Activities of occupational physicians for occupational health services in small-scale enterprises in Japan and in the Netherlands.

Abstract

Occupational health service (OHS) for small-scale enterprises (SSEs) is still limited in many countries. Both Japan and the Netherlands have universal OHS systems for all employees. The objective of this survey was to examine the activities of occupational physicians (OPs) in the two countries for SSEs and to investigate their proposals for the improvement of service.
Questionnaires on types and sizes of the industries they serve, allocation of service hours (current and desired), sources of information for occupational health activities etc. were mailed in 2006 to 461 and 335 Japanese and Dutch OPs, respectively, who have served in small- and medium-scale enterprises. In practice, 107 Japanese (23%) and 106 Dutch physicians (32%) replied, respectively.
Total service time per month was longer for OPs in the Netherlands than OPs in Japan. Japanese OPs spent more hours for health and safety meetings, worksite rounds, and prevention of overwork-induced ill health (14-16% each). Dutch OPs used much more hours for the guidance of absent workers (48%). Thus, service conditions were not the same for OPs in the two countries. Nevertheless, both groups of OPs unanimously considered that employers are the key persons for the improvement of OHS especially in SSEs and their education is important for better OHS. The conclusions should be taken as preliminary, however, due to study limitations including low response rates in both groups of physicians.

Full text

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Int Arch Occup Environ Health (2010) 83:389–398
DOI 10.1007/s00420-010-0514-6
123
ORIGINAL ARTICLE
Activities of occupational physicians for occupational health
services in small-scale enterprises in Japan and in the Netherlands
Jiro Moriguchi · Masayuki Ikeda · Sonoko Sakuragi ·
Kazuo Takeda · Takashi Muto · Toshiaki Higashi ·
André N. H. Weel · Frank J. van Dijk
Received: 11 April 2009 / Accepted: 14 January 2010 / Published online: 4 February 2010
© The Author(s) 2010. This article is published with open access at Springerlink.com
Abstract
Objectives
scale enterprises (SSEs) is still limited in many countries.
Both Japan and the Netherlands have universal OHS sys-
tems for all employees. The objective of this survey was to
examine the activities of occupational physicians (OPs) in
the two countries for SSEs and to investigate their propos-
als for the improvement of service.
Methods
Questionnaires on types and sizes of the indus-
tries they serve, allocation of service hours (current and
desired), sources of information for occupational health
activities etc. were mailed in 2006 to 461 and 335 Japanese
and Dutch OPs, respectively, who have served in small- and
Occupational health service (OHS) for small-
medium-scale enterprises. In practice, 107 Japanese (23%)
and 106 Dutch physicians (32%) replied, respectively.
Results and Conclusions
Total service time per month
was longer for OPs in the Netherlands than OPs in Japan.
Japanese OPs spent more hours for health and safety meet-
ings, worksite rounds, and prevention of overwork-induced
ill health (14–16% each). Dutch OPs used much more
hours for the guidance of absent workers (48%). Thus, ser-
vice conditions were not the same for OPs in the two coun-
tries. Nevertheless, both groups of OPs unanimously
considered that employers are the key persons for the
improvement of OHS especially in SSEs and their educa-
tion is important for better OHS. The conclusions should be
taken as preliminary, however, due to study limitations
including low response rates in both groups of physicians.
Keywords
Occupational health services · Small-scale enterprises
Education · Employer · Occupational physician ·
Introduction
Occupational health service (OHS) activities for small-scale
enterprises (SSEs) are often insuYcient in many countries
(Bradshaw et al. 2001; Park et al. 2002) as they have limited
access to human, economic, and technical resources
(Champoux and Brun 2003). Thus, workers employed in
SSEs are usually provided with lower quality occupational
health services (OHS) and sometimes have poorer health
conditions when compared with their counterpart workers in
large-scale enterprises (Furuki et al. 2006; Kubo et al.
2006). Good OHS require supports of competent OH profes-
sionals (Nicholson 2004), and well-trained occupational
physicians (OP) or nurses would be the best experts to
provide proper OHS (Bradshaw et al. 2001).
