Workplace disclosure and employment outcomes in infertility treatment: implications for workplace support in Okinawa, Japan

Workplace disclosure and employment outcomes in infertility treatment: implications for workplace support in Okinawa, Japan | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Workplace disclosure and employment outcomes in infertility treatment: implications for workplace support in Okinawa, Japan Chinatsu Nagata, KUMIKO NISHIHIRA, CHIAKI HESHIKI, KEIYA GIBO, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9191241/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Introduction Infertility is increasingly recognized as a public health and social issue with implications for employment and workplace policy. In Japan, the use of assisted reproductive technology (ART) has increased alongside rising female labor force participation. Consequently, balancing infertility treatment and employment has become an important social issue. Okinawa Prefecture, historically one of the highest fertility regions in Japan and undergoing demographic transitions, provides a unique setting to examine infertility treatment and employment. This setting may be relevant to regions with increasing female labor force participation and delayed childbearing. This study aimed to clarify employment-related impacts, workplace disclosure, and employer support in Okinawa Prefecture, Japan. Methods A regional cross-sectional web-based survey was conducted between March 16 and July 31, 2023. Individuals undergoing infertility treatment were recruited through facilities, and companies with 10–1,200 employees were also surveyed. The study followed the STROBE statement. Descriptive statistics summarized employment impact, workplace disclosure, and organizational support. Results A total of 163 individuals and 38 companies responded. Among women, 25.6% experienced employment-related impacts and 10.9% resigned during treatment. Partial or no workplace disclosure was reported by 71.2%, while adverse workplace experiences were reported by 11.7%. Among companies, 84.2% had not implemented support measures. Conclusions Workplace disclosure remains limited and is a key challenge in balancing infertility treatment and employment. Organizational and policy-level interventions—particularly improved workplace communication and greater awareness of available support systems—may support work–treatment balance. Further longitudinal and multi-regional research is warranted. Infertility Employment Work–treatment balance Workplace disclosure Assisted reproductive technology Japan Figures Figure 1 Figure 2 Figure 3 Introduction Infertility affects approximately one in six individuals worldwide and is increasingly recognized as a public health and social issue with substantial psychosocial and economic implications [ 1 , 2 ]. The expanding use of assisted reproductive technologies (ART) reflects delayed childbearing and persistent fertility challenges globally, as evidenced by increasing ART utilization in international registries [ 3 , 4 ]. In Japan, ART utilization has increased markedly. In 2022, 77,206 births were achieved through ART, accounting for approximately one in ten births nationwide [ 5 ]. Since April 2022, infertility treatment has been covered by national health insurance, further increasing accessibility [ 6 ]. At the same time, women’s labor force participation has risen steadily, and dual-income households now outnumber single-income households [ 7 ]. Consequently, a growing number of women undergo infertility treatment while maintaining employment. Balancing infertility treatment and work has emerged as a significant occupational and social policy challenge. Infertility treatment has been associated with psychological distress, reduced quality of life, and employment-related difficulties, including challenges in maintaining workplace functioning during treatment [ 8 , 9 ]. In Japan, resignation after initiating infertility treatment has been reported, and work environment factors—including limited flexibility and insufficient workplace support—may contribute to employment discontinuation [ 10 ]. While governmental initiatives aim to promote compatibility between infertility treatment and employment [ 11 , 12 ], the degree of awareness and implementation at the organizational level remains unclear. However, few studies have integrated employee and employer perspectives to clarify how organizational awareness aligns with employees’ support needs within a shared regional context. Okinawa Prefecture provides a distinctive demographic context within Japan. It has historically maintained one of the highest total fertility rates among Japanese prefectures, although birth numbers have declined in recent years in line with national trends [ 13 ]. This setting may also be relevant to other regions with increasing female labor force participation and delayed childbearing. Therefore, this regional cross-sectional study aimed to examine employment-related experiences and workplace disclosure among women undergoing infertility treatment. It also assessed employer awareness and organizational support in a high-fertility region undergoing demographic change. Methods Study design and setting This regional cross-sectional questionnaire survey was conducted in Okinawa Prefecture, Japan, from March 16 to July 31, 2023. The study aimed to explore the current status and challenges of balancing infertility treatment and employment from both patient and employer perspectives. This study was exploratory in nature and designed to describe current practices and experiences within a specific regional context rather than to test predefined hypotheses. The study was reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. Participants and data collection Patients undergoing infertility treatment Questionnaires were distributed via clinics and hospitals in Okinawa Prefecture providing infertility treatment, including timing therapy, artificial insemination, and assisted reproductive technology (ART). Flyers containing a QR code and URL linking to a web-based questionnaire were made available to outpatients. Eligible participants included individuals currently undergoing infertility treatment or those who had previously undergone treatment and were employed at the time of treatment. Participation was voluntary and anonymous. A total of 163 individuals (156 women and 7 men) responded. As questionnaires were distributed through participating institutions without tracking the total number of eligible patients, the response rate could not be calculated. Participation may be subject to self-selection bias. Employers A web-based questionnaire was distributed to 303 companies in Okinawa Prefecture. Companies agreeing to participate accessed the questionnaire via a QR code or URL. Thirty-eight of 303 companies responded (12.5%). Questionnaire content For patients, the questionnaire included: Demographic characteristics (age, employment type) Treatment modality and employment status during treatment Employment-related impacts (change in employment status, leave of absence, resignation) Workplace disclosure status and reasons for limited disclosure Adverse workplace experiences Physical symptoms requiring rest or leave Workplace systems used to balance treatment and employment Desired workplace or governmental support measures For employers, the questionnaire included: Awareness of employees undergoing infertility treatment Workplace support measures for affected employees Reasons for not implementing support measures Awareness of government-provided support tools and subsidies Free-text responses regarding expectations for governmental support Outcome measures The primary outcome was continued employment during infertility treatment among female respondents. Secondary outcomes included employment-related impacts, workplace disclosure status, adverse workplace experiences, and employer-provided support measures. Statistical analysis Descriptive statistics were used to summarize the data. Continuous variables are presented as means ± standard deviations (SD), and categorical variables are presented as frequencies and percentages. Percentages were calculated using appropriate subgroup denominators as indicated in each table. Given the exploratory and descriptive nature of the study, no inferential statistical analyses were conducted, and no a priori sample size calculation was performed. Ethical considerations The study was approved by the Ethics Review Committee for Life Science and Medical Research Involving Human Subjects at the University of the Ryukyus (Approval No. 2048). All participants provided informed consent electronically prior to participation. Data were anonymized and analyzed in aggregate form to ensure confidentiality. No