health promotion and disease prevention in the workplace in japan - lessons learned from us-japan...
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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
Evolution of Worksite Health-related Policies
• 1972 Occupational Health & Safety Act• 1979 Silver Health Plan– An Emphasis on Physical Fitness among Older
Workforce
Annual Physical Checkups
Secondary Prevention: Screenings
Physical Fitness
Older Workforce
Target Population
Target Diseases/Behaviors
Personnel Occupational Physicians and Nurses
Fitness Instructors
Evolution of Worksite Health-related Policies
• 1972 Occupational Health & Safety Act• 1979 Silver Health Plan• 1988 Total Health Promotion Plan– Expansion of the Target Behaviors– Expansion of Occupational Health Staff
Annual Physical Checkups
Secondary Prevention: Screenings
Physical Fitness Smoking, Nutrition, Stress
Older Workforce
Middle-aged & Younger Workforce
Target Population
Target Diseases/Behaviors
Personnel Occupational Physicians and Nurses
Fitness Instructors Dietitians and Counselors
Evolution of Worksite Health-related Policies
• 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
Annual Physical Checkups
Secondary Prevention: Screenings
Physical Fitness Smoking, Nutrition, Stress
Older Workforce
Middle-aged & Younger Workforce SpousesTarget
Population
Target Diseases/Behaviors
Personnel Occupational Physicians and Nurses
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)
Program Development (Program Materials/Booklets)
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
Initial Interview Name: John Doe
Negative Impacts of Smoking
Positive Impacts of Quitting
According to WHO, everyday ………….
Next
Quitting smoking results in significant risk reduction ……………
Ask
Explain
Advise
Assist
Initial Interview Name: John Doe
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
Initial Interview Name: John Doe
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 (MXS@it.com)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
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
Computer-assisted Practitioner Support System
• 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)
Computer-assisted Practitioner Support System
• 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 atyosuke.chikamoto@gmail.com
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