Characteristics of health counselling in the workplace via

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1 Characteristics of health counselling in the workplace via Sumiko Kurioka *, Takashi Muto and Kimio Tarumi * Department of Health Sciences, Kobe University School of Medicine, Kobe; Department of Public Health, Juntendo University School of Medicine, Tokyo; and Ocupational Health Training Center, University of Occupational and Environmental Health, Kitakyushu, Japan This study was conducted to examine how health counselling via electronic mail ( health counselling) was used in the workplace. The definition of health counselling employed in this study was any assistance to an individual seeking to solve any health problem. A total of 2119 health counsellings conducted at a Japanese company s head office (700 employees) in 1997 and 1998 was used for the analysis, which compared four health counselling methods: , face-to-face, telephone and ordinary mail. This study distinguished four main characteristics of health counselling. First, the most and second most frequently used counselling methods were face-to-face and telephone counselling, at 70 and 15%, respectively, with health counselling ranked third at 13%. counselling was the second most frequently used method for employees in their 20s and 30s, while it ranked third among those over 40. Only 6% of employees in their 50s used counselling. Secondly, the proportion of mental health issues treated via counselling was significantly higher, at 26%, than for other counselling methods, which was at or below 10% for each of the other methods. Thirty-two per cent of all mental health counselling was conducted via . Thirdly, compared with face-to-face counselling, counselling dealt with more health issues related to primary prevention than with those related to secondary or tertiary prevention. Fourthly, compared with face-to-face counselling, counselling dealt more with health issues of third parties. These results suggest that health counselling may be useful in reaching people other than those targeted by the remaining counselling methods. Key words: ; health counselling; internet; Japan; mental health; occupational health. Received 19 February 2001; revised 9 July 2001; accepted 30 July 2001 Introduction Economic globalization has resulted in increased competition among enterprises, and this has led to an increased level of stress among workers. The percentage of employees experiencing work-related stress has been increasing among Japanese workers [1], leading to the issuance of guidelines by the Japanese Ministry of Labour in 2000 on the management of mental health in the workplace [2]. Correspondence to: Sumiko Kurioka, Visiting Lecturer, Department of Health Sciences, Kobe University School of Medicine, , Tomogaoka, Suma-ku, Kobe, Japan. Tel: ; fax: ; sumiko-k@sd5.so-net.ne.jp As one of the methods of dealing with work-related stress mentioned in the guidelines, health counselling in the workplace has become more significant. Owing to an increase in the average age of employees and to lifestyle changes, diseases such as hypertension, cardiovascular disease, hyperlipidaemia and diabetes mellitus have emerged as major occupational health issues in Japan karoshi (death due to overwork) may be attributed to these diseases [3]. In order to prevent karoshi, the Ministry of Labour issued guidelines on post-examination health maintenance and management in 1996 [4]. According to the guidelines, employers were obliged to provide health guidance by occupational Occup. Med. Vol. 51 No. 7, pp , 2001 Copyright Society of Occupational Medicine. Printed in Great Britain. All rights reserved /01

2 428 Occup. Med. Vol. 51, 2001 physicians or health nurses to employees whose health examinations yielded any abnormal findings. In this context, effective and efficient methods of health counselling are now being sought in the workplace, and health counselling via electronic mail ( health counselling) is emerging as one of the most promising methods. First, even the busiest workers can get easy access to health counselling via , as they do not have to leave their desks to visit the company s health care facility. Secondly, workers may approach health counselling more freely than they would face-to-face sessions, due to the relative anonymity of health counselling. Thirdly, with the rapid development in Japan of information and communication technologies (referred to as the IT revolution ), most workers are already using the internet (especially ) extensively. Physicians [5 8], nutritionists [9,10] and pharmacists [11] have utilized counselling in clinical settings, and its characteristics have been studied and discussed. Although several papers have dealt with issues concerning the use of the internet or in relation to occupational health activities [12 14], little research has been undertaken on the characteristics of health counselling in the workplace. In order to promote the use of health counselling in the workplace, its characteristics should be clarified, along with various legal, ethical and professional issues. This study was conducted to clarify the characteristics of health counselling in the workplace. Methods This study was conducted at a head office of 700 employees in a Japanese manufacturing company (the T Company) with a total of employees. All were white-collar workers engaged in management, sales or clerical jobs. Males comprised 74% of all employees, and their age distribution was as follows: 20s, 32%; 30s, 24%; 40s, 31%; 50s, 13%. An information network linking all workplaces in the T Company was established in April 1995, in an effort to improve efficiency. Although the term counselling is generally used very loosely, it is very important to establish a clear definition of what this entails, to allow comparison with other studies and facilitate future meta-analysis, and to help other organizations considering such an approach to get a better idea of all that is involved. In this context, we defined health counselling in this study as assistance to an individual who was seeking to solve any health problem, and health counselling as any such counselling using . health counselling was implemented in December 1995, in a health care department located in the head office. Two health nurses working on a full-time basis and one part-time occupational physician worked in the head office health care department. The health nurses were in charge of the health counselling services, including health counselling. No health care staff transfers occurred in the head office between 1996 and The status of the health counselling services was surveyed and described using descriptive epidemiology. Data were collected on the health counselling services provided by the head office health care department in 1996 and Health nurses in charge of health counselling recorded the content of each health counselling session, later entering these data into a computer database. The data included the client employee s name, sex and age, the method of counselling employed and the contents of the counselling session. The methods of counselling were classified into four categories: counselling, face-to-face counselling, telephone counselling and counselling by ordinary mail. The contents of the counselling session included the target, subject and stage of prevention. The counselling targets were classified into three categories: the employee himself, other employees (colleagues, subordinates or superiors) and others (mainly family members). The subjects of the counselling sessions were classified into two categories: physical health issues and mental health problems. Included among the mental health problems were psychological or psychiatric problems, character disorders, behavioural disorders and issues relating to human relationships, employment or life goals. The subjects of the counselling sessions were classified by the occupational physician or by the two health nurses. The stages of prevention were classified into two categories: (i) primary prevention and (ii) secondary or tertiary prevention. When a single counselling session involved diverse problems, one main issue was selected by the occupational physician or the health nurse in charge. In order to examine characteristics of health counselling, the number of counselling sessions was tallied. If the same employee was given counselling on two or more occasions, each such occasion was counted as a separate session. The number of employees seeking counselling was not used as an indicator, because there were some employees who did not disclose their names, and it was therefore impossible to determine whether a given employee had sought counselling before or was a new client. The χ 2 test was used to identify significant differences among the four counselling methods in relation to age groups, or in relation to the targets, subjects or prevention stages of counselling sessions. The data were analysed using the computer software package SPSS [15]. Results Table 1 shows the relationship between counselling methods and client age groups. Overall, the most and

