Survey on Health Promotion and Working Women2018
Health and Global Policy InstituteMarch 22, 2018

I. Executive Summary
Health is an essential element for women to take charge of their own life plans, including when they become
pregnant, when they raise children, where and how they work, and how they make contributions to society.
However, social support for the improvement of knowledge and behaviors related to women's health, andthe promotion of women’s health in general, is still insufficient.
Health and Global Policy Institute (HGPI) conducted a survey targeting 2,000 working women, to examine
associations between levels of health literacy and health behaviors, work productivity, and access tonecessary healthcare. This study defined health literacy as the “ability for a woman to access, understandand utilize necessary information to maintain and promote health.” In other words, knowledge of bodymechanisms or diseases along is not sufficient for true health literacy. Such knowledge should beaccompanied by behaviors, including the ability to discern the accuracy of health information, consultations
with health professionals, and coping actions for the management of symptoms.
The results showed that levels of health literacy were associated with work performance, planned
pregnancies and health seeking behaviors, implicating the importance of strengthening efforts to improvelevels of health literacy among women.
Key Findings
High health literacy was associated with high work performanceHigh health literacy was associated with being able to plan pregnancies and the use of infertility treatment



Women with high levels of health literacy were more likely to seek treatment for health symptoms thatare specific to women

There is high need for education on the mechanisms, prevention, screening, and treatment of diseases
that are common among women, as well as when to consult a doctor about these diseases



Health check-ups organized by workplaces encourage women to make regular visits toobstetricians/gynecologists

Policy Recommendations
The Government should take leadership on the creation of school

Provide theinformation women

Government

curriculums focusing on the specific areas that women need toknow about

need to enable themto take action

Schools/against women’s

academic

health risks

institutions
Companies

Focus on the subjects related to lifelong health management andself-care for women
Offer training or seminars to provide employees with necessary
information according to their life stages
1Include efforts to improve women’s health literacy as a selection

Strengthen healthpromotional

Government

criteria for the Government’s Health & Productivity Stock Selection
portfolio

activities to improvehealth literacy in

Research

Develop an evaluation method to assess the health promotional

workplaces

institutes

activities being implemented by companies

Companies

Develop a consultation system to improve health literacy levels
among women

Improve access toCompanies

Incorporate women-specific diseases into regular check-ups

obstetrics &Healthcare

Communicate to women the necessity of making regular visits togynecology

providers

health professionals

departments

Healthfacilities

Develop healthcare delivery systems based on client needs

Create environmentsthat ensure womenDevelop a flexible paid leave system that can be used to take time

can plan pregnancies
and receive

Companies

infertility treatment
as necessary

off of work for as little as a few hours at a time
Ensure friendly work atmospheres where women can utilize theopportunities and systems available to them

II. Overview of the studyA) Study design:This was a cross-sectional study.
B)

Participants:

The study targeted 2,000 women between the ages of 18 and 49 who were registered with the survey company
that assisted HGPI with the data collection process. Women were included in this study if they worked fulltime (regardless of their status as both regular and temporary workers).
This study excluded women who either were or had family members who were health professionals.1 The age
and regional profile of the survey cohort matched Japan’s national demographic structure (Figure 1).
C)

Methods:

This survey was conducted over the internet between February 2 and February 8, 2018 (Figure 1). The survey
was conducted with the approval of the Ethics Review Committee of the Health Outcome Research Institute.
1

This survey defined “healthcare professionals” as follows:
Medical doctors, dentists, veterinarians, pharmacists, public health nurses, midwives, nurses (including associate nurses), medical
radiology technicians, clinical laboratory technicians, physiotherapists, occupational therapists, vision trainers, speech-languagehearing therapist, dental hygienists, dental technicians, nutritionists, massage shiatsu therapists, acupuncturists, moxibutionists, Judobonesetters2Participants were provided with a written form explaining the purpose of the study and their right to opt outof it. The survey was administered only to those who provided informed consent. Each respondent was
identified on questionnaire forms only with a serial number to ensure anonymity.

D)

Scales used for this survey:
1.

Health literacy around women’s health

Levels of health literacy were measured by the “Health literacy scale for women of reproductive age”
2

(hereafter referred to as the Health Literacy Scale), which was developed for the prevention andearly detection of women-specific diseases among working women in Japan (Table 1). The Health
Literacy Scale consists of 4 categories, namely, “Women’s choices and practices related to healthinformation,” “Self-care during menstruation,” “Knowledge of the female body,” and “Sexual healthdiscussions with partners.” These four categories contain 21 items, covering knowledge andbehavioral factors. Respondents were asked to choose appropriate answers on a 4-point Likert scale.
Respondents could select “Agree,” “Somewhat agree,” “Disagree,” or “Strongly disagree” for each
item.

