Click here to view the Health and Productivity Management Strategy Map[550KB]
Policy
Marubeni Group Health Declaration
The Marubeni Group has established the following Marubeni Group Health Declaration based on the Marubeni Group Basic Policy on Occupational Health and Safety.
Marubeni Group Health Declaration
Employees are a vital asset for the Marubeni Group, and their health is of paramount importance. Therefore, the Marubeni Group considers the maintenance and improvement of the health of its employees to be a top management priority.
The Marubeni Group supports employees’ success by working to create an environment where each individual can autonomously and proactively take steps to maintain and promote his or her health. These efforts will lead to the growth of the Marubeni Group.
Health and Productivity Management Strategy Map
To put our Marubeni Group Health Declaration into practice, we will manage the progress of our health and productivity management by using indicators formulated in the map of health and productivity management strategy.
Structures and Systems
Marubeni Health Promotion Structure
Marubeni has established the “Marubeni Health Promotion Structure,” which is under the responsibility of the director in charge of the Human Resources Department. This system promotes health and productivity management through the coordination of four groups: occupational physicians (Company Medical Clinics), the Health Insurance Association, the Human Resources Department, and Health and Productivity Management Promotion Officers selected from among the Company’s employees. Representatives of these groups gather at a Health Management Promotion Meeting to review health management measures and discuss future initiatives. The Health Management Promotion Committee, which is made up of representatives from occupational physicians (Company Medical Clinics), the Health Insurance Association, and the Human Resources Department, meets twice a year to discuss Health Insurance Association’s health programs of the Health Insurance Association, various health management initiatives, and other matters relating to occupational health and safety in general.
The term “health and productivity management” is a registered trademark of the Workshop for the Management of Health on Company and Employee.
| Officer in Charge | Jun Horie (Senior Managing Executive Officer, CAO; Chief Operating Officer, Human Resources Dept., Chief Heath Management Officer) |
|---|---|
| Committee in Charge | The Health Management Promotion Committee, Health Management Promotion Meeting |
| Department in Charge | Human Resources Dept. |
In addition, a legally mandated Health Committee is chaired by the Chief Health and Safety Supervisor (General Manager of the Human Resources Department) and comprises members including Health Supervisor, occupational physicians (Company Medical Clinics), Health and Productivity Management Promotion Officers in each Business Division and the Corporate Staff Group, representatives of the labor union, and the Health Insurance Association. The committee meets once a month to discuss various issues including health management and health and productivity management initiatives, improving the working environment, measures to tackle long working hours, and countermeasures for occupational accidents.
Marubeni Health Project Indicators
Taking regular health checkups have an extremely significant role in the early discovery and early treatment of diseases. Thus, achieving a 100% participation rate for regular health checkups is one of Marubeni's Health Project Indicators, and the results are reviewed annually. By establishing metrics and implementing various measures, we will aim for solutions to health issues. In FYE 3/2024, we took thoroughgoing measures to ensure that employees undergo regular health checkups, aiming for the early discovery and early treatment of diseases. This resulted in 100% of employees who underwent regular health checkups at 100% (employees working in Japan) and greater health awareness among employees.
To confirm if the series of health and productivity management initiatives lead to solutions towards management issues, we also check indicators such as employee engagement on a regular basis.
| Item | Target | Status of Achievement (FYE 3/2024) |
|---|---|---|
| Regular Health Checkup Rate (Employees Working in Japan) | 100% each year | 100.0% |
| Regular Health Checkup Rate (Employees Working Overseas) | 100% each year | 98.3% |
| Rate of Employees Undergoing Stress Check Tests | 90% or more each year | 96.5% |
Additionally, we set targets for implementation rate of specific health guidance (year-on-year increase), rate of employees undergoing specific health guidance (year-on-year decrease) and smoking rate (year-on-year decrease).