identifying information regarding individuals or companies was included in publications or presentations. Results Results from individuals undergoing infertility treatment Participant characteristics A total of 163 individuals responded to the patient survey, including 156 women and 7 men. Participant characteristics are presented in Table 1 . The mean age of female respondents was 36.5 ± 4.9 years. Among women, 84 of 156 (57.9%) were full-time employees and 49 (33.8%) were non-regular employees. The most common treatment modality was in vitro fertilization (IVF), reported by 72 women (46.2%). Table 1 Characteristics of individuals undergoing infertility treatment (n = 163) Characteristic Women (n = 156) Men (n = 7) Total (n = 163) Mean age (years) 36.5 ± 4.9 37.4 ± 6.7 36.5 ± 5.0 Employed, n (%) 145 (92.9) 7 (100.0) 152 (93.3) Full-time employee 84 (57.9) 5 (71.4) 89 (58.2) Non-regular employee 49 (33.8) 0 (0.0) 49 (32.0) Assisted reproductive technology (ART) 72 (46.2) 5 (71.4) 77 (47.2) Employment impact among women Among 156 female respondents, 116 (74.4%) reported continued employment during infertility treatment, whereas 40 (25.6%) experienced employment-related impact (Table 2 ; Fig. 1 ). Employment-related impact included change in employment status (20/156, 12.8%), leave of absence (3/156, 1.9%), and resignation (17/156, 10.9%). Twelve women (7.7%) reported treatment-related symptoms requiring rest or leave. Among women experiencing employment-related impact (n = 40), the most frequently cited reason was difficulty adjusting work schedules due to unpredictable clinic visits (32/40, 80.0%). Additionally, 16 of 40 (40.0%) reported that work-related stress negatively affected their treatment. All seven male respondents (100%) reported continued employment during infertility treatment (Table 2 ). Table 2 Employment status during infertility treatment Variable n % Women (n = 156) Continued employment 116 74.4 Employment-related impact† 40 25.6 Change in employment status 20 12.8 Leave of absence 3 1.9 Resignation 17 10.9 Men (n = 7) Continued employment 7 100.0 † Includes change in employment status, leave of absence, or resignation. Percentages were calculated using the number of women respondents (n = 156) as the denominator. Workplace disclosure and adverse experiences Workplace disclosure and adverse experiences are summarized in Table 3 and Fig. 2 . Among all respondents (n = 163), 116 (71.2%) reported partial or no disclosure of infertility treatment in the workplace. Nineteen respondents (11.7%) reported experiencing disadvantageous treatment at work including refusal of schedule adjustments and inappropriate remarks. Among those reporting partial or no disclosure (n = 116), the most frequently cited reasons were reluctance to disclose treatment status (47/116, 40.5%) and concerns about workplace reactions if treatment was unsuccessful (47/116, 40.5%). Table 3 Workplace disclosure status and adverse workplace experiences Variable n % Women (n = 156) Partial or no disclosure 110 70.5 Men (n = 7) Partial or no disclosure 6 85.7 All respondents (n = 163) Partial or no disclosure 116 71.2 Any disadvantageous workplace experience 19 11.7 Percentages are calculated within each subgroup denominator. Percentages were calculated using the total number of respondents (n = 163) as the denominator. Utilization of workplace support systems Annual paid leave was the most commonly utilized workplace resource (102/163, 62.6%), whereas infertility treatment-specific support systems were rarely used (Table 4 ). Table 4 Systems used or planned for work–treatment balance System n % Annual paid leave 102 62.6 Permission for medical visits/rest 19 11.7 Flexible working arrangements (time/location) 15 9.2 Employer financial support for treatment costs 5 3.1 Leave of absence system 4 2.5 Other (each n = 1) 6 3.7 Not used / no plan to use 49 30.1 Percentages were calculated among all respondents (n = 163). Percentages may not total 100% because multiple responses were permitted. “Other” includes accumulated expired paid leave, sick leave, paid leave specifically for infertility treatment, consultation services, maternity support leave, and unawareness of available systems. Employer survey results A total of 38 companies responded to the employer survey (response rate: 38/303, 12.5%). Responding companies represented a diverse range of industries and company sizes (Additional file 1: Table S1 ). Employer-related findings are summarized in Table 5 and Fig. 3 . Among responding companies, 6 of 38 (15.8%) reported providing some form of support for employees undergoing infertility treatment, whereas 32 (84.2%) reported no support measures. Among companies not providing support (n = 32), the most frequently cited reasons were lack of internal requests or no eligible employees (16/32, 50.0%) and lack of awareness of employees undergoing infertility treatment (15/32, 46.9%). Other commonly cited reasons included no previous cases (9/32, 28.1%) and considering infertility treatment a private matter of employees (6/32, 18.8%) (Table 5 ). Table 5 Company support for employees undergoing infertility treatment and main reasons for non-implementation Support status (n = 38) n % Support provided 6 15.8 No support provided 32 84.2 Main reasons for non-implementation (n = 32) No internal requests or no eligible employees 16 50.0 Unaware of employees undergoing infertility treatment 15 46.9 No previous cases 9 28.1 Considered a private matter of employees 6 18.8 Percentages were calculated among responding companies (n = 38) for support status and among companies not implementing support measures (n = 32) for reasons. Multiple responses were permitted for reasons. Percentages were calculated using the number of responding companies (n = 38) as the denominator. Regarding awareness of governmental resources, 31 of 38 companies (81.6%) reported being unfamiliar with workplace support manuals, and 26 (68.4%) were unaware of subsidies for small- and medium-sized enterprises. Free-text responses from patients and employers are provided in Additional files 2 and 3. Discussion Principal findings In this cross-sectional study, 10.9% of women undergoing infertility treatment reported resigning due to difficulties balancing treatment and employment. Notably, 71.2% of respondents had not disclosed their infertility treatment to their workplace, highlighting the high prevalence of limited workplace disclosure identified in this study. Moreover, only 15.8% of employers reported providing specific support measures. Taken together, the findings suggest that employment outcomes during infertility treatment may be influenced not only by treatment demands but also by workplace communication and organizational responsiveness. The observed resignation rate is comparable to national Japanese findings [ 14 ] and consistent with prior studies identifying workplace inflexibility and insufficient support as risk factors for employment discontinuation [ 8 – 10 ]. Unlike prior research that has primarily examined employee-reported outcomes, this study integrates both employee and employer perspectives, thereby situating employment decisions within broader organizational contexts. Structural support and organizational responsiveness Infertility treatment is associated with psychological distress and treatment-related strain [ 15 , 16 ]. Workplace accommodation theory emphasizes the importance of organizational responsiveness for employees managing recurrent medical visits and treatment schedules [ 17 ], and work–life balance literature similarly indicates that policy effectiveness depends on practical implementation rather than formal policy presence alone [ 18 , 19 ]. Previous Japanese research has linked limited workplace flexibility to resignation after treatment initiation [ 10 , 14 ]. Although governmental manuals and guidance have been introduced to promote infertility-friendly workplaces [ 11 , 12 ], our findings suggest that awareness and practical uptake remain uneven. These observations suggest that workplace support systems alone may be insufficient without corresponding recognition of employees’ needs and open communication within organizations. Disclosure, stigma, and workplace communication Limited workplace disclosure emerged as a central contextual factor. Disclosure process theory suggests that individuals weigh anticipated risks and benefits before revealing concealable health conditions [ 20 ]. Concerns about stigma or negative evaluation may discourage disclosure within workplace environments [ 21 , 22 ]. Infertility, as a socially constructed and culturally sensitive condition, has been shown to carry stigma across sociocultural contexts [ 23 , 24 ]. Psychological safety—the belief that one can express concerns without fear of negative