2

Kawata, S. et al. (2014) Development of a health literacy scale for women of reproductive age: An examination of reliability andvalidity in a study of female workers. Japan Journal of Public Health, 61 (4), p.186-96
3

Table 1: Health literacy scale for women of reproductive age
Items
１．Women’s choices and practices related to health information
１.1 I can seek advice from health professionals (doctors, nurses, public health nurses,
midwives, etc.) when concerned about my health
１.2 I can examine the validity of information related to women’s health that is available on theinternet or in magazines
１.3 There are specific activities that I regularly do to maintain my health
１.4 I can obtain information on women’s health when needed
１.5 I can select appropriate information for me from the wealth of information available on
women’s health
１.6 I can ask questions of health professionals (doctor, nurse, midwife, etc.) when I do notunderstand his/her advice or guidance
１.7 I can understand the information that I hear in my daily life
１.8 I can take necessary actions after considering advice and information about my health
１.9 I can explain my symptoms to health professionals when I visit them
２．Self-care during menstruation
２.1 I know my menstrual cycle
２.2 I can predict my menstrual period based on the changes in my health２.3 I see menstruation as a barometer (indicator/sign) of my overall health
２.4 I actively take treatment for menstrual symptoms and discomforts
２.5 I recognize changes in my physical and mental status before or during menstruation
３．Knowledge of the female body
３.1 I have knowledge about menstruation
３.2 I have knowledge about the mechanisms of pregnancy
３.3 I have knowledge about uterine and ovarian cancers
３.4 I have knowledge about the prevention of sexually transmitted diseases (STDs)
３.5 I have knowledge about means of contraception
４．Sexual health discussions with partners
４.1 I can discuss contraception with my partner when necessary
４.2 I can discuss the prevention of STDs with my partner when necessary
2.

Work performance
Work performance/productivity was measured by the validated Japanese version of the World HealthOrganization Health and Work Performance Questionnaire (WHO-HPQ)3. The WHO-HPQ is a scale which
can measure both loss due to absence (“absenteeism”) and loss of work performance (one’s ability toperform their job) due to poor physical or mental functionality even though the person continues toreport for work (“presenteeism.” This can occur, for example, when someone continues to show up forwork even though they are sick). The questionnaire accomplishes this by asking questions regarding work
performance over the previous four weeks. In this study, absolute absenteeism and presenteeism were
calculated based on WHO-HPQ scores.

3

Kessler RC, Barber C, Beck A, et al. (2003) The World Health Organization Health and Work Performance Questionnaire (HPQ). J
Occup Environ Med, 45, p.156-74.
WHO Health and Work Performance Questionnaire (WHO-HPQ) https://www.hcp.med.harvard.edu/hpq/info.php [Accessed on
March 7, 2018]4

We developed similar questions about work performance when experiencing Premenstrual Syndrome(PMS)4 and menopausal symptoms or disorder5 by referring to the presenteeism items on the WHOHPQ.
3.

Quality of Life (QOL)6

Although there are disease-specific scales to measure QOL, such scales are difficult to convert to asingle dimension QOL score (0 as death and 1 as perfect health). QOL measurement can also take along period of time to investigate, creating extra work for both participants and investigators. For
these reasons, the EQ-5D-5L7 scale was selected for this survey.
The EQ-5D-5L is a questionnaire developed by the EuroQOL Group, consisting of 5 items, namely,“Degree of mobility,” "Management of personal belongings," "Daily activities," "Pains anddiscomforts," and "Anxiety and depression." Respondents were asked to rate their abilities related
to these items on a 5-point Likert scale ranging from “No problem” to “Totally unable.” The EQ-5D5L is an update to the EQ-5D-3L intended to address a “ceiling effect” whereby results from the oldscale tended to skew toward 1 (Perfect health), particularly for people living with only mild cases of
diseases. Furthermore, it was difficult to capture small changes in health status using the old scale.
The EQ-5D-5L was developed to address the “ceiling effect” issue and sensitivity while maintaining
convenience, using a 5-point scale. The Japanese version of EQ-5D-5L was developed in 2012, with aconversion table (tariff) developed in 2014, which was used in this survey.
E)

Analytical methods
Results are divided into five parts: ”Health literacy and work performance,” “Health literacy and planned
pregnancies,” “Health literacy and coping behaviors related to women-specific symptoms,” “Healthliteracy and regular visits to obstetrics/gynecology departments,” and “Health literacy and unwanted
pregnancy.” Descriptive statistics and covariance analyses (ANCOVA tests) were carried out. Statisticaltests were run to assess correlation among variables. Logistic regression analyses were also conducted,
with health literacy as an independent variable and other indicators as dependent variables.
This study grouped respondents into one of two groups depending on their level of health literacy.
Respondents reporting health literacy scores at or above the median score were considered to have “Highhealth literacy,” while patients with scores lower than the median score had “Low health literacy” (Figure
2).

