2023 Volume 259 Issue 2 Pages 143-150
Telemedicine has significant potential for helping workers access medical treatment. To improve workers’ access to telemedicine, it is important to analyze current utilization rates and influencing factors. Therefore, the purpose of this study is to evaluate the associations between occupational factors and telemedicine use. A 1-year follow-up study of 4,882 full-time workers receiving regular treatment in Japan was conducted from December 2020 to December 2021. Occupational factors associated with the use of telemedicine were evaluated by multivariate logistic regression analysis. In total, 191 participants had experience of using telemedicine (3.9%). The most common comorbidity was hypertension (37.0%), followed by back pain and arthritis (19.8%) and depression and psychiatric disorders (14.5%). Managers and executives [adjusted odds ratio (aOR) = 1.92, 95% confidence interval (CI): 1.68-3.43, P < = 0.026], finance industry workers (aOR = 2.61, 95% CI: 1.24-5.49, P = 0.011), and individuals with experience of teleworking (aOR = 2.08, 95% CI: 1.52-2.85, P < 0.001) were more likely to use telemedicine. Telemedicine usage was least common among workers aged 50-59 years (aOR = 0.35, 95% CI: 0.22-0.57, P < 0.001) and those with long working hours (≥ 9.0 hours/day) (aOR = 0.59, 95% CI: 0.38-0.93, P < 0.022). The utilization rate of telemedicine in Japan is still low. This study identified occupational factors related to the use of telemedicine, such as worker’s age, employee status, working hours, and experience of teleworking. Our findings suggest that flexible work arrangements could promote widespread use of telemedicine.
The coronavirus disease 2019 (COVID-19) pandemic has dramatically changed the nature of medical care, including telemedicine. Lockdowns and “stay at home” recommendations have made it difficult for physicians to continue to offer patients traditional face-to-face medical care (Baum et al. 2021). To cope with this problem, the use of telemedicine was promoted worldwide (World Health Organization 2020). In Japan, telemedicine was officially approved as a medical option in 1997, but for a long time its use was limited to special situations such as the remote island setting (Kadoya et al. 2020). However, during the COVID-19 pandemic, the Japanese government promoted wider use of telemedicine.
Despite the efforts of the government, telemedicine is not in widespread use in Japan, even in the era of the COVID-19 pandemic. Miyawaki et al. (2021) reported that the use rate of telemedicine in Japan increased from 2.0% in April 2020 to 4.7% in September 2020. Obstacles to telemedicine provision reported by physicians include legal restrictions, fixed investment costs, technological issues, privacy concerns, and limited capacity to gather information compared with face-to-face consultations (Scott Kruse et al. 2018; Shimizu et al. 2021). In terms of limiting patient factors, belonging to an ethnic minority group, residing in a rural area, low education level, and elderly status have all been cited (Lam et al. 2020; Yang et al. 2021). The key to widespread use of telemedicine, as with other medical services, is the development of communication tools and maturation of people’s understanding of the technology (Ishimaru et al. 2021). It is also important to develop a legal framework for providing telemedicine (Kinoshita et al. 2020).
Telemedicine has the potential to help workers access medical treatment. For example, if a patient is unable to visit the hospital due to busy work schedule, telemedicine will make it easier for them to receive medical care. To improve worker access to telemedicine, it is important to analyze their utilization characteristics. In Japan, patients with higher education and income levels, and those residing in urban areas, are more likely to use telemedicine (Miyawaki et al. 2021). However, few reports have investigated the relationship between occupational factors and telemedicine. Therefore, the purpose of this study is to evaluate the associations between occupational factors and telemedicine use among Japanese employees.
We retrieved data from the Collaborative Online Research on the Novel-coronavirus and Work (CORoNaWork) project. In brief, a 1-year follow-up study was conducted, which enrolled full-time workers aged 20-65 years who registered with an online survey company. Details of the study population were published elsewhere (Fujino et al. 2021). In December 2020, the CORoNaWork project baseline survey enrolled 27,036 participants, 18,560 of whom completed the 1-year follow-up survey (response rate = 68.6%). We excluded participants who indicated that they were not receiving regular treatment, in either the baseline (n = 11,943) or follow-up (n = 1,735) survey. A total of 4,882 participants who were receiving regular treatment were included in the analysis.