consequences—has been associated with more open communication in organizations [ 25 ]. In workplaces where employees do not feel safe discussing health-related needs, they may avoid disclosure, which can limit opportunities for support. Although causal relationships cannot be determined in this cross-sectional study, the coexistence of limited disclosure and measurable resignation suggests that workplace communication environments may play an important role in employment stability. Gendered dimensions of employment outcomes Global scholarship has emphasized that infertility experiences are shaped by gendered social roles and expectations [ 3 ]. Even in cases of male-factor infertility, treatment procedures disproportionately involve women. Infertility and assisted reproduction have been discussed within broader gendered labor frameworks [ 23 ], in which reproductive responsibilities intersect with occupational roles. Within this context, employment discontinuation may reflect structural labor dynamics rather than solely individual-level coping decisions. Given the limited number of male respondents in this study, these findings should be interpreted cautiously. The low male participation itself may reflect the gendered dynamics surrounding infertility, in which reproductive responsibility and treatment engagement are often disproportionately borne by women. Nevertheless, these observations underscore the importance of incorporating gender-sensitive perspectives into analyses of infertility-related employment outcomes. Regional context and sociocultural considerations Compared with national survey findings [ 14 ], respondents in Okinawa more frequently reported concerns regarding workplace disclosure. Regional sociocultural characteristics, including close interpersonal networks and strong kinship ties, may influence perceptions of visibility and privacy. Cross-cultural research suggests that in collectivist sociocultural contexts, infertility-related stigma and disclosure decisions are influenced by social expectations and community visibility [ 3 , 23 , 24 ]. These findings underscore the importance of considering regional sociocultural dynamics when designing workplace support strategies. Policy and implementation implications Employer awareness of governmental resources designed to support infertility-friendly workplaces appeared limited [ 11 , 12 ]. Consistent with broader work–life policy research [ 18 , 19 ], the presence of formal guidelines does not necessarily ensure their practical implementation. Addressing this gap may require combined efforts in policy dissemination, managerial training, and promotion of supportive workplace cultures. Framing infertility treatment within occupational health and workforce sustainability discussions may also encourage broader institutional engagement beyond individual-level accommodation. Strengths and limitations A key strength of this study is the integration of employee and employer perspectives within the same regional and temporal framework. Although surveys were not matched at the individual organizational level, this concurrent design enables cautious aggregate-level comparison of perceived needs and organizational awareness. Several limitations should be acknowledged. Response rates could not be calculated because the total number of eligible individuals was not tracked. Participation may have been influenced by self-selection bias. The cross-sectional design precludes causal inference, and findings from a single prefecture may limit generalizability. These results should therefore be interpreted as exploratory and hypothesis-generating. Conclusion Workplace disclosure remains limited and is a key challenge in balancing infertility treatment and employment. Organizational and policy-level interventions—such as improved workplace communication, clearer disclosure pathways, and increased awareness of infertility-related needs—may help support continued employment during treatment. Further longitudinal and multi-regional research is warranted. Declarations Ethics approval and consent to participate The study was approved by the Ethics Review Committee for Life Science and Medical Research Involving Human Subjects at the University of the Ryukyus (Approval No. 2048). All procedures were performed in accordance with the ethical standards of the institutional research committee and with the Declaration of Helsinki. Electronic informed consent was obtained from all participants prior to participation. Consent for publication Not applicable. Funding The authors received no specific funding for this work. Author Contribution KM supervised the study and drafted the manuscript. CN conceived the study and contributed to data analysis and manuscript drafting. KN coordinated the ethical review procedures as a clinical research coordinator. CH, KG, AI, and SN contributed to data collection and interpretation. All authors reviewed and approved the final manuscript. Acknowledgement The authors thank all participants and cooperating institutions for their contributions to this study. Data Availability The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request. References World Health Organization. 1 in 6 people globally affected by infertility. 2023. https://www.who.int/news/item/04-04-2023-1-in-6-people-globally-affected-by-infertility . Accessed 21 Feb 2026. Mascarenhas MN, Flaxman SR, Boerma T, Vanderpoel S, Stevens GA. National, regional, and global trends in infertility prevalence since 1990: a systematic analysis of 277 health surveys. PLoS Med. 2012;9(12):e1001356. 10.1371/journal.pmed.1001356 . Inhorn MC, Patrizio P. Infertility around the globe: new thinking on gender, reproductive technologies and global movements in the 21st century. Hum Reprod Update. 2015;21(4):411–26. 10.1093/humupd/dmv016 . De Geyter C, Wyns C, Calhaz-Jorge C, et al. 20 years of the European IVF-monitoring Consortium registry: trends and developments in ART in Europe. Hum Reprod Open. 2020;2020(3):hoaa035. 10.1093/hropen/hoaa035 . Japan Society of Obstetrics and Gynecology. ART Registry 2022: ART births and treatments in Japan. 2023. https://fa.kyorin.co.jp/jsog/readPDF.php?file=77/12/077121886.pdf . Accessed 21 Feb 2026. Ministry of Health, Labour and Welfare (Japan). Insurance coverage for infertility treatment (April 2022). 2022. https://www.mhlw.go.jp/stf/seisakunitsuite/bunya/kodomo/kodomo_kosodate/boshi-hoken/funin-01_00004.html . Accessed 21 Feb 2026. Gender Equality Bureau, Cabinet Office (Japan). White Paper on Gender Equality 2022: Status and challenges. 2022. https://www.gender.go.jp/english_contents/pr_act/pub/status_challenges/pdf/202205.pdf . Accessed 21 Feb 2026. Gameiro S, Boivin J, Peronace L, Verhaak CM. Why do patients discontinue fertility treatment? Hum Reprod Update. 2012;18(6):652–69. 10.1093/humupd/dms031 . Payne N, Seenan S, van den Akker O. Experiences and psychological distress of fertility treatment and employment. J Psychosom Obstet Gynaecol. 2019;40(2):156–65. 10.1080/0167482X.2018.1460351 . Imai Y, Endo M, Kuroda K, et al. Risk factors for resignation from work after starting infertility treatment among Japanese women: Japan-FEMA study. Occup Environ Med. 2021;78(6):426–32. 10.1136/oemed-2020-106745 . Ministry of Health, Labour and Welfare (Japan). Manual for creating workplace environments that support employees receiving infertility treatment. 2025. https://www.mhlw.go.jp/bunya/koyoukintou/pamphlet/dl/30k.pdf . Accessed 21 Feb 2026. Ministry of Health, Labour and Welfare (Japan). Infertility treatment and work balance support handbook. 2025. https://www.mhlw.go.jp/bunya/koyoukintou/pamphlet/dl/30l.pdf . Accessed 21 Feb 2026. Ministry of Health, Labour and Welfare (Japan). Population statistics for 2024 (Final vital statistics). 2025. https://www.mhlw.go.jp/toukei/saikin/hw/jinkou/kakutei24/index.html . Accessed 21 Feb 2026. Ministry of Health, Labour and Welfare (Japan). Survey on compatibility between infertility treatment and work. 2023. https://www.mhlw.go.jp/content/11909000/000930556.pdf . Accessed 21 Feb 2026. Hämmerli K, Znoj H, Barth J. The efficacy of psychological interventions for infertile patients: a meta-analysis examining mental health and pregnancy rate. Hum Reprod Update. 2009;15(3):279–95. 10.1093/humupd/dmp002 . Cousineau TM, Domar AD. Psychological impact of infertility. Best Pract Res Clin Obstet Gynaecol. 2007;21(2):293–308. 10.1016/j.bpobgyn.2006.12.003 . Beatty JE, Joffe R. An overlooked dimension of diversity: the career effects of chronic illness. Organ Dyn. 2006;35(2):182–95. 10.1016/j.orgdyn.2006.03.006 . OECD. Policies to promote work–life balance. 2021. https://www.oecd.org/social/family/ . Accessed 21 Feb 2026. Lewis S, Beauregard TA. The meanings of work–life balance: a cultural perspective. Hum Relat. 