Initiatives
Marubeni Health Improvement Project
Under the Marubeni Health Improvement Project, Marubeni continues to implement various initiatives based on four key themes:
- Improving Health Literacy
- Strengthening Countermeasures against Cancer and Lifestyle-related Diseases
- Strengthening Mental Health Measures
- Strengthening Initiatives for Maintaining and Promoting Women’s Health
1. Improving Health Literacy
In cooperation with the Health Insurance Association and occupational physicians, Marubeni implements initiatives to improve employees’ health literacy.
| Measures (Initial fiscal year) | Overview |
|---|---|
| Health Management E-learning (FYE 3/2025) | Implementing an e-learning program that includes useful information to support each employee for independently and proactively working on maintaining and improving their health. |
| Introduction of Shingles Vaccination Assistance (FYE 3/2024) | Subsidized the cost of inoculation to prevent the onset and severity of shingles. |
| Establishment and Announcement of Health-related Index (FYE 3/2020) | Set and announced health indicators that the company values as “Marubeni Health Improvement Project Indicators.” Utilize the indicators for consistent consideration of measures based on fixed-point reviews. |
| Participated in Corporate Actions Promoting Measures Against Cancer (FYE 3/2020) | Encouraged cancer screening by distributing pamphlets and displaying posters. |
| Utilizing Health Management App (FYE 3/2020) | Improved health literacy of employees and their families using health management app. |
| Introduced an App for Health Consultation and Doctor/Hospital Referrals (FYE 3/2020) | Conducted consultations on disease symptoms and health in chat-format and referrals to doctors and hospitals according to the individual’s preferences. |
| Implementing Walking Events (FYE 3/2019) | Held walking events in conjunction with the health management app. |
| Participation Rate of Regular Health Checkups | Strengthening of efforts to achieve 100% participation in regular health checkups (FYE 3/2019). Focused efforts on ensuring participation in legally mandated regular health examinations, which play a significant role in early discovery and treatment of disease. Recommended participation to every employee yet to have a health checkup to achieve 100% participation every year. Also focused efforts on increasing participation in thorough checkups among employees who were found to need these checkups as a result of regular checkups. |
| Strengthening Initiatives to Provide Healthy Menu Options at Company Cafeteria (FYE 3/2019) | Held a health promotion campaign, provided special menu options to support blood donation, and labeled nutritional information. |
| Conducted Health Seminars (FYE 3/2018) | Conducted seminars on various topics including oral healthcare, prevention of decreased physical function, etc., by outside experts to raise employees’ health awareness. |
2. Strengthening Countermeasures Against Cancer and Lifestyle-related Diseases
Among our measures to maintain and promote health, we focus on countermeasures against cancer and lifestyle-related diseases and are implementing the following initiatives.
| Measures (Initial fiscal year) | Overview |
|---|---|
| Five Year No-Smoking Plan (FYE 3/2025) | Starting in FYE 3/2025, we aim to gradually extend no-smoking hours and create a work environment that is completely smoke free from the beginning to the end of the workday by FY2028. |
| Trial Introduction of Power Naps (FYE 3/2025) | To revitalize and improve concentration, we are encouraging short naps lasting 15 to 30 minutes between 10:00 PM and 3 PM. |
| Introduction of Alcohol Gene Testing (FYE 3/2025) | Alcohol gene testing will be offered to new employees who wish to participate, helping them understand their genetic predisposition and encourage moderate drinking. |
| Expansion of Dental Checkups at the Company Dental Clinic (FYE 3/2024) | Recognizing that oral health affects overall health, dental checkups will be provided at the company’s expense every three years for employees aged 35 and older at the Company Dental Clinic. |
| Introduction of Advanced Medical Treatment Support System (FYE 3/2024) | Support for the cost of advanced medical treatment as defined by the Ministry of Health, Labor and Welfare. |
| Introduced Fully Subsidized Colonoscopies (FYE 3/2024), Neurological Checkups (FYE 3/2016) and Comprehensive Medical Checkups (FYE 3/2015) | For employees aged 35 and over, the Company subsidizes comprehensive medical checkups received at external medical institutions, up to a maximum amount of 60,000 yen for men and 65,000 yen for women. This amount covers most costs for ordinary comprehensive medical checkups. In addition, the Company subsidizes colonoscopies and neurological checkups for employees aged 45, 50, 55, and 60. |
