(2021) 19:71
Hirano et al. Hum Resour Healthhttps://doi.org/10.1186/s12960-021-00614-yOpen Access

RESEARCH

Measuring attentiveness toward oral careneeds: a comparative study of Indonesian care
workers in Japan and Indonesia
Yuko O. Hirano1* , Susiana Nugraha2, Hiroyasu Shiozu3, Misako Higashijima4 and Tri Budi W. Rahardjo2

Abstract
Background: Japan has opened its labor market to care workers from Indonesia under the Japan–Indonesia Economic Partnership Agreement (EPA). However, few studies have examined the types of care skills transferred between
countries. We therefore analyzed Indonesian care workers employed in Japan and Indonesia to identify discrepancies
in their attentiveness toward oral care in older adults.
Methods: A checklist comprising 42 items of universal oral care assessment was developed prior to the study anddistributed via the Internet to 418 Indonesian EPA care workers in Japan and via a paper survey to 213 Indonesiancare workers in Indonesia. The Mann–Whitney U test was used to compare the distribution of scores for each checklist
item for each group.
Results: The respondents were 110 Japan-based EPA care workers (response rate: 26.3%) and 213 Indonesia-basedcare workers (response rate: 99.1%). Japan-based care workers were significantly more likely to perform environmental observations of their older adult patients (p < 0.001) and to check items on the oral care checklist during feeding(p < 0.001) and post-meal (p = 0.001), while Indonesia-based care workers were more likely to check the overall condition of patients before meals (p = 0.021).
Conclusions: Discrepancies in checking oral care between the two groups were attributed to the differences in laws
and regulations governing the care environments. Indonesian care workers employed in Japan have the advantage
of learning to employ a more systematic approach in caring for older adults, in accordance with Japan’s Long-TermCare Act. This approach could contribute toward lowering the risk of aspiration pneumonia in Indonesia. A training
program designed for returning migrant workers to transfer newly developed oral care skills will thus be essential for
Indonesia to diminish the negative impacts of its aging population.
Keywords: Older adults, Oral care, Care skills transfer, Indonesia, Japan, EPA care workers
Background
The movement of care workers across national borders is
a global trend, with the Organization for Economic Cooperation and Development (OECD) reporting that morethan 5.1 million labor migrants entered OECD countries*Correspondence: hirano@nagasaki-u.ac.jp1
Institute of Biomedical Sciences, Nagasaki University, 1‑7‑1 Sakamoto,Nagasaki, Nagasaki 852‑8520, Japan
Full list of author information is available at the end of the article

on temporary migration programs in 2018, which represents a 5% increase over 2017 [1]. Japan is not an exception. Since 2008, Japan has recruited foreign care workers
under economic partnership agreements (EPAs) with
Asian countries, starting with Indonesia and followed by
the Philippines (in 2009) and Vietnam (in 2014). The total
number of care workers entering Japan from these three
countries under EPAs was 5026, as of June 2019 [2]. Oneof the most important motivations of Indonesian care
workers coming to Japan is to develop professionally and© The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to theoriginal author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images orother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
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Hirano et al. Hum Resour Health(2021) 19:71

learn a high quality of care [3] based on Japan’s prolificexperience in providing care for older adults. Indonesiancare workers in Japan, especially those among the first
EPA batch, experienced some friction because of the differences in the care cultures between the two countries;
however, most of them were gradually able to adjust [4].
Japan offers unique learning opportunities for Indonesian care workers, who report high satisfaction with theiremployment in Japan [5]. Indonesian care workers tend
to return to their home country after working in Japanfor several years. Based on data publicized by the Ministry of Health, Labour and Welfare of Japan [6], we calculated that approximately 60.3% of care workers whotake the test, pass the national board examination forcertified care workers. This means that approximately
40% of Indonesian workers—those who failed and were
therefore not qualified as a care worker—returned home,as per Annex 10 of the EPA [7]. Moreover, it is obvious
from their narrative that most Indonesian returnees wish
to contribute through the care skills that they obtained inJapan. In Hirano et al.’s [8] study, an Indonesian returnee
reported that she surprised her family and friends by providing sufficient water for bedridden older adults, whoshowed remarkable revitalization afterward. This showsthat Indonesian care workers are likely to learn Japan’shigh quality of care for older adults and employ theseskills when they return to Indonesia.
Although extensive research exists on the training ofcare workers worldwide, there are few studies involving migrant care workers [9]. Furthermore, most existing literature on migrant care workers [10] focuses on
migrants’ continuous engagement in care work in destination countries, not their potential to transfer skills
to their home country. Nonetheless, as per the World
Health Organization’s Global Code of Practice on theInternational Recruitment of Health Personnel [11], it isessential for the destination countries to facilitate circular migration, so that the care skills migrant care workers obtain in the destination countries can be used to thebenefit of both source and destination countries.
This study focused on the potential for the transfer oforal care skills, which are essential for satisfying the basic
needs of care recipients, such as older adults. Oral care is
the job most frequently conducted by care workers whoentered Japan under EPAs [12]. The importance of oral
care is underpinned by the association between pneumonia and oral health [13]. Moreover, when considering
nursing for home-acquired pneumonia, which reflects
a clinical environment similar to the one of the current
study, professional oral care may reduce mortality due toaspiration pneumonia, compared with usual care [14].
Specifically, the transfer of oral care skills is important for older adults, who may be at risk of aspiration

