Mental and Physical Effects of Tanshin funin, Posting without Family, on Married Male Workers in Japan

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1 J Occup Health 2006; 48: Journal of Occupational Health Mental and Physical Effects of Tanshin funin, Posting without Family, on Married Male Workers in Japan Hiroto NAKADAIRA 1, Masaharu YAMAMOTO 1 and Toh MATSUBARA 2 1 Division of Social and Environmental Medicine, Department of Community Preventive Medicine, Niigata University Graduate School of Medical and Dental Sciences and 2 Niigata Occupational Health Promotion Center, Japan Labour Health and Welfare Organization, Japan Abstract: Mental and Physical Effects of Tanshin funin, Posting without Family, on Married Male Workers in Japan: Hiroto NAKADAIRA, et al. Division of Social and Environmental Medicine, Department of Community Preventive Medicine, Niigata University Graduate School of Medical and Dental Sciences This paper investigates the effects of tanshin funin, a posting without family, on the health of married male workers. A prospective study using the pair-matched method was performed. One hundred and twenty-nine married male tanshin funin workers in their 40s and 50s and as many matched workers living with their family (regular workers) participated. Fewer tanshin funin workers took breakfast everyday (OR=3.3, p<0.001). Tanshin funin workers more frequently suffered from stress due to daily chores (OR=3.6, p<0.001) and from stress-related health problems, namely headache (OR=4.7, p=0.013) and gastric/ duodenal ulcers (OR=8.7, p<0.001). They also developed more frequently common cold/bronchitis (OR=14.5, p<0.001). The levels of γ-glutamyl transpeptidase for workers reluctant to work under tanshin funin and workers who spent less than two years in tanshin funin increased significantly from the fiscal year 1997 to year 2001 (46.7 to 67.5 IU/l, p<0.001, and 36.9 to 72.4 IU/l, p=0.005, respectively), although those of their matched regular workers did not show significant changes. The daily alcohol intake of reluctant tanshin funin workers (the equivalent of approximately 817 ml of beer) was higher than that of the matched regular workers (582 ml, p=0.026). In summary, abrupt changes in lifestyle and elevated mental stress were thus important effects of tanshin funin. Tanshin funin workers should be provided with health and lifestyle education programs and mental Received Mar 5, 2005; Accepted Nov 30, 2005 Correspondence to: H. Nakadaira, *Present address: Faculty of Nursing, Social Welfare and Psychology, Niigata Seiryo University, Suido-cho, Niigata , Japan health care before and during tanshin funin. Doctors and nurses in the healthcare departments of companies should play a leading role. (J Occup Health 2006; 48: ) Key words: Tanshin-funin workers, Job-transfer, Medical check-ups, Mental stress, γ-glutamyl transpeptidase Tanshin funin is a system under which employees are compelled to live in a different municipality, region, or country from their families as a result of being transferred to a different office within the organization for which they work. This unique working system was introduced and adopted by Japanese companies in the 1960s and 1970s, a period of rapid economic development for the country, and increased during the following decades. According to the 1997 Employment Status Survey by the Ministry of Internal Affairs and Communications (MIAC) of Japan, the number of tanshin funin workers was 690,000 in 1997, up 21,000 from The Housing and Land Survey conducted by MIAC in 1998 indicated that at least 870,000 families had a tanshin funin worker, and that 54,000 households had two or more such workers. Tanshin funin is now one of the major features of working life across a broad range of industries 1, 2). The 2004 General Survey on Working Conditions by the Ministry of Health, Labour and Welfare (MHLW) indicates that, in 2004, 29.2% of total companies had a system of personnel relocation accompanied by change of address, up from 28.1% in With respect to married tanshin funin workers, the General Surveys on Working Conditions indicated that the percentage of companies with married employees working away from home was 19.1% in 1998 and 19.6% in In addition, the survey revealed that larger companies tended to employ a higher percentage of married tanshin funin workers. The percentages of companies having married tanshin funin workers rose

2 114 J Occup Health, Vol. 48, 2006 from 30.0% to 66.8% and 81.0% as the range of the total number of employees increased from to and 1,000 or more, respectively. It also indicated that married tanshin funin workers in Japan increased in number from 254,000 in 1994 to 314,000 in 1998 and to 317,000 in The average number of married tanshin funin workers per company was 15.0 in 2004 according to the survey. Tanshin funin is unique in that workers are ordered to relocate without their families in order to pursue their careers. Life employment, another characteristic of the traditional Japanese working system, forces workers to accept a tanshin funin job assignment in order to receive a promotion 1). These working systems were introduced based on the traditional idea that men should have professional careers and women should be homemakers, and because many Japanese companies have taken this role division by gender for granted, there are far more male married tanshin funin workers than females. In fact, the percentage of companies with female married tanshin funin workers was 0.6% in 2004 according to the 2004 General Survey on Working Conditions. According to the 1998 General Survey on Wages and Working Hours System, the number of female tanshin funin workers was as small as 900. Therefore, the present study was done on an entirely married male sample. Several studies have reported that tanshin funin has contributed to a drastic worsening of the lifestyles of workers, particularly with respect to mental health and dietary habits 2 5). In addition, the recent recession in Japan has increased the number of companies offering tanshin funin without guarantee of promotion 2, 4). These facts, along with recent increases in the rates of Japanese workers with abnormal results in statutorily provided medical examinations 6), suggest that the interruption of the lives of tanshin funin workers, particularly the married ones, by job transfer may have adverse effects on their mental and physical health. Therefore, we hypothesized that tanshin funin causes a marked deterioration in the lifestyles of married male workers, and that this deterioration would be quantifiable as a decline in the results of health examinations. The possible mental and physical overloads caused by working under the tanshin funin system are also a great occupational concern in Japan in that mental and physical stresses are suspected to be causally linked to karoushi, death from overwork, through their contribution to the development of lifestyle-related diseases in the workplace 7, 8). Despite this concern, however, the effects of tanshin funin on the health of workers, especially the physical ones, have been less often