4Premenstrual Syndrome (PMS): physical or mental discomforts before menstruation“Menopausal symptoms” refers to various symptoms that may appear during menopause (including the five years before and after
menopause) such as hot flashes, sweating, and so on. These symptoms are not accompanied by other diseases. If the symptoms are sosevere that they impact the woman’s daily life, she may be considered to have a menopausal disorder.
6 A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.
7 Ikeda, T. et al. (2015) Developing a Japanese version of the EQ-5D-5L value set. J.Natl. Inst. Public Health, 64 (1), p.47-55.
・EuroQol Group Website http://www.euroqol.org/ [Accessed on March 7, 2018]
5

5

6

F)

Adjustments:



Tests for association were adjusted by education level, number of children, and the presence ofunderlying diseases8, as a correlation was found between health literacy and each of these items
among this sample (see comments in the result sections for details). Tests were also adjusted by age,although no significant association was found between age and health literacy (Figure 3).

No adjustment was made for job level and income as there was no association found between healthliteracy and these variables (Figure 3).

8 In this survey, the following 12 diseases were regarded as underlying gynecological diseases:

1. Sexually transmitted diseases (STDs; HIV, syphilis, chlamydia, etc.)
2. Cervical cancer
3. Uterine cancer
4. Ovarian cancer
5. Breast cancer
6. Endometriosis
7. Uterine myoma
8. Polycystic ovary syndrome
9. Premenstrual syndrome/PMS (Physical and mental discomforts before menstruation)
10. Menstrual symptoms (Pain or discomfort during menstruation, or other related symptoms such as abnormal bleeding)
11. Menopausal disorders
12. Osteoporosis
7G) Limitations: Internet surveys have an inherent sampling bias, as respondents are limited to those who canaccess to and use the internet. It is important to take caution when interpreting results, as internet
literacy is associated with level of education.

 Since this survey was a cross-sectional study, causal relationships could not be estimated.

8

III. Results
A)High health literacy was associated with high work performance

Nearly half (45%) of women reported that their work performance dropped to less than half of theirusual performance due to premenstrual syndrome (PMS) or menstruation associated symptoms(Figure 4). Similarly, about half (46%) of women reported that their work performance dropped toless than half of their usual performance due to menopausal symptoms or disorders (Figure 5).

9Survey respondents were classified into two groups based on whether they were judged to havehigh or low health literacy. Work performance was significantly higher among women with highlevels of health literacy compared to those with low literacy (when comparing self-reported
performance over the previous month) (Figure 6). Furthermore, the high literacy group was alsoless likely to experience decreased work performance during times of PMS or menstruation, or due
to menopausal symptoms or disorders (Figure 7 & 8). Work performance while experiencing
PMS/menstruation or menopausal symptoms had a significant correlation with the scale item
"knowledge of the female body" on the health literacy scale (Figure 9 & 10).

10

11

Interpretations

It revealed that many women feel that their work performance is affected by PMS/menstrual
symptoms or menopausal symptoms/disorders. Results showing that women with high healthliteracy are more likely to maintain work performance levels while experiencing PMS or
menstrual/menopausal symptoms highlight the need to reinforce efforts to improve healthliteracy among women.
12B)High health literacy was associated with being able to plan pregnancies and the use of infertility treatment

Planned pregnanciesMore than half (53.3%) of the women in this study reported that they felt unable to plan theirpregnancies (Figure 11).



Women with high health literacy levels were 1.9 times more likely to report being able to plan theirpregnancies, compared to those with low health literacy (Figure 12). There was a significant
correlation between “Being able to plan pregnancies” and the “Knowledge of the female body” on
the health literacy scale (Figure 13).

13In terms of the factors that woman say helps them to plan pregnancies, “A friendly atmosphere in
the workplace that encourage women to take paid leave” was the most common answer, cited by
57% of women. Other popular responses included “A flexible paid leave system (hourly leave,
shortened work hours, etc.) that can be used to for screening and medical consultations” (43%) and“An atmosphere in the workplace that encourages women to return to work after taking childcare
leave” (38%).
14



Need for school education was also high, as shown by the popularity of answers such as "School
lessons on suitable times for pregnancy and fertility," (34%) and "Schools lessons on life planning,
including pregnancy and childbirth" (23%) (Figure 14).

Use of infertility treatment among women who were unable to become pregnant
Among those who were unable to become pregnant at the time they desired, only 23.2% initiatedinfertility treatment (Figure 15).

15The high health literacy group was about 1.8 times more likely to initiate infertility treatmentcompared to the low health literacy group (Figure 16). There was a significant correlation between“Use of infertility treatment” and “Sexual health discussions with partners” on the health literacy
scale (Figure 17).

16

Interpretations


The association between “Being able to plan pregnancies” and “knowledge of the female body”
indicates the importance of providing information on such matters as the mechanisms ofpregnancy.