J. Moriguchi (&) · S. Sakuragi
Kyoto Industrial Health Association (Mibu OYce),
4-1 Mibu-Sujakucho, Nakagyo-ku, Kyoto 604-8871, Japan
e-mail: moriguchi@kyotokojohokenkai.or.jp
M. Ikeda · K. Takeda
Kyoto Industrial Health Association (Kyoto OYce),
Kyoto 604-8472, Japan
T. Muto
Department of Public Health, Dokkyo Medical University,
Tochigi 321-0293, Japan
T. Higashi
Department of Work Systems and Health, Institute of Industrial
Ecological Sciences, University of Occupational
and Environmental Health, Japan, Kitakyushu 807-8555, Japan
A. N. H. Weel
Centre of Excellence, Netherlands Society
of Occupational Medicine, 3500 GC Utrecht, the Netherlands
F. J. van Dijk
Coronel Institute of Occupational Health,
Academic Medical Center, University of Amsterdam,
22700 Amsterdam, the Netherlands

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390 Int Arch Occup Environ Health (2010) 83:389–398
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In Japan, the Industrial Safety and Health (ISH) Law
deWnes that the provision of OHS to protect health of
employees is among the duties of employers irrespective of
enterprise size and stipulates that companies employing 50
or more workers must establish a health and safety commit-
tee and appoint an OP (the number of OPs varies as a func-
tion of employee numbers; Ministry of Health, Labour and
Welfare, Japan 1972a). The enterprises with less than 50
employees are regarded as SSEs, and Japanese government
recently has made several eVorts to improve OHS in SSEs.
For example, Regional Occupational Health Centers (347
in total) have been established to support OHS.
In the Netherlands, all enterprises have been obliged to
have a contract with a certiWed external OHS after a revi-
sion of the Working Conditions Act in 1994 (Weel and
Plomp 2007). After further amendment in 2005, employ-
ers are no longer obliged to have a full contract with an
external OHS provider. Under the condition of an appro-
priate collective agreement between employers and
employees, employers are allowed to arrange legally
required OH activities by themselves. If the results are not
satisfactory, however, they should contract with an exter-
nal OHS provider. A contract with an OP is still compul-
sory for pre-employment examinations, periodical health
examinations, and medical sickness absence guidance
activities (Ministry of Social AVairs and Employment, the
Netherlands 2006).
Thus, although OHSs for SSEs are not similar, the two
countries have established universal OHS for all employees
including those in SSEs. The present study was initiated to
investigate the activities of OPs in Japan and the Nether-
lands, with additional foci of collecting suggestions from
OPs in the two countries for improvement in OHS in SSEs.
It was expected that such study should be valuable for the
improvement of the quality of OHS for SSEs not only in the
two countries but also in other countries.
Methods
Study subjects
Participants of the present study in the two counties were
OPs who were working in SMEs, and not associated with
in-company OHS. A questionnaire survey was conducted in
December 2006. Subjects in Japan were OPs who belonged
to member external OHS organizations of National Federa-
tion of Industrial Health Organizations, Japan (NFIHO).
Full-time OPs for large companies and practitioners in
clinic/hospital facilities were not aYliated to NFIHO mem-
ber organizations, and they were automatically excluded
from this study. Questionnaires (for details, see below)
were mailed to all 461 physicians in NFIHO.
Subjects in the Netherlands were selected from 1,780
physicians who were the members of the Netherlands Soci-
ety of Occupational Medicine (Nederlandse Vereniging
voor Arbeids—en Bedrijfsgeneeskunde, NVAB). Based on
the post codes, the country was grouped into 4 regions and
20% of all OPs from each region were selected. A stratiWed
random sampling strategy by decade of years of age and
gender was employed for the selection. After exclusion of
apparently non-active physicians (e.g., retired, or exclu-
sively researching or teaching), questionnaires were sent to
335 physicians. Reminder letters were sent only to OPs in
the Netherlands and only once.
In practice, 107 Japanese (23%) and 106 Dutch physicians
(32%) replied, respectively. Of these physicians, 28 Japanese
and 17 Dutch physicians were non-active as an OP and they
were excluded. In addition, 19 Dutch OPs were full-timers for
large companies and were also excluded from the analysis.
Thus, eVective replies from remaining 79 Japanese (17%) and
70 Dutch OP cases (21%) were employed for analysis.
Questionnaires
The questionnaires (for details, see the Appendix) included
questions on gender, age (by decade of years), working
actively as OP or not, working as OP exclusively for one or
more large companies or not (only in the Netherlands), expe-
rience as an OP and as a clinician, qualiWcations for OP, ser-
vice time (hours per month) as an OP, the number of
companies (and the size by employee numbers) serving for,
units (1 unit = 3 h) spent for each company per month, total
number of employees covered, types of industries, estimations
of the service hours for diVerent activities and the perceived
ideal (desired) service hours for diVerent activities, sugges-
tions on infrastructure to strengthen OHS for SSEs, requests
on resources for professional service in OH, and any problems
in improving OHS in SSEs as well as possible solutions.
