International Journal ofEnvironmental Researchand Public Health

ArticleRelationship between Willingness and Psychological
Characteristics of Suicide Prevention Telephone Counselors:
A Retrospective Observational Study
Osamu Murakami *, Kanae Kanda, Nlandu Roger Ngatu and Tomohiro Hirao
Department of Public Health, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe Miki-cho Kita-gun,
Kagawa 761-0793, Japan; kanda.kanae@kagawa-u.ac.jp (K.K.); ngatu@kagawa-u.ac.jp (N.R.N.);
hirao.tomohiro@kagawa-u.ac.jp (T.H.)* Correspondence: nrtc_sam@yahoo.co.jp; Tel.: +81-87-891-2133; Fax: +81-87-891-2134

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Citation: Murakami, O.; Kanda, K.;
Ngatu, N.R.; Hirao, T. Relationshipbetween Willingness andPsychological Characteristics of
Suicide Prevention TelephoneCounselors: A Retrospective
Observational Study. Int. J. Environ.

Abstract: Suicide is a major public health issue worldwide, and telephone counseling is an important
preventive measure. As the number of telephone counselors is insufficient in Japan, public needs
cannot be fully met. Willingness is important for securing telephone counselors, but few studies haveexamined the willingness to engage in telephone counseling activities. Therefore, we investigated
the relationship between telephone counselors’ willingness to perform their activities and their
psychological characteristics, health status, and received social support. In this study, a questionnaire
survey was conducted by mail among telephone counselors belonging to the Federation of Inochi
No Denwa in Japan. The total number of valid responses was 709 (recovery rate: 50.4%). Following
an exploratory factor analysis, three factors were extracted: (1) willingness to engage in telephonecounseling activities, (2) sense of being burdened by telephone counseling activities, and (3) senseof difficulty in coping. Structural equation modeling, using all the factors, showed that social
support and grit were directly related to the willingness to engage in telephone counseling activities,
while physical health, mental health, and general self-efficacy were indirectly related to it. The
findings obtained may be useful in devising concrete measures for telephone counselors to continue
their activities.

Res. Public Health 2021, 18, 9800.
https://doi.org/10.3390/
ijerph18189800

Keywords: telephone counselor; willingness; grit; mental health; physical health; self-efficacy;social support

Academic Editor: Kyoung-Sae Na
Received: 13 August 2021
Accepted: 14 September 2021
Published: 17 September 2021

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distributed under the terms andconditions of the Creative Commons
Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).

1. Introduction
With more than 700,000 deaths per year worldwide, suicide is a major public health issue. The World Health Organization (WHO) has stated that reducing suicide-related mortality is a “global responsibility” [1,2]. Although the number of suicides per 100,000 populationin Japan has been on a downward trend since peaking at 27.0 in 2003, having fallen to 16.7
in 2020 [3], it is still a serious social problem. Telephone counseling is one approach topreventing suicide. Organizations that provide this service were established in the United
Kingdom in the 1950s, and today, volunteer counselors with prescribed training provide
telephone counseling in many countries [4]. It can reduce isolation and enhance social
support for people at risk of suicide. Therefore, the provision of telephone counseling is
an important tool for determining suicide rates [5,6]. In Japan, 24-h telephone counselingcenters have been established throughout the country by the Federation of “Inochi no
Denwa” (FIND), playing an important role in suicide prevention.
The number of telephone counseling sessions in Japan is large, even with the declining
suicide rates, indicating the persistence of the demand for such services [7]. However, thenumber of telephone counselors is chronically small because all of them are volunteers.
Furthermore, the response rate to incoming calls is very low, implying that they are notable to adequately respond to requests [8]. In addition, it is difficult to secure counselors toInt. J. Environ. Res. Public Health 2021, 18, 9800. https://doi.org/10.3390/ijerph18189800