Women reported the desire to have flexible work systems and work environments thatencourage women to utilize such systems in order to make it easier to plan pregnancies. These
results indicate the need for efforts by companies for institutional reforms and to improve work
environments. Results also highlighted the need for school education to provide women with
opportunities to learn about pregnancy and to think about their own life plans.



The main reasons for not starting infertility treatment once it was discovered by the women thatthey were unable to become pregnant were "The cost of treatment" (29%) and "The difficulty ofbalancing work and treatment requirements" (21%) (Figure 18).



Main reasons for infertility included "I put my career first during the time of my life that I was mostfertile," (28%) and "I thought that only very few people need infertility treatment, and I wasn’t oneof them" (26%) (Figure 19).

17



Regarding the information women wanted to know before starting infertility treatment, common
answers included "The cost of treatment," "The details of treatment," "The probability of pregnancy
while on treatment," "The details of examinations," "Suitable ages for pregnancy," and "Suitabletimes to start infertility treatment." All of these answers were selected by about 40% of the
respondents (Figure 20).

18

Interpretations
 Results suggest that decisions to start infertility treatment are impacted by whether or not
women have partners who understand the issue of infertility and can discuss the matter withthem.
 Among those who initiated infertility treatment, many wanted to know more about pregnancy
and infertility treatment in general, including the cost of treatment, details about examinations,and the mechanisms of pregnancy. Many women stated that they thought “it is rare for people toneed infertility treatment.” Lack of knowledge was one of the impeding factors that caused
people to overlook the opportunity for treatment. Both women and men need greater access to
information on this issue in order to better plan out their lives.


There was a certain number of women who stated that they could not start infertility treatment
due to difficulties in balancing treatment requirements with work. There were also women who
stated that they put their work priorities first during the time of life when they were most fertile.
These results further underscore the need to promote the creation of women-friendly work
environments that can help women balance these life events with work as they wish.

C)

Women with high levels of health literacy were more likely to seek treatment for health symptoms thatare specific to women

Menstrual abnormalities


About half (50%) of women experienced menstrual abnormalities9 either at present or in the past
(Figure 21), but 45% of them did “Nothing in particular” that was the most common answer for them
(Figure 22). More than half of them (53%) visited an obstetrician/gynecologist after 4 months ormore since the onset of symptoms (Figure 23).

9

The following symptoms were regarded as menstrual abnormalities:
Irregular and unpredictable menstrual cycles
Short cycles (within 24 days)
Long cycles (over 39 days)
Missed periods over several months
Insufficient bleeding at menstruation
Excessive bleeding at menstruation
Abnormal period length lasting within 2 days
Abnormal period length lasting more than 8 days
Strong symptoms during menstruation (lower abdominal pain, lower back pain, abdominal bloating, nausea, headache,fatigue/weakness, loss of appetite, irritability, diarrhea, depression, etc.)
Abnormal bleeding










19

20



Women with high levels of health literacy were approximately 2.8 times more likely to undertake
coping behaviors for menstrual abnormalities, including taking medicines (prescribed or over thecounter) or seeing a doctor (Figure 24).

21

Premenstrual syndrome (PMS)

About 66% of women had experienced PMS at the time of the survey or in the past (Figure 25).
Regarding coping behaviors, however, 63% of respondents reported that they did "Nothing inparticular"toaddress

their

PMS

(Figure

26).

More

than

half

(51%)

visitedanobstetrician/gynecologist after 4 months or more of experiencing regular PMS symptoms (Figure 27).

22



Women with high levels of health literacy were approximately 1.9 times more likely to undertake coping
behaviors for PMS, including taking medicines (prescribed or over the counter) or seeing a doctor(Figure 28).

23

Menopausal symptoms or disordersAbout 42% of respondents stated that they had experienced menopausal symptoms or disorders
recently or in the past (Figure 29). However, 64% said they did "Nothing in particular" to address these
symptoms (Figure. 30). Approximately 63% of women visited an obstetrics/gynecology department
after 4 months or more of experiencing regular symptoms (Figure. 31).

24



Women with high levels of health literacy were approximately 1.9 times more likely to undertake
coping behaviors for menopausal symptoms or disorders, including taking medicines (prescribed orover the counter) or seeing a doctor (Figure 32).

25

Regular visits to an obstetrician/gynecologist and self-careThe high health literacy group was 2.2 times more likely to regularly see anobstetrician/gynecologist (Figure 33).



Looking at self-care activities related to women’s health, about half (50%) of women with highlevels of health literacy "Receive regular screenings for gynecological cancers (breast, cervicaletc.)." This was the most commonly performed self-care activity for these women. Other common
activities included “Use of health applications (mobile apps) to track my menstrual cycle”, “Visiting
an obstetrician/gynecologist immediately whenever I have symptoms (abnormal bleeding,menstrual disorders, etc.)”, and "Use of contraceptives (condoms, pills10, etc.) to avoid unwanted
pregnancy,”. On the other hand, more than half of women with low literacy levels were doing“Nothing in particular” (55%). This was the most common answer among these women (Figure 34).

