Yosuke Chikamoto, PhD

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

2. Healthcare Situations Japan U.S.A. 48.6 millions (15.7%) Uninsured Various Mechanisms to Control Access • Universal Coverage • Universal Access

3. Lower Healthcare Costs in Japan 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.

4. Lower Healthcare Costs in Japan 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.

5. Higher Life Expectancy in Japan

6. Lower Obesity Rates in Japan

7. Japan seems to be doing pretty well

8. 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).

9. Healthcare Expenditure: An Increasing Burden OECD 2010

10. Impact of Increasing Healthcare Costs on Employersin Japan • Not only for: • Their Workforce and Its Dependents • But also: • Contributions to the Nation’s Elderly Care

11. Aging Population Total: 128,057,352 Statistics Bureau, Ministry of Internal Affairs and Communications (2010)

12. High Smoking Rate among Japanese Men WHO Report on the Global Tobacco Epidemic (2008)

13. Japanese “Obesity”

14. 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/screeningpurpose

15. Secondary Prevention: Screenings Target Diseases/ Behaviors OccupationalPhysicians and Nurses Personnel Annual Physical Checkups

16. Evolution of Worksite Health-related Policies • 1972 Occupational Health & Safety Act • 1979 Silver Health Plan • An Emphasis on Physical Fitness among Older Workforce

17. Older Workforce Target Population Secondary Prevention: Screenings Physical Fitness Target Diseases/ Behaviors OccupationalPhysicians and Nurses Fitness Instructors Personnel Annual Physical Checkups

18. 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

19. Older Workforce Middle-aged & Younger Workforce Target Population Secondary Prevention: Screenings Physical Fitness Smoking, Nutrition, Stress Target Diseases/ Behaviors OccupationalPhysicians and Nurses Fitness Instructors Dietitians and Counselors Personnel Annual Physical Checkups

20. 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

21. 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)

22. Building Blocks of Worksite Health Older Workforce Middle-aged & Younger Workforce Spouses Target Population 40 or older Secondary Prevention: Screenings Physical Fitness Smoking, Nutrition, Stress Target Diseases/ Behaviors Health Behaviors as They Relate to Metabolic Syndrome OccupationalPhysicians and Nurses Fitness Instructors Dietitians and Counselors Personnel Annual Physical Checkups

23. Why Dissemination from the U.S. to Japan? Urgency Culture of Innovations Application of Behavior Science

24. 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

25. US-Japan Collaborations U.S. 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 • 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

26. 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

27. Practitioner Training • Skills unique to worksite health could be enhanced among occupational health professionals through brief training • Ambivalenceexisted 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 Lessons Learned

28. Program Development (Program Materials/Booklets)

29. Program Development (Program Materials/Booklets)

30. 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 Lessons Learned

31. Program Development (Web-based Programs: Health Risk Assessment) • Comprehensive Coverage of Health Behaviors • Addition of Psychological Readiness Assessment and Tailoring of Messages

32. 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 Lessons Learned

33. Program Development (Web-based Program: Follow-up Programs) Initial Health Risk Assessment Pre- contemplation Contemplation Preparation Maintenance Action Personal Reports Tailored for Psychological Readiness Periodical Emails Addressing Their Perceived Barriers Invitations to Interactive Websites Pull Approach Push Approach

34. 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 Lessons Learned

35. 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

36. Computer-assisted Practitioner Support System • Applications of Selected Behavior Change Principles • Behavioral Trigger • Self-monitoring • Specific Behavior

37. Welcome to Health Promotion Practitioner Support System Today is Thursday April 11th USER ID PASSWORD

38. Monday Tuesday Wednesday Thursday Friday 4/1 4/2 4/3 4/4 4/5 5 3 4 2 8 4/8 4/9 4/10 4/11 4/12 4 9 3 6 4 4/15 4/16 4/17 4/18 4/19 7 3 12 4 5 4/22 4/23 4/24 4/25 4/26 4 8 3 9 6

39. Time Name Stage Action 12:30 John Doe ? Initial Interview 1:45 Mary Smith Prep. Phone Call: The Day Before NA Tom Johnson Prep. E-mail: 1 wk Before NA Bob Carlson Act. E-mail: 1 wk Later NA Nancy Robertson No Int. E-mail: Stage Assessment NA David Clark Precont. E-mail: Newsletter

40. Name: John Doe Initial Interview Ask Q1. Do you currently smoke cigarettes? Currently smoke Quit smoking Never smoked Q2. How many cigarettes do you smoke a day? Explain Cigarettes/day Q3. Have you ever tried quitting smoking? If so, how many times? Advise Yes Never times Assist Next

41. Name: John Doe Initial Interview Ask Negative Impacts of Smoking According to WHO, everyday …………. Explain Positive Impacts of Quitting Quitting smoking results in significant risk reduction …………… Advise Assist Next

42. Name: John Doe Initial Interview Ask 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. Explain Check this box after the above advice is given Advise Assist Next

43. Name: John Doe Initial Interview Inform the Availability of Resources at Med. Dept. Ask 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. …………………………………………………… Provide a Videotape Explain Accepted Rejected Advise Express gratitude for coming Assist Done

44. No Interest DATE: April 11, 2002 To: Mary Smith (MXS@it.com) From: Beverly Care, RN Subject: Message from Medical Dept. Initial Interview 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 RN Medical Department ext. 5000 Email: 1wk Email: 2 months Edit Send

45. For David Clark Contemplation ABC corporation Newsletter Initial Interview ………………………….. ………………………….. Newsletter 1 It’s too late……? Newsletter 2 ……………………………………………………………………………………………………………… ………………………… Newsletter 3 Newsletter 4 Newsletter 5 Print Newsletter 6

46. Computer-assisted Practitioner Support System • Setting • The medical department at a regional office of a large IT corporation in Japan • Two TargetPopulations • Occupational Health Nurses (N = 5) • Smokers in the Employee Population (N = 529)

47. Smokers Smokers who received interventions by Stage Smokers who received interventions Quit Smoking 84% 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 No Interest N=274 (61.7%) Precontemplation N=137 (30.9%) Contemplation N=15 (3.4%) Preparation N=18 (4.0%) N=529 N=444 N=40

48. 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)

49. 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 Lessons Learned

50. Data-driven Advocacy