Statistical analysis
Arithmetic means and modes were taken as representative
parameters. When data did not follow normal distribution,
Mann–Whitney test and Wilcoxon test were employed as
necessary. Chi-squares test was also used. Values of p < 0.05
were considered statistically signiWcant.
Results
Basic characteristics
Gender distribution among OPs showed that male domi-
nancy was common in the two countries and it was more so
in Japan (men:women = 85%:15%) than in the Netherlands

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Int Arch Occup Environ Health (2010) 83:389–398391
123
(68%:32%; p < 0.01 by chi-squares test). Age distributed
with a mode of ¸60 years in Japan (41% of all) and 40–
59 years in the Netherlands (84%). Despite the younger age
for the Dutch OPs, experience as an OP was signiWcantly
longer in the Netherlands [mean (mode) being 10.9 (10)
years in Japan versus 16.4 (15) years in the Netherlands;
p < 0.01 by Mann–Whitney test]. Expectedly, Japanese
OPs had substantially longer clinical experience than Dutch
OPs [mean (mode) being 21.5 (21) years in Japan versus
2.4 (0) years in the Netherlands; p < 0.01 by Mann–Whit-
ney test].
As to qualiWcations for OP, 86% of Japanese OPs had a
qualiWcation of the Japan Medical Association (JMA), 10%
had a qualiWcation of the Japan Society for Occupational
Health (JSOH), 37% had a qualiWcation for occupational
health consultant of the Japanese Ministry of Health,
Labour and Welfare, and 6% had the Diploma of Occupa-
tional Health from the University of Occupational and
Environmental Health, Japan. In the Netherlands, 87% of
Dutch OPs had a qualiWcation of registered OP of NVAB,
9% were still in vocational training for OP, and 3% had
other qualiWcations (e.g., a registered social insurance phy-
sician, medical adviser .).
Comparison of the number of employees covered by one
OP showed that Dutch OPs managed a signiWcantly larger
number of employees than Japanese OPs; the mean
(the mode) of employees covered in Japan was 1,823
employees (1,000 employees) in contrast to 3,227 employees
(2,000 employees) in the Netherlands (p < 0.01 by Mann–
Whitney test; the top half in Table 1). It should be noted,
however, that one OP serves more than one enterprise. Clas-
siWcation of enterprises covered by OPs showed that Dutch
OPs focused more (85.1%) in SSEs (with <50 employees)
than Japanese OPs (11.0%). Monthly service hours as an OP
(the bottom half in Table 1) were longer in the Netherlands
[mean (mode) of 24.9 (20) hours) in Japan versus 130.5 (160)
hours in the Netherlands; p < 0.01 by Mann–Whitney test].
Regarding types of industries, manufacturing industries,
electricity, gas/water supply companies, and information
companies formed a major target of services for OPs in Japan
(87 out of 232, or 37.5%) than in the Netherlands (46 out of
276, or 16.6%; p < 0.01 by chi-squares test for the diVer-
ence). In contrast, education and learning support companies
formed a signiWcantly (p < 0.01 by chi-squares test) larger
proportion (23 out of 276, or 8.3%) covered by Dutch OPs
than by Japanese OPs (2 out of 232, or 0.9%; Table 2).
Current activities
Japanese OPs spent a signiWcantly (p < 0.01 by chi-squares
test) larger percentage of hours for attendance at health and
safety committee meetings, rounds of the work areas, health
and hygiene education, and prevention of health hazards due
to overwork (Table 3). The hours spent for general health
examinations and mental health care were relatively longer in
Japan than in the Netherlands as well, although the diVer-
ences were statistically insigniWcant (p > 0.05). Dutch OPs
used many more hours for guidance of absent workers and
spent more hours for the planning and advice on OSH policy
than their Japanese counterparts (p < 0.01 for both).