10

Oral contraceptives can suppress the secretion of female hormones. They are highly effective contraceptives when correctly
administered. They can also be used to reduce menstrual pain or to correct menstrual dysfunctions.
26 Regarding coping behaviors, this study asked questions on “Women’s choices and practices related
to health information” and “Self-care during menstruation.” These questions informed Health
Literacy Scale groupings, and results were compared by age group. Age groups differed in terms of
the positive response rate for the following factors: “There are specific activities that I regularly do
to maintain my health,” “I know my menstrual cycle,” “I can select appropriate information for mefrom the wealth of information available on women’s health,” and “I can ask questions to healthprofessionals (doctor, nurse, midwife, etc.) when I do not understand his/her advice or guidance”(Figure 35, 36, 37 & 38). Among these four items, a significant difference was observed among age
groups for “There are specific activities that I regularly do to maintain my health” and “I know mymenstrual cycle.” The percentage of people who selected these answers was about 6.5% lessamong women aged 18-29 years compared to their senior counterparts in their 30/40s (Figure 35).

27

28

Interpretations


There is the possibility that the ability to handle health problems contributes to enhanced work
performance. It is critical to provide women with correct information, as there was a more than
10% difference between the high literacy vs. low literacy groups in terms of the uptake of cancer
screenings, use of mobile applications to track menstrual cycles, visits to obstetrics/gynecology
departments when necessary, and the use of contraceptives to avoid unwanted pregnancies.
29

Younger women aged 18-29 years are less likely to know their own menstrual cycle or takemeasures to maintain their health compared to women over the age of 30. The proportion ofyounger women who responded that they felt able to discern what information is appropriate forthem related to women’s health was also low. It is important to provide young women with
opportunities to learn about women’s health issues from an early age.

D) There is high need for education on the mechanisms, prevention, screening, and treatment ofdiseases that are common among women, as well as when to consult a doctor about these diseasesMore than 40% of women responded that they wished they could have learned more in school about
the “Mechanisms, prevention, screening and treatment of diseases common among women” and“When to see a doctor (symptoms of concern)” (Figure 39).

30



In terms of knowledge, we compared health literacy scale items related to "Knowledge of the female
body" across the different age group. There was a difference between age groups in terms of thenumber of people who responded “I have knowledge about menstruation," "I have knowledge about
the stages of pregnancy,” and “I have knowledge about uterine and ovarian diseases” (Figure 41, 42& 43). Among these three items, there was a significant age-stratified difference for "I haveknowledge about uterine and ovarian diseases." About 10% fewer women in the 18-29 and 30-39
age groups selected this answer compared to those in their 40s (Figure 43).

31

32



The internet was the main source of information used by women when concerned about women's
health. School education and materials were also utilized for some issues such as “Secondary
sexual characteristics (menstruation, ejaculation),” “Sexual intercourse, mechanisms ofpregnancy,” “Suitable times for pregnancy, fertility/infertility,” “Means of contraception andabortions,” and “Sexually transmitted diseases (STDs; HIV, Syphilis, Chlamydia, etc.)” (Figure 44, 45,& 46).

33

Interpretations


Women are exposed to risks associated with female-specific health problem throughout their lives
due to hormonal changes accompanying their transitions between life stages. It is essential toprovide them with the information they need and education about women’s health so that they
can understand these risks and take appropriate measures to prevent and cope with any problems
34

they face. Information and education also help women to better plan out their own lives, including
pregnancies.
In this survey, fewer women responded that they had knowledge about uterine and ovariandiseases compared to the number of women that said they understood mechanisms of
menstruation or pregnancy. Many women also reported that they wished they had learned morein school about the mechanisms, prevention, screening, and treatment of diseases that arecommon among women, as well as when to consult a doctor about these diseases. These results
highlight the need to provide women with further opportunities to learn about women’s healthissues.

The Internet was the most commonly used tool for women when collecting information around
women's health. Although information can be easily found on the internet, not all of it is correct.
It is thus essential for women to be able to judge and select the information that suits their needs.



School education could be more effective by focusing on the areas that were highlighted by
women through this survey. Companies also play an important role in providing information tofemale employees who have difficulty obtaining such information otherwise.

E)

Health check-ups organized by workplaces encourage women to make regular visits toobstetrician/gynecologists
The most common reason for making a first visit to an obstetrician/gynecologist was “I had
symptoms,” followed by “To receive cancer screening (breast, uterine etc.)." Only 19.6% of womenmade a visit "To know the conditions of my body" (Figure 47).

35



About 70% of women reported that they do not made regular visits to an
obstetrician/gynecologist (Figure 48).