This study was approved by the Ethics Committee of the University of Occupational and Environmental Health, Japan (approval No. R2-079). Informed consent was obtained from all participants prior to completion of the online self-administered questionnaire.
Use of telemedicineThe outcome measure was experience with telemedicine, which was determined during follow-up via the following question: “Have you regularly used an online medical service in the past year for any illnesses?” The response options were “yes” and “no”.
Independent variablesThe independent variables were extracted from the baseline data. On the basis of previous studies (Jaffe et al. 2020; Miyawaki et al. 2021) and discussions with the expert project members (see Acknowledgments), the following variables were defined as occupational factors or covariates: age, sex, marital status, education, work area, annual household income, employment status, industry, company size (number of employees), working hours, teleworking, and comorbidities. The age groups were 20-39, 40-49, 50-59, and 60-65 years. We requested zip codes for the places of work (Hokkaido, Tohoku, Kanto, Chubu, Kansai, Chugoku/Shikoku, Kyushu/Okinawa, or unknown). Industry was classified as public service, manufacturing, information technology, retail and wholesale, food/beverage, medical and welfare, finance, construction, or other. Employment status was classified as civil servant, permanent employee, manager or executive, dispatched or contract worker, self-employed, or other. Company size (number of employees) was classified as 1-9, 10-49, 50-999, or ≥ 1,000. Working hours were categorized as ≤ 7.5, 8.0-8.5, or ≥ 9.0. Telework was evaluated in a dichotomous manner. Regarding comorbidities, we asked the respondents whether they receive regular treatment; those who answered “yes” were required to identify the specific disease via a multiple choice item.
Statistical analysisMultiple logistic regression analysis was performed to assess the associations between occupational factors and the use of telemedicine. As the dependent variable, the prevalence of new and existing telemedicine users was analyzed cross-sectionally. The multivariate model included age, sex, marital status, education, work area, and annual household income. The results are presented as adjusted odds ratios (aORs), 95% confidence intervals (CIs) and two-sided P values. P < 0.05 was considered statistically significant. All statistical analyses were performed using Stata/SE 16.1 software (StataCorp, College Station, TX, USA).
A total of 4,882 participants were eligible for the analysis. Table 1 shows the general characteristics of the study participants. In total, 191 participants had experience using telemedicine (3.9%). The 50-59 years age group was the largest (43.3%), and the 40-49 (23.3%) and 60-65 (22.9%) years age groups were almost equal in size. Approximately two-thirds of the participants were male (65.2%), more than half were married (58.7%), and more than half graduated from university or graduate school (51.3%). The industry sector employing the largest proportion of participants was manufacturing (16.7%). The largest employment status category was permanent employee (38.8%). More than 60% of the participants worked for companies with ≥ 50 employees, and the 50-999 employees company size category contained the largest proportion of participants (34.6%). More than half of the participants (55.4%) worked 8-8.5 hours per day. A quarter of the participants teleworked (24.3%). The most frequent comorbidity was hypertension (37.0%), followed by back pain and arthritis (19.8%) and depression and psychiatric disorders (14.5%). There were significant differences in age (P < 0.001), as well as telework (P < 0.001), hypertension (P = 0.009) and diabetes (P = 0.017) prevalence, between telemedicine users and non-users.
Table 2 presents the occupational factors associated with the use of telemedicine. Compared with participants aged 20-39 years, the rate of telemedicine use was significantly lower among those aged ≥ 40 years, especially in the 50-59 years group (aOR = 0.35, 95% CI: 0.22-0.57, P < 0.001). Participants who were married were more likely to use telemedicine than those who were single (aOR = 1.77, 95% CI: 1.19-2.63, P = 0.005). The rate of telemedicine use among financial industry workers was significantly higher than among public service workers (aOR = 2.61, 95% CI: 1.24-5.49, P = 0.011). Regarding employment status, managers and executives had higher odds of telemedicine use compared with civil servants (aOR = 1.87, 95% CI: 1.08-3.43, P = 0.026). Participants who worked > 9 hours/day were significantly less likely to use telemedicine than those who worked < 7.5 hours/day (aOR = 0.59, 95% CI: 0.38-0.93, P = 0.022). Teleworkers were about twice as likely to use telemedicine than those who did not engage in teleworking (aOR = 2.08, 95% CI: 1.52-2.85, P < 0.001).
