Health and Labor Sciences Research Grant (H27-Rodo-Ippan-004) from the Ministry of Health, Labour and Welfare, Japan. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.