The results showed that consistent with our hypothesis, the manager and owners of bars and izakaya-pubs who participated in the present study reported having had conversations regarding personal/private issues, including serious problems and concerns, with their customers. They also felt that by holding such conversations, they provided emotional care and helped the customers to relieve stress.
Past studies have indicated that while poor mental health and family problems are possible factors which hinder access to consultation at primary care level, [26
] being married showed protective effect against suicide regardless of socioeconomic inequality [27
]. Relatives and friends also played key roles in encouraging suicidal individuals to seek help and a range of lay interventions, including non-medical help-seeking, have been identified among suicide victims [28
]. Help-seeking behaviors in times of crisis and access to effective treatment could also reduce risks of committing suicide [29
]. However, in cultures where such family and partner function cannot be expected to function, it becomes necessary to explore other alternatives. In Japan, even when they believe they have good relationship with their wives or other family members, men tend not to talk about serious problems, such as business failure and debts due to gambling and/or other reasons to which negative social stigma is attached, at home, because of their wish to maintain dignity and avoid losing face. They often also prefer not to talk about work-related problems with colleagues or their supervisors/as they tend to fear that such issues will be reflected in their performance evaluation.
Our results showed that owners and managers of bars and izakaya-pubs who participated in the present study had experiences of having conversations regarding personal/private issues, including serious problems, with their customers. There are several possible reasons why bars and izakaya-pubs may become the ideal place for Japanese men to unburden their troubles. For one, as noted earlier, because of their relatively small spatial size and close distance between the customer and the owners/managers, bars and izakaya-pubs easily facilitate intimate conversations. Since the main objective of the customers is to drink, they are usually at ease and “talking” becomes the natural act, and not something they are formally asked to do. As there is no perceived conflict of interest, the customers may talk about anything, from family problems to work and financial troubles. Our results have also indicate, respondents with longer years of working in the business tended to experience customers confiding in them about debt and loans, while female respondents tended to experience listening to customers talk about family and relationship problems. Furthermore, since such drinking activity is already settled as a cultural part of everyday lives of Japanese men, access is much easier than compared to, for example, professional counseling services or other medical institutions.
Bar and izakaya-pub owners and managers are not specialists in solving such problems and it is unrealistic to expect them to take on the role of professional counselors. However, our results pointed to the possibility of them playing a key role in referring their customers, whom they judge as requiring professional help, to appropriate counseling and other relevant services. For example, they may be offered seminars on mental health, alcoholism and basic conversation skills with people suspected of having depressive symptoms. Some of the respondents in the present study reported that they encouraged their customers who were depressed, however, as is well-know, encouragement is often not a suitable reaction to depressed individuals. Had they known this and received appropriate training, they may have been able to respond differently.
Bar and izakaya
-pub owners and managers may also be informed about the role of public health centers. Although it is often the case that Japanese men, if they were to seek care because of their depressive symptoms, firstly consult primary health care physicians, assessment can sometimes be crucially inadequate because of lack of knowledge about mental health among the physicians [30
]. Certainly, it is important to promote knowledge and understanding of mental health among the physicians. However, sometimes people suffering from depression may receive the care they need faster by being referred to their local public health center.
Furthermore, local governments may involve such establishments in suicide prevention activities by, for example, distributing educational pamphlets and information regarding how and where to seek help through bars and izakaya-pubs, thereby further enhance help-seeking behaviors.
Finally, it has been said that knowledge of and attitudes toward suicide and depression are correlated with suicide rate [6
]. It may thus be necessary to improve the mental health literacy of the target population and enable them to seek help when they most need it. Kaneko and Motohashi have reported that poor mental health literacy was a possible factor contributing to male vulnerability to suicide, [32
] and other studies indicated a significant reduction in suicide rate after implementation of community-based interventions by health promotion approach [33
]. For example, participation in mental health workshops facilitated conversation with specialists regarding depression or suicidal ideation and improved access to counseling [35
]. At primary care level, an approach using educational pamphlet about depression and suicide contributed to an increase in willingness to confide in clinicians, friends, and spouses among people feeling depressed or with suicidal ideation [33
]. Interventions directed toward company employees, especially small company/factory employees, have also been suggested to increase their mental health literacy [30
]. Skills training for school staff serving as natural gatekeepers who facilitated appropriate help-seeking demonstrated positive impact on increasing students’ help-seeking behaviors [36
The response rate was too low to conduct detailed statistical analysis in this study, and it may reflect on the results as selection bias and reporting bias, which are under or over estimations of experiences regarding conversation of private issues between owners or managers and their customers. One possible reason for the low response is that both bars and izakaya-pubs are subject to hygiene inspections by public health offices. Thus, even though the section responsible for such inspections and the section involved in the present study are different, managers and/or owners of such establishments may have felt awkward or annoyed in responding. Or, they may simply have had no time, or not have been interested or motivated in the topic of the questionnaire if they had no experience of participating in serious conversations with their customers. No comparisons were performed with other cities or regions with different socioeconomic characteristics, and therefore the results cannot be generalized to other areas. The present study included no discussion of the relationships between alcohol consumption and depression and/or suicide. Further studies are required to evaluate the associations between how drinking alcohol facilitates conversation and outcomes of conversations in bar and izakaya-pub establishments, such as the effects on resolution of customers’ problems and customers’ health status. In addition, future assessments of the relations between alcoholism and frequenting bars and/or izakaya-pubs are necessary to determine the possible negative impacts of alcohol drink on customers’ mental health status. The present study also did not directly target the customers of bar and izakaya-pub establishments. Therefore, it was not possible to discuss the detailed effects and outcomes on the customers after conversation with owners/managers, e.g., how many people avoided suicide, and the customers’ intention to talk and consult with a professional regarding their personal/private problems. These points should also be investigated in future studies.
Despite these limitations, the study results indicated a potential for managers and owners of bars and izakaya-pubs, especially those with longer years of working experience, to play a role in assisting middle-aged and elderly men to seek professional mental care, by providing appropriate seminar and workshops on mental health, and building partnership with local governments and professional organizations.