General characteristics of the study participants.
*Derived from the chi-square test.
Occupational factors associated with the use of telemedicine.
*Adjusted for age, sex, marital status, education, workplace area and annual household income.
OR, odds ratio; CI, confidence interval.
This study identified occupational factors related to the use of telemedicine, such as worker’s age, employee status, working hours, and teleworking. The COVID-19 pandemic triggered an increase in the use of telemedicine worldwide (World Health Organization 2020). In Japan, telemedicine use more than doubled during the early stages of the COVID-19 pandemic, increasing from 2.0% in April 2020 to 4.7% in September 2020 (Miyawaki et al. 2021). However, we found that the use rate of telemedicine subsequently plateaued and was 3.9% in December 2021. One reason for this is the impact of mutations of the COVID-19 virus; weaker variants have enabled the resumption of face-to-face medical care. It has also been reported that factors such as the number of COVID-19 patients and lockdown policies affect the use of telemedicine (Chu et al. 2021). To improve telemedicine, it is important not only to enhance the law and communications infrastructure, but also to understand the background of each individual patient. We believe that this study has important implications regarding the dissemination of telemedicine to the working-age population of Japan and elsewhere.
Telemedicine utilization showed a U-shaped relationship with age in this study: initially, there was a gradual decline in use with age (from 7.2% in the 20-39 years age group to 3.0% in the 50-59 years age group), but the use rate subsequently increased in the 60-65 years age group (3.9%). Such a U-shaped relationship was reported in a previous Japanese study (Miyawaki et al. 2021) and there are several plausible explanations. First, younger people use electronic devices more frequently, and are more familiar with the Internet than middle-aged and older people. However, the elderly have more underlying diseases requiring regular medical examinations than the young and middle-aged (Alexander et al. 2020); the interplay between these factors may be responsible for the U-shaped relationship between the telemedicine utilization rate and age. Second, aging is the major risk factor for severe COVID-19 infection, and the desire to avoid infection among the elderly could have led to avoidance of face-to-face treatment (Gao et al. 2021). In fact, previous studies have reported that many elderly people adopted telemedicine relatively quickly during the COVID-19 pandemic (Nouri et al. 2020; Rivera et al. 2021).
The executives and managers in our study used telemedicine more proactively than civil servants. In the United States, wealthy individuals tend to have higher rates of telemedicine use (Jaffe et al. 2020; Rivera et al. 2021). Conversely, a previous Japanese study reported a weak correlation between income level and telemedicine use (Miyawaki et al. 2021). In the current study, we adjusted for income in the multivariate analysis and found no difference in telemedicine utilization rate between permanent employees and dispatched/contact workers. These findings suggest that flexible work practices among executives and managers may promote the use of telemedicine (Rodriguez Socarrás et al. 2020; Breton et al. 2021). Thus, more flexible work hours for public officers could increase their utilization of telemedicine.
The workers with long hours (≥ 9 hours/day) in this study were significantly less likely to use telemedicine than those with comparatively few hours (≤ 7.5 hours/day). Long hours is a major risk factor for various lifestyle-related diseases because of lifestyle disruption, high stress, and deficient sleep (Kuwahara et al. 2019; Cheng et al. 2021). Previous studies indicated that the reduced treatment access and physical burden associated with long hours were risk factors for serious physical disease (e.g., acute myocardial infarction) (Sokejima and Kagamimori 1998; Liu et al. 2002). Patients undergoing treatment for vascular or serious lifestyle-related diseases are likely to favor face-to-face treatment over telemedicine because of the need for hospital examinations. We hope that telemedicine will help workers balance work and treatment. However, this study showed that, at present, busy workers tend to lack the time required to use telemedicine. Further work reforms in Japan may be needed to increase the utilization rate of telemedicine.