https://www.mdpi.com/journal/ijerphnot able to adequately respond to requests [8]. In addition, it is difficult to securelors to work late at night (10 p.m. to 6 a.m.) in a 24-h service. To solve this short
Int. J. Environ. Res. Public Health 2021, 18, 9800
2 of 10necessary to acquire and train new counselors, as well as take measures to prevefrom leaving the service by improving the working condition of those working t[9]. to 6 a.m.) in a 24-h service. To solve this shortage, it is necessary
work late at nightshift(10 p.m.
Inprevious study,
supportfor volunteers
andleaving
their perceived
to acquire and train new acounselors,
as wellsurrounding
as take measures
to prevent
them fromofactivities
affected
theirwillingness
toengageincounseling[10].
the service by improving the working condition of those working the night shift [9]. In addition
withhighergrit and self-efficacy
more likely
to continue
working
In a previous
study,
surrounding
support for were
volunteers
and their
perceived
burdenon diffic[11–13].
Furthermore,
it
has
been
reported
that
healthy
volunteersof activities affected their willingness to engage in counseling [10]. In addition, peoplehavewith a longer
period andwere
less avoidance[14],
and workers
in good
healthhave a highhigher grit and self-efficacy
more likelybehavior
to continue
working
on difficulttasks[11–13].
ingness
continuethat
working
after
retirement[15].
In telephonecounseling,
Furthermore, it has
beentoreported
healthy
volunteers
havea longer
activity
period willin
importantvolunteers
to participate
and continue
their activities;
however,few
and less avoidance
behaviorfor[14],
and workers
in good healthhave a higher
willingness
tohave
examinedfactors
relatedtothewillingness
toengageintelephonecounsecontinue working after retirement [15]. In telephone counseling, willingness is important
relationshipbetweenthem.
for volunteers tothe
participate
andcontinue
their activities; however, few studies have
Therefore,
hypothesized(Figurethat (1) thewillingness
to engagein teexamined factors related
to the wewillingness
to engagein1)telephonecounselingandthecounseling
relationship between
them. increases when the “health-related quality of life” is favorable, the “
Therefore, wehypothesized(Figureis 1)
thatand(1) thethe“ability
willingness
to engagein teleburden
from activities”
low,
to tackle
challenges”
is high, aphone counselingincreases
when“health-related
qualitylife” is favorable,situationwithhighthe“socialsupport” will
have ofa positive
impact on theeach factor“sense of burdencrease
from activities”
is low, and the “ability to tackle challenges” is high, andwillingness.
“socialsupport”
will havepositiveon eachthefactorandthat enh(2) a situation with highThe purpose of this study
wasatoexploreimpact
and examine
factorsincrease willingness.
willingness to engage in telephone counseling activities for suicide prevention.

Figure 1. Analytical model.

Figure 1. Analytical model.

2. ofMaterials
andMethods
The purpose
this study
wasto explore and examine the factors that enhance thewillingness to engage
in telephonecounseling2.1. Target
Population
and Data activities
Collectionfor suicide prevention.

A questionnaire survey was conducted, targeting telephone counselors w
2. Materials and Methods
longed to suicide prevention centers in Japan (FIND). We asked 23 centers, nati
2.1. Target Population and Data Collectionthat provide FIND’s 24-h telephone counseling service to cooperate in the surv
A questionnaire
surveywas conducted,
targetingtelephone1408
counselors
belonged (quest
receivedconsent
from 10 centers.
Therefore,
sets of who
questionnaires
to suicide prevention centers in Japan (FIND). We asked 23 centers, nationwide, thatbooklets, implementation instructions, and return envelopes) were sent to 10 ceprovide FIND’s 24-h telephone counseling service to cooperate in the survey, and received
response to their requests. The questionnaires were then distributed individuallyconsent from 10 centers. Therefore, 1408 sets of questionnaires (questionnaire booklets,
selors at each center. The questionnaire was anonymous, and the provision of re
implementation instructions, and return envelopes) were sent to 10 centers in response
was left to the counselors’ choice. The completed questionnaires were individuallyto their requests. The questionnaires were then distributed individually to counselors
to Kagawa University. The survey was initially planned to be conducted from 1 F
at each center. The questionnaire was anonymous, and the provision of responses was
to 31 March 2020; however, considering the influence of COVID-19, the deadline
left to the counselors’ choice. The completed questionnaires were individually mailed totended to 31 July 2020.
Kagawa University. The survey was initially planned to be conducted from 1 February
to 31 March 2020; however, considering the influence of COVID-19, the deadline was
extended to 31 July 2020.

