Health Promotion and Disease Prevention in the Workplace in Japan - Lessons Learned from US-Japan Collaborations - Yosuke Chikamoto, PhD

Health Promotion and Disease Prevention in the Workplace in Japan

- Lessons Learned from US-Japan Collaborations -

Yosuke Chikamoto, PhD

Healthcare Situations

Japan• Universal Coverage• Universal Access

U.S.A.• 48.6 millions (15.7%)

Uninsured• Various Mechanisms to

Control Access

Japa

n

Ital

y

Spai

n

U.K

.Aus

tral

ia

Swed

en

Bel

gium

Fran

ceG

erm

any

Aus

tria

Net

herlan

ds

Can

ada

Switz

erla

nd

Nor

way

U.S

.A.

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

$2,729$2,870$2,902$3,129$3,353$3,470$3,677$3,696$3,737

$3,970$4,063$4,079$4,627

$5,003

$7,538

Total Health Expenditure per Capita, U.S. and Selected Countries, 2008

Per

Cap

ita S

pen

din

g -

PPP A

dju

sted

Source: Organisation for Economic Co-operation and Development (2010), "OECD Health Data", OECD Health Statistics (database). doi: 10.1787/data-00350-en (Accessed on 14 February 2011).Notes: Data from Australia and Japan are 2007 data. Figures for Belgium, Canada, Netherlands, Norway and Switzerland, are OECD estimates. Numbers are PPP adjusted.

Lower Healthcare Costs in Japan

Japan

Aust

ralia

Nor

way

U.K

.

Spai

n

Ital

y

Sw

eden

Net

her

lands

Can

ada

Aust

ria

Ger

man

ySw

itze

rlan

d

Bel

giu

m

Fran

ce

U.S

.A.

0%

200%

400%

600%

800%

1000%

1200%

1400%

1600%

1800%

810.0%850.0%850.0%870.0%900.0%910.0%940.0%990.0%1040.0%1050.0%1050.0%1070.0%1110.0%1120.0%

1600.0%

Total Health Expenditure as a Share of GDP, U.S. and Selected Countries, 2008

As

Perc

en

tag

e o

f G

DP

Source: Organisation for Economic Co-operation and Development (2010), "OECD Health Data", OECD Health Statistics (database). doi: 10.1787/data-00350-en (Accessed on 14 February 2011).Notes: Data from Australia and Japan are 2007 data. Figures for Belgium, Canada, Netherlands, Norway and Switzerland, are OECD estimates. Numbers are PPP adjusted.

Lower Healthcare Costs in Japan

Higher Life Expectancy in Japan

Total Male FemaleJapan 83 80 86U.S.A. 79 76 81

Lower Obesity Rates in Japan

Total Male Female Total Male Female Total Male FemaleJapan Poland USA

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

3.9% 4.3% 3.5%

12.5% 12.6% 12.5%

33.8%32.2%

35.5%

Obesity (BMI>30)

Japan seems to be doing pretty well

Aus

tralia

Aus

tria

Bel

gium

Can

ada

Fra

nce

Ger

man

y It

aly

Japa

n

Net

herla

nds

Nor

way

Spa

in

Swed

en

Switz

erla

nd U

.K.

U.S

.A.

Avera

ge $-

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

Total Health Expenditure Per Capita, U.S. and Selected Countries, 1970, 1980, 1990, 2000,

2008

1970

1980

1990

Per

Cap

ita S

pen

din

g -

PPP A

dju

sted

Healthcare Expenditures: An Increasing Burden

Source: Organisation for Economic Co-operation and Development (2010), "OECD Health Data", OECD Health Statistics (database). doi: 10.1787/data-00350-en (Accessed on 14 February 2011).