Proposed time allocation for OH activities
From the comparison between current and ideal (desired)
working hours of OPs (Table 4), more time for planning
and advices on OHS policy, attendance at the health and
safety meetings, worksite rounds, activities related to the
work environment such as risk assessment and manage-
ment of work and work environment, health and hygiene
education, and health promotion activities were wishes
common to both groups. OPs in both countries also wished
to preserve more time for general health examination and
mental health care. In addition, Japanese OPs wished to
Table 1 Distribution of enterprises by employee numbers and distri-
bution of service frequencies
an = 79
bn = 70
cNumber of employees
dBy Mann–Whitney test
eBy chi-squares test
fOne unit = 3 h
gMonthly service hours as an OP
CategoryJapanese OPsa
Dutch OPsb
P-value
No. (%)No. (%)
Enterprise size by number of employees
Meanc
Modec
ClassiWcation by category
Less than 50
From 50 to 99
From 100 to 499
From 500 to 999
More than 1,000
Total
Frequencies of service by OPs (unitf/month)
Meang
Modeg
ClassiWcation by category
Less than 1
From 1 to 4
From 5 to 15
More than 16
Total
1,822.6
1,000
3,226.8
2,000
<0.01d
<0.01d
<0.01e
58 (11.0)
183 (34.9)
217 (41.4)
48 (9.1)
19 (3.6)
525 (100.0)
4,480 (85.1)
334 (6.3)
355 (6.8)
42 (0.8)
54 (1.0)
5,265 (100.0)
24.9
20
130.5
160
<0.01d
<0.01d
<0.01e
294 (57.2)
183 (35.6)
34 (6.6)
3 (0.6)
514 (100.0)
1,443 (73.7)
332 (17.0)
114 (5.8)
69 (3.5)
1,958 (100.0)

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392Int Arch Occup Environ Health (2010) 83:389–398
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increase hours for sick leave guidance and perusal of the
answers of ‘Other’ (responses to an open-end question)
showed that they hoped to reduce hours for the after-care of
the health examinations (Current: 1.62 h month¡1, Ideal:
0.67 h month¡1).
Japanese OPs also wished to increase total working
hours as an OP. Dutch OPs wished to decrease the hours
spend for sick leave guidance (Table 4) and wanted to
increase the hours for speciWc health examinations, preven-
tion of overwork-induced ill health and health examinations
at the initiation of employment compared to current condi-
tions. Similar analyses of ‘Other’ answers showed that they
wished to take more time to improve OPs’ quality by
attending e.g., quality assurance meetings with colleagues,
continuous professional education, and coaching (Current:
1.85 h month¡1, Ideal: 1.97 h month¡1).
Major information sources
In Japan, the main resources to support professional work
in OH care were occupational health promotion centers
(OHPCs; the major function is to supply information to OH
professionals in the region), the Medical Association, and
websites for OH (Table 5). The main resources in the Neth-
erlands were websites for OH, colleagues in NVAB and
other physicians, and research institutes. Research institutes
mentioned were the National Applied Research Organiza-
tion (TNO) and the Netherlands Centre for Occupational
Diseases (NCvB). Educational institutes included the Neth-
erlands School of Public and Occupational Health
(NSPOH) and the School for Public and Occupational
Health Professionals (SGBO).
Infrastructures to be strengthened
OPs in both countries considered that many aspects of the
infrastructure should be strengthened for SSEs. For organi-
zational facilities such as branch-organized (branched by
business categories) occupational health centers, demands
of both countries were at the same level (answers for “agree
strongly” plus “agree”: 66% in Japan, 66% in the Nether-
lands, p > 0.10 by chi-squares test.
The rates of OPs who suggested education and training of
employers were very high in both countries (positive answers:
87% in Japan, 74% in the Netherlands, p < 0.01). The rates
were comparable to (p > 0.10 in Japan by chi-squares test) or
even higher than (0.10 > p > 0.05 in the Netherlands) that for
education and training of employees (positive answers: 85%
in Japan, 60% in the Netherlands, p < 0.01). Demands for the
availability of brochures, websites, and other educational
materials were also high in both countries (positive answers:
73% in Japan, 50% in the Netherlands), being stronger in
Japan than in the Netherlands (p < 0.01).
Problems and solutions in OH for SSEs
OPs in both countries considered that advice by profession-
als, provision of inexpensive educational courses, and shar-
ing good practices was necessary to improve the insuYcient
knowledge of employees, health managers, and employers
on various OH matters (results of analyses of other miscella-
neous comments in the questionnaires). There were many
suggestions for sharing good practices of various OH activi-
ties in both countries. Especially with regard to conditions in
workplaces, developments of inexpensive solutions in Japan
and more eVective solutions based on cost-beneWt analysis in
the Netherlands were requested.
It was also suggested that opportunities for communication
and lectures to deliver OH information for employers,
managers, and employees were insuYcient in both countries.
Arranging regular opportunities for communication was
regarded as important to solve these problems. OPs in the
Netherlands considered time and budget for communication as
a part of oYcial tasks so that they proposed that a clear state-
ment should be made in the contract with the companies.
Necessity of more budgets, by means of e.g., governmental
subsidization for OH activities, was mentioned in both groups
of OPs.