The main sources of information that led women to schedule regular visits toobstetricians/gynecologists were “Recommendations during a check-up organized by aworkplace” (22%) and “Recommendations from an obstetrician/gynecologist during a check-up”(20%) (Figure 49).

36

37% of women reported that they did not see an obstetrician/gynecologist when they thought it
might be necessary (Figure 50). The main reason for this was “I thought my symptoms were notserious” (55%). This was consistent regardless of the level of health literacy (Figure 51). However,the second most common reason was differed between the two health literacy groups. That reason
was “It was difficult for me to visit a hospital during its opening hours” for the high health literacy
group and “I felt embarrassed/uncomfortable receiving an examination at an obstetrics/gynecology
department” for the low health literacy group (Figure 51).

37

Interpretations
Regular visits to an obstetrician/gynecologist are crucial for a woman to fully understand herhealth. However, only very few women made a first visit to an obstetrician/gynecologist "To know
the conditions of (their) body." More should be done to ensure that women have opportunities tolearn about their bodies and health and to seek advice by encouraging women to make regular38

visits to obstetricians/gynecologists from a young age.


For working women, health check-ups organized by workplaces are particularly influential in
shaping their self-care behaviors. This suggests that companies play a critical role in women’s
health, including related to the promotion of regular gynecological check-ups.

One of the impeding factors preventing women from visiting obstetricians/gynecologists wasunawareness of abnormalities or the severity of symptoms. We thus need to reinforce
interventions to improve access to necessary healthcare, such as by providing information onwhen to consult a doctor and the process of gynecological treatment.

F)

Other findings


There were high unmet needs related to healthcare facilities and the cost of treatment

Regarding factors that could encourage women to make visits to obstetricians/gynecologist, many
women had requests for healthcare facilities such as “Create systems where reservations for a
consultation can be made on the internet,” “Offer consultations by female doctors,” and “Promote
friendly/kind attitudes among doctors.” There were also demands related to cost, such as "Offer
financial support to cover the treatment costs" and "Reduce charges for medications" (Figure 52).



There is high unmet need for education among men as well to prevent unwanted pregnancies

Regarding factors that could prevent avoid unwanted pregnancies, the most common answer was“School lessons providing practical information on contraceptive measures.” These lessons should
not only be aimed at women but men as well (Figure 53).

39

The second most common response was “A system allowing morning after pills11 to be purchased
over the counter at pharmacies” (Figure 53).

Morning after pills (emergency contraceptives) were judged unsuitable as an over-the-counter (OTC)
medication by the Ministry of Health, Labour and Welfare (MHLW) during the “3rd Review Meetingon Reclassifying Prescription Medications to OTC Medications.” However, more than 40% of
respondents stated that access to these pills is necessary to avoid unwanted pregnancies.

Two agree/disagree questions were asked to evaluate the health literacy scale’s “Sexual Health
Discussions with Partners” item, namely, “I can discuss contraception with my partner whennecessary” and “I can discuss the prevention of STDs with my partner when necessary.” Abouthalf of women were unable to discuss these issues with their partners (Figure 54 & 55). It istherefore necessary for men as well to be taught necessary knowledge around sexuality andhealth, ensuring a common ground where they can discuss and talk to each other.

11

Emergency contraceptive pills that can used within 72 hours in case of the absence or failure of usual contraceptive measures(rupture of condoms, etc.)40High levels of health literacy about women’s health is associated with high levels of job satisfaction,living satisfaction, and QOL



Women with high levels of health literacy also had significantly high levels of job satisfaction(Figure 56), life satisfaction (Figure 57), and QOL scores (Figure 58).

41

42

43

IV. Opinions
This survey revealed that there are a certain number of women who feel unable to take appropriate
measures when faced with women’s health problems due to a lack of knowledge about this topic.
Nevertheless, the survey also implied that improving health literacy among women can have a positive
impact on health behaviors and consequently on work performance and socioeconomic activities as well as
well. The following section presents the opinion of the research team on these results in the form ofrecommendations for the policy measures needed to further promote women’s health.
All of these measures are related to each other. As such, it is crucial that they be implemented as part of anational policy to support women’s health. It may also be desirable to establish a national institution to
implement these interventions.
A)

Provide the information women need to enable them to take action against women’s health risksThis survey showed that there is high need among women for enhanced knowledge on women’s health.
“Knowledge of the female body” was significantly associated with high work performance and the ability
to plan pregnancies. It is vital to prioritize the provision of educational opportunities for women to obtainsuch knowledge.
1. Relevant results from the surveyThere is high need for education on women’s health issue and coping measures, pregnancy, andinfertility treatments in generalThe extent that work performance drops due to PMS or menstrual symptoms as well as
menopausal symptoms/disorders is related to a woman’s level of health literacyKnowledge of women’s health was associate with the ability to plan pregnancies