Int. J. Environ. Res. Public Health 2021, 18, 9800

3 of 102.2. Sample-Size Calculation
The sample size was calculated based on the physical component (PCS) SF-8 summaryscore after reviewing the relevant literature for each rating scale [16]. The effect size was
2.8; standard deviation, 7.24; significance level, 0.05; and power, 0.8. The calculated sample
size was 212. Based on the results, the required sample size was set to 250. Assuming a
40% response rate, the minimum number of copies required for distribution was calculated
to be 625.
2.3. Contents of the Questionnaire
To evaluate the willingness to engage in telephone counseling activities, 26 questions
on “thoughts on activities” were prepared (Table 1). These questions were developed basedon the questionnaire contents used in other researchers’ studies [8–10] and a preliminary
survey of counselors. A four-point Likert scale was used as the response method, including“completely agree”, “somewhat agree”, “somewhat disagree” and “completely disagree.”
Regarding telephone counseling activities during the night shift, 20 questions asked participants whether they had experience working the night shift, the number of years they had
been worked night hours, reasons for taking the night shift, and problems while on thenight shift, using a 4-point Likert scale.
Table 1. Questions on “thoughts on activities”.
Items
1
2
3
4
5
6
7
8
9
10

12

Activities lead to my personal growth.
I am able to help the people I consult with.
I am able to participate in society.
I am able to build good relations with my colleagues.
Telephone counseling activities fulfill me and are rewarding.
My interests and activities are aligned.
I would like to continue telephone counseling activities.
I would like to improve myself through independent study and training sessions.
I am willing to adjust my daily life for telephone counseling activities.
I am satisfied with telephone counseling activities.
I would recommend participate in telephone counseling activities to my friends ifthey wanted to.
I would like to increase my allotted time.

13
14
15
16
17
18
19
20
21
22
23
24
25
26

The organization’s system and management are appropriate.
Physical burden is high.
Mental burden is high.
Economic burden is high.
Time burden is high.
My competence as a telephone counselor is insufficient.
The rhythms of my life are disrupted.
Commuting to the center is a burden.
Dealing with serious issues such as suicide is difficult.
Dealing with sexual counseling is difficult.
Dealing with frequent callers is difficult.
Balancing work (schoolwork) and housework with activities is difficult.
Gaining understanding and cooperation from family is difficult.
It would be desirable to be compensated for my telephone counselling activity.

11

The Japanese version of the Grit-S [17] was used to measure grit; grit refers to the ability
to respond to and achieve long-term goals through passion (consistency of interest) andperseverance (consistency of effort), which are necessary for sustained effort. Self-efficacy
is the degree of confidence and conviction in one’s ability to perform and accomplish
the necessary actions to produce results for a given task; it was measured through theJapanese version of the General Self-Efficacy Scale (GSES) [18]. The Japanese versionof the Multidimensional Scale of Perceived Social Support (MSPSS) [19] was used tomeasure social support, which refers to the emotional and material support exchanged inInt. J. Environ. Res. Public Health 2021, 18, 9800