3 S. Kurioka et al.: Health counselling in the workplace via 429 Table 1. Relationship between health counselling methods and client age groups Method of health counselling Age group All ages Table 2. Relationship between counselling methods and subjects of health counselling Method of health counselling a Subjects Physical health Mental health Total a P < 0.05 by χ 2 test. second most frequently used counselling methods were the face-to-face and telephone counselling methods, at 70 and 15%, respectively, with health counselling ranked third, at 13%. However, this rate varied significantly among the different age groups: counselling was the second most used method for employees in their 20s and 30s, while it ranked third for those in their 40s and 50s. Of particular note, only 6% of employees in their 50s used counselling. The relationship between counselling methods and the subjects of the health counselling sessions is shown in Table 2. Overall, 11% of all health counselling sessions related to mental health issues, while a significantly higher proportion (26%) of health counselling sessions dealt with these issues. Thirty-two percent (71/223) of all counselling sessions related to mental health problems were conducted via , as opposed to 54% (121/223) conducted through face-to-face counselling. Table 3 shows the relationship between counselling methods and prevention stage. Compared with other methods, health counselling dealt with health issues related to primary prevention significantly more than those related to secondary or tertiary prevention. Primary prevention included issues such as methods for promoting health, health regimens, quitting smoking and fitness plans. The relationship between counselling methods and the client s relationship to the person presumed to have the health issue is shown in Table 4. In face-to-face counselling, 93% of the health issues presented by client employees were those relating to the employee himself, while that rate was significantly lower, at 83%, for counselling. The remaining 17% of counselling was related to the health of other employees (such as colleagues or subordinates) and family members. Discussion Characteristics of health counselling This study has clarified four main characteristics of health counselling conducted in the context of occupational health services in the workplace. First, relatively young employees (i.e. those in their 20s and 30s) used health counselling more often than those in their 50s. Secondly, employees who had mental health problems preferred health counselling over other counselling methods. Thirdly, compared with faceto-face counselling, counselling dealt with more health issues related to primary prevention than those related to secondary or tertiary prevention. Fourthly, compared with face-to-face counselling, counselling dealt more with health issues of third parties. These results suggest that health counselling may be

