key: cord-0990199-ds8cjz9n
authors: Fukita, Susumu; Kawasaki, Hiromi; Yamasaki, Satoko
title: Managers’ awareness of mental health measures for their employees in small and medium-sized enterprises in a depopulated mountainous area in Japan: A qualitative study
date: 2022-03-04
journal: Medicine (Baltimore)
DOI: 10.1097/md.0000000000028999
sha: aaede36200fb39c6800a238848f81db71d5e6271
doc_id: 990199
cord_uid: ds8cjz9n

The local economy is often supported by small and medium-sized enterprises. There is a need to consider effective promotion methods for mental health measures in these enterprises in depopulated mountainous areas. It is important to understand managers’ awareness when considering effective mental health measures in these enterprises. The study's aim is to explore managers’ awareness of mental health measures for employees in small and medium-sized enterprises in depopulated mountainous areas in Japan. Qualitative semi-structured interviews were conducted with 6 managers in 2019. The primary issues addressed by the interview were regarding the awareness among managers about mental health promotion measures for employees. These are the primary prevention measures. The interview also addressed issues related to the awareness of measures for mental health problems that are fundamental to the secondary and tertiary prevention measures. A qualitative descriptive analysis was conducted. Three categories and 8 subcategories emerged regarding the managers’ awareness of mental health promotion measures for employees. The 3 categories were: “Individual support, including their life's aspect, while taking advantage of formal and informal relationships,” “The difficulty of drawing out an employees’ motivation to work, due to the changes over time in the work size or in their working relationships,” and “Creating a comfortable working environment for employees, by complying with the labor standards and adjusting relationships.” Regarding managers’ awareness of the measures for mental health problems, four categories and 8 subcategories emerged. The 4 categories were: “Prevention and awareness of the incidence of mental health problems,” “Individual support based on the enterprise's or employee's characteristics,” “A lack of support for the manager to address employees’ mental health problems,” and “Employees quitting the job, due to the lack of appropriate support.” Though managers in depopulated mountainous areas were well aware of the mental health activities offered, the categories showed the need to foster social capital. It also showed the need to collaborate with external support organizations, and the difficulties faced by small and medium-sized enterprises.

Many enterprises are small and medium-sized enterprises (SMEs), and many employees work in SMEs across the world. The ratio of SMEs to the total number of enterprises is 99.7% in Japan, [1] 99.9% in the US, [2] 88.8% to 99.9% in ASEAN, [3] and 99.8% in the EU. [4] In addition, the ratio of employees in SMEs to the total number of employees in Japan is 68.8%, [5] 47.1% in the US, [2] 51.7% to 97.2% in ASEAN, [3] and 67% in the EU. [4] As SMEs generate employment and flexibly fulfill the markets' demands, they play an important role in the economy. [6] Local economies and employment are often supported by SMEs in depopulated mountainous areas. Therefore, it is important to promote their stable management. For this reason, support for the employees' health promotion that contribute to stable management is required.

Mental health problems are a health challenge in SMEs and large enterprises. [7] Therefore, there needs to be measures for the employees' mental health welfare in SMEs. However, SME managers have to play various roles and focus on efforts to keep the company thriving. [8] Mental health measures for employees may, therefore, not be of high priority for them. In addition, owing to a lack of financial margins, resources, and expertise, it is difficult to conduct worksite mental health promotion in SMEs. [9] The influence of economic downturn caused by COVID-19 may strengthen this tendency. Furthermore, it has been indicated that receiving mental healthcare is difficult, because of a lack of psychiatrists in rural areas. [10] Thus, there is a lack of healthcare resources. It is difficult for SMEs in depopulated mountainous areas to utilize resources outside the workplace. Therefore, SMEs have difficulty offering mental health support for employees, especially in depopulated mountainous areas. There is thus a need to consider effective promotion methods for mental health measures in SMEs in depopulated mountainous areas.

The effective promotion of mental health measures in SMEs contribute to protecting the local economy and employment in depopulated mountainous areas, in addition to improving the mental health and productivity of many employees. Socioeconomic factors are key determinants of health. [11] It is known that financial difficulties are positively correlated with mental disorders. [12] Protecting the local industry is connected to health promotion in the community. The United Nations adopted the 2030 agenda for sustainable development, which has an idea representing "no one will be left behind," (p.3) and with sustainability and diversity as key concepts. [13] The economy and health in a depopulated mountainous area also should be protected like large population cities. Measures of mental health that are affected by the economic situation of SMEs should be supported by the government in depopulated mountainous areas.