In this study, the rate of telemedicine use was significantly higher among workers who had experience of teleworking. This is consistent with the findings of a Canadian study showing that teleworking promotes the use of telemedicine (Breton et al. 2021). In a previous study from our team, workers in information technology industries were more likely than workers in other industries to use COVID-19 contact tracing apps (Ishimaru et al. 2021). The psychological stress caused by telemedicine may be reduced by experience with telecommunication (i.e., telework), and the use of telemedicine may increase as telework becomes more established.
The current study had several limitations. First, the participants were workers who registered with an online survey company and responded to the 1-year follow-up survey; these participants might not be representative of typical Japanese workers. Second, we did not determine the number of telemedicine users or duration of drug prescriptions. Therefore, the cumulative incidence of telemedicine use, and the duration and effectiveness of treatment, could not be assessed. Third, we defined telemedicine use as the receipt of online medical treatment for any illness. However, as the study was conducted under the unique circumstances of the COVID-19 pandemic, different results may have been obtained by a post-COVID-19 pandemic survey. According to the Japanese government, most of the illnesses treated by telemedicine during the COVID-19 pandemic were common acute diseases (e.g., upper respiratory tract infections, bronchitis, etc.; for details, see https://www.mhlw.go.jp/content/10803000/000690548.pdf). If we only classified participants treated for acute diseases as telemedicine users, the results may have been different. However, there was no significant difference in the use rate of telemedicine between our study and previous ones, which indicates that our study design was reasonable (Miyawaki et al. 2021).
In conclusion, this study identified occupational factors associated with the use of telemedicine among the Japanese working-age population. Young workers, managers and executives, and participants who worked shorter hours or had experience of teleworking had relatively high telemedicine use rates. Currently, the number of telemedicine users in Japan is relatively low compared with other developed countries, even though the telecommunications infrastructure in Japan does not impose any constraints on the use of telemedicine. Flexible work arrangements are important for the widespread use of telemedicine, which can workers balance work and treatment, as well as help prevent the spread of infection (Dorsey et al. 2013; Wang et al. 2017; Sekimoto et al. 2019).
This study was supported and partly funded by research grants from the University of Occupational and Environmental Health, Japan (no grant number); Japanese Ministry of Health, Labour and Welfare (grant nos. H30-josei-ippan-002, H30-roudou-ippan-007, 19JA1004, 20JA1006, 210301-1, and 20HB1004); Anshin Zaidan (no grant number), the Collabo-Health Study Group (no grant number), and Hitachi Systems, Ltd. (no grant number), and by a scholarship from Chugai Pharmaceutical Co., Ltd. (no grant number). The funder was not involved in the study design; collection, analysis, or interpretation of the data; or the writing of or decision to submit this article for publication.
The current members of the CORoNaWork Project are as follows (in alphabetical order): Dr. Akira Ogami, Dr. Ayako Hino, Dr. Hajime Ando, Dr. Hisashi Eguchi, Dr. Keiji Muramatsu, Dr. Koji Mori, Dr. Kosuke Mafune, Dr. Makoto Okawara, Dr. Mami Kuwamura, Dr. Mayumi Tsuji, Dr. Ryutaro Matsugaki, Dr. Seiichiro Tateishi, Dr. Shinya Matsuda, Dr. Tomohiro Ishimaru, and Dr. Tomohisa Nagata, Dr. Yoshihisa Fujino (chairperson of the study group), and Dr. Yu Igarashi. All members are affiliated with the University of Occupational and Environmental Health, Japan.
Y.F. is the chairperson of the study group. H.U. and T.I. conceived the research questions. All of the authors contributed to the design of the research protocol and development of the questionnaire. T.I. conducted the statistical analysis. H.U. drafted the initial manuscript in collaboration with T.I. All authors revised and approved the final manuscript.
The authors declare no conflict of interest.