| Introduction of Tumor Marker Tests (FYE 3/2021) | Added tumor marker tests to the regular health checkups for employees who are 35 years old or older to support the early detection of cancer. |
| Expansion of Cancer Screening Subsidies (FYE 3/2021) | Expanded screening subsidies for prostate cancer, uterine cancer, and breast cancer to support early detection. |
| Strengthening Anti-smoking Measures (FYE 3/2019) | Expansion of smoking cessation treatment cost subsidies, implementation of smoking cessation treatment programs, and introduction of smoking cessation app. |
| Strengthening Measures for Employees Eligible for Specific Health Guidance (FYE 3/2019) | Provided health and nutrition guidance from occupational physicians, public health nurses, and registered dieticians at our company medical clinic not only to employees aged 40 and above who qualify for specific health checkups but also to younger employees. To improve the rate of receiving guidance, the HR Department recommends that eligible employees receive medical examinations. |
| Implementation of Sleep Apnea Syndrome (SAS) Treatment Program at Company Medical Clinic (FYE 3/2018) | Started sleep apnea syndrome screening and treatment at our company medical clinic. |
| Implementation of “Three-month intensive program” (FYE 3/2018) Aiming at Improving Lifestyle and Exercise Habits | With a total of eight lectures and exercises, the program aims to eliminate metabolic syndrome through daily dietary guidance and exercise. 18 employees participated in the program and all of these employees completed it in FYE 3/2024. |
| Strengthening Health Guidance from Registered Dieticians (FYE 3/2011) | Established a system from registered dieticians to provide specialized nutritional management and guidance, etc., at our company medical clinic. |
| Strengthening Health Guidance from Public Health Nurses (FYE 3/2009) | Established a system for public health nurses to provide individual health guidance and consultations, etc., at our company medical clinic. |
| Introduction of H. Pylori Testing (FYE 3/2009) | Added H. pylori test to health examination to enhance early detection and medical care system of diseases such as stomach cancer. |
| Implementation of Hepatitis B and Hepatitis C Testing (late 1990s) | Added viral hepatitis testing to health examination to enhance prevention and early detection of cirrhosis and liver cancer. |
3. Strengthening Mental Health Measures
Marubeni recognizes mental health as an important issue for improving occupational health and safety and is taking the following measures for employees and their families.
| Measures (Initial fiscal year) | Overview |
|---|---|
| Implementation of Mindful Seminars (FYE 3/2024) | Held seminars to learn measures for stress reduction and mental and physical self-care by external experts. |
| Introduction of Employee Assistance Program (EAP) Services (FYE 3/2007); Promotion of EAP Service Use; Trial Counseling Implementation (FYE 3/2019) | Established external counselor consultation service, available to employees and their families on a 24-hour, year-round basis (EAP Services). Offered counseling sessions on a trial basis to all new employees and newly appointed section general managers in order to raise awareness of EAP services and strengthen self-care and awareness/care from managers. Also, provided online self-check and mental health study programs and articles to promote accurate knowledge and awareness of mental health care and to assist employees in monitoring their own mental condition. Send information on the use of EAP services to employees returning from childcare leave and those working long hours. |
| Implementing Stress Checks (FYE 3/2017) | Conducted stress checks for employees at all offices in Japan and overseas (including seconded employees), including offices where there is no legal requirement. |
| Expansion of Examination Times for Mental Health Outpatients at Company Medical Clinics (FYE 3/2007) | Increased number of examination times for mental-health related outpatients from one to two a week. |
| Mental Health Care-related Training (FYE 3/2007) | Conducted training related to mental health care for new employees, line managers, employees posted overseas and their families. Created and distributed a manual with information about mental health care and consultation service. |
4. Strengthening Initiatives for Maintaining and Promoting Women’s Health
Recognizing that the maintenance and improvement of women’s health is a new challenge, Marubeni will continue strengthening the following initiatives going forward.