chronicled. The purposes of this study were to reassess the effects of tanshin funin on the lifestyles and psychological health of married male workers and to investigate the effects of tanshin funin on their physical health based on the results of health check-ups. We aimed to propose effective preventive measures for married male tanshin funin workers. Subjects and Methods Study subjects Study subjects were selected from among a tanshin funin worker population based on the following criteria: (1) they were married male employees in their 40s and 50s, (2) they worked at companies with 200 employees or more in Niigata Prefecture, Japan, and (3) they had been working under tanshin funin for at least one year at the end of the 2001 fiscal year, March The reasons why middle-aged workers and enterprises with 200 employees or more were targeted were as follows: (1) middle-aged workers are more likely to be assigned new posts that require them to separate from their family and are more likely to show abnormal data in their medical checkups; (2) larger companies tend to employ a higher percentage of married tanshin funin workers; (3) there are remarkable differences in working conditions between smaller-scale companies and larger-scale ones in Japan; and (4) in the locality of this study, the size of 200 workers was considered to be the cut off point between a small and large scale enterprise. We sent letters soliciting the participation of 15 local companies that have a nationwide network of branches. For each subject, a matched regular worker who was close in age (± 2 yr) and had the same type of job was selected from among all married male workers in the same company who had never experienced tanshin funin. All tanshin funin workers and regular workers from whom informed written consent was obtained were enrolled in the study. Data collection To ensure the confidentiality of the subject data, a study leader was appointed in each company, and access to the participants was strictly restricted to this individual. Two types of data were collected: questionnaire data and medical examination data. The self-administered questionnaires, which were delivered and collected by the study leader, contained items about occupation, including the experience of and attitude toward tanshin funin; dietary and non-essential consumption habits, such as cigarette smoking and alcohol intake; exercise; workrelated stress; stress caused by daily chores; and the development of psychological and physical disorders and diseases. The answers to the questions on attitude, stress, and disorders were subjective estimates. In order to ascertain changes related to tanshin funin, we asked the tanshin funin workers to answer each question as it pertained to two different years, i.e., the 1997 fiscal year or, for the subjects who were already working under tanshin funin in the 1997 fiscal year, the most recent fiscal

3 Hiroto NAKADAIRA, et al.: Mental and Physical Effects of Tanshin funin on Male Workers 115 year before their relocation, and the 2001 fiscal year when they worked apart from their family under tanshin funin. The regular workers answered questions in response to their situation in the 2001 fiscal year only. The results of regular medical examinations performed at each company in fiscal years 1997 and 2001 were gathered by the study leader at each company and transferred to the authors without any information that could be used to identify the individuals. The extracted parameters were body mass index (BMI), blood pressure, hemoglobin (Hb), red blood cell (RBC), glutamic oxaloacetic transaminase (GOT), glutamic pyruvic transaminase (GPT), γ-glutamyl transpeptidase (γ-gtp), total cholesterol (Tchol), high-density lipoprotein (HDL), triglycerides (TG), fast blood glucose (FBS), hemoglobin A 1c (HbA 1c ), hearing test, chest X-ray, urine test, and electrocardiograph. There were no changes in the methods of analysis or the laboratories. We used an interval of 5 yr between the two medical examinations because this is the period that companies are legally required to preserve the medical check-up data of their employees. The earliest fiscal year for which all the companies had preserved data was Statistical analysis The statistical analyses for categorical data from the questionnaires and medical check-ups and for proportions were performed by means of chi-square test or Fisher s exact test. When the matched pair method was used, McNemar s test was done. Comparisons of the means of continuous data were done using either Student s t-test or Welch s t-test according to the result of an F-test for equality of variances. In the case of paired data, a paired t-test was performed. When data were not normally distributed, they were logarithmically transformed before they were analyzed by the methods indicated above. Values of p<0.05 (two-paired) were considered to indicate statistical significance. The statistical analyses for medical checkups were performed for three types of the tanshin funin workers which were decided in advance. The first subgrouping was made by attitude toward the tanshin funin system, since it has been reported that senior workers in their 40s and 50s do not feel comfortable relocating even in order to receive a promotion 1). The second was by the length of time spent in the tanshin funin system, since the length of the tanshin funin period varied among workers. In fiscal year 1997 the study subjects included workers who had never experienced tanshin funin, those who had previously worked a tanshin funin assignment but who were not doing so currently, and those who were currently tanshin funin workers. We therefore divided tanshin funin workers into those who had spent less than 2 yr in the system and those who had spent 2 yr or more. Lastly, because the diets of tanshin funin workers are influenced by whether they are provided with meals (i.e., in a boarding house) or must procure their own 7), we subcategorized the workers according to whether or not they were provided with meals during tanshin funin. Results Participants A total of 13 companies (86.7%) agreed to take part, and all of their married male workers in their 40s and 50s who had experienced tanshin funin for at least one year by March 2002 were enrolled in the study, along with an equal number of matched regular workers (n=129 for each group). The characteristics of the participants are shown in Table 1. The average age, the number of family members, and the distribution of titles in their companies were not significantly different between the two groups. Results of the questionnaire study on tanshin funin The percentage of the tanshin funin workers who had Table 1. Characteristics of the participants Tanshin funin workers Regular workers p No. of participants Average age (mean ± SD) 49.1 ± ± * No. of family members (mean ± SD) 4.5 ± ± * No. of titles in companies (%) Executive 1 (0.8) 0 (0.0) Director 36 (27.9) 21 (16.3) Section manager 52 (40.3) 61 (47.3) Chief 27 (20.9) 38 (29.5) Rank and file 12 (9.3) 9 (7.0) No answer 1 (0.8) 0 (0.0) 0.131# *p value for paired t-test. #p value for χ 2 -test.