Project implementation is affected by the managers' value or priority in SMEs. [14] It is important to understand the managers' thoughts or circumstances to consider and support effective measures of mental health in SMEs. However, the managers' awareness of mental health measures for employees are not fully revealed. There is a need to clarify the managers' awareness regarding mental health measures for employees. Therefore, the aim of this study was to reveal managers' awareness of mental health measures for employees in SMEs in depopulated mountainous areas. The study's results may be used to inform effective mental health measures in SMEs in depopulated mountainous areas.

The participants were SME managers in 1 municipality in a depopulated mountainous area in Japan. The inclusion criteria were as follows: a) an owner or manager in SME, and b) having long-term work experience of 10 years or more in the SME. In this study, SMEs were defined as enterprises with less than 50 employees. In Japan, there is no need to deploy a person in charge of health promotion in enterprises with less than 50 employees.

Employees who worked for 10 years or more were also included as eligible participants because they could play the same role as managers regardless of their job title.

Semi-structured interviews were conducted in 2 days in November 2019. Since a list of all SMEs in the municipality was not available for conducting the survey, convenience sampling was used. Individuals judged to be appropriate by a public health nurse were recruited. Recruitment of new participants was stopped when the data had reached saturation as determined from the participants' responses. Interviews were conducted in a room at the workplace or public health center, at the participants' requests. The mean interview time was approximately 45 minutes. The interviews were recorded using a recorder.

An interview guide was used in this study. The primary interview contents were as follows: a) demographic characteristics (job title, and experience year of work), b) workplaces' characteristics (business type, and the number of employees), c) awareness of mental health conditions of managers and their employees, d) awareness of mental health promotion measures for employees as a form of primary prevention, and e) awareness of the measures for mental health problems as secondary and tertiary forms of prevention.

First, participants were asked open-ended questions about the basic interview contents. Next, depending on the participants' responses, questions were asked to confirm the content of the participants' remarks or to gain a deeper understanding of their remarks.

A qualitative descriptive analysis was conducted in this study. First, the interviews were transcribed verbatim and read thoroughly. Thereafter, we extracted the narratives with a set of meanings. Finally, we classified the narratives by comparing the common points. Categories and subcategories emerged after repeating the classification. Regarding the confirmability of the analysis, we shared the analysis process among researchers and discussed the analysis process and results.

Interviews for managers in SMEs were conducted by municipalities to consider health promotion measures for middle-aged residents. The interview data were used as a secondary data in this study. Data that did not contain personally identifiable information were provided to the researcher and were analyzed. Consent for secondary analysis was obtained from the person in charge of the municipality. In addition, the study's information was disclosed to participants on the homepage of the author's institution and through posters at the government's office. The ethics committee of the university approved this study (E-2016).

The interviews were conducted with 6 SME managers. There were 2 owners, three managers, and 1 person who worked long term. The range of years of working was 9 to 38 years. In the category of business type, 2 belonged to the field of construction, 2 belonged to the field of health and welfare, 1 had an association with the primary industry, and 1 was in retail business. The number of employees ranged from 3 to 45 people.

Regarding the managers' awareness of mental health promotion among the employees, three categories and 8 subcategories emerged ( Table 1) . The 3 categories were: "Individual support, including their life's aspect, while taking advantage of formal and informal relationships," "The difficulty of drawing out an employees' motivation to work, due to the changes over time in the work size or in their working relationships," and "Creating a comfortable working environment for employees, by complying with the labor standards and adjusting relationships."

3.2.1. Individual support, including their life's aspect, while taking advantage of formal and informal relationships. Managers recognized that they obtain a consultation from employees about all aspects of life, including economic matters through formal and informal relationships, and they offer specific support. Furthermore, they recognized that recreation at work is needed to build relationships with employees and to create a positive workplace atmosphere.

The difficulty of drawing out an employees' motivation to work, due to the changes over time in the work size or in their working relationships. Managers acknowledged that they could not improve employees' motivation to work by transmitting knowledge or skills in a relationship like the old apprenticeship system. In addition, they wanted to improve employees' motivation for work by encouraging the acquisition of qualifications. However, they recognized that this is difficult due to a lack of employees' desire for capacity improvement or advancement because the enterprises did not receive orders for major jobs in depopulated mountainous areas.

3.2.3. Creating a comfortable working environment for employees, by complying with the labor standards and adjusting relationships. Although managers find it difficult to easily change the work content and placement of employees due to SMEs, they recognize that they create a comfortable working environment by complying with labor standards or promoting paid holidays, and by adjusting workplace relationships, such as ingenuity of the placement of employees.

Regarding managers' awareness of measures for mental health problems in employees, four categories and 8 subcategories emerged ( Table 2 ). The 4 categories were "Prevention and awareness of the incidence of mental health problems," "Individual support based on the enterprise's or employee's characteristics," "A lack of support for the manager to address employees' mental health problems," and "Employees quitting the job, due to the lack of appropriate support."