| Measures (Initial fiscal year) | Overview |
|---|---|
| Expansion of Gynecological Cancer Screenings Subsidies (FYE 3/2025) | Increased screening subsidies for Gynecological Cancer (e.g., breast and cervical cancer) from 60,000 yen to 65,000 yen to support early detection. Up to 5,000 yen is subsidized even if the employee does not undergo a thorough physical checkup. In FY2023, approximately 50% of female employees underwent the screenings. |
| Trial Introduction of Femtech Program (Menstruation and Menopause Support) (FYE 3/2023) | To create an environment where women can work actively from the time they join the company until they retire, the Company offers seminars tailored to stages in women’s lives. We also provide online medical consultations, advice, medication guidance, and prescriptions for issues related to menstruation and menopause. Among program participants, work performance during periods of discomfort associated with menstruation and menopause has improved by 10% compared to before their participation in this program. In FYE 3/2024, 96 employees participated in the menstruation-related program and 55 employees participated in the menopause-related program. Also held a seminar on women’s physical health by a specialist physician. The percentage of positive survey answers regarding the participants’ satisfaction and understanding was 100%. The total amount of expenses for the menstruation-related and menopause-related programs is approx. 10 million yen per year. |
| Introduction of Tumor Marker Tests (FYE 3/2021) | Added tumor marker tests to the regular health checkups for employees who are 35 years old or older and supported the early detection of cancer. |
| Implementation of Seminars to Raise Literacy Regarding Maintaining and Promoting Women’s Health (FYE 3/2019) | Held seminars by external experts to increase awareness of all employees regarding maintaining and promoting women’s health. |
| Establishment of Dedicated Health Consultation Service for Women (FYE 3/2019) | Established a consultation service for women’s health issues. |
| Dissemination of Articles on “Maintaining and Promoting Women’s Health Maintenance” to All Employees (FYE 3/2019) | Used company-wide notification system to spread knowledge about maintaining and promoting women’s health to all employees. |
Other Policies and Initiatives
Appropriate Working Hour Management and Leave Policies
The Marubeni Group has established the following policies and initiatives regarding working hour management in order to realize sustainable growth through improved productivity and a working style that takes into consideration the safety and health of our employees.
Policies
- Reducing long working hours and ensuring proper working hour management.
- Marubeni creates a work environment where employees can maintain and care for their health, engage in work with enhanced well-being, and produce high quality results efficiently.
Initiatives
- Establishing Guidelines
From the perspective of occupational safety (i.e., health management), our guidelines stipulate compliance under Article 36 of the Labor Standards Act, the reduction of long working hours, appropriate working hour management, and monitoring working hours for those in management and supervisory roles, who are traditionally outside the scope of working hour management. - Addressing Employees with Longer Working Hours
At Marubeni, the Human Resources Department regularly conducts individual interviews with departments that consistently register long working hours to check on which measures they are taking to improve this situation. This helps reduce the number of employees who are constantly working long hours. - Establishment of Special Leave Systems
In addition to annual paid leave, Marubeni also offers its own unique special leave systems, such as premium leave and family support leave. Every employee is encouraged to concentrate fully on work during work hours and to take time to fully relax during vacation periods.
Measures to Combat Infectious Diseases
Our number one priority is to ensure the safety and health of our employees and stakeholders, and we are striving to achieve a balance between the prevention of the spread of infection and our business activities by thoroughly establishing appropriate behaviors and working environments. Based on the policies and guidelines set forth by the government and local authorities, we have established and made known to all employees our policies regarding attendance at work, business trips, dinners, and so forth, and in the event of an outbreak of illness or infection among employees, we place the highest priority on preventing the spread of infection.
Establishment of Company Medical Clinics
The company medical clinics at the Tokyo Head Office and Osaka Branch play an important role in promoting health management. At the Tokyo Head Office medical clinic, specialist departments for internal medicine, dermatology, radiology, neuropsychiatric, and dental services are available for employees at any time. Regular annual and specified health examinations are conducted by the company medical clinics, and based on the results, employees can receive follow-up services including re-testing and other treatment for lifestyle diseases, as well as health guidance from an occupational physician, public health nurse, or registered dietician.
Initiatives on Global Health Issues
Marubeni is expanding its business globally around the world. HIV/AIDS, tuberculosis, and malaria are serious problems in some of these countries/regions.
We take appropriate and timely measures against infectious diseases such as HIV/AIDS, tuberculosis, and malaria, overseas and in Japan.
Overseas, we strive to collect information and understand the situation regarding the outbreak and spread of infectious diseases in collaboration with occupational physicians, based on information provided by the WHO and local authorities, and on-site surveys. Employees and their families receive health examinations prior to travel overseas, as well as vaccinations against infectious diseases that pose a risk at overseas postings. Furthermore, when employees based in Japan travel to areas where there is a high risk of infection, they are given appropriate precautions and business trips are restricted if necessary.
In Japan, we offer vaccinations against influenza to all employees, and our company medical clinics offer vaccinations against infectious diseases such as measles, rubella, and mumps. Furthermore, the Health Insurance Association subsidizes employee vaccinations at external medical institutions.