4 116 J Occup Health, Vol. 48, 2006 experienced a job transfer unaccompanied by their family for a period of no longer than 5 yr between April 1997 and March 2002 was 89.1%. In fiscal year 1997 the tanshin funin worker group was thus composed of those who had never worked under tanshin funin and those who were working or had worked before under the system. As to the type of residence during tanshin funin, 54.3% of the tanshin funin workers took up residence in company-owned boarding houses where meals (breakfast and supper) were provided, 22.0% lived in private apartments, and 17.3% resided in company-owned boarding houses where meals were not provided. The average number of return trips home during tanshin funin was 4.7 ± 2.9 times per month. The frequency of return trips varied widely, with 30% of the tanshin funin workers returning home more than twice a week, and 1.6% not returning home at all. On the other hand, 70.5% of the families did not visit the tanshin funin workers. As the reasons for their decision to accept a position away from home, 66.4% of the tanshin funin workers responded that they had already purchased a home, 63.3% replied that they did not want to change their children s educational environment, and 28.1% answered that their wives jobs were a reason. Half of the tanshin funin workers reported having a positive attitude toward tanshin funin (i.e., very positive [16.4%] or positive [30.3%]), while the same proportion confessed to having negative attitudes (i.e., negative [28.7%] or very negative [18.0%]). There was no difference in workload between the tanshin funin workers and the regular workers and no change between before and during tanshin funin. Workloads were assessed in this study by the length of overtime work, the number of workdays over holidays, and whether the workers were scheduled to work overnight shifts. The commuting time was shorter than that of the regular workers and decreased during tanshin funin (data not shown). Comparison of lifestyles between the tanshin funin workers and the regular workers Table 2 shows the results of the cross-sectional comparison of lifestyles between the tanshin funin workers and the regular workers. The percentage of the tanshin funin workers who did not take breakfast every day was significantly higher than that of the regular workers. However, the tanshin funin workers paid as much attention to the contents of meals as the regular workers, and did not snack between meals more often than the regular workers. Only 8.0% of the tanshin funin workers ate out for supper, but this percentage was significantly higher than that of the regular workers (Table 2). The rate of those who drank alcohol at least once a week did not differ between the tanshin funin workers and the regular workers (Table 2). The average daily alcohol intake of the tanshin funin workers (the equivalent of approximately 779 ml of beer) was not significantly higher than that of the regular workers (684 ml, p=0.187). However, when the tanshin funin workers were categorized, the percentage of those who drank alcohol at least once a week was higher than that of the regular workers and the average daily alcohol intake of the workers with a negative attitude towards tanshin funin was higher than that of the regular workers (817 vs. 582 ml, p=0.026). In the case of the workers with a positive attitude, the alcohol intake was not different from that of the regular workers (722 vs. 703 ml, p=0.901). That of the tanshin funin workers who had been relocated for less than 2 yr was 899 ml versus 646 ml for the corresponding regular workers, but the difference was not statistically significant (p=0.112). The alcohol intake of those who were away for a longer period did not differ from that of the regular workers (747 vs. 690 ml, p=0.513). The average daily alcohol intake of the tanshin funin workers who were provided with meals was significantly higher than that of the regular workers (817 ml vs. 582 ml, p=0.026). On the other hand, that of the tanshin funin workers who cooked for themselves was not different from that of the regular workers (746 vs. 584 ml, p=0.131). The percentage of those who took physical exercise at least once a week was not affected by tanshin funin (Table 2). When the workers were divided into subgroups, a difference in the habit of physical exercise was not observed between any subgroup and the matched regular workers (data not shown). The percentages of those who smoked, who had never smoked, and who had given up smoking were significantly different between the tanshin funin workers and the regular workers (45.7%, 49.6%, and 4.7% vs. 39.1%, 31.3%, and 29.7%, respectively, p<0.001), although the smoking rates were not different between the two groups (45.7% vs. 39.1%, p=0.298). The smoking secession rate for the overall tanshin funin workers was significantly lower than that of the regular workers. The smoking rates were not different between any subgroup of the tanshin funin workers and the matched regular workers, and the smoking secession rates were significantly lower for all the subgroups than for the corresponding regular workers (data not shown). Comparison of mental and physical disorders between the tanshin funin workers and the regular workers We asked the subjects whether they felt job stress and/ or stress caused by their daily chores while living alone (Table 2). More than 60% of the tanshin funin workers and more than 50% of the regular workers answered that they suffered from work-related stress; these percentages did not differ significantly. On the other hand, the rate of those who experienced mental stress related to daily chores was significantly higher in the tanshin funin workers than in the regular workers (Table 2). Similarly,