2018;71(11):1463–89. 10.1177/0018726718765610 . Chaudoir SR, Fisher JD. The disclosure processes model: understanding disclosure decision making and postdisclosure outcomes among people living with a concealable stigmatized identity. Psychol Bull. 2010;136(2):236–56. 10.1037/a0018193 . Quinn DM, Chaudoir SR. Living with a concealable stigmatized identity. Psychol Bull. 2009;135(4):634–51. 10.1037/a0015815 . Major B, O’Brien LT. The social psychology of stigma. Annu Rev Psychol. 2005;56:393–421. 10.1146/annurev.psych.56.091103.070137 . Greil AL, McQuillan J, Slauson-Blevins K. The social construction of infertility. Sociol Compass. 2011;5(8):736–46. 10.1111/j.1751-9020.2011.00397.x . Ying LY, Wu LH, Loke AY. Gender differences in experiences with and adjustments to infertility: a literature review. Int J Nurs Stud. 2015;52(10):1640–52. 10.1016/j.ijnurstu.2015.05.004 . Edmondson AC. Psychological safety and learning behavior in work teams. Adm Sci Q. 1999;44(2):350–83. 10.2307/2666999 . Additional Declarations No competing interests reported. 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disclosure and adverse workplace experiences (n = 163).\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-9191241/v1/403184a17cd8681dc7ec0bea.png"},{"id":107340606,"identity":"5a856cc6-d42d-486b-bb51-35591934fe15","added_by":"auto","created_at":"2026-04-20 14:19:07","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":130421,"visible":true,"origin":"","legend":"\u003cp\u003eCompany support for employees undergoing infertility treatment (n = 38).\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-9191241/v1/a5bdfb456b1a51de9ce4de45.png"},{"id":107488511,"identity":"933bc269-cc74-49a3-97a2-99d781391010","added_by":"auto","created_at":"2026-04-22 02:44:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":531676,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9191241/v1/d2d656c6-8793-49f7-9788-a46068c35ec4.pdf"},{"id":107340603,"identity":"69a31c7d-0ed9-4967-b832-bf2fea3d1d20","added_by":"auto","created_at":"2026-04-20 14:19:07","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":31068,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfiles.docx","url":"https://assets-eu.researchsquare.com/files/rs-9191241/v1/e2d8dc3bb39392ec990933a8.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Workplace disclosure and employment outcomes in infertility treatment: implications for workplace support in Okinawa, Japan","fulltext":[{"header":"Introduction","content":"\u003cp\u003eInfertility affects approximately one in six individuals worldwide and is increasingly recognized as a public health and social issue with substantial psychosocial and economic implications [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The expanding use of assisted reproductive technologies (ART) reflects delayed childbearing and persistent fertility challenges globally, as evidenced by increasing ART utilization in international registries [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Japan, ART utilization has increased markedly. In 2022, 77,206 births were achieved through ART, accounting for approximately one in ten births nationwide [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Since April 2022, infertility treatment has been covered by national health insurance, further increasing accessibility [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. At the same time, women\u0026rsquo;s labor force participation has risen steadily, and dual-income households now outnumber single-income households [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Consequently, a growing number of women undergo infertility treatment while maintaining employment.\u003c/p\u003e \u003cp\u003eBalancing infertility treatment and work has emerged as a significant occupational and social policy challenge. Infertility treatment has been associated with psychological distress, reduced quality of life, and employment-related difficulties, including challenges in maintaining workplace functioning during treatment [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In Japan, resignation after initiating infertility treatment has been reported, and work environment factors\u0026mdash;including limited flexibility and insufficient workplace support\u0026mdash;may contribute to employment discontinuation [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. While governmental initiatives aim to promote compatibility between infertility treatment and employment [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], the degree of awareness and implementation at the organizational level remains unclear. However, few studies have integrated employee and employer perspectives to clarify how organizational awareness aligns with employees\u0026rsquo; support needs within a shared regional context.\u003c/p\u003e \u003cp\u003eOkinawa Prefecture provides a distinctive demographic context within Japan. It has historically maintained one of the highest total fertility rates among Japanese prefectures, although birth numbers have declined in recent years in line with national trends [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This setting may also be relevant to other\u003c/p\u003e \u003cp\u003eregions with increasing female labor force participation and delayed childbearing. Therefore, this regional cross-sectional study aimed to examine employment-related experiences and workplace disclosure among women undergoing infertility treatment. It also assessed employer awareness and organizational support in a high-fertility region undergoing demographic change.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy design and setting\u003c/p\u003e \u003cp\u003eThis regional cross-sectional questionnaire survey was conducted in Okinawa Prefecture, Japan, from March 16 to July 31, 2023. The study aimed to explore the current status and challenges of balancing infertility treatment and employment from both patient and employer perspectives.\u003c/p\u003e \u003cp\u003eThis study was exploratory in nature and designed to describe current practices and experiences within a specific regional context rather than to test predefined hypotheses. The study was reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement.\u003c/p\u003e \u003cp\u003eParticipants and data collection\u003c/p\u003e \u003cp\u003ePatients undergoing infertility treatment\u003c/p\u003e \u003cp\u003eQuestionnaires were distributed via clinics and hospitals in Okinawa Prefecture providing infertility treatment, including timing therapy, artificial insemination, and assisted reproductive technology (ART). Flyers containing a QR code and URL linking to a web-based questionnaire were made available to outpatients.\u003c/p\u003e \u003cp\u003eEligible participants included individuals currently undergoing infertility treatment or those who had previously undergone treatment and were employed at the time of treatment. Participation was voluntary and anonymous. A total of 163 individuals (156 women and 7 men) responded. As questionnaires were distributed through participating institutions without tracking the total number of eligible patients, the response rate could not be calculated. Participation may be subject to self-selection bias.\u003c/p\u003e \u003cp\u003eEmployers\u003c/p\u003e \u003cp\u003eA web-based questionnaire was distributed to 303 companies in Okinawa Prefecture. Companies agreeing to participate accessed the questionnaire via a QR code or URL. Thirty-eight of 303 companies responded (12.5%).\u003c/p\u003e \u003cp\u003eQuestionnaire content\u003c/p\u003e \u003cp\u003eFor patients, the questionnaire included:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDemographic characteristics (age, employment type)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTreatment modality and employment status during treatment\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eEmployment-related impacts (change in employment status, leave of absence, resignation)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWorkplace disclosure status and reasons for limited disclosure\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAdverse workplace experiences\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePhysical symptoms requiring rest or leave\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWorkplace systems used to balance treatment and employment\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDesired workplace or governmental support measures\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eFor employers, the questionnaire included:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAwareness of employees undergoing infertility treatment\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWorkplace support measures for affected employees\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eReasons for not implementing support measures\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAwareness of government-provided support tools and subsidies\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eFree-text responses regarding expectations for governmental support\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eOutcome measures\u003c/p\u003e \u003cp\u003eThe primary outcome was continued employment during infertility treatment among female respondents. Secondary outcomes included employment-related impacts, workplace disclosure status, adverse workplace experiences, and employer-provided support measures.