3.3.1. Prevention and awareness of the incidence of mental health problems. Managers recognized that it is important to prevent depression. In addition, they recognized that employees did not have a severe mental illness, which would require consultation in a specialized agency.

Individual support based on the enterprise's or employee's characteristics. The managers acknowledged that they took individual measures for the employees with challenges. In addition, they addressed the employees' mental health problems based on the management system or occupational health system of the enterprise. For example, if they have an industrial physician, they consult with them, and if they are a family business, they consult with their relatives.

A lack of support for the manager to address employees' mental health problems. When employees have mental health problems, managers recognize that they need to address the problem within their authority, such as coordinating their work content. However, they do not consult specialists. Furthermore, they acknowledged that there is a lack of opportunity for them to gain knowledge or skills to address employees' mental health problems.

3.3.4. Employees quitting the job, due to the lack of appropriate support. Managers recognized that they were not able to support employees because of the characteristics of their work or difficulty in counseling and responding to mental health problems. They recognized that, as a result, employees quit the job because of a lack of appropriate support. In addition, they recognized that it is unavoidable for employees who have a Table 1 Managers' awareness of the mental health promotion measures for their employees (Primary prevention).

Individual support, including their life's aspect, while taking advantage of formal and informal relationships Participating in recreational activities, such as a drinking party at a workplace, is needed to encourage communication and create a positive workplace atmosphere Providing an individual consultation to employees through formal and informal relationships Offering specific support throughout their life including for economic problems or other issues in life The difficulty of drawing out an employees' motivation to work, due to the changes over time in the work size or in their working relationships Experiencing difficulty in supporting the work in a relationship, such as the old apprenticeship system Accessing support for employees to improve their abilities by encouraging the acquisition of qualifications Lack of employees' desire for capacity improvement or advancement due to not having an environment where they can do any major work Creating a comfortable working environment for employees, by complying with the labor standards and adjusting relationships

Adjusting the workplace relationships to make it easier for employees to work Complying with the labor standards or promoting paid holidays 

The results from managers' interviews indicated 3 categories of managers' awareness for mental health promotion measures for employees. Managers recognized that individual support for all aspects of life through not only formal but also informal relationships, are necessary. In addition, they acknowledged that recreational activities, such as dinner parties or recreational trips with workplace colleagues are needed to build relationships or an atmosphere that enables personalized support. It is an advantage for SMEs to provide employee support, including for life aspects such as economic issues or residency problems, to their employees. Therefore, SMEs' advantage is their social capital. Workplace recreation is thought to be 1 of the methods used to foster social capital in SMEs. In a previous study, it was found that higher workplace social capital was related to better mental health of employees. [15] Furthermore, workplace recreation or having hobbies could influence mental health. [16, 17] Thus, fostering social capital through workplace recreation is an effective mental health measure for SMEs. However, employees who do not want to have intimate relationships at work are currently increasing. [18] Considering such changes, new methods to foster workplace social capital in SMEs are needed. Managers recognized the difficulty in improving employees' motivation for work, due to the changes in the size of the work and relationships in the workplace, with the changing times. It is important for employees' mental health to be able to work actively. However, the present study revealed that it is difficult to improve employees' motivation for work for 2 reasons: First, it is difficult to educate employees in relationships, like in the old apprenticeship system, due to changes in employee awareness over time. Second, due to the characteristics of the depopulated mountainous areas, there is a current situation where the company does not obtain major jobs. In contrast, the concept of work engagement has attracted attention. Work engagement is the absorption in work with dedication, and getting vigor from work. [19] The methods to increase work engagement have also been developed. [20] Thus, these methods can be used to help employees derive vigor in SMEs.

Managers recognized that they had ingenuity in creating a comfortable working environment by complying with the labor standards or promoting paid holidays. It was found that reducing overtime hours helps prevent mental health issues in employees. [21] Therefore, it is important to comply with the legal working hours for employees' as a mental health promotion measure. In addition, compliance with the labor standards is of high social interest. Therefore, SMEs should also comply with these. However, the labor standards are rarely clearly understood and practiced in SMEs, and labor management is often conducted in a trust-based manner. Thus, it is expected that the system and knowledge is not sufficient for proper labor management in the company. Skill-support provided by experts, or financial support, is required to ensure that SMEs comply.