5 Hiroto NAKADAIRA, et al.: Mental and Physical Effects of Tanshin funin on Male Workers 117 Table 2. Effects of tanshin funin on lifestyle, mental stress, and physical disorders Questions Tanshin funin workers Regular workers Pair Odds p # [Overall] Yes No Yes No ratio* Lifestyle Do you take breakfast every day? 87 (70.2%) 37 (29.8%) 112 (90.3%) 12 ( 9.7%) <0.001 Do you pay attention to what you eat? 91 (71.7%) 36 (28.3%) 90 (70.9%) 37 (29.1%) >0.95 Do you drink alcohol? 122 (95.3%) 6 (4.7%) 114 (89.1%) 14 (10.9%) Do you usually eat out for supper? 8 ( 8.0%) 92 (92.0%) 1 ( 1.0%) 99 (99.0%) Do you have a habit of physical exercise? 56 (44.1%) 71 (55.9%) 68 (53.5%) 59 (46.5%) Mental disorders Do you feel work-related stress? 78 (61.4%) 49 (38.6%) 67 (52.8%) 60 (47.2%) Do you feel stress due to daily chores? 48 (37.8%) 79 (62.2%) 17 (13.4%) 110 (86.6%) <0.001 Physical disorders Have you had a cold or bronchitis? 30 (24.4%) 93 (75.6%) 3 ( 2.4%) 120 (97.6%) <0.001 Have you developed gastric or duodenal ulcers? 26 (21.0%) 98 (79.0%) 3 ( 2.4%) 121 (97.6%) <0.001 Have you had headache? 14 (11.3%) 110 (88.7%) 3 (2.4%) 121 (97.6%) [Attitude towards tanshin funin: negative] Do you feel work-related stress? 41 (73.5%) 15 (26.8%) 27 (48.2%) 29(51.8%) Do you feel stress due to daily chores? 29 (51.8%) 27 (48.2%) 9 (16.1%) 47 (83.9%) <0.001 Do you drink alcohol? 55 (98.2%) 1 (1.8%) 48 (85.7%) 8 (14.3%) [Attitude towards tanshin funin: positive] Do you feel work-related stress? 26 (47.3%) 29 (52.7%) 31 (56.4%) 24 (43.6%) Do you feel stress due to daily chores? 13 (23.6%) 42 (76.4%) 6 (10.9%) 49 (89.1%) Do you drink alcohol? 52 (92.9%) 4 (7.1%) 51 (91.1%) 5 (8.9%) >0.95 [Length of tanshin funin: less than 2 yr] Do you feel work-related stress? 12 (52.2%) 11 (47.8%) 12 (52.2%) 11 (47.8%) >0.95 Do you feel stress due to daily chores? 10 (43.5%) 13 (56.5%) 4 (17.4%) 19 (82.6%) Do you drink alcohol? 23 (100.0%) 0 (0.0%) 22 (95.7%) 1 (4.3%) $ >0.95 [Length of tanshin funin: 2 yr or more] Do you feel work-related stress? 66 (64.1%) 37 (35.9%) 54 (52.4%) 49 (47.6%) Do you feel stress due to daily chores? 38 (36.9%) 65 (63.1%) 13 (12.6%) 90 (87.4%) <0.001 Do you drink alcohol? 98 (94.2%) 6 (5.8%) 91 (87.5%) 13 (12.5%) *Odds ratios were calculated so as to be equal to 1.0 or over except the ratio with $, which contains zero. # p: p value for McNemar s χ 2 -test. the tanshin funin workers reported that they experienced stress related to daily chores with significantly greater frequency during tanshin funin than before they had started to work under tanshin funin (37.8% vs. 9.4%, p<0.001). The workers who were reluctant to participate in tanshin funin experienced both types of stress more frequently than those who were willing to accept their job assignment (Table 2). When the period of tanshin funin was 2 yr or more, a greater number of the tanshin funin workers felt stress due to daily chores than the regular workers (Table 2). The responses in regard to the history of physical disorders indicated that the tanshin funin workers suffered more frequently from common cold/bronchitis and gastric/duodenal ulcers than the regular workers, and that they complained of headache more often than regular workers (Table 2). Comparison of the results of health check-ups in fiscal year 1997 between the tanshin funin workers and the regular workers The results of medical examinations for tanshin funin workers and regular workers for the 1997 fiscal year are shown in Table 3. There were no statistically significant differences in the means between the two groups, with the exception of mean TG which was higher in the tanshin funin workers than the regular workers. In fiscal year 1997, the percentages of participants with abnormal results for each of the test parameters in the medical check-ups were not statistically different between the tanshin funin workers and the regular workers, except in the case of dbp (Table 4). Abnormal dbp was found in a significantly higher

6 118 J Occup Health, Vol. 48, 2006 Table 3. Changes in the results of medical examinations for tanshin funin workers and regular workers from 1997* to 2001* 1997* 2001* Change in value (1997* 2001*) Parameters # pair Tanshin funin Controls p $ Tanshin funin p Controls p & Tanshin funin Controls p & workers workers (vs 1997*) (vs 1997*) workers Mean±SD BMI ± ± ± ± ± ± sbp (mmhg) ± ± ± ± ± ± dbp (mmhg) ± ± ± ± ± ± Hb (g/dl) ± ± ± 1.0 < ± ± ± RBC ( 10,000/mm 3 ) ± ± ± 37.2 < ± 33.1 < ± ± GOT (IU/l) ± ± ± ± ± ± GPT(IU/l) ± ± ± ± ± ± γ-gtp(iu/l) ± ± ± 59.5 < ± 47.9 < ± ± Tchol (mg/dl) ± ± ± ± ± ± HDL (mg/dl) ± ± ± ± 14.4 < ± ± TG (mg/dl) ± ± ± ± ± ± FBS (mg/dl) ± ± ± ± ± ± HbAlc (%) ± ± ± ± ± ± *1997: the 1997 fiscal year; 2001: the 2001 fiscal year. #BMI: body mass index; sbp: systolic blood pressure; dbp: diastolic blood pressure; Hb: hemoglobin; RBC: red blood cell; GOT: glutamic oxaloacetic transaminase; GPT: glutamic pyruvic transaminase; γ-gtp: γ-glutamyl transpeptidase; Tchol: total cholesterol; HDL: HDL cholesterol; TG: triglycerides; FBS: fast blood glucose; HbA 1c : hemoglobin A 1c. $ p value for t-test (GOT, GPT, γ-gtp and TG were logarithmically transformed). p value for paired t-test (GOT, GPT, γ-gtp and TG were logarithmically transformed), & p value for t-test. Table 4. Comparison of numbers of workers with abnormal test results in medical examinations between tanshin funin workers and regular workers from 1997* to 2001* 1997* 2001* p $ Parameters # pair Tanshin funin Controls p $ Tanshin funin p $ Controls p $ Tanshin funin vs Controls workers workers (vs 1997*) (vs 1997*) workers Mean ± SD BMI (28.6 ) 33 (26.2) (31.7) (31.0) >0.95 sbp (mmhg) (16.3) 12 (9.3) (22.5) (13.2) dbp (mmhg) (19.4) 17 (13.2) (22.5) (10.1) Hb (g/dl) (0.0) 1 (0.8) > (1.7) > (0.8) >0.95 >0.95 RBC ( 10,000/mm 3 ) (0.0) 0 (0.0) & 1 (0.8) > (0.0) >0.95 GOT (IU/l) (11.8) 7 (5.5) (5.5) (5.5) >0.95 >0.95 GPT (IU/l) (16.5) 14 (11.0) (17.3) > (13.4) γ-gtp (IU/l) (27.0) 39 (31.0) (34.9) (38.1) Tchol (mg/dl) (38.6) 38 (33.3) (36.8) (33.3) > HDL(mg/dl) (97.9) 95 (97.9) > (95.9) (96.9) >0.95 >0.95 TG(mg/dl) (34.5) 25 (22.7) (30.0) (23.6) > FBS(mg/dl) 83 7 (8.4) 9 (10.8) (15.7) (14.5) >0.95 HbAlc (%) 18 2 (11.1) 1 ( 5.6) > (11.1) > (11.1) >0.95 >0.95 *1997: the 1997 fiscal year; 2001: the 2001 fiscal year. # BMI: body mass index; sbp: systolic blood pressure; dbp: diastolic blood pressure; Hb: hemoglobin; RBC: red blood cell; GOT: glutamic oxaloacetic transaminase; GPT: glutamic pyruvic transaminase; γ-gtp: γ-glutamyl transpeptidase; Tchol: total cholesterol; HDL: HDL cholesterol; TG: triglycerides; FBS: fast blood glucose; HbA 1c : hemoglobin A 1c. $ p: p value for McNemar s χ 2 -test. : values in parentheses are percentages. & : McNemar s χ 2 could not be calculated with zeros.