4 of 10social relationships. For health-related quality of life (QOL), the Japanese version of the
Short-Form 8-Item Health Survey (SF-8) [20] was used to measure the physical component
summary (PCS) and mental component summary (MCS). Grit and general self-efficacy wereused to assess the ability to tackle challenges. Gender, age, family members living together,
employment status, telephone-counseling-activity status, and licenses or certificates wereasked as basic information.
2.4. Data Analysis
Descriptive statistics were used to assess age, family-living-together, employment
status, telephone-counseling-activity status, and qualifications. An exploratory factor
analysis was conducted to find potential common factors in the “thoughts on telephonecounseling activities,” and the reliability of each factor was evaluated using Cronbach’s
alpha coefficient. Structural equation modeling was used to identify the causal relationships
between variables. The model fit was assessed using the comparative fit index (CFI) androot mean square error of approximation (RMSEA) indices. To compare each factor andthe night shift task, a one-way analysis of variance (Welch’s method) was conducted. The
significance level was set at 5% (two-tailed). JMP Pro 15 (SAS Institute Inc., Cary, NC, USA)and SPSS Statistics 25 (IBM, Armonk, NY, USA) were used for the statistical analyses.
2.5. Ethics Statement
This study was approved by the Ethics Committee of the Kagawa University Graduate
School of Medicine (No. 2019-205). The answers to all questionnaires were voluntary andanonymous. Respondents were asked to mark their consent to their participation in
the survey.
3. Results
The total number of collected questionnaires was 710 (recovery rate: 50.4%), of which
709 were used for analysis after excluding missing data from the required items. The
attributes of the subjects and scores for each scale are shown in Table 2. Of all the subjects,
138 were men (19.5%) and 569 women (80.3%). The most common age group for bothgenders was their 60s, accounting for about half of the respondents, and most lived with
their spouses. In terms of employment status, more than half of the men were full-time
employees or retired, while more than half of the women were occupied by housekeeping
or worked part-time. The highest percentage of respondents (both men and women) had
been active for nine years or less. There was a wide range of qualifications, but mostparticipants were in healthcare or teaching. The status of the counselors in charge of
midnight shifts is shown in Table 2.
The scores of Grit-S, GSES, MSPSS, SF-8 PCS, and SF-8 MCS were similar to those inprevious studies [19–22], and there was no specific trend within the survey subjects. In the
MSPSS, the scores were significantly higher for women, a trend that has also been observedin prior research [19].
Table 3 shows the results of the analysis of the questionnaire item “thoughts on
telephone counseling activities.” Following the factor analysis, 16 items representing
3 factors were extracted from 26 items (extraction method: maximum likelihood method;rotation method: Promax, factor loading threshold: 0.40). Based on the tendency shown by
the content of the items in each factor, we named the first factor “willingness to engage inactivities,” the second factor “sense of burden from activities,” and the third factor “sense ofdifficulty in coping.” For internal consistency, Cronbach’s α coefficient for each factor was
calculated at 0.82, 0.82, and 0.75, respectively, confirming the high reliability of each factor.
Correlation coefficients were calculated to confirm the relationship between the willingness to engage in activities (WtE) and each factor (Table 4). A negative correlation was
found between WtE and sense of burden from activities. A positive correlation was foundbetween the latter and the sense of difficulty in coping. Weak positive correlations were
found between Grit-S and GSES, Grit-S and WtE, MSPSS and WtE, and GSES and SF-8

Int. J. Environ. Res. Public Health 2021, 18, 9800

5 of 10

MCS. Weak negative correlations were found between GSES and sense of burden from
activities, GSES and sense of difficulty in coping, SF-8 MCS and sense of burden from
activities, as well as between WtE and a sense of difficulty in coping.
Table 2. Characteristics of participants and scores for scales.
Variables
Age (years)
Over 80
70–79
60–69
50–59
40–49
30–39
Total
Family members living together(Multiple answers)
SpouseChildren
Parents
Grandparents
Total respondents
Employment status
Full-time
Self employed
Part-time
Housekeeping
Student
Retired
Other
Total
Experience as a telephone counsellor (years)
Over 30
25–29
20–24
15–19
10–14
5–9
Under 4
Total
Licenses or certicates (Multiple answers)
Healthcare
Education
OthersTotal respondents
State in charge of midnight shift