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eDescriptive statistics were used to summarize the data. Continuous variables are presented as means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviations (SD), and categorical variables are presented as frequencies and percentages. Percentages were calculated using appropriate subgroup denominators as indicated in each table.\u003c/p\u003e \u003cp\u003eGiven the exploratory and descriptive nature of the study, no inferential statistical analyses were conducted, and no a priori sample size calculation was performed.\u003c/p\u003e \u003cp\u003eEthical considerations\u003c/p\u003e \u003cp\u003e The study was approved by the Ethics Review Committee for Life Science and Medical Research Involving Human Subjects at the University of the Ryukyus (Approval No. 2048).\u003c/p\u003e \u003cp\u003e All participants provided informed consent electronically prior to participation. Data were anonymized and analyzed in aggregate form to ensure confidentiality. No identifying information regarding individuals or companies was included in publications or presentations.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eResults from individuals undergoing infertility treatment\u003c/p\u003e \u003cp\u003eParticipant characteristics\u003c/p\u003e \u003cp\u003eA total of 163 individuals responded to the patient survey, including 156 women and 7 men. Participant characteristics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The mean age of female respondents was 36.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.9 years. Among women, 84 of 156 (57.9%) were full-time employees and 49 (33.8%) were non-regular employees. The most common treatment modality was in vitro fertilization (IVF), reported by 72 women (46.2%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of individuals undergoing infertility treatment (n\u0026thinsp;=\u0026thinsp;163)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWomen (n\u0026thinsp;=\u0026thinsp;156)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMen (n\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;163)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean age (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.4\u0026thinsp;\u0026plusmn;\u0026thinsp;6.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e145 (92.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e152 (93.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFull-time employee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84 (57.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (71.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e89 (58.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-regular employee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49 (33.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49 (32.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAssisted reproductive technology (ART)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72 (46.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (71.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e77 (47.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eEmployment impact among women\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAmong 156 female respondents, 116 (74.4%) reported continued employment during infertility treatment, whereas 40 (25.6%) experienced employment-related impact (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e; Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Employment-related impact included change in employment status (20/156, 12.8%), leave of absence (3/156, 1.9%), and resignation (17/156, 10.9%).\u003c/p\u003e \u003cp\u003eTwelve women (7.7%) reported treatment-related symptoms requiring rest or leave.\u003c/p\u003e \u003cp\u003eAmong women experiencing employment-related impact (n\u0026thinsp;=\u0026thinsp;40), the most frequently cited reason was difficulty adjusting work schedules due to unpredictable clinic visits (32/40, 80.0%). Additionally, 16 of 40 (40.0%) reported that work-related stress negatively affected their treatment. All seven male respondents (100%) reported continued employment during infertility treatment (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEmployment status during infertility treatment\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWomen (n\u0026thinsp;=\u0026thinsp;156)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContinued employment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e116\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e74.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployment-related impact\u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChange in employment status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeave of absence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResignation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMen (n\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContinued employment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u0026dagger; Includes change in employment status, leave of absence, or resignation.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePercentages were calculated using the number of women respondents (n\u0026thinsp;=\u0026thinsp;156) as the denominator.\u003c/p\u003e \u003cp\u003eWorkplace disclosure and adverse experiences\u003c/p\u003e \u003cp\u003eWorkplace disclosure and adverse experiences are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Among all respondents (n\u0026thinsp;=\u0026thinsp;163), 116 (71.2%) reported partial or no disclosure of infertility treatment in the workplace.\u003c/p\u003e \u003cp\u003eNineteen respondents (11.7%) reported experiencing disadvantageous treatment at work including refusal of schedule adjustments and inappropriate remarks.\u003c/p\u003e \u003cp\u003eAmong those reporting partial or no disclosure (n\u0026thinsp;=\u0026thinsp;116), the most frequently cited reasons were reluctance to disclose treatment status (47/116, 40.5%) and concerns about workplace reactions if treatment was unsuccessful (47/116, 40.5%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eWorkplace disclosure status and adverse workplace experiences\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWomen (n\u0026thinsp;=\u0026thinsp;156)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePartial or no disclosure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e70.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMen (n\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePartial or no disclosure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e85.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAll respondents (n\u0026thinsp;=\u0026thinsp;163)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePartial or no disclosure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e116\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e71.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny disadvantageous workplace experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePercentages are calculated within each subgroup denominator.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePercentages were calculated using the total number of respondents (n\u0026thinsp;=\u0026thinsp;163) as the denominator.\u003c/p\u003e \u003cp\u003eUtilization of workplace support systems\u003c/p\u003e \u003cp\u003eAnnual paid leave was the most commonly utilized workplace resource (102/163, 62.6%), whereas infertility treatment-specific support systems were rarely used (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSystems used or planned for work\u0026ndash;treatment balance\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSystem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnnual paid leave\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e62.