Healthcare Expenditure: An Increasing Burden

1970 1980 1990 2000 20080.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

7.1%

9.0%

12.2%13.4%

16.0%

4.6%

6.5% 6.0%

7.7% 8.1%

Total Health Expenditure as % GDP by Year

U.S.A.Japan

OECD 2010

Impact of Increasing Healthcare Costs on Employers in Japan

• Not only for:– Their Workforce and Its Dependents

• But also:– Contributions to the Nation’s Elderly Care

Premiums from the Elderly

10%

Gov-ern-

ments50%

Contributions from the Employer-

based Health In-surance

40%

Aging Population

048

12162024283236404448525660646872768084889296

100 or older

0 500 1,000 1,500 2,000 2,500

Statistics Bureau, Ministry of Internal Affairs and Communications (2010)

Total: 128,057,352

High Smoking Rate among Japanese Men

Male Female Male Female Male FemaleJapan Poland U.S.A.

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%

44.3%

14.3%

43.9%

27.2% 26.3%21.5%

Smoking Rates

WHO Report on the Global Tobacco Epidemic (2008)

Japanese “Obesity”

1987 1997 2007 20090.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

20.4%23.3%

30.4% 29.3%

21.2% 20.9% 20.2% 20.2%

"Obesity (BMI>25)" by Gender

MaleFemale

Evolution of Worksite Health-related Policies

• 1972 Occupational Health & Safety Act– Employers were mandated to provide annual

physical checkups– Occupational health staff (Physicians and Nurses)

were hired to provide the checkups for a secondary prevention/screening purpose

Annual Physical Checkups

Secondary Prevention: Screenings

Target Diseases/Behaviors

Personnel Occupational Physicians and Nurses


• 1972 Occupational Health & Safety Act• 1979 Silver Health Plan– An Emphasis on Physical Fitness among Older

Workforce



Physical Fitness

Older Workforce

Target Population



Fitness Instructors


• 1972 Occupational Health & Safety Act• 1979 Silver Health Plan• 1988 Total Health Promotion Plan– Expansion of the Target Behaviors– Expansion of Occupational Health Staff



Physical Fitness Smoking, Nutrition, Stress

Older Workforce

Middle-aged & Younger Workforce

Target Population



Fitness Instructors Dietitians and Counselors


• 1972 Occupational Health & Safety Act• 1979 Silver Health Plan• 1988 Total Health Promotion Plan• 2000 Healthy Japan 21– Nation’s Objectives

Evolution ofWorksite Health-related Policies

• 1972 Occupational Health & Safety Act• 1979 Silver Health Plan• 1988 Total Health Promotion Plan• 2000 Healthy Japan 21• 2003 Health Promotion Law• 2008 Special Health Screening/Special Health

Guidance (Screening for Metabolic Syndrome)

Building Blocks of Worksite Health



Physical Fitness Smoking, Nutrition, Stress

Older Workforce

Middle-aged & Younger Workforce SpousesTarget

Population



Fitness Instructors Dietitians and Counselors

40 or older

Health Behaviors as They Relate to Metabolic Syndrome

Why Dissemination from the U.S. to Japan?

UrgencyCulture of Innovations

Application of Behavior Science

International Dissemination Efforts

• Practitioner Training• Program Development– Program Brochures– Web-based Programs• Health Risk Assessments• Follow-up Programs

• Computer-assisted Practitioner Support Programs

• Data-driven Advocacy Effort

US-Japan Collaborations

U.S.• Stanford Center for Research in

Disease Prevention• Stanford Comparative

Healthcare Policy Research Project

• California State University-Fullerton

• American University Institute for International Health Promotion

• American Journal of Health Promotion

Japan• University of Occupational and

Environmental Medicine• Keio University Graduate

School of Business• Ministry of Health, Labour and

Welfare• Osaka Cancer Prevention

Center• NTT Corporation• NTT DATA• An anonymous employer

Practitioner Training

• 5-day In-Person Training Workshops on Health Promotion/Disease Prevention– Going beyond knowledge-based education– Going beyond advice– Applications of Behavior Science Principles to Health

