Lack of awareness of bus workers’ healthcare
The participants continued to maintain a naïve attitude towards health issues, despite their declining physical and mental health. Apprehending the severity of a health problem might help participants to adopt better health behaviors. Most participants, however, acknowledged the necessity of healthcare but continued being negligent of their health due to lack of time. Furthermore, they were not aware of the accurate figures for their blood pressure and blood sugar levels, to prevent cardiovascular diseases, which are likely to be caused by their work environment (e.g. shift-work, sitting posture, conflict with passengers). Moreover, they recognized the discrepancy in their knowledge on basic self-healthcare, although they made very few attempts to ameliorate it. They believed that perceptions of healthcare vary with age and willingness. That is, the higher the age, the more interested in health status one is. Engaging in health-related behaviors depends on the will of a person. Therefore, they anticipated that positive reformation of a work environment would not have any effect on their health.
Participant 8: It is no fun when you do it alone.
Participant 4: I use the gym equipment on the riverside when I have the time, but to be honest, I do not really work out at home.
Participant 8: I must do it when I have time, but I just do not. Twenty-four hours is not enough.
Participant 5: I do not have the time for it.
Participant 3: Younger people in their 20s and 30s are not interested at all. They are reluctant and feel awkward to get involved in a program like this.
Participant 7: I personally think that the will of a person is the most important regarding matters of health, whether it is about using a handbook or an app (smartphone application) on health. I think that no more than 30% of workers will use it.
The positive first impression of the health promotion program
The participants did not have any previous experience with other health promotion programs, despite their extensive career. Some participants engaged in exercise as a hobby and managed their health without considering the health issues arising from work. Under these circumstances, the present health promotion program was sufficient to attract the attention and involvement of the participants in the program.
No experience participating in prior health promotion programs
All participants recognized that their physical and mental health was deteriorating due to the detrimental working environment. Some of the participants managed their health through fitness and soccer during their days off. These activities, however, did not contribute to the improvement of the musculoskeletal symptoms, a constant inconvenience sustained by their work. None of the participants had any prior experience of participating in health promotion programs, including programs held by public health centers or employee health support centers.
Moderator: Have you ever tried a similar program like this? Have you tried it before?
All participants: No, I have not.
Moderator: You are aware of a public health center or an employee health support center, I assume? Have you ever participated in any similar programs there?
All participants: No, I have not.
Participant 9: This is the first time…the first time since 1991, when I started my job.
Motivation to participate in the health promotion program
There were various reasons for participants to join the health promotion program. Most of them took an interest in the program after seeing the promotional banner or promotional articles on social networks. In addition, some voluntarily joined in hopes of relieving their physical pain.
Moderator: How did the rest of you hear about the program?
Participant 6: I saw the banner.
Participant 5: … It could be spotted at the garage.
Participant 6: I received a text message.
Participant 3: There was an announcement in my company, and for some other companies, a union leader posted the announcement on the union social network.
Participant 9: I thought I should give it a try. When I saw it, nobody told me about it, but I wanted to give it a shot when I spotted it.
Participant 6: I thought it could be helpful because my neck and shoulder ache…
Satisfaction and changes after participating in the health promotion program
Participation in the program was an opportunity to reassess the health problems that they had been neglecting. Participants reported experiencing positive changes and significant satisfaction. They were able to gradually relax the persistent pain through quick stretching and understood their current health status through various medical examinations. The lack of publicity for the program, however, generated a low participation rate. This phenomenon was regarded unsatisfactory, which led to the participants encouraging their peers to join.
Positive changes as a result of participating in the health promotion program
The number of involvement in the health promotion program varied by the participants from one to eight-time involvement, but they experienced a positive transformation from the stretching skills they acquired. The most significant change was that the stretching skills enabled them to take health-related actions in daily life. In the long-term, it is expected to improve their healthcare behavior and health status. They also recognized a shift in their perception of the working condition after participating in the program. Before the program, they considered the working environment and the short dispatch intervals to be the significant factors, which forced them to feel helpless about healthcare. However, they learned to utilize the workspace to stretch efficiently for a short amount of time. From this understanding, they established a routine, which comprised stretching, and observed improvement in their physical discomfort. This encouraged them to participate in other available health promotion programs.
Moderator: Is it better after the stretching? Can you feel it?
Participant 5: I had some shoulder pain, and there were two physical therapists; two of them gave me shoulder massages, and I got them about three times. Then, I did it at home, and it was quite pleasant.