4 430 Occup. Med. Vol. 51, 2001 Table 3. Relationship between counselling methods and stage of prevention Method of health counselling a Stage of prevention Secondary or tertiary Primary Total a P < 0.05 by χ 2 test. Table 4. Relationship between counselling methods and client s relationship to the person in question Method of health counselling a Client s relationship to the person in question Employee him-/herself Other employees Family members etc Total a P < 0.05 by χ 2 test. useful in reaching people other than those targeted by the alternative counselling methods. Considering the relatively high level of information technology literacy among the younger employees, we hypothesized that the youngest workers, aged between 20 and 29, would represent the highest rate of use in health counselling. However, this study showed that they used at a rate similar to that of the age group, and lower than that of employees aged between 30 and 39. A possible reason for this unexpected result may be as follows. In 1991, the T Company started to provide a health education programme for newly hired employees, 22 or 23 years old, in order to help them develop healthy lifestyles. Health nurses participated in the programme as instructors and facilitators, so these young employees are personally acquainted with the health nurses. This personal acquaintance may have lowered resistance to face-to-face health counselling among this group. The higher level of information technology literacy among the younger employees is cited as a possible reason for the greater use of health counselling among this group, not previously accustomed to using health counselling services, as opposed to the middle-aged employees. Nonetheless, the drastic changes occasioned by the recent IT revolution in Japan have resulted in a drastic increase in corporate internet use. Older employees will have no choice but to incorporate information networks into their working life in the very near future, and this may consequently lead to a greater receptiveness to the use of health counselling. As possible reasons for the higher percentage of mental health problems in health counselling, we may cite the fragmentation of personality and the self-invention encouraged by the nature of the exchange. In a limited medium such as , the client and counsellor images are formed by the selective extraction and presentation of fragmented parts of the participants personalities [16]. While it is more difficult to conceal elements of one s personality in face-to-face counselling sessions, the client employee need not reveal his or her entire personality when using health counselling services. The counsellor, on the other hand, may isolate and emphasize the empathic elements of his or her personality, presenting the image of an ideal counsellor who can fully understand a client s distress. The success of projecting this image of the health nurse as an ideal counsellor may depend upon his or her quick responses and the appropriateness of his or her advice. As a possible reason for counselling s higher proportion of primary prevention issues than the other health counselling methods, employees may feel that there is less formality in counselling than there is

5 S. Kurioka et al.: Health counselling in the workplace via 431 in face-to-face counselling. It has been shown that it is sometimes easier to broach difficult subjects via before raising the topic during face-to-face counselling [8]. When employees want to know about health issues that seem to them too simple or odd to discuss in face-toface counselling, they may use . Such issues include methods for promoting health, quitting smoking or improving sports performance, none of which is related to concrete guidance on how to deal with abnormal or illhealth. Thus, health counselling may represent a more casual counselling method for employees. This perceived casual nature of counselling may also be one of the possible reasons for the higher percentage of health counselling sought on behalf of third parties. Because an employee s mental health disorders are most often noticed for the first time by his or her colleagues or bosses, it is very important for them to have easy access to the company s health care division, as early detection of mental health disorders invariably leads to better prognosis. If employees are worried about family members health problems, their work efficiency will fall significantly. Although not representative of the main activity of occupational health services, it may be desirable for employees to be able to discuss such issues with members of the company health care division. In this context, health counselling may be considered a very good counselling method. Although not examined in this study, counselling may have two more benefits. First, counselling may be beneficial for employees working at remote and separate workplaces, or for small-scale enterprises where it is hard to find a counsellor this has been suggested by previous research [17]. Secondly, health counselling is flexible, for both the clients and the counsellors [7]. Clients do not have to take time out of their busy schedules to visit a company health care facility. Counsellors can work and send replies at their convenience, as time permits. Considerations Counselling clients without face-to-face contact has its limits. You may miss the many visual cues you notice when you see an employee in person, and it can be harder to tell if the person understands what you have explained. Clients can misinterpret written information; the risk of misunderstanding may in fact be greater when using health counselling than it is in a face-to-face session. Such misunderstandings may result in serious psychological damage, opening up the possibility of litigation. Therefore, it is very important to keep hardcopy records of all communication to and from clients. Such records may later be needed in court. In some companies, is used only once at the start of health counselling, the frequent use of health counselling being prohibited [12]. This is due to the fear that counsellors may have to spend a great deal of time responding to a small number of repeat clients. The internet s addictive qualities have attracted a great deal of attention [18]. Clients who use health counselling may run the risk of thereby becoming internet addicts [19]. Health counselling sessions may deal with private issues, and it is very important to maintain strict respect for the client s privacy. There are two possible sources of risk to this privacy: the counsellor s personal computer and the network itself. Risks due to the former may involve such scenarios as an inadvertent reply to the wrong party, incorporating earlier correspondence from the original party without his or her consent. Such personal mishandling issues may be better addressed by the counsellors themselves than by legislation or regulation. Counsellors should re-confirm the address of all return mail before sending it. They should obtain informed consent from the client before transferring the original correspondence to any third parties, and should get assurance of confidentiality from all such parties. With respect to the risks to privacy due to network system management, there is no applicable legislation or regulation in Japan. Even if legislation were to be enacted, such legislation could be practically inapplicable in the context of private enterprises, superseded by company rules or by agreements between the company and the labour union. For private enterprises, company rules governing privacy should be established. Given the many potential problems relating to the use of health counselling in the workplace, general guidelines for health counselling, resembling those of the American Medical Informatics Association [5], should be developed. With respect to the classification of counselling according to physical and mental issues, the possibility of subjective bias cannot be completely discounted. Especially in the case of psychosomatic diseases, some physical issues may eventually reveal themselves to be psychological in nature. Taking these weaknesses into consideration, the results of this study should be considered not as definitive, but rather as suggestive. This study has clarified the characteristics of health counselling in the workplace; however, the question of the effectiveness of the counselling in helping the clients solve their problems was beyond the scope of the study. Further research is needed to clarify this issue. With respect to the external validity of this study, due caution should be exercised when drawing generalizations from its results, as its subject consists of only a single company. References 1. Shimizu Y, Makino S, Takata T. 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