In this study, we compared the quality of oral care provided to older adults by Indonesia-based care workers with Japan-based EPA care workers. Although all of the participants in this study were of a common nationality (Indonesian), there were differences between the groups in the oral care items that participants checked. Apart from the meal preparation and swallowing periods, there were other significant differences between the two groups. Specifically, Japan-based EPA care workers were more likely to make environmental observations during the feeding and post-meal periods, whereas those based in Indonesia were more likely to make observations about the overall condition of their patients before meals. We offer three possible interpretations for these discrepancies.
First, the working environments in these two countries are different. Generally, care workers in Japan have higher caseloads than their counterparts in Indonesia, and are also expected to provide care for several older adults simultaneously. A more hectic schedule might have prevented the Japan-based EPA care workers from focusing on the overall condition of each patient prior to meals. Conversely, the ratio of care workers to older adults is higher in Indonesia compared with Japan, thereby allowing for more time to carefully observe each patient.
Second, regulations that dictate the minimum physical requirements for institution-based care of older adults differ between the two countries. Japan-based EPA care workers are expected to follow all of the rules and regulations established in Japan, with care facilities required to uphold ministerial ordinances. Specifically, Ministerial Ordinance No. 39 (enacted on March 31, 1999) established parameters for the physical environment of a special nursing home. Under this ordinance, a special nursing home must provide a dining room that is larger than three square meters per patient, as well as a number and size of bedrooms appropriate for maintaining proper sanitation and avoiding medical risk. The ordinance also states that food should be provided in a form that meets the physical requirements of each individual older adult. These provisions are crucial for dysphagia management, which requires postural adjustments, swallowing maneuvers, and diet modifications [10–12]. This ordinance has directly led to improvements in the care environment and skill sets of care workers in Japan; by contrast, there is a lack of comparable regulation in Indonesia.
Third, the formal job description and employer expectations for care workers differ between Japan and Indonesia. Having no specific legislation to regulate the role of a care worker in Indonesia, all care workers share in the common work, regardless of their occupational title. In this study, Indonesia-based care workers were comparatively more attentive to the overall condition of their older adult patients, particularly during the pre-meal period. This included checking vital signs including blood pressure, and assessing sleep deprivation, fever and cough. In Japan, such tasks are often under the purview of nurses, and the job descriptions for nurses and care workers are clearly delineated by law. Under this system, a nurse is defined as someone who is licensed under the Japanese Ministry of Health, Labour and Welfare to provide medical treatment or to assist in providing medical care for people who are injured, ill or recovering from childbirth . The role of a care worker is broader, being defined as “care worker must in good faith engage in the services so as to allow the persons under their charge to maintain personal dignity and live an independent life in light of their standing at all times” . In accordance with these laws, the duties of care work in Japan are clearly divided: nurses check vital signs (because this is a form of medical care) and care workers assist older adults with activities of daily living that are important to maintain quality of life.
The strengths of the institution-based care environment in Japan were reflected in the differences in practical application of oral care skills between our two study groups. The environmental observations made during the feeding and post-meal periods enabled the Japan-based EPA care workers to be attentive to helping older adults maintain not only oral functioning, but also good posture and motion while eating. Care skills that assist older adults with maintaining a good posture while eating can help prevent dysphasia and decrease pharyngeal residue, and include the “chin down technique” and “head rotation technique,” which minimize dysphasia risk by changing the angle of the head [13–16]. Apart from the present study, the authors have routinely observed Japanese care workers instructing their Indonesian EPA counterparts in these very skills.
Another beneficial practice that Indonesian care workers appeared to gain from working in Japan was greater attentiveness to oral care needs, particularly during the post-meal period. Post-meal oral care, such as tooth brushing, is also useful for dysphasia prevention, as reported by Yoneyama et al. [17, 18]. More than 65% of the Japan-based EPA care workers in this study engaged in oral care during the post-meal period, regardless of care institution. We propose that Indonesian EPA care workers could help their compatriots by transferring these skills to care settings in Indonesia.
Currently, older adults represent 10.1% of the Indonesian population and the older-age dependency ratio (age 65+/age 15–64) is 9.2% . The workload for care providers has yet to be overburdened; thus, care providers have the latitude to be flexible when providing care. However, it has been predicted that by the year 2050 the older segment of the Indonesian population will rise to 21.1%, with the older-age dependency ratio skyrocketing to 24.5%. Thus, in the near future, Indonesian society may face some of the same issues that Japan is currently experiencing. The results of our study suggest that Indonesia may benefit from learning some of Japan’s recent lessons.
There are important factors to bear in mind when attempting to transfer care skills and practices between these two countries. First, we must remain aware that care work varies in accordance with the cultural and societal setting. As indicated above, there are large discrepancies between Japan and Indonesia in terms of provision and regulation of care, job descriptions for nurses and care workers, and responsibility distribution between care providers. Our study has identified areas in which we need to focus if we are to bridge the gaps in older-age care provision between Japan and Indonesia, assuming that such discrepancies reflect cultural and societal differences in caregiving that can be further scrutinized. Accordingly, we must adopt a multidisciplinary approach to the development of a training module for oral care that will involve medical professionals, sociologists and anthropologists. Second, a discussion on the governance of returning migrant workers is a prerequisite for the dissemination of any such training module. Indeed, our ultimate goal is to contribute not only to the well-being of older adults in Indonesia, but also its returning migrant workers. Recently, as part of the launch of the Law on Protection of Migrant Workers (No. 18/2019) , the National Agency for the Protection and Placement of International Migrant Workers of Indonesia initiated a program in which returning migrants, particularly those who have engaged in care work in Japan, will serve as leaders in training local care workers and Japan-bound Indonesian care workers. Therefore, establishment of a system to maximize the experiences of care workers as they return from Japan could facilitate the effective transfer of oral care skills to Indonesia in the near future.
There were some limitations to this study. First, the response rate for the Japan-based EPA care workers was low, which made sampling bias unavoidable. This might have occurred because the participants were too busy to respond to the online survey. Second, the sample was limited to institution-based care workers. Further research is required to evaluate the oral care skills of home-based care workers.