The results indicated 4 categories of managers' awareness for mental health problems among their employees. The managers recognized that in addition to the prevention and awareness of the incidence of mental health problems, customized support based on the characteristics of enterprises or employees are needed to measure the mental health problems of employees. The practice of noticing changes in employees and providing individual support by manager is a basic element of any mental health measures provided at workplace. In a previous study, it was found that leaders' support or their considerate behavior is related to low stress levels in employees' stress. [22] Managers' understanding their role in prevention of mental health issues in SMEs indicates that they have achieved the early stages of action. The next step is to practice this role. Managers recognized that there is not enough support for them to deal with employees' mental health problems. In particular, they recognized that there is a lack of opportunities to gain knowledge or skills to deal with mental health problems. Technical support is needed for managers to practice their roles. Training for managers to learn how to observe the state of employees and provide individual consultation is required to help them deal with their employees' mental health issues. In addition, managers recognized that they deal with employees' mental health problems using their authority, such as in the coordination of work. However, they do not consult specialists when an employee has a mental health problem. It is important for managers to do both. [23] Managers should learn not only to provide direct support to employees but also how to cooperate with an expert. Responses that are not Table 2 Managers' awareness of the measures of mental health problems (secondary and tertiary prevention).

Prevention and awareness of the incidence of mental health problems Keeping in mind the need to prevent depression in employees No severe mental health issues among employees that need a consultation from specialized agency Individual support based on the enterprise's or employee's characteristics Taking individual measures by approaching employees who have concerns To consult the appropriate place depending on the management system or the occupational health system A lack of support for the manager to address employees' mental health problems

To assist an employee with depression by changing their circumstances, such as their work content, yet not consulting a specialist for assistance. Not having enough opportunities for managers to learn how to assist with employees' mental health problems Employees quitting the job, due to the lack of appropriate support

There are some early retirement cases due to lack of appropriate support which caused by the characteristics of the work content It is unavoidable for the employees to quit the job because there is no clear contact information regarding mental health support services or they can't work when they get a mental health illness based on expert judgment may result in the worsening of the condition. Occupational physicians are often not assigned to SMEs. It is necessary for managers not only to learn how to collaborate with specialists but also to introduce a consultation desk of an external organization where they can consult concretely about their employees' mental health problems. The consultation desk is a support system that can be implemented by the government. Managers recognized that employees who have mental health problems are likely to quit their jobs because of the lack of appropriate assistance in SMEs. Regarding the lack of appropriate support, they recognized that they could not provide sufficient support due to the difficulty in providing counseling on mental health problems. In addition, they also recognized that there were situations in which it was not possible for employees to consult because the contact information was unclear. This was due to the lack of a consultation system within the workplace. In a previous study, it was found that having mental health problems was related to an increased risk of unemployment. [24] If an employee retires due to a mental health problem, the workplace loses the a well-trained employee and it costs them more to train a new employee. In addition, not addressing an employee's mental health issues until the employee quits the job can also lead to liability issues. However, the present study showed that it is difficult for managers to have an appropriate response to an employee's mental health problem while concurrently performing normal work. It is necessary to establish a system wherein employees can obtain consultations about mental health problems. It is also important to inform employees of the consultation desk. However, it is known that not informing the workplace about mental health issues was the default option for employees, due to a fear that their personal information may not be protected in the workplace. [25] As a result of an intimate work environment in SMEs, employees may not consult further due to fear of not being able to maintain confidentiality in the workplace. Managers need to consider a consultation desk of an external organization, which employees can approach for consults. This can be solved with the support of the government.

This study has some limitations. First, the sampling method was convenience sampling. Managers who were judged to be appropriate by public health nurse were recruited. Thus, there is a possibility that managers who were interested in employees' health were selected as interview participants. Second, the study's participants were managers of SMEs in depopulated mountainous areas in Japan. Therefore, situations may differ in another country or region where there are different occupational health systems or cultural backgrounds. Third, we conducted interviews with participants of various backgrounds in order to understand the actual situation of various types of SMEs. However, the background of the participants may affect the results. Therefore, there is a need to conduct a study that limits the target participants according to the size and type of industry. In spite of these limitations, this study was valuable because it involved interviews with managers of SMEs in depopulated mountainous areas who have difficulty in cooperating with surveys and research.

Managers of SMEs in depopulated mountainous areas in Japan were interviewed to reveal their awareness of mental health measures for employees. The extracted categories showed that managers are aware of measures to maintain the mental health of their employees and prevent early retirement with appropriate supports like adjusting the work environment and supporting the employees' overall lives. The results indicated the need to foster social capital and collaborate with external support organizations. It also indicated the need for managers to learn activities to maintain employees' mental health. Difficulties of being small companies are also recognized. Managers in depopulated mountainous areas are committed to mental health activities. The study's results will help guide mental health measures in SMEs that support the economy in depopulated mountainous areas. 

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Editor: Massimo Tusconi. This study was supported by the Grants-in-Aid for Scientific Research (KAKENHI), Japan (grant number 19K19775).The authors have no conflicts of interest to disclose.The datasets generated during and/or analyzed during the current study are not publicly available, but are available from the corresponding author on reasonable request.