Participant 9: (I have a) frozen shoulder. I have terrible shoulder pain, and I felt great relief doing it.
Participant 2: Yes, it felt untangled.
Participant 9: They also gave tools. If you do what you learn from them, you could actually pull it through. Because my body is in pain…
Participant 1: I do it whenever I start the engine.
Participant 9: Yes, it helped a lot.
Satisfaction factors of the health promotion program
The program primarily focused on the prevention of musculoskeletal disease through stretching and exercise and included examinations of the body fat, body mass, osteoporosis, blood pressure, blood sugar, and cholesterol. Such a comprehensive healthcare program resulted in high satisfaction among the participants. Furthermore, considering the lack of free time, they were content with the availability of health counseling and individualized posture correction for painful areas from professionals, in their workplace (bus garages). Moreover, they were satisfied with the strategy to associate the stretching tools, compensation of the program involvement, engaging in a daily healthcare routine, and the companionship of colleagues throughout the engagement.
Moderator: You have had various experiences. You underwent blood drawing and stretching exercises, but which one was the best of all?
Participant 2: It was the body fat analysis.
Participant 1: I went for that (body fat analysis) to see the body fat percentage and to be assessed. I wanted to know my body measurements, and therefore, I was recommended to colleague.
Participant 3: Things you could conveniently do, like stretching, by seeing a doctor. You feel like a patient when you visit a hospital, but you could go there (garage) without any pressure. I can casually go there, and at the same time, I can receive professional diagnosis and treatment.
Participant 1: I had easy access. For so-called-hospitals, you have to visit deliberately and that is inconvenient. However, there (garage), you could just do it for just being there.
Participant 9: I tried the gift (stretching tool) at home, and it was really good. It stretched my back, and I experienced immense relief.
Participant 7: I used to have shoulder pain when exercising. It was damaged, so I stopped it, but the pain did not subside. Therefore, I went to an orthopedic, but the doctor told me that nothing was wrong with me. So I just let it slip. … I clearly did not know how to treat it…during the stretching activity, I was informed about an injured area that I was not aware of. It was not the most impactful exercise, but I wish they taught me muscle or ligament stretching movements…because lately, it has made me feel much better.
Limitations of the health promotion program
The participants expressed great satisfaction with the program but noted the limitations as well. One of the most mentioned points was the lack of program publicity. Participants who reflected on their health and experienced improvements through the informative sessions despite the short-term period felt sorry for their colleagues, who could not get involved due to the lack of publicity. Moreover, some of them worried that the unmodifiable working environment would eventually worsen the symptoms regardless of the stretching skills and felt unsatisfied with an insufficient health consultation.
Participant 9: I think with good PR (public relations); I mean many workers did not do it simply because they did not hear about it. But if you were to recommend it to your co-workers by saying “It is really nice when you actually try it out” and “Just try it! It is truly helpful!” then they might become willing to participate. But the PR was almost invisible, which made the workers hesitate. You need proper promotion for this.
Participant 3: It is a good idea to hop on a car and stretch. However, the unpleasant part, rather than feeling better from the exercise is that… if you get an old car, you would feel the symptoms worsen quickly, rather than improving.
Participant 8: I benefitted from the exercising or other activities, but I did not benefit from, for example, finding out how good or bad my health was.
Recommendation of the health promotion program to colleagues
The great fulfillment with the program led to participants recommending the program to other colleagues. Participants shared their positive involvement in the program with their peers who could not join because of insufficient advertising. They believed that those who have experienced the program should enthusiastically inspire others to participate.
Moderator: What would be a good PR strategy for this (addressing the low participation rate)?
Participant 6: We should actively promote it.
Participant 1: People who have participated in this program can spread the word, but people who have not cannot; if more people participated in the program, then the word would have traveled faster.
Moderator: Would you consider recommending this program to others?
Participant 1: Yes. If your body gets better, of course, you will recommend it.
Participant 5: I encouraged a lot of them by saying things like “It is nicer than I expected.”
Improvement of the health promotion program
Participants mentioned several aspects of the program that could be enhanced. The current program manages only physical health. They emphasized the importance of sleep disorders and mental predicament as a result of their work environment and the inclusion of a mental health consultation session in the program. Moreover, they asserted that the continuity of the program would amend the core of the problem lied in health. Further, the persistent obstacles as a result of the two-shift work system and short dispatch intervals were other compelling reasons for the low participation rate. They highlighted the necessity of adopting a unique shift system for a smooth implementation of the program. They also noted that maintaining a health handbook or distributing health-related posters could serve as adequate substitutes in case of participation failure. The also stated that not only should the program be expanded to other regions but also small establishments with less than five employees should be prioritized for the program.