7 Hiroto NAKADAIRA, et al.: Mental and Physical Effects of Tanshin funin on Male Workers 119 Table 5. Changes in the results of medical examinations from 1997* to 2001* by subgroup 1997* 2001* Change in value (1997* 2001*) Parameters # pair Tanshin funin Regular p $ Tanshin funin p Regular p & Tanshin funin Regular p & workers workers workers (vs 1997*) workers (vs 1997*) workers workers Attitude towards tanshin funin Negative γ-gtp (IU/l) ± ± ± 67.4 < ± ± ± Tchol (mg/dl) ± ± ± ± ± ± TG (mg/dl) ± ± ± ± ± ± HDL (mg/dl) ± ± ± ± ± ± Positive γ-gtp(iu/l) ± ± ± 52.1 < ± 54.9 < ± ± Tchol (mg/dl) ± ± ± ± ± ± TG (mg/dl) ± ± ± ± ± ± HDL (mg/dl) ± ± ± ± 14.3 < ± ± Length of tanshin funin Less than 2 yr γ-gtp (IU/l) ± ± ± ± ± ± Tchol (mg/dl) ± ± ± ± ± ± TG (mg/dl) ± ± ± ± ± ± HDL (mg/dl) ± ± ± ± ± ± yr or more γ-gtp (IU/l) ± ± ± 51.2 < ± 50.9 < ± ± Tchol (mg/dl) ± ± ± ± ± ± TG (mg/dl) ± ± ± ± ± ± HDL (mg/dl) ± ± ± ± 14.5 < ± ± Meals during tanshin funin Provided Hb (g/dl) ± ± ± ± ± ± γ-gtp (IU/l) ± ± ± 57.9 < ± ± ± Tchol (mg/dl) ± ± ± ± ± ± TG (mg/dl) ± ± ± ± ± ± HDL (mg/dl) ± ± ± ± 13.4 < ± ± Cooked themselves Hb (g/dl) ± ± ± ± ± ± γ-gtp (IU/l) ± ± ± 62.5 < ± 49.8 < ± ± Tchol (mg/dl) ± ± ± ± ± ± TG (mg/dl) ± ± ± ± ± ± HDL (mg/dl) ± ± ± ± ± ± *1997: the 1997 fiscal year; 2001: the 2001 fiscal year. # γ-gtp: γ-glutamyl transpeptidase; Tchol: total cholesterol; TG: triglycerides; HDL: HDL cholesterol; Hb: hemoglobin. $ p value for t-test (γ-gtp and TG were logarithmically transformed). p value for paired t-test (γ-gtp and TG were logarithmically transformed). & p value for t-test.