Male (n = 138)n%Female (n = 569)n%Total (n = 707)
n
%

2
37
73
22
4
0
138

1.4
26.8
52.9
15.9
2.9
0
100

8
132
286
111
27
5
569

1.4
23.2
50.3
19.5
4.7
0.9
100

10
169
359
133
31
5
707

1.4
23.9
50.8
18.8
4.4
0.7
100

113
17
17
2
119

95
14.3
14.3
1.7
100

390
93
45
2
434

89.9
21.4
10.4
0.5
100

503
110
62
4
553

91
19.9
11.2
0.7
100

38
27
17
0
0
41
14
137

27.7
19.7
12.4
0
0
29.9
10.2
100

89
36
162
165
1
83
25
561

15.9
6.4
28.9
29.4
0.2
14.8
4.5
100

127
63
179
165
1
124
39
698

18.2
9
25.6
23.6
0.1
17.8
5.6
100

5
4
10
8
20
45
46
138

3.6
2.9
7.2
5.8
14.5
32.6
33.3
100

21
33
51
79
114
134
132
564

3.7
5.9
9
14
20.2
23.8
23.4
100

26
37
61
87
134
179
178
702

3.7
5.3
8.7
12.4
19.1
25.5
25.4
100

21
23
32
138

15.2
16.7
23.2
100

113
145
144
569

19.9
25.5
25.3
100

134
168
176
707

19
23.8
24.9
100

n
393
Scores for scales
Grit-SGSES
MSPSS
SF-8 PCS
SF-8 MCS

Past In Charge

No Experience ofBeing In Charge

%

n

%

n

57.7

137

20.1

151

Currently In Charge

Male

Female

%
22.2
Total

mean

SD

mean

SD

mean

SD

3.42
9.82
4.97
49.6
48.33

0.67
4.17
1.11
7.37
7.68

3.45
9.15
5.31
49
48.2

0.63
3.94
1.04
7.36
6.98

3.45
9.3
5.25
49.06
48.19

0.64
4
1.06
7.36
7.11

Note: Two respondents did not answer the gender question; therefore, the total of gender responses was 707. Abbreviations: GSES, General
Self-Efficacy Scale; MSPSS, Multidimensional Scale of Perceived Social Support; SF-8, Short-Form 8-Item Health.

Int. J. Environ. Res. Public Health 2021, 18, 9800

6 of 10

Table 3. Factor analysis on “thoughts on telephone counseling activities”.
Factor Loading
Items

Willingness to Engage
in Activities

Sense of Burden
from Activities

Sense ofDifficulty in Coping

0.784

0.019

−0.024

0.712

0.006

−0.0020.697−0.029−0.0300.601−0.114−0.126

0.598

0.013

0.123

0.568

0.083

0.071

Time burden is high.
Physical burden is high.
Rhythm of life is disrupted.
Balancing work (schoolwork) andhousework with activities is difficult.
Mental burden is high.
Economic burden is high.

−0.0270.053−0.023

0.792
0.709
0.658

−0.013−0.068−0.062−0.064

0.640

0.043

0.009
0.065

0.596
0.559

0.173
−0.017

Dealing with frequent callers is difficult.
Dealing with sexual
counseling is difficult.
Dealing with serious cases such as
suicide is difficult.
My competence as a telephone counselor
is insufficient.

0.056−0.0500.740−0.048−0.032

0.732

0.072

0.042

0.611

−0.024

0.026

0.551

0.82

0.82

0.75

Telephone counseling activities fulfill me
and are rewarding.
My interests and activities are aligned.
I would like to continue telephonecounseling activities.
I am satisfied with telephonecounseling activities.
I would like to improve myself throughindependent study and training sessions.
I am willing to adjust my daily life fortelephone counseling activities.

Cronbach’s coefficient α

Note: Extraction method: maximum likelihood method; rotation method: Promax, factor loading threshold: 0.40.

Table 4. Correlations among factors related to willingness to engage in activities.