Initiatives of Group Companies
Maynilad Water Services, Inc. (Maynilad), which provides water and wastewater services to the West Zone of the Metropolitan Manila area in the Philippines with a population of 10.5 million, has been conducting programs on health issues, measures to prevent infections, and hygiene education for its employees and local residents.
For its employees, Maynilad provides opportunity of regular physical examinations, in addition, care for their monitoring after physical examination results. From 2009, Maynilad has provided vaccination at reduced price each year for influenza, pneumonia, hepatitis A and B, meningitis, chickenpox, rabies, tetanus, cervical cancer, etc., and it vaccinated 1,077 employees and family members in 2022 and 954 in 2023.
On-site employees engaged in wastewater service were also provided with rabies and tetanus vaccinations, free of charge.
Education programs for local residents, who are the customers of Maynilad, to deepen their understanding of the importance of handwashing and maintaining a hygiene environment have also been conducted, while disinfectant alcohol, gloves, masks, etc. were donated to 14 school districts.
Maynilad’s “Daloy Dunong” has empowered 80 teachers and educators through innovative methods to teach Water, Sanitation, and Hygiene (W.A.S.H). This program enhances their ability to deliver engaging and effective W.A.S.H education. Additionally, on Global Handwashing Day, Daloy Dunong reached 420 students across three schools, promoting the importance of proper handwashing practices through interactive and educational activities. Expanding its impact, the Daloy Dunong Campus Tour engaged 1600 students from eight schools, providing comprehensive W.A.S.H education to foster healthier and more hygienic practices among young learners.
Lectures to residents of our service area 
Lectures to residents of our service area
Click here to view Maynilad’s initiatives
Support for Expatriates and Their Families
Currently, there are approximately 800 Marubeni employees and around 650 of their family members living overseas on assignment from Japan. Ensuring the health of employees and their families is essential for enabling expatriates to perform at their best.
Before and during overseas assignments, we conduct health examinations and training for employees and their families to get an accurate assessment of their health status and to raise their awareness of disease prevention and health maintenance. We place particular emphasis on health examinations to achieve prevention and early treatment of diseases, and in addition to the legally mandated examination for employees assigned overseas, we require each employee to undertake annual health examinations during their assignments. We have achieved close to 100% participation by following up with employees who have not had their examinations, and we are taking measures to ensure that employees continue to take health checkups. We also offer annual health examinations and examinations after repatriation to accompanying family members. If health examination services are not available at the overseas assignment location, our system for subsidizing travel to a nearby area with advanced medical facilities or to Japan ensures peace of mind for our employees. We encourage both employees and their families to consult with occupational physicians regarding examination results and their daily health status.
In the event of a dramatic outbreak of COVID-19 or a rapid deterioration of the medical environment in a foreign country, employees and their families posted in that respective country concerned will be repatriated as necessary.
We have systems in place to transport people to a nearby area with advanced medical facilities or Japan in the case of an emergency so that they can receive the necessary treatment. We also partner with specialist organizations to provide nursing care support for employees’ family members living apart from them in Japan.
Initiatives on Crisis Management
We recognize that people at every business site of the Marubeni Group in Japan and overseas are exposed to various risks, including acts of terrorism, natural disasters, civil unrest, robbery, traffic accidents, aviation accidents, injury, and disease. In particular, we have positioned international crisis management as a highly important Company measure. When an incident occurs, the safety of employees and their families is our primary concern. Accordingly, we strive to foster everyday awareness of crises, and we have established a permanent International Crisis Management Headquarters that is able to respond immediately should a crisis occur.
Specifically, the International Crisis Management Headquarters has prepared a manual summarizing crisis management measure, such as initial actions to be taken in the event of a crisis, and conducts crisis management training for employees who are assigned overseas and their accompanying family members. We have a system in place for gathering and analyzing the latest public security information from areas around the world and share it with the relevant people. In the event of an emergency, we have established a system in which relevant parties can centrally manage information and make timely and accurate decisions and actions in cooperation with overseas bases.
Marubeni Selected for 2024 Health & Productivity Stock Selection and Certified as a “White 500” Company
Marubeni has been selected as a brand for the 2024 Health & Productivity Stock Selection, jointly organized by the Japanese Ministry of Economy, Trade and Industry and the Tokyo Stock Exchange (TSE).