8 120 J Occup Health, Vol. 48, 2006 percentage of tanshin funin workers than regular workers. The percentages of the positive findings by audiography, chest X-ray examination, urinalysis (sugar and protein) and electrocardiography did not differ between the tanshin funin workers and the regular workers. Comparison of changes in the results of health checkups from fiscal year 1997 to 2001 between the tanshin funin workers and the regular workers For the tanshin funin workers, γ-gtp and HDL elevated significantly, while Hb and RBC significantly decreased (Table 3). On the other hand, for the regular workers, in addition to γ-gtp and HDL, Tchol increased, while RBC decreased significantly. The means of γ-gtp for both of the study groups exceeded the normal limit. The percentages of workers with abnormal test results in γ- GTP examinations were significantly increased from fiscal year 1997 to year 2001 for tanshin funin workers, but not for the regular workers. Comparisons of the changes in medical check-up data between fiscal years 1997 and 2001 in the tanshin funin workers with the changes in medical check-up data between fiscal years 1997 and 2001 in the regular workers revealed that there were no significant differences. Analysis of the results of health check-ups by subgroup of the tanshin funin workers The difference in the results of the health examinations between the tanshin funin workers and the regular workers was more remarkable when the comparison was performed by subgroups of the tanshin funin workers (Table 5). When the tanshin funin workers were subgrouped by their attitude towards tanshin funin, the γ-gtp level for those who answered that they felt negative or very negative about tanshin funin was significantly elevated and exceeded the normal limit in fiscal year On the other hand, the level for the regular workers remained unchanged during the 5-yr period. When the tanshin funin workers were divided by the length of time spent in tanshin funin, the mean γ-gtp in fiscal year 2001 for those who were away for a shorter period, namely, less than 2 yr, was twice the mean in fiscal year 1997, while that of the regular workers remained unchanged. The change in the value of γ-gtp for the tanshin funin workers was significantly higher than that of the regular workers. The workers who lived away from their families for 2 yr or more because of tanshin funin did not show significant increases in Tchol and TG while the regular workers did. When the tanshin funin workers were categorized according to whether or not they were provided with meals during tanshin funin, the means of Hb, γ-gtp, Tchol, TG, HDL for those who were provided with meals changed in the same fashion as those for the regular workers. The change in the value of HDL during the 5-yr period was significantly higher for the regular workers than that for those who were provided with meals. On the other hand, the mean Hb decreased significantly for those who cooked for themselves, while that of the regular workers did not change. The means of Tchol and TG remained steady in those who cooked for themselves, while the regular workers had significantly elevated values for these parameters. The changes in the value of Hb and TG during the 5-yr period were significantly different between those who cooked for themselves and the regular workers. Discussion The effects of tanshin funin on various facets of the lives of workers have long been one of the study targets for research into occupational health problems in Japan. Three types of effects were investigated in the present study: changes in the lifestyles of tanshin funin workers; the relation between tanshin funin and mental stress; and physical disorders due to the tanshin funin system. A few authors have already reported on changes in lifestyles, such as meals and alcohol intake 3), and the effects of stress due to work under tanshin funin 2, 4, 5), but there have been few reports on physical disorders and changes in the results of medical check-ups. The results of the present study revealed that tanshin funin affected the lifestyles and the mental and physical health of workers. The most striking change in the lifestyle of the tanshin funin workers was the decrease in the number of workers who took breakfast everyday. The decrease was considered to be due to tanshin funin, because there was a significant difference between the number of tanshin funin workers who took breakfast every day prior to their tanshin funin assignment and the number who took breakfast every day during their tanshin funin assignment. On the other hand, the tanshin funin workers paid as much attention to the nutritional aspect of their meals as the workers who lived together with their families. They did not eat out as often as previously reported 3, 5). Togawa et al. reported that almost half of married male tanshin funin workers over 40 yr old ate out 3). Married male workers in their 40s and 50s are becoming more healthoriented because of their own health problems and due to education through the media or the health departments of their companies 3). In addition, the overall intake of meals for the tanshin funin workers was thought to decrease after the separation from their families. More than half of the tanshin funin workers (52.8%) answered that they suffered from mental stress related to their work, versus 61.2% for the regular workers, and these percentages did not differ significantly. In the present study, the difference in the perception of mental stress between the tanshin funin workers and the regular workers was that the former suffered from chore-related stress more frequently than the latter, while both of the groups were equally affected by job stress. Men are more apt to

9 Hiroto NAKADAIRA, et al.: Mental and Physical Effects of Tanshin funin on Male Workers 121 experience stress due to unfamiliar house chores than are women, and women are more likely to experience occupational stress than are men 7). This tendency is magnified when a male worker is compelled to work under tanshin funin 5). Thus, in a study on local civil servants who lived with their families, the workers suffered mainly from work-related stress, rather than from chore-related stress 8). The present study also revealed that chore-related stress was much stronger when the tanshin funin workers were reluctant to accept their posting. Such reluctance has been reported to arise from the fact that it is difficult for the whole family to relocate 1), not only because of the expense of renting or purchasing another house in Japan and the difficulty of selecting a new school for one s children 1 4), but also because of the difficulty in finding a new job for the spouse 2 4). Nonetheless, the marked daily chore-related stress found in the tanshin funin workers who had been dispatched away from their home for more than 2 yr or more remains unexplained. It was thus revealed that the tanshin funin workers experience two-way stress, i.e., job-related and chorerelated stresses. Recently, tanshin funin dispatches without promotion are increasing in number 2, 4), a fact which has generated another mental stressor for tanshin funin workers. Taken together, these facts suggest an urgent need for efforts to control the burden of mental stress on tanshin funin workers. Negative mental health is related to an increase in alcohol intake and smoking 7). The most common way Japanese workers alleviate stress is by sleeping or taking a nap, and the second most common way is by consuming alcoholic beverages 2, 3, 9). In this study, sleeping time and alcohol consumption of the tanshin funin workers did not differ from those of the regular workers, but alcohol intake was increased when the tanshin funin workers had a negative attitude towards