Promoting and Disease Management Counseling• Eliciting the client’s perspective• Behavioral analysis• Tailored approaches

– Program planning for prioritization toward population health based on readiness as well as on risk levels

Practitioner Training

• Skills unique to worksite health could be enhanced among occupational health professionals through brief training

• Ambivalence existed among health professionals in providing health advice

• Reluctance existed among health professionals in giving advice to quit smoking

• Newly acquired skills and initial enthusiasm would not survive without systematic support

Less

ons

Lear

ned

Program Development (Program Materials/Booklets)



• Needs to go beyond simple translation of the words for cultural adaptation– Easier: Smoking cessation and fitness– More difficult: Nutrition

• Integration with the existing protocol (the annual physical check ups) would help institutionalize the program– Limitation of behavior-specific programs

Less

ons

Lear

ned

Program Development (Web-based Programs: Health Risk Assessment)

• Comprehensive Coverage of Health Behaviors• Addition of Psychological Readiness

Assessment and Tailoring of Messages

Program Development (Web-based Programs: Health Risk Assessment)

• Relatively easy adoption and implementation• Effectiveness was limited by its stand-alone

implementation• Follow-up using the readiness-based approach

was not feasible if it relied on existing staff

Less

ons

Lear

ned

Program Development (Web-based Program: Follow-up Programs)

Initial Health Risk Assessment

ActionPreparationContemplationPre-contemplation Maintenance

Personal Reports Tailored for Psychological Readiness

Periodical Emails Addressing Their Perceived Barriers

Invitations to Interactive Websites

Push Approach Pull Approach

Program Development (Web-based Program: Follow-up Program)

• Readiness-based approach to the entire employee population is made possible by web technology

• Practitioners did not find pride or satisfaction in the outcomes that the web-based programs yielded

• Wider dissemination would require buy-in from decision makers

Less

ons

Lear

ned

Computer-assisted Practitioner Support Program

• Practitioners seem to find pride and satisfaction in the sense of their “directly providing services” to their clients

• Consider the practice pattern change as behavior change effort among practitioners

Computer-assisted Practitioner Support System

• Applications of Selected Behavior Change Principles– Behavioral Trigger– Self-monitoring– Specific Behavior

Health Promotion Practitioner Support System

Welcome to

USER ID

Today is

Thursday April 11th

PASSWORD

4/1 4/2 4/3 4/4 4/5

4/8 4/9 4/10 4/11 4/12

5 3 4 2 8

Monday Tuesday Wednesday Thursday Friday

4 9 3 6 4

4/15 4/16 4/17 4/18 4/19

4/22 4/23 4/24 4/25 4/26

7 3 12 4 5

4 8 3 9 6

Time Name Action12:30 John Doe Initial Interview1:45 Mary Smith Phone Call: The Day BeforeNA Tom Johnson E-mail: 1 wk BeforeNA Bob Carlson E-mail: 1 wk LaterNA Nancy Robertson E-mail: Stage AssessmentNA David Clark E-mail: Newsletter

Stage

?

Prep.

Prep.

Act.

No Int.

Precont.

Ask

Explain

Advise

Assist

Initial Interview Name: John Doe

Q1. Do you currently smoke cigarettes?

Q2. How many cigarettes do you smoke a day?

Q3. Have you ever tried quitting smoking? If so, how many times?

Currently smoke Quit smoking Never smoked

Cigarettes/day

Yes Never

times

Next

Ask

Explain

Advise

Assist


Negative Impacts of Smoking

Positive Impacts of Quitting

According to WHO, everyday ………….

Next

Quitting smoking results in significant risk reduction ……………

Ask

Explain

Advise

Assist


As explained to you, you are at high risk for various diseases because of your current smoking.I am concerned about your health. I strongly advise you to quit smoking for your health.

Check this box after the above advice is given

Next

Ask

Explain

Advise

Assist


Provide a Videotape

Inform the Availability of Resources at Med. Dept.