Younger women (aged from their late teens to 30s) tended to have lower levels of knowledge
about women’s health or self-care behaviors

2. Recommendations
Provide information, through school education or seminars, about pregnancy and women’s
health issues and coping measures

Government: The Government should take leadership on the creation of school curriculums
focusing on the specific areas that women need to know aboutSchools/academic institutions: Focus on subjects related to lifelong health management andselfcare for womenCompanies: Offer training or seminars to provide employees with necessary informationaccording to their life stage

3. Points that will be crucial to the implementation of these recommendations


Subjects to be covered in school classes or seminars
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Women’s healthissues Women’s health issues and the stages, prevention, screening, andtreatment of diseases that are common among women (uterine andovarian diseases, prevention of STDs, etc.)
 When to consult a doctor about these diseases or symptoms
 The importance of knowing about your own health from an earlystage by making regular visits to an obstetrician/gynecologist
 Treatment at obstetrics/gynecology departments

Pregnancy The stages of pregnancy
 Ages when it is easy to become pregnant
 Suitable times of pregnancy and fertility
 Means of contraception
 Life planning, including related to pregnancies

Infertility treatment

 Details of infertility treatment
 Necessary examinations
 Probability of pregnancy through infertility treatment
 Appropriate timing to initiate infertility treatment
 Costs of treatment
 Discussions with partners about infertility treatment

Menstruation (esp.

 The mechanism of menstruation

for ages 19-29)

 How to keep track of menstrual cycles
 PMS, menstrual symptoms, and coping measures

Menopausal

 The mechanisms of menopausal symptoms or disorders

symptoms/disorders

 Coping measures for menopausal symptoms or disorders(esp. for ages 30-40s)
Selection of
information How to discern what kind of women’s health information isappropriate for your situation

Implementation Methods


Although many of the subjects related to women’s health are already incorporated in school
curriculums, many working women reported that they wished they had learned more atschool, particularly about women’s health issues, coping measures for those issues, andpregnancy. The role of school education was also highlighted through the fact that many
women used education materials as a source of information, even after leaving school.
Necessary education on focused areas could contribute to better health in the future forwomen, even if class time is limited.



As the above mentioned topics require technical knowledge about medicine, it would be best
if schools collaborated with healthcare professionals, including obstetricians/gynecologists,
45

nurses, public health nurses, and midwives. External lecturers could help provide students
with information about practical topics and case examples, in addition to expert guidance.
In the case of corporate seminars, it is critical to provide information appropriate for the ageof participants, as the knowledge women need varies depending on their life stage.



Men should also be encouraged to participate in these educational opportunities in order todevelop a common understanding about women’s health.

B)

Strengthen health promotional activities to improve health literacy in workplaces
High levels of health literacy were associated with high work performance as well as the coping behaviors
for women’s health issues. Interventions to improve health literacy among women should not only
provide information but also empower women to utilize such knowledge and take necessary actions.

1.

Relevant results from the survey


Women with high levels of health literacy had high levels of work performance on average over themonth prior to the survey

Although many women experienced negative effects on their work performance from
PMS/menstruation or menopausal symptoms/disorders, the high health literacy group was lesslikely to experience decreased work performance when experiencing these symptoms



Women with high levels of health literacy were more likely to undertake coping behaviors for
women’s health issues, including taking medicine or seeing a doctor

2.

Recommendations
Establish a baseline for the improvement of health literacy among working women

Government: Include efforts to improve women’s health literacy as one of the criteria to be
included in the Health & Productivity Stock Selection portfolioGovernment / Research institutes: Develop evaluation methods to assess health promotional
activities in companies

Carry out interventions to improve health literacy among working women

3.

Companies: Develop a consultation system to improve health literacy levels among women

Points that will be crucial to the implementation of these recommendations


Since FY2014, the Ministry of Economy, Trade and Industry (METI) and the Tokyo Stock Exchange(TSE) have been managing a Health & Productivity Stock Selection portfolio. This program aims topromote “Health and Productivity Management”12 efforts within companies by encouraging
people to invest in those companies that are engaging in outstanding, strategic efforts to maintaintheir employees’ health. An increasing number of companies see women’s health as a priority.

12“Health and productivity management” is a registered trademark of the Workshop for the Management of Health on
Company and Employee46

Efforts to improve women’s health literacy should be incorporated into the criteria used to certify
the Government’s Health & Productivity Stock Selection portfolio, in order to further promotewomen’s health in workplaces.


The PDCA process (Plan → Do → Check → Act) should be used to evaluate specific objectives,
activities, and outcomes for women’s health promotion.

 As mentioned earlier, improving "Knowledge of the female body" is a priority task. Levels of healthliteracy can only be improved by enhancing the ability of women to act using the acquired
knowledge. We should establish an effective support system where occupational healthprofessionals can provide technical advice to women or their supervisors/colleagues andencourage them to take appropriate actions.
C)

Improve access to obstetrics & gynecology departments
Regular visits to an obstetrician/gynecologist are crucial for a woman to fully understand her healthstatus. Through the consultations, we should communicate with women the importance of knowing
their physical conditions.