tanshin funin. In addition, the tanshin funin workers in this study did not give up smoking while working under the system. Because tanshin funin workers do not have their family members present to encourage them to limit their drinking and smoking, it will be important to provide future tanshin funin workers with health and lifestyle education programs. As to diseases associated with tanshin funin, our study showed that the tanshin funin workers suffered from stressrelated medical problems, headache, and gastric/duodenal ulcers more frequently than the regular workers. Kasahara and his colleagues 1) reported that the most frequent mental health problem observed in male middle-aged employees was psychosomatic disturbances, which included, in order of frequency, hypertension, peptic ulcers, lumbago, and disturbances of the autonomous nervous system. Headache is one of the features related to mental stress 10). Torelli et al. 11) reported that weekend incidence of migraine attacks was more common in men than in women. In this study, the tanshin funin workers suffered more often from another type of health problem, i.e., common cold/bronchitis, which might be caused by carelessness in regard to health care in their everyday lives during tanshin funin. A newly manifested problem related to the health of tanshin funin workers is the unwarranted cessation of medication during tanshin funin 5). To date, there have been few investigations about the effects of tanshin funin on medical check-up data. The overall analyses in our study revealed no remarkable changes in medical check-up data. In the present study, parameters which showed a significant increase from fiscal year 1997 to 2001 for both of the study groups were γ- GTP and HDL, while RBC decreased significantly for both of the study groups. These results are not surprising, inasmuch as γ-gtp levels have been shown to increase with age 12, 13), and RBC has been shown to decrease with age 14). The cause of the observed elevation of HDL is a bit more complicated. Alcohol intake 15 17) and physical exercise 15, 16) increase HDL, while aging 16), smoking 16), and increases in TG or BMI decrease HDL 15). The two study groups in the present study differed in smoking habits but did not differ in ages or changes in TG and BMI levels and shared a frequent drinking habit and a mediocre physical exercise habit, and these facts suggest that continuous alcohol consumption by Japanese workers was most responsible for the increase in HDL in both study groups, masking the negative effect of smoking. In the analysis of subgroups of the tanshin funin workers, the tanshin funin workers who were provided with meals showed a significantly smaller change in the value of HDL during the 5-yr interval than the regular workers, although their alcohol intake was significantly higher than that of the regular workers. We could not explain the reasons for this finding in the present study, because these two groups did not differ in terms of physical exercise, smoking rates, and changes in TG or BMI. Hb decreased significantly from fiscal year 1997 to 2001 only in the tanshin funin workers in the present study. Hb levels in healthy people have been reported to decrease with age 18). The Hb level of the tanshin funin workers who cooked their own meals dropped more markedly, and this suggests that the nutrition status of these tanshin funin workers was worse than that of the corresponding regular workers, because the Hb level reflects nutritional status 18). As to other diet-related parameters, the tanshin funin workers did not show as great an increase in serum Tchol as the workers living with their families. When the length of time spent apart from the families was 2 yr or more or when the tanshin funin workers cooked their own meals, another diet-related parameter, TG, increased only for the matched regular workers. This was considered to be attributed to the tendency of the tanshin funin workers to skip breakfast and to eat snacks between meals no more frequently than the regular workers, and to the fact that

10 122 J Occup Health, Vol. 48, 2006 the tanshin funin workers ate out less frequently than was previously reported 3, 5). Further studies are needed particularly on the nutritional aspects of the tanshin funin workers who cooked their own meals because the differences of changes in the values of Hb and TG between them and the regular workers were most remarkable. When the tanshin funin workers were categorized by their attitude towards tanshin funin and the length of time spent apart from their families, there were marked increases in the level of γ-gtp for the tanshin funin workers who were unwilling to work under tanshin funin and for those who had been relocated for less than 2 yr. In the case of the reluctant tanshin funin workers, we suspect that the reasons are, in addition to aging 12, 13), the findings that mental stresses related to job and daily chores were stronger and that alcohol intake increased in terms of the percentage of workers who drank alcohol and the volume of intake. For the inexperienced tanshin funin workers, however, statistical significance was not obtained in mental stress or alcohol intake. In order to discuss a causal association between the period of tanshin funin and an increase in the level of γ-gtp, further studies are needed. In order to cope with the changes in lifestyles of tanshin funin workers and their effects, companies should adopt health and lifestyle education programs for tanshin funin workers. In terms of coping with stress, it has been shown that organizational support in the workplace is crucial 19). However, the current support systems for tanshin funin workers offered by companies mainly consist of the provision of company housing and financial benefits. Our results indicate that allowing male workers to live with their families will allow greater variety in the methods of decreasing stress and that reluctant tanshin funin workers and workers who have been located apart from their families for a long period of time should be well supported systemically to protect against adverse mental health states. More concrete assessment of the personal stress-coping strategies of tanshin funin workers should be done to form effective support programs. In recent years, work-related diseases have become an important health problem in Japanese industries 20). Among work-related diseases, karoushi, mental disorders, heart diseases, and cerebrovascular diseases caused by overwork have been the main targets of diseaseprevention efforts in this country. Background factors include the change in the population structure associated with the aging society and the change in the employment structure due to various working systems, including tanshin funin 20). The aging labor force has brought lifestyle-related diseases into workplaces and the change in the employment structure has yielded an environment in which many workers feel mental stress. The tanshin funin system is one of the working formats under which workers are exposed to excess mental stress, as disclosed in the present study. The government is now taking measures to combat some of these work-related diseases. The recently published total preventive measures of karoushi 21) are going to be added to the next revision of the Industrial Safety and Health Law. However, no specific proposals to prevent workers from adverse effects of mental stress caused by tanshin funin have been made. We are supposed to utilize the conventional health promotion programs to promote and maintain mental health of tanshin funin workers 20). As health promotion activities in workplaces continue to gain in importance, the role of occupational health professionals is being increasingly emphasized 