FactorGrit-S

MSPSS

GSES

Grit-SMSPSS
GSES
SF-8 PCS
SF-8 MCS
Willingness to Engage
in Activities
Sense of Burden
from Activities
Sense of Difficultyin Coping

0.062
0.329 ***
−0.022
0.113 **

0.191 ***
0.076 *
0.154 ***

0.101 **
0.262 ***

0.247 ***

−0.256 ***−0.163 ***−0.179 ***Willingness
to Engage inActivities

Sense of
Burdenfrom
Activities

SF-8 PCS

SF-8 MCS

0.165 ***

−0.185 ***0.055−0.127 **-−0.102 **−0.216 ***−0.183 ***−0.224 ***−0.404 ***-−0.032−0.362 ***−0.070−0.162 ***−0.240 ***0.416 ***

Sense ofDifficulty in
Coping-Note: *** p < 0.001, ** p < 0.01, * p < 0.05.

Structural equation modeling was conducted to identify the causal relationships
between the variables (Figure 2). The analysis was as follows: WtE was set as the objective
variable, and the explanatory variables were the sense of burden from activities, senseof difficulty in coping, MSPSS, Grit-S, GSES, SF-8 PCS, and SF-8 MCS. The path diagramshows a high degree of fit (CFI = 0.958, RMSEA = 0.049), with grit having a direct effecton WtE (standard partial regression coefficient β = 0.18, p < 0.001). Social support had adirect effect on WtE (β = 0.21, p < 0.001), and an indirect effect by affecting mental healthand self-efficacy (β = 0.02). General self-efficacy had an indirect effect on WtE by affecting
the sense of difficulty in coping (β = 0.05), and physical and mental health had an indirect

Int. J. Environ. Res. Public Health 2021, 18, 9800

7 of 10effect on WtE by affecting the sense of being burdened by activities (β = 0.07/0.07). The
2
coefficientInt. J. Environ. Res. Public Health 2021,
18, 9800 of determination (R ) for WtE in this model was 0.22 (p < 0.001), which
8 of 11means
each factor explained 22% of the variation in participants’ WtE.

2. Relationship among factors related to willingness to engage in activities. Note: Arrows indicate regressions;FigureFigure
2. Relationshipamong factors related to willingness to engage in activities. Note: Arrows indicate regressions;
numbers are standard partial regression coefficients. Double-headed arrows indicate correlations; numbers are partial
numbersarestandard
partialregressionofcoefficients.
arrows indicate correlations; numbers are partial
determination.Double-headed*** p < 0.001.
correlation coefficients. R2: coefficientcorrelation coefficients. R2 : coefficient of determination. *** p < 0.001.
Regarding the influence of the night shift, significant differences were found in the
Regardingtheininfluenceof SF-8
the night
shift,5).
significant
differences
were
found
sense
of difficulty
coping and
PCS (Table
The “currently
in chargeof thenight in thesense
ofgroupdifficulty
in tocopingand SF-8
PCS health(Tableand5). lower
The “currently
in chargeof the night
shift”
tendedhave higher
physicalsense of difficultyin coping.

shift” group tended to have higher physical health and lower sense of difficulty in coping.
Table 5. Relationship between the experience of night shift and factors related to willingness to engage in activities.

Table 5. Relationship between theexperienceand factors
to willingness
Currently
in of night
Pastshiftin Charge
Norelated
Experienceof Being to engage in activities.