Expectation of the inclusion of mental as well as physical healthcare in the program
Mental health problems were an imperative factor deteriorating a healthy routine. The physical pain and mental difficulties could remain unaddressed and eventually threaten the responsibilities of the worker. Chronic pain and fatigue accumulation from working in such an environment can decrease the concentration level and increase sleep disturbances. In addition, unfair treatment and criticism from passengers could trigger mental stress, which could hinder bus operation. They, therefore, strongly argued that mental difficulties should be managed to avoid operational complications.
Participant 1: We (workers) talk a lot about grievances when we take a break in the employees’ room. This has something to do with psychological wellbeing as well … it might be quite helpful to get some counseling or… Because I am extremely stressed out, bus driving is not only physically taxing but also psychologically stressful. Therefore, psychological counseling is needed.
Participant 9: It might be because of my age, but I have not been able to sleep since last March; sleeping does not work on me anymore. So I consulted a few psychiatrists… strangely, if I wake up in the middle of the night, I cannot go back to sleep. Moreover, I have been suffering for one year and seven months. I am seeing a counselor too…
There are more ways than I thought. They just keep their mouth shut and keep it to themselves. Rather than just telling us to lower the accident rate, I wish we could have some peace of mind. Loss of sleep is often directly associated with accidents, as you know.
Continuous health management support from professionals
Many participants pointed out the inevitable need for a regular program rather than a one-time event. A sudden healthcare event is not practical under circumstances, where it is challenging to transform the working condition. They also claimed that there is a need for permanence to understand their health status and maintain a proper stretching posture.
Participant 8: It is an only a one-time thing if you do it for a week and you rest a bit. … I want the current program to be gradually developed and continued for a longer period of time.
Participant 6: I wish it became a long-term program.
Participant 3: I think it would be appropriate to make things like this last for a while…
Carrying out the program in consideration of the working conditions
Participants’ irregular working hours and short dispatch interval times hindered program engagement. Participants whose pain improved through the program attempted to get more involved in the program. However, inconsistent working and program hours led them to neglect their health again. They inquired about operating hours at various times and wished to be informed of the program’s location and schedule through social networks.
Need for including training for improving self-healthcare skills in the program
They presented a positive response to a healthcare handbook as a way to self-manage health. Considering the relatively high age range of the bus workers, they expected that the handbook would suit them better than an unfamiliar smartphone application and that it would provide them an opportunity to manage their health without being involved in the program. Furthermore, some considered that the posters at the workplace would naturally encourage stretching activities, which would enhance the effectiveness of the program.
Moderator: What do you think about being provided with a health handbook so that one can keep a record of their health?
Participant 9: It would be nice if you could give it out.
Participant 6: It is good to keep a track; I will know when and what I did, and I can reflect on it too.
Participant 2: I will have the “Ah ha! I got it!” moments.
Moderator: What about a smartphone application? Do you generally use it well?
Participant 2: It is okay, but I would prefer a handbook.
Participant 5: Me too.
Participant 6: People like us do not really know…youngsters do though…
Participant 8: Remember when there was a national gymnastic exercise or some sort of an event with instructions? I think it would be more effective if you stick a poster on a wall and follow it regularly whenever you have the time.
Moderator: Are you suggesting making a poster about it?
Participant 8: Indeed. Even I would follow it naturally if it was in the office.
Expansion of the health promotion program
The participants felt positive about the expansion of the program. They suggested prioritizing small-scale businesses with less than five employees as the companies often do not provide proper healthcare for financial reasons. Moreover, they recommended the expansion of the program to other regions.
Participant 5: Where should it start… There are tons of small businesses. Regular small businesses go through a health checkup process once a year. But smaller ones hardly do it. There are just thousands of them out there.
Participant 8: You have no idea how many companies with three to four people are there… Never in their wildest dreams would they go to a hospital.
Participant 5: No, never.
Participant 2: I wish other regions will get a chance to experience it too… The good part of the program is that stretching is essential, but it is not so easy to do it as you picture it in your head. If you squeeze it in every second, I think it would be nice to see the program in every region.