Express gratitude for coming

Accepted Rejected

Done

Here’s a videotape on our “smoke-free” program. Please take just a minute or so to see it at your convenience and return it to us in a week. ……………………………………………………

Send

Edit

No Interest

Initial Interview

Email: 1wk

Email: 2 months

DATE: April 11, 2002To: Mary Smith ([email protected])From: Beverly Care, RNSubject: Message from Medical Dept.

Dear Mary, Hope this note finds you well. As you recall, we discussed the health impacts of smoking about 2 month ago. I understand that you were not interested in quitting smoking back then. I still feel strongly that you could benefit significantly from quitting smoking. At our medical department, resources are available to help you quit smoking. If you are interested, please contact us. I hope we will hear from you soon.

Beverly Care RNMedical Department ext. 5000

Print

Contemplation

Initial Interview

Newsletter 1

Newsletter 2

Newsletter 3

Newsletter 6

Newsletter 4

Newsletter 5

It’s too late……?

ABC corporation Newsletter

…………………………..…………………………..

………………………………………………………………………………………………………………

…………………………

For David Clark


• Setting– The medical department at a regional office of a

large IT corporation in Japan

• Two Target Populations– Occupational Health Nurses (N = 5)– Smokers in the Employee Population (N = 529)

84%

N=529 N=444 N=40

SmokersSmokers who

received interventions

No InterestN=274 (61.7%)

PrecontemplationN=137 (30.9%)

ContemplationN=15 (3.4%)

PreparationN=18 (4.0%)

Quit Smoking

7.6% of all smokers

9.0%of participants

23.5%of participants

excluding “no interest”

35.0%of participants who

entered into action stage

Smokers who received

interventionsby Stage

• Practice is context-based, time-bound, situation-specific, and action-oriented

(Jennett PA & Premkumar K, 1996)

• CME is most effective when it incorporates practice-based, enabling, and reinforcing strategies

(Davis DA, 1994)


• Little additional burden felt by practitioners• Practitioners felt that they were making a

difference• Sense of ownership• Serves as a quality assurance/standardization tool• Consider the organizational development aspect

• Reluctance in the “planting the seed” approach• Hesitation in simply following the protocol/scripts

Less

ons

Lear

ned

Data-driven Advocacy

Prevalence of Lifestyle Disease, Extremely High Risk, High Risk and No Risk by Age

5.0713.63

25.8133.3319.19

24.40

30.2725.0042.28

38.46

30.19 25.00

33.4623.51

13.73 16.67

0

20

40

60

80

100

30s 40s 50s 60s

No risk (%)

High Risk (%)

Extremely High Risk (%)

Lifestyle Disease (%)

(%)

(N=1204) (N=910) (N=1166) (N=12)

Lifestyle Disease: Those with the Diagnosis of One or More of the Following: Diabetes, Hypertension, and HyperlipidemiaExtremely High Risk: If seen by a doctor, most likely to be diagnosed with the disease

Nishimura, Chikamoto, Arima, Mitsutake (2005)

Data-driven Advocacy

• The merging of medical/dental claims data and physical checkups/health risk assessment data provides valuable information

• Comparative perspectives provided lessons to both Japan and U.S.

Less

ons

Lear

ned

Lessons Learned and Future Implications- From an International Dissemination Perspective -

• Context, context, context– Policies– Organizational Dynamics– Professionalism

Future Challenges in Worksite Health in Japan

• Integration with Primary Care• Preventive Care for Spouses• Legitimacy of the Almost Exclusive Emphasis

on the Metabolic Syndrome• Accountability/Evaluation• Further Improvement in Behavior Change

Support Strategies

Dziękuję! Please feel free to contact me [email protected]

Documents

Health Promotion and Disease Prevention in the Workplace in Japan - Lessons Learned from US-Japan Collaborations - Yosuke Chikamoto, PhD