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePermission for medical visits/rest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFlexible working arrangements (time/location)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployer financial support for treatment costs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeave of absence system\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther (each n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot used / no plan to use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePercentages were calculated among all respondents (n\u0026thinsp;=\u0026thinsp;163). Percentages may not total 100% because multiple responses were permitted. \u0026ldquo;Other\u0026rdquo; includes accumulated expired paid leave, sick leave, paid leave specifically for infertility treatment, consultation services, maternity support leave, and unawareness of available systems.\u003c/p\u003e \u003cp\u003eEmployer survey results\u003c/p\u003e \u003cp\u003eA total of 38 companies responded to the employer survey (response rate: 38/303, 12.5%). Responding companies represented a diverse range of industries and company sizes (Additional file 1: Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e). Employer-related findings are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Among responding companies, 6 of 38 (15.8%) reported providing some form of support for employees undergoing infertility treatment, whereas 32 (84.2%) reported no support measures. Among companies not providing support (n\u0026thinsp;=\u0026thinsp;32), the most frequently cited reasons were lack of internal requests or no eligible employees (16/32, 50.0%) and lack of awareness of employees undergoing infertility treatment (15/32, 46.9%). Other commonly cited reasons included no previous cases (9/32, 28.1%) and considering infertility treatment a private matter of employees (6/32, 18.8%) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCompany support for employees undergoing infertility treatment and main reasons for non-implementation\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSupport status (n\u0026thinsp;=\u0026thinsp;38)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSupport provided\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo support provided\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e84.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMain reasons for non-implementation (n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo internal requests or no eligible employees\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnaware of employees undergoing infertility treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo previous cases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsidered a private matter of employees\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePercentages were calculated among responding companies (n\u0026thinsp;=\u0026thinsp;38) for support status and among companies not implementing support measures (n\u0026thinsp;=\u0026thinsp;32) for reasons. Multiple responses were permitted for reasons.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePercentages were calculated using the number of responding companies (n\u0026thinsp;=\u0026thinsp;38) as the denominator.\u003c/p\u003e \u003cp\u003eRegarding awareness of governmental resources, 31 of 38 companies (81.6%) reported being unfamiliar with workplace support manuals, and 26 (68.4%) were unaware of subsidies for small- and medium-sized enterprises.\u003c/p\u003e \u003cp\u003eFree-text responses from patients and employers are provided in Additional files 2 and 3.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePrincipal findings\u003c/p\u003e\n\u003cp\u003eIn this cross-sectional study, 10.9% of women undergoing infertility treatment reported resigning due to difficulties balancing treatment and employment. Notably, 71.2% of respondents had not disclosed their infertility treatment to their workplace, highlighting the high prevalence of limited workplace disclosure identified in this study. Moreover, only 15.8% of employers reported providing specific support measures. Taken together, the findings suggest that employment outcomes during infertility treatment may be influenced not only by treatment demands but also by workplace communication and organizational responsiveness.\u003c/p\u003e\n\u003cp\u003eThe observed resignation rate is comparable to national Japanese findings [\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e] and consistent with prior studies identifying workplace inflexibility and insufficient support as risk factors for employment discontinuation [\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e]. Unlike prior research that has primarily examined employee-reported outcomes, this study integrates both employee and employer perspectives, thereby situating employment decisions within broader organizational contexts.\u003c/p\u003e\n\u003cp\u003eStructural support and organizational responsiveness\u003c/p\u003e\n\u003cp\u003eInfertility treatment is associated with psychological distress and treatment-related strain [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]. Workplace accommodation theory emphasizes the importance of organizational responsiveness for employees managing recurrent medical visits and treatment schedules [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e], and work\u0026ndash;life balance literature similarly indicates that policy effectiveness depends on practical implementation rather than formal policy presence alone [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e]. Previous Japanese research has linked limited workplace flexibility to resignation after treatment initiation [\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e]. Although governmental manuals and guidance have been introduced to promote infertility-friendly workplaces [\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e], our findings suggest that awareness and practical uptake remain uneven. These observations suggest that workplace support systems alone may be insufficient without corresponding recognition of employees\u0026rsquo; needs and open communication within organizations.\u003c/p\u003e\n\u003cp\u003eDisclosure, stigma, and workplace communication\u003c/p\u003e\n\u003cp\u003eLimited workplace disclosure emerged as a central contextual factor. Disclosure process theory suggests that individuals weigh anticipated risks and benefits before revealing concealable health conditions [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]. Concerns about stigma or negative evaluation may discourage disclosure within workplace environments [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e]. Infertility, as a socially constructed and culturally sensitive condition, has been shown to carry stigma across sociocultural contexts [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003ePsychological safety\u0026mdash;the belief that one can express concerns without fear of negative consequences\u0026mdash;has been associated with more open communication in organizations [\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e]. In workplaces where employees do not feel safe discussing health-related needs, they may avoid disclosure, which can limit opportunities for support. Although causal relationships cannot be determined in this cross-sectional study, the coexistence of limited disclosure and measurable resignation suggests that workplace communication environments may play an important role in employment stability.\u003c/p\u003e\n\u003cp\u003eGendered dimensions of employment outcomes\u003c/p\u003e\n\u003cp\u003eGlobal scholarship has emphasized that infertility experiences are shaped by gendered social roles and expectations [\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e]. Even in cases of male-factor infertility, treatment procedures disproportionately involve women. Infertility and assisted reproduction have been discussed within broader gendered labor frameworks [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e], in which reproductive responsibilities intersect with occupational roles. Within this context, employment discontinuation may reflect structural labor dynamics rather than solely individual-level coping decisions.\u003c/p\u003e\n\u003cp\u003eGiven the limited number of male respondents in this study, these findings should be interpreted cautiously. The low male participation itself may reflect the gendered dynamics surrounding infertility, in which reproductive responsibility and treatment engagement are often disproportionately borne by women. Nevertheless, these observations underscore the importance of incorporating gender-sensitive perspectives into analyses of infertility-related employment outcomes.