1.

Relevant results from the survey
About 70% of women reported that they do not made regular visits to an obstetrician/gynecologist

Among those who are already making regular visits to obstetrics/gynecology departments, regularcheck-ups organized by their workplace was the main source of information that them to schedulethose regular visits. Recommendations from an obstetrician/gynecologist during a check-up was
also effective.



In terms of the factors that encouraged women to make visits to an obstetrician/gynecologist,
many women responded that they wanted a system that would allow for reservations to be madeover the internet, as well as financial support to cover treatment/consultation costs.

2.

Recommendations
Communicate the importance of making regular visits to obstetrics & gynecology departmentsCompanies: Incorporate women’s health issues into regular check-ups



Healthcare providers: Communicate to women the necessity of making regular visits to an
obstetrician/gynecologist

Alter the healthcare system to encourage women to receive necessary check-ups orconsultations
3.

Healthcare facilities: Develop healthcare delivery systems based on client needs

Points that will be crucial to the implementation of these recommendations47In order to better support working women, it would be best if companies collaborated withinsurers, occupational health specialists, etc., to incorporate gynecological items into regularcheckups. These partnerships could be expected to make a positive impact on work performanceas they would provide women with technical advice that could enable them to take effective
selfcare or coping measures.

More than any other measure, respondents stated that they hoped that more
obstetrician/gynecologist departments would use online reservation systems. Healthcare delivery
systems should aim to meet outpatient needs.

D) Create environments that ensure women can plan pregnancies and receive infertility treatment as
necessary
Survey results show that there is high need among women not only for knowledge about pregnancy andinfertility treatment, but also for the creation of better systems related to these topics, and thedevelopment of supportive atmospheres in workplaces. It is important that an environment be fostered
to ensure that women can get the help they need related to pregnancy planning and infertility treatment.
1.

Relevant results from the survey
Many women responded that a flexible paid leave system and friendly atmospheres in workplaces
that encourage women to take paid leave or return to work after taking childcare leave would help
them to better plan pregnancies.



There was a certain number of women who reported that they were unable to become pregnant
when they wanted to due to work responsibilities. In addition, one of the top reasons women said
that they did not receive infertility treatment was difficulty in balancing with treatment schedules
with work.

2.

RecommendationsCreate environments that ensure women can plan pregnancies and receive infertility treatment
as necessaryCompanies: Develop a flexible paid leave system that can be used to take as little as a few
hours of leaveCompanies: Ensure friendly atmospheres in workplace that encourage women to utilize theopportunities and systems available to them

3.

Points that will be crucial to the implementation of these recommendations


It is important that flexible systems related to pregnancy and infertility treatment be developed inworkplaces that suit the needs of female employees and facilitate a better understanding about
these issues among their colleagues.

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V. Acknowledgement
HGPI would like to express its sincere gratitude to the following supervisors who provided expert guidance forthis survey, sharing their insights on issues related to health promotion and working women, including theirview of these topics in the future.
(Titles omitted)

Yuji Taketani (Chairman, Artemis Women’s Hospital; Supervisor, Project for Whole Implementation
to Support and Ensure the Female Life (WISE), Japan Agency for Medical Research andDevelopment (AMED))

Honami Yoshida (Associate Professor, Department of Health and Welfare, Kanagawa University of
Human Services)

VI. “Health Promotion and Working Women 2018” Project Team
(Titles omitted)



Yutaka Osuga (Professor, Department of Obstetrics and Gynecology, Graduate School of Medicine,
University of Tokyo)

Naho Morisaki (Chief, Division of Life-course Epidemiology, Department of Social Medicine, National
Center for Child Health and Development (NCCHD))

Kazumi Kubota (Assistant Professor, Department of Biostatistics, School of Medicine, Yokohama City
University)



Shu Suzuki (MSc candidate, Division of Health Sciences and Nursing, Department of Community
Health Nursing, Graduate School of Medicine, University of Tokyo)

Yuko Imamura (Senior Associate, Health and Global Policy Institute)

Mariko Oyamada (Vice President, Health and Global Policy Institute)Yukiko Yoshida (Program Specialist, Health and Global Policy Institute)

HGPI conducted this survey with the financial support of Bayer Yakuhin, Ltd. and docomo Healthcare, Inc. The

Sponsor’s opinions were solicited, but we exercised independent judgment in determining whether any such
opinions should be reflected in the survey. We also have received financial support from The National Graduate
Institute for Policy Studies (GRIPS) for the English translation.
Contact:
Health and Global Policy Institute (Imamura/Oyamada)
Mail: info@hgpi.org
Tel: 03-4243-7156

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