FactorCharge (n = 393)
(n = 137)
Currently in
Charge
Past
in
Mean
SD
MeanChargeSD(n = 393)(n = 137) 0.68
3.46
0.64
3.42

in Charge (n = 151)
No Experience ofMeanSD
Being in Charge
3.46 (n = 151)
0.63
9.27
3.74
Mean
SD
62.1
13.6
3.46
0.63
48.8
7.8
9.27
3.74
48.0
6.8
62.1
13.6
48.8
7.8
−0.096
0.879
48.0
6.8

p Value

Partial η2

p Value 0.001
Partial η2
Grit-S
0.824
GSES
9.52
3.99
8.79
4.21
0.232
0.005
Mean
SD
Mean
SD
MSPSS
62.6
12.8
64.5
11.9
0.252
0.004
Grit-S SF-8 PCS
3.46
0.64
0.68
0.824
49.7
6.6 3.4247.6
8.4
0.027
0.013 0.001
GSES
9.52
3.99
8.79
4.21
0.232
0.005
SF-8 MCS
48.5
7.1
47.4
7.8
0.301
0.004
MSPSS
62.6
12.8
64.5
11.9
0.252
0.004
Willingness to Engage
SF-8 PCS
49.7
6.6 0.940 47.60.070
8.4
0.027
0.001
0.898
0.283
0.004 0.013
in Activities 48.5
SF-8 MCS
7.1
47.4
7.8
0.301
0.004
Sense
of Burden
Willingness to Engage
0.021
0.936
0.082
0.903
−0.029
0.909
0.593
0.002
0.940
0.070
0.898
−0.096
0.879
0.283
0.004
from Activities0.001
in Activities
of Difficulty
Sense ofSense
Burden−0.111
0.081
0.801
0.157
0.819
0.002
0.018 0.002
0.021
0.936 0.918 0.082
0.903−0.0290.909
0.593
from Activities
in Coping2
Sense ofNote:
Difficulty
Welch’s test was used for the one-factor analysis of variance. Partial η : Effect size (partial correlation ratio). The−0.111
0.918
0.081
0.801
0.157
0.819
0.002
0.018
in Copingvalues of “willingness to engage in activities.” “sense of burden from activities,” and “sense of difficulty in coping” areFactorthe factor scores.
Note: Welch’s test was used for the one-factor analysis of variance. Partial η 2 : Effect size (partial correlation ratio). The values of“willingness to engage in activities.” “sense of burden from activities,” and “sense of difficulty in coping” are the factor scores.

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4. Discussion
The purpose of this study was to extract the factors that constitute the willingness
to engage in telephone counseling activities and to examine the relationships among
those factors.
The results revealed that social support was the factor most related to willingness toengage in telephone counseling. The path diagram showed that social support had both adirect and an indirect effect on willingness to engage in telephone counseling activities, thelatter by affecting mental health and self-efficacy. Previous studies have reported that thosewith high social support have better mental health than those with low social support [23],while the prevention of emotional exhaustion and promotion of a healthy social work
climate may support the willingness to work [24]. While the social support received intelephone counseling activities is expected to be multifaceted, including from organizations,co-workers, family, and others, this study focused on support from the organization andco-workers, examining what measures the organization can take to ensure the continuationof its counselors’ activities.
Grit was the second factor related to the willingness to engage in telephone counselingactivities. Winkler et al. [11] reported that in strict special military instruction, memberswith high grit were more likely to complete their training, and salesclerks with high grit
were less likely to quit their jobs. In this study, grit had a direct effect on WtE and showed
a positive correlation, suggesting that high grit is a factor that improves the willingness of
telephone counselors to engage their work and motivates them to continue counseling.
Similar to grit, self-efficacy is an important indicator for evaluating the ability totackle challenges. In this study, a negative correlation was found between self-efficacy
and the sense of difficulty in coping, and the path diagram showed an indirect effecton the willingness to engage in telephone counseling activities. Devarajooh et al. [12]found that high self-efficacy facilitated the practice of difficult self-care in diabetes, andKawamura et al. [13] reported that a diet program enhanced self-efficacy, which promotedchanges in health behavior. These findings suggest that self-efficacy is also a factor in thecontinuation of activities.
Therefore, it can be inferred that enhancing social support and the ability to tackle
challenges will be effective in increasing willingness to engage in telephone counseling activities. For this purpose, it is necessary to develop specific strategies. The following studies
provided specific strategies: Duckworth et al. [25] showed that the grit of students is fostered and enhanced when the goal structure in schools is more acquisition-oriented, whichemphasizes the value of learning, rather than high-achievement-oriented. Mirza et al. [26]reported that the use of five thematic strategies in the educational curriculum of medical
students, namely “planning,” “metacognitive skills,” “mastery-based learning,” “cognitive strategies,” and “self-regulation,” significantly increased grit, improved academic
performance, and reduced the number of dropouts. Tompkins [27] described strategies
to increase the supervisee’s self-efficacy in cognitive therapy based on four items: “performance accomplishment” as a successful experience, “vicarious experience” throughobservation, “persuasion” through suggestion and instruction, and “physiological states”
through the perception of physiological responses. Incorporating these strategies into thetraining of telephone counselors may increase the effectiveness of such programs.
Finally, the results of the analysis of the night shifts are discussed. In this study, acomparison of the three groups, according to their night-shift status, showed significant
differences in physical health and the sense of difficulty in coping. Those in charge of night
shifts had higher levels of physical health, while those who had worked night shifts in thepast had lower levels. In addition, those in charge of night shifts had less sense of difficultyin coping, while those who had never worked night shifts had more. Based on these results,
two issues were considered. First, counselors with no night shift experience tend to havemore difficulty in coping, which may inhibit their willingness to choose these shifts. The
second issue is that counselors who quit night shifts tend to have low physical-healthlevels, which may inhibit their willingness to adopt a physically demanding schedule. At