\u003c/p\u003e\n\u003cp\u003eRegional context and sociocultural considerations\u003c/p\u003e\n\u003cp\u003eCompared with national survey findings [\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e], respondents in Okinawa more frequently reported concerns regarding workplace disclosure. Regional sociocultural characteristics, including close interpersonal networks and strong kinship ties, may influence perceptions of visibility and privacy. Cross-cultural research suggests that in collectivist sociocultural contexts, infertility-related stigma and disclosure decisions are influenced by social expectations and community visibility [\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e]. These findings underscore the importance of considering regional sociocultural dynamics when designing workplace support strategies.\u003c/p\u003e\n\u003cp\u003ePolicy and implementation implications\u003c/p\u003e\n\u003cp\u003eEmployer awareness of governmental resources designed to support infertility-friendly workplaces appeared limited [\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e]. Consistent with broader work\u0026ndash;life policy research [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e], the presence of formal guidelines does not necessarily ensure their practical implementation. Addressing this gap may require combined efforts in policy dissemination, managerial training, and promotion of supportive workplace cultures.\u003c/p\u003e\n\u003cp\u003eFraming infertility treatment within occupational health and workforce sustainability discussions may also encourage broader institutional engagement beyond individual-level accommodation.\u003c/p\u003e\n\u003cp\u003eStrengths and limitations\u003c/p\u003e\n\u003cp\u003eA key strength of this study is the integration of employee and employer perspectives within the same regional and temporal framework. Although surveys were not matched at the individual organizational level, this concurrent design enables cautious aggregate-level comparison of perceived needs and organizational awareness.\u003c/p\u003e\n\u003cp\u003eSeveral limitations should be acknowledged. Response rates could not be calculated because the total number of eligible individuals was not tracked. Participation may have been influenced by self-selection bias. The cross-sectional design precludes causal inference, and findings from a single prefecture may limit generalizability. These results should therefore be interpreted as exploratory and hypothesis-generating.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWorkplace disclosure remains limited and is a key challenge in balancing infertility treatment and employment. Organizational and policy-level interventions\u0026mdash;such as improved workplace communication, clearer disclosure pathways, and increased awareness of infertility-related needs\u0026mdash;may help support continued employment during treatment. Further longitudinal and multi-regional research is warranted.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003eThe study was approved by the Ethics Review Committee for Life Science and Medical Research Involving Human Subjects at the University of the Ryukyus (Approval No. 2048). All procedures were performed in accordance with the ethical standards of the institutional research committee and with the Declaration of Helsinki. Electronic informed consent was obtained from all participants prior to participation.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eConsent for publication\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe authors received no specific funding for this work.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eKM supervised the study and drafted the manuscript. CN conceived the study and contributed to data analysis and manuscript drafting. KN coordinated the ethical review procedures as a clinical research coordinator. CH, KG, AI, and SN contributed to data collection and interpretation. All authors reviewed and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors thank all participants and cooperating institutions for their contributions to this study.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. 1 in 6 people globally affected by infertility. 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news/item/04-04-2023-1-in-6-people-globally-affected-by-infertility\u003c/span\u003e\u003cspan address=\"https://www.who.int/news/item/04-04-2023-1-in-6-people-globally-affected-by-infertility\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 21 Feb 2026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMascarenhas MN, Flaxman SR, Boerma T, Vanderpoel S, Stevens GA. National, regional, and global trends in infertility prevalence since 1990: a systematic analysis of 277 health surveys. PLoS Med. 2012;9(12):e1001356. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pmed.1001356\u003c/span\u003e\u003cspan address=\"10.1371/journal.pmed.1001356\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInhorn MC, Patrizio P. Infertility around the globe: new thinking on gender, reproductive technologies and global movements in the 21st century. Hum Reprod Update. 2015;21(4):411\u0026ndash;26. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/humupd/dmv016\u003c/span\u003e\u003cspan address=\"10.1093/humupd/dmv016\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Geyter C, Wyns C, Calhaz-Jorge C, et al. 20 years of the European IVF-monitoring Consortium registry: trends and developments in ART in Europe. Hum Reprod Open. 2020;2020(3):hoaa035. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/hropen/hoaa035\u003c/span\u003e\u003cspan address=\"10.1093/hropen/hoaa035\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJapan Society of Obstetrics and Gynecology. ART Registry 2022: ART births and treatments in Japan. 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://fa.kyorin.co.jp/jsog/readPDF.php?file=77/12/077121886.pdf\u003c/span\u003e\u003cspan address=\"https://fa.kyorin.co.jp/jsog/readPDF.php?file=77/12/077121886.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 21 Feb 2026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Health, Labour and Welfare (Japan). Insurance coverage for infertility treatment (April 2022). 2022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.mhlw.go.jp/stf/seisakunitsuite/bunya/kodomo/kodomo_kosodate/boshi-hoken/funin-01_00004.html\u003c/span\u003e\u003cspan address=\"https://www.mhlw.go.jp/stf/seisakunitsuite/bunya/kodomo/kodomo_kosodate/boshi-hoken/funin-01_00004.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 21 Feb 2026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGender Equality Bureau, Cabinet Office (Japan). White Paper on Gender Equality 2022: Status and challenges. 2022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.gender.go.jp/english_contents/pr_act/pub/status_challenges/pdf/202205.pdf\u003c/span\u003e\u003cspan address=\"https://www.gender.go.jp/english_contents/pr_act/pub/status_challenges/pdf/202205.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 21 Feb 2026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGameiro S, Boivin J, Peronace L, Verhaak CM. Why do patients discontinue fertility treatment? Hum Reprod Update. 2012;18(6):652\u0026ndash;69. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/humupd/dms031\u003c/span\u003e\u003cspan address=\"10.1093/humupd/dms031\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePayne N, Seenan S, van den Akker O. Experiences and psychological distress of fertility treatment and employment. J Psychosom Obstet Gynaecol. 2019;40(2):156\u0026ndash;65. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/0167482X.2018.1460351\u003c/span\u003e\u003cspan address=\"10.1080/0167482X.2018.1460351\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eImai Y, Endo M, Kuroda K, et al. Risk factors for resignation from work after starting infertility treatment among Japanese women: Japan-FEMA study. Occup Environ Med. 2021;78(6):426\u0026ndash;32. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/oemed-2020-106745\u003c/span\u003e\u003cspan address=\"10.1136/oemed-2020-106745\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Health, Labour and Welfare (Japan). Manual for creating workplace environments that support employees receiving infertility treatment. 2025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.mhlw.go.jp/bunya/koyoukintou/pamphlet/dl/30k.pdf\u003c/span\u003e\u003cspan address=\"https://www.mhlw.go.jp/bunya/koyoukintou/pamphlet/dl/30k.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 21 Feb 2026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Health, Labour and Welfare (Japan). Infertility treatment and work balance support handbook. 2025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.mhlw.go.jp/bunya/koyoukintou/pamphlet/dl/30l.pdf\u003c/span\u003e\u003cspan address=\"https://www.mhlw.go.jp/bunya/koyoukintou/pamphlet/dl/30l.