22). When asked whom they consulted for health advice, however, more than half of the tanshin funin workers in this study (57.7%) answered that they consulted their family, and 11.4% answered that they consulted their colleagues, while smaller percentages said that they consulted doctors (7.3%) and nurses (8.1%) at their companies. Doctors and nurses in the healthcare departments of companies should understand the significance of health and lifestyle education programs and mental health care at the workplace, and should put them into practice on a routine basis. They should place an emphasis on reluctant tanshin funin workers. It would also be useful to introduce an occupational health and safety management system into the workplace. One of the biases that must be considered in this study was the selection of the subjects. We requested companies that met the selection criteria to join the present study, but some companies did not do so without explicit reasons. The tanshin funin worker group in this study might thus not be representative of the population and might not be large enough in number to detect differences in the data of medical health check-ups, such as those in the proportions of workers who suffered from mental stress, alcohol intake, and changes in values of γ-gtp for the subgroups of tanshin funin workers. The length of tanshin funin varied from worker to worker. We selected a five-year interval to assess the changes of data of medical checkups, because many companies did not keep the medical records of health examination data longer than the statutory period of 5 yr. In the present study, however, about 90% of the tanshin funin workers had experienced tanshin funin for less than 5 yr. When the analyses were limited to the tanshin funin workers with experience of less than 5 yr, the results remained unchanged. The data collection methods used may have influenced the strength of the statistical analyses in the present study. That is, the use of self-administered questionnaire surveys that gathered subjective information may have limited the strength of the statistical analyses. In particular, answers to questions on events that took place 5 yr before the survey are subject to recall bias. In addition, because we used simple yes/no questions to detect mental disorders, it was

11 Hiroto NAKADAIRA, et al.: Mental and Physical Effects of Tanshin funin on Male Workers 123 difficult to quantify an individual s level of stress. Finally, the regular workers were asked only about their current situation. It was thus impossible to elucidate any changes in data during the five-year intervals in order to compare with those of the tanshin funin workers. In summary, abrupt changes in lifestyle, including diet and healthcare changes, and mental stress related to living alone were the problems manifested by tanshin funin workers in the present study, while the degradation of data of medical check-ups was not remarkable. When workers were reluctant to participate in tanshin funin, their mental stress, alcohol consumption, and level of γ- GTP significantly increased. Tanshin funin might be a hotbed of work-related diseases, but there are no effective official countermeasures. It is therefore important for doctors and nurses in the healthcare departments of each company to provide future tanshin funin workers with health and lifestyle education programs before they start to work under the system, and to supply current tanshin funin workers with mental health care. Acknowledgments: This study was funded by a grant from the Japan Labor Health and Welfare Organization. We are also very grateful to the Niigata Occupational Health Promotion Center for their continuing cooperation. Reference 1) Y Kasahara, O Fujita and K Sakai: Industrialization and mental health in Japan mental health of large enterprise employees in their 40s and 50s. Jpn J Psychiatry Neurol 41, (1987) 2) Y Tosaka and Y Yamada: Stress and stress coping in the case of the tanshin funin workers. Sangyo Eisei Gakkaishi (Jpn J Ind Hyg) 42, A97 A98 (2000) (in Japanese) 3) K Togawa, R Nakamura and K Koda: Life style of the tanshin funin workers. Roudo no Kagaku (Sci Labor) 52, (1997) (in Japanese) 4) Y Tanaka: Transferred employees psychological stress due to tanshin funin family separation: a study of stress responses. Shinrigaku Kenkyu 65, (1995) (in Japanese) 5) I Yoshimi: Japan s National Health Promotion in the 21st Century, Health Japan 21, and health supporting system for the tanshin funin workers. Roudo no Kagaku (Sci Labor) 56, (2001) (in Japanese) 6) Labour Standards Bureau. Current situation of industrial health. In: the Ministry of Health, Labour and Welfare ed. General Guidebook on Industrial Health. Tokyo: the Ministry of Health, Labour and Welfare, 2004: ) M Irie, M Miyata, S Nagata, N Mishima, M Ikeda and S Hirayama: The relationship between workers attitudes towards health, lifestyle and mental health. San Ei Shi 39, (1997) (in Japanese) 8) S Uzura: The effects of stressors at work and in family life on self-rated health and psychological well-being. Jpn J Pub Health 49, (2002) (in Japanese) 9) K Yanagida: Behaviors of kitchen drinkers and tanshin funin drinkers. Kosyu Eisei (Public Health) 63, (1999) (in Japanese) 10) PA Davis, JE Holm, TC Myers, and KT Suda: Stress, headache, and physiological disregulation: a time-series analysis of stress in the laboratory. Headache 38, (1998) 11) P Torelli, D Cologno and DC Manzoni: Weekend headache: a possible role of work and life style. Headache 39, (1999) 12) Y Ono, R Fujine, Y Taguchi, K Hiroi, T Furuta, M Ogawa, T Yamaguchi and Y Arakawa: Aging and liver function. J Jpn Conference Geriat Gastroenterol 3, 5 15 (2001) (in Japanese) 13) N Nakanishi1, K Nakamura, K Nakajima, K Suzuki and K Tatara: Coffee consumption and decreased serum gamma-glutamyltransferase: a study of middle-aged Japanese men. Eur J Epidemiol 16, (2000) 14) M Sugiura, R Yamamoto and H Kawai: The second report on the results of a traveling clinic for 22 yearseffects of aging. Jp J Med Technol 51, (2002) (in Japanese) 15) A Yamamoto, H Temba, H Horibe, H Mabuchi, Y Saito, Y Matsuzawa, T Kita and H Nakamura: Life style and cardiovascular risk factors in the Japanese population - from an epidemiological survey on serum lipid levels in Japan 1990 Part 1: Influence of life style and excess body weight on HDL-cholesterol and other lipid parameters in men. J Atheroscler Thromb 10, (2003) 16) H Takanari, H Oshima and E Takahashi: Effects of age, physical index and alcohol on serum lipid levels. Occup Health J 22, (1999) (in Japanese) 17) C Nishimura, H Imamura, K Uchida, N Miyamoto and D Obata: Associations between alcohol intake and blood pressure/serum lipid levels among Japanese middle-aged men. Japanese Journal of the MHTS 26, (1999) (in Japanese) 18) T Shirota, A Oishi, A Shinohara, K Uchida, Y Kiyohara and M Fujishima: Changes in nutritional intake among elderly residents of a community over a 10-year period: the Hisayama study. Jpn J Geriat 39, (2002) (in Japanese) 19) PR Vagg and CD Spielberger: Occupational stress; measuring job pressure and organizational support in the workplace. J Occup Health Psychol 3, (1998) 20) Labour Standards Bureau. Measures to promote health. In: the Ministry of Health, Labour and Welfare ed. General Guidebook on Industrial Health. Tokyo: the Ministry of Health, Labour and Welfare, 2004: (in Japanese). 21) Labour Standards Bureau. Measures to disorders due to overwork. In: the Ministry of Health, Labour and Welfare ed. General Guidebook on Industrial Health. Tokyo: the Ministry of Health, Labour and Welfare, 2004: ) RJ McCunney: Health and productivity: a role for occupational health professionals. J Occup Environ Med 43, (2001)

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