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Mental Health Helplines in New Zealand, the implementation of a high-quality training
program is regarded as useful, not only for improving consultation skills but also for
personal growth and self-care. In addition, it has been reported that such organizational
support creates a sense of belonging and is effective for sustaining activities [10]. It has
also been pointed out that proper shift scheduling is important in preserving the health ofworkers [28]. Therefore, to address these issues, it is important to improve response skills
through training sessions, and to set up an appropriate schedule that considers the healthcondition of each counselor when planning the assignment.
This study had several limitations. First, it was a cross-sectional study, and thetime axis was not considered, therefore it was not possible to make definitive statements
regarding causality. Second, counselors who responded may have been more active in
telephone counseling than those who did not, and the low response rate to the questionnaire
may have biased the results. Third, as this study was conducted from the perspective ofvolunteer activities, the questionnaire mainly consisted of questions about the counselors,and no reference was made to the organization.
Thus, the future challenge is to develop specific strategies to motivate telephonecounselors and promote their continuation as counselors based on the findings of thisstudy. As specific support measures for telephone counselors, we would like to suggest
considerations of (1) improving the contents of various training programs, (2) supporting
the planning of appropriate responsibilities, based on an understanding of each counselor’s
situation, and (3) creating opportunities for staff and counselors to interact with each other.
In addition, the factors discussed in this study were able to explain 22% of the willingness to engage in activities in telephone counseling; however, exploring other determinants
is an interesting topic for future research.
5. Conclusions
This study revealed that social support and grit have a significant impact on thewillingness to engage in telephone counseling activities. In addition, psychological andhealth factors were also found to be interrelated, influencing the sense of being burdenedby activities and that of difficulty in coping, consequently playing an important role in thewillingness to engage in activities.
By clarifying the relationship between these factors, it is possible to suggest concretemeasures for continuing telephone counselors’ activities.
Author Contributions: O.M. conceived the study, participated in its design and coordination, anddrafted the manuscript. O.M., K.K., N.R.N. and T.H. participated in the research design, managed
data collection, and contributed to the statistical analysis. All authors have read and agreed to the
published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: This study was approved by the Ethics Committee of the
Kagawa University Faculty of Medicine (approval number: 2019-205).
Informed Consent Statement: Informed consent was obtained from all the subjects involved in
the study.
Acknowledgments: We would like to thank all study participants, research assistants, and colleagues.
Conflicts of Interest: The authors declare no conflict of interest.

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