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 21 Feb 2026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Health, Labour and Welfare (Japan). Population statistics for 2024 (Final vital statistics). 2025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.mhlw.go.jp/toukei/saikin/hw/jinkou/kakutei24/index.html\u003c/span\u003e\u003cspan address=\"https://www.mhlw.go.jp/toukei/saikin/hw/jinkou/kakutei24/index.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 21 Feb 2026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Health, Labour and Welfare (Japan). Survey on compatibility between infertility treatment and work. 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.mhlw.go.jp/content/11909000/000930556.pdf\u003c/span\u003e\u003cspan address=\"https://www.mhlw.go.jp/content/11909000/000930556.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 21 Feb 2026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eH\u0026auml;mmerli K, Znoj H, Barth J. The efficacy of psychological interventions for infertile patients: a meta-analysis examining mental health and pregnancy rate. Hum Reprod Update. 2009;15(3):279\u0026ndash;95. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/humupd/dmp002\u003c/span\u003e\u003cspan address=\"10.1093/humupd/dmp002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCousineau TM, Domar AD. Psychological impact of infertility. Best Pract Res Clin Obstet Gynaecol. 2007;21(2):293\u0026ndash;308. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.bpobgyn.2006.12.003\u003c/span\u003e\u003cspan address=\"10.1016/j.bpobgyn.2006.12.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeatty JE, Joffe R. An overlooked dimension of diversity: the career effects of chronic illness. Organ Dyn. 2006;35(2):182\u0026ndash;95. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.orgdyn.2006.03.006\u003c/span\u003e\u003cspan address=\"10.1016/j.orgdyn.2006.03.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOECD. Policies to promote work\u0026ndash;life balance. 2021. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.oecd.org/social/family/\u003c/span\u003e\u003cspan address=\"https://www.oecd.org/social/family/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 21 Feb 2026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLewis S, Beauregard TA. The meanings of work\u0026ndash;life balance: a cultural perspective. Hum Relat. 2018;71(11):1463\u0026ndash;89. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0018726718765610\u003c/span\u003e\u003cspan address=\"10.1177/0018726718765610\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChaudoir SR, Fisher JD. The disclosure processes model: understanding disclosure decision making and postdisclosure outcomes among people living with a concealable stigmatized identity. Psychol Bull. 2010;136(2):236\u0026ndash;56. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1037/a0018193\u003c/span\u003e\u003cspan address=\"10.1037/a0018193\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQuinn DM, Chaudoir SR. Living with a concealable stigmatized identity. Psychol Bull. 2009;135(4):634\u0026ndash;51. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1037/a0015815\u003c/span\u003e\u003cspan address=\"10.1037/a0015815\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMajor B, O\u0026rsquo;Brien LT. The social psychology of stigma. Annu Rev Psychol. 2005;56:393\u0026ndash;421. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1146/annurev.psych.56.091103.070137\u003c/span\u003e\u003cspan address=\"10.1146/annurev.psych.56.091103.070137\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGreil AL, McQuillan J, Slauson-Blevins K. The social construction of infertility. Sociol Compass. 2011;5(8):736\u0026ndash;46. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1751-9020.2011.00397.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1751-9020.2011.00397.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYing LY, Wu LH, Loke AY. Gender differences in experiences with and adjustments to infertility: a literature review. Int J Nurs Stud. 2015;52(10):1640\u0026ndash;52. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ijnurstu.2015.05.004\u003c/span\u003e\u003cspan address=\"10.1016/j.ijnurstu.2015.05.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEdmondson AC. Psychological safety and learning behavior in work teams. Adm Sci Q. 1999;44(2):350\u0026ndash;83. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2307/2666999\u003c/span\u003e\u003cspan address=\"10.2307/2666999\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-social-science-and-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"diss","sideBox":"Learn more about [Discover Social Science and Health](https://www.springer.com/journal/44155)","snPcode":"","submissionUrl":"","title":"Discover Social Science and Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Infertility, Employment, Work–treatment balance, Workplace disclosure, Assisted reproductive technology, Japan","lastPublishedDoi":"10.21203/rs.3.rs-9191241/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9191241/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIntroduction\u003c/p\u003e\n\u003cp\u003eInfertility is increasingly recognized as a public health and social issue with implications for employment and workplace policy. In Japan, the use of assisted reproductive technology (ART) has increased alongside rising female labor force participation. Consequently, balancing infertility treatment and employment has become an important social issue. Okinawa Prefecture, historically one of the highest fertility regions in Japan and undergoing demographic transitions, provides a unique setting to examine infertility treatment and employment. This setting may be relevant to regions with increasing female labor force participation and delayed childbearing. This study aimed to clarify employment-related impacts, workplace disclosure, and employer support in Okinawa Prefecture, Japan.\u003c/p\u003e\n\u003cp\u003eMethods\u003c/p\u003e\n\u003cp\u003eA regional cross-sectional web-based survey was conducted between March 16 and July 31, 2023. Individuals undergoing infertility treatment were recruited through facilities, and companies with 10–1,200 employees were also surveyed. The study followed the STROBE statement. Descriptive statistics summarized employment impact, workplace disclosure, and organizational support.\u003c/p\u003e\n\u003cp\u003eResults\u003c/p\u003e\n\u003cp\u003eA total of 163 individuals and 38 companies responded. Among women, 25.6% experienced employment-related impacts and 10.9% resigned during treatment. Partial or no workplace disclosure was reported by 71.2%, while adverse workplace experiences were reported by 11.7%. Among companies, 84.2% had not implemented support measures.\u003c/p\u003e\n\u003cp\u003eConclusions\u003c/p\u003e\n\u003cp\u003eWorkplace disclosure remains limited and is a key challenge in balancing infertility treatment and employment. Organizational and policy-level interventions—particularly improved workplace communication and greater awareness of available support systems—may support work–treatment balance. Further longitudinal and multi-regional research is warranted.\u003c/p\u003e","manuscriptTitle":"Workplace disclosure and employment outcomes in infertility treatment: implications for workplace support in Okinawa, Japan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-20 14:19:03","doi":"10.21203/rs.3.rs-9191241/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-05T11:38:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"265979613335494542702180086197921604345","date":"2026-04-25T06:52:39+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-13T08:06:12+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-25T14:45:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-24T11:48:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-24T11:48:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Social Science and Health","date":"2026-03-22T12:35:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-social-science-and-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"diss","sideBox":"Learn more about [Discover Social Science and Health](https://www.springer.com/journal/44155)","snPcode":"","submissionUrl":"","title":"Discover Social Science and Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"373388b1-8f7e-4943-a981-2e5ef4ce9fb4","owner":[],"postedDate":"April 20th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-05T11:38:33+00:00","index":76,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-20T14:19:03+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-20 14:19:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9191241","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9191241","identity":"rs-9191241","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}