Table 2 Types of industries for which OPs serve in Japan and in the
Netherlands
aRegistration by multiple choices
bn = 79
cn = 70
dBy chi-squares test
Type of industriesNumber of OPsa
p-valued
Japaneseb
Dutchc
Agriculture, forestry, and Wshery
Cafe, restaurants, and hotels
Construction
Education and learning support
Electricity, gas and water supply
Finance and insurance
Information and communication
Manufacturing
Medical, health,
and welfare services
Mining
Public business
Real estate agent
Services
Transportation
Wholesale or retail trade
Others
1
7
6
8
<0.10
>0.10
>0.10
<0.01
<0.05
>0.10
<0.05
<0.01
>0.10
14
2
11
8
19
57
13
24
23
4
9
11
31
24
26>0.10
>0.10
>0.10
<0.10
>0.10
>0.10
>0.10
21
2
21
22
21
11
29
4
40
27
18
12

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Table 4 Current and ideal
working hours per month by the
types of activities of OP in Japan
and in the Netherlands
Type of activitiesJapanese OPsa
Dutch OPsb
Currentc
Idealc
Pd
Currentc
Idealc
Pd
Attendance at the meeting of HSe committee
Development of comfortable workplaces
Diagnosis for return to work and follow-up
General health examination
Guidance of workers on sick leave
Health and hygiene education
Health examination at the start of employment
Health promotion activity
Maintenance and management of work
Maintenance and management
of work environment
Mental health care
Plan and advice for OSHe policy
Pre-employment health examination
Prevention of health hazards due to overwork
Rehabilitation during the absent periodf
Risk assessment
Rounds of the work area
SpeciWc health examination
Others
Total
2.3
0.3
2.0
1.8
0.8
1.1
0.3
0.8
0.3
0.5
2.8
0.8
2.5
1.5
1.9
2.0
0.3
1.4
0.8
1.0
<0.01
<0.01
0.99
0.37
<0.01
<0.01
0.36
<0.05
<0.01
<0.01
2.1
4.9
6.7
3.8
64.4
2.9
0.8
4.1
5.7
4.3
5.0
5.7
8.1
4.1
39.6
6.2
2.6
6.1
6.2
6.4
<0.01
0.06
0.04
0.35
<0.01
<0.01
<0.01
<0.01
<0.01
<0.01
3.3
0.5
0.1
3.1
–
0.2
2.5
0.7
1.7
22.1
3.7
1.3
0.2
3.9
–
0.7
3.3
0.7
1.7
30.5
0.61
<0.01
<0.01
0.24
–
<0.01
<0.01
>0.99
0.72
<0.01
9.4
8.1
1.1
3.2
21.9
1.1
4.3
7.0
11.8
167.4
9.6
12.3
1.6
4.8
20.8
3.4
12.0
11.1
6.2
171.5
0.12
<0.01
0.12
0.04
0.41
<0.01
<0.01
<0.01
<0.01
>0.88
an = 79
bn = 70
cMean service duration
(in hours) was given by each
occupational physician, from
which the arithmetic means were
calculated for Japanese and
Dutch physicians. Unit is in
hours/month
dBy Wilcoxon test
e(Occupational) health and
safety
fThis question is only to Dutch
physicians
Table 3 Proportion of working
hours by types of current activi-
ties as an OP in Japan and in the
Netherlands
Types of activities Time allocation by OPs (%)a
p-valued
Japaneseb
Dutchc
Attendance at health and safety committee
Development of comfortable workplaces
Diagnosis for return to work and follow-up
General health examination
Guidance of workers on sick leave
Health and hygiene education
Health examination at the start of employment
Health promotion activity
Maintenance and management of work
Maintenance and management of work environment
Mental health care
Plan and advice for OHSe policy
Pre-employment health examination
Prevention of health hazards due to overwork
Risk assessment
Rounds of the work area
SpeciWc health examination
Others
Total
Total working hours per month
13.7
0.8
7.1
9.5
2.5
7.6
1.2
4.5
1.2
2.1
9.5
2.5
0.5
13.8
0.3
15.6
2.5
5.1
100.0
22.1
1.4
3.8
3.8
2.9
47.8
1.6
0.6
1.9
2.6
2.3
5.4
6.3
0.8
1.6
0.8
3.2
5.1
8.1
100.0
145.5
<0.01
<0.01
0.10
0.22
<0.01
<0.01
0.18
0.34
<0.01
<0.01
0.07
<0.01
<0.01
<0.01
<0.01
<0.01
<0.01
<0.01
aMean service duration
(in hours) was given by each
occupational physician, from
which the arithmetic means were
calculated for Japanese and
Dutch physicians
bn = 79
cn = 70
dBy Mann–Whitney test
e(Occupational) health and
safety