This selection is for outstanding listed enterprises on TSE which approach health and productivity management from a strategic business management perspective for their employees. 53 enterprises in 27 industries have been selected in 2024, and Marubeni was chosen as one of five companies in the wholesale trade category. This is the third time Marubeni has been selected for two consecutive years following 2023, and it is also the seventh consecutive year the company has been certified as a “White 500” company.
Employees are a vital asset for Marubeni, and their health is of paramount importance. Therefore, Marubeni is working to create an environment where each employee can autonomously and proactively take steps to maintain and promote their health. Marubeni will work on promoting health and productivity management as well as deepening human capital management into the future to support employees’ success, and these efforts link to the continued growth of the Marubeni Group.
Data
Regular Health Checkups and Stress Check Tests
| FYE 3/2022 | FYE 3/2023 | FYE 3/2024 | |
|---|---|---|---|
| Ratio of regular health checkup participation (employees working in Japan) | 100.0% | 100.0% | 100.0% |
| Ratio of regular health checkup participation (employees working overseas) | 80.1% | 99.7% | 98.3% |
| Rate of employees undergoing stress check tests | 91.6% | 95.5% | 96.5% |
Training and Education in Health Management
| Program | Outline | Number of Participants (FYE 3/2022) |
Number of Participants (FYE 3/2023) |
Number of Participants (FYE 3/2024) |
|---|---|---|---|---|
| Package Program for New Graduates | Lecture by head of the medical clinic on “safety and health management” | 126 | 127 | 116 |
| Follow Up Training for Mid-career Heires | Lecture on “working hour management, health management, and mental health care” | 29 | 22 | 34 |
| Mental Health | Lecture by head of the medical clinic on “working hour management, health management, and mental health care” from the perspective of developing subordinates | 91 | 420 | 446 |
| Training for New Dept. GMs | Lecture on “working hour management, health management, and mental health care” | 28 | 24 | 20 |
| Training for New Section GMs | Lecture on “working hour management, health management, and mental health care” | 70 | 61 | 81 |
| Step Up Training*1 | Lecture on “working hour management, health management, and mental health care” | 226 | 76 | 87 |
| Career Development Program for Senior Employees | Lecture on health management | 88 | 89 | 138 |
- : The trainings were suspended during FYE 3/2021 due to the COVID-19 pandemic and postponed until FYE 3/2022 to implement appropriate COVID-19 prevention measures.
Indicators for Health and Productivity Management
| FYE 3/2022 | FYE 3/2023 | FYE 3/2024 | |
|---|---|---|---|
| Ratio of Employees Undertaking a Detailed Checkup after Their Regular Health Examination | 42.0% | 66.0% | 60.6% |
| Ratio of Employees Maintaining an Appropriate Weight*2 | 69.8% | 68.3% | 68.5% |
| Ratio of Employees Having a Regular Exercise Habit*3 | 38.7% | 38.4% | 38.3% |
| Ratio of Employees with High Stress | 7.4% | 8.7% | 8.8% |
| Employee Performance (Presenteeism)*4 | － | 82.1% | 82.3% |
| Absence from Work Due to Health Problems (Sick Leave) (Absenteeism)*5 | 1.5 days | 1.7 days | 1.6 days |
| Work Engagement*6 | 64% | 75% | 77% |
- Individuals with a BMI between 18.5 and Less Than 25
- Percentage of individuals who answered “yes” to the following question on the health checkup questionnaire: “Do you engage in exercise that makes you sweat lightly for at least 30 minutes per session, at least twice a week, for more than a year?”
- Average response to the University of Tokyo’s single-item stress check “Please evaluate your work performance over the past four weeks, assuming your performance is at 100% when you are not ill or injured.” Approximately 4,000 individuals were surveyed (response rate of 96.5%). This measurement started from FYE 3/2023 to assess presenteeism.
- Average number of days of leave due to injury or illness (including temporary leave of absence and absenteeism) for employees based in Japan
- Until FYE 3/2024, affirmative response rate to the work engagement question “I find my work meaningful” on the stress check. Additionally, an engagement survey to measure satisfaction with the working environment is conducted regularly and an engagement score is calculated. For FYE 3/2025, the affirmative response rate to “Do you feel energized while working?” and “Do you take pride in your work?” in our independently conducted survey was 74%. The survey was conducted with approximately 4,000 participants, with a response rate of 97.7%.