Page 2 of 9pneumonia, which is caused by a defective swallowing
mechanism and occurs in patients with malfunctioning
deglutition and cough reflex. Older adults are particularly
vulnerable, with aspiration pneumonia being the fourth
leading cause of death in Japan [15, 16]. Although there
are no specific statistical data on aspiration pneumonia
in Indonesia, it is likely present. As part of the effort tocombat the negative effects of aging in society, Japanese
researchers have developed various approaches to promote proper deglutition, which is influenced by age andbolus size [17] and is related to the level of nutrition andactivities of daily living, particularly for older adults withsarcopenia [18]. Applying the appropriate trunk position
was shown to be beneficial for shortening oral and pharyngeal transfer times in older adults with dysphagia in aclinical setting [19]. These findings suggest that aspiration pneumonia could be prevented via attentive intervention that focuses on maintaining a good posture and abolus size appropriate for older adults.
Oral care in Japan has begun to evolve to strategically
prevent aspiration pneumonia. We propose that improving the level of excellence in the care work for older
adults must involve a combination of careful observation and medical knowledge. The effective managementof dysphagia, for example, is particularly important for
older adults recovering from a stroke or receiving treatment for dementia. Older adults who have experienced aright-hemisphere stroke are likely to ignore the left sideof their vision field because of the malfunction in the partof the brain damaged by the stroke. Therefore, food thatolder adults with this condition cannot see is likely toremain uneaten; thus, care workers must alert their carereceivers to the uneaten food or, occasionally, turn theirplates around to help them to see all of their food.
The provision of training in techniques and skills
that build upon evidence-based medicine are urgently
required for care workers who aid older adults who arevulnerable to swallowing dysfunction. It is also crucial
that care environments for older adults provide appropriate oral care practices, such as providing food that carereceivers can easily cut to a proper bolus size for swallowing, helping them maintain a good posture when eating, and rearranging food items to maximize their visual
attention. We suggest that the proper adoption of theseskills may contribute to lower the risk of aspiration pneumonia in Indonesia, where the population is expected toage rapidly in the coming decades.
The current global era of care worker migration offers
high potential for the efficient transfer of care skills
between care workers and among countries. However, few studies have examined the types of care skills
that foreign care workers could learn abroad and apply
on returning to their country of origin. Therefore, weHirano et al. Hum Resour Health(2021) 19:71

investigated the potential for transferring oral care skills
from Japan to Indonesia for the prevention of aspiration
pneumonia.

Methods
We studied two groups of care workers for older adults
who shared the same nationality (Indonesian) but worked
in different countries (Indonesia and Japan) to decrease
the influence of cultural or societal context on our findings. To understand the oral care settings in Japan andIndonesia, both participant groups were asked to verify
the essential points of which they were aware during theprovision of oral care for older adults.
Instrument

The list to check the essential points for oral care (hereafter, checklist) was developed by the following procedure.
First, to satisfy the construct validity of the checklist
and confirm that the checklist contained the entire process of ingestion, 62 items were developed in Japanese by
one of the authors (HM), based on Leopold’s Five-Stage
Process of Ingestion [20], which consists of the anticipatory, preparatory, lingual, pharyngeal, and esophageal
stages. Each stage is compatible with the five periods
under the second domain developed by the authors, as
shown in Table 1.
Second, the 62 items were translated by one of theauthors (NS), who can speak both Japanese and Indonesian, and an Indonesian bilingual translator. The twoworked independently to translate the Japanese checklist.
One of them translated the original Japanese version toIndonesian and the second translated the Indonesian version back into Japanese; the process was blinded and thesecond translator did not see the original Japanese version beforehand. The two Japanese versions (original andback-translated) were then checked for discrepancies.
Any inconsistencies were discussed with another Indonesian bilingual translator engaged in care work in Japan,
and consensus was reached.
Third, a multidisciplinary meeting was held to selectitems from the checklist that satisfied the analyzed careenvironments and observe the conditions of care receivers to maintain safe ingestion. The original checklist
was intended for use prior to care provision in Japan;
therefore, we chose the items indifferent to the culturaldifferences between Japan and Indonesia. The multidisciplinary team consisted of three nurses (NS and twoothers, one of whom was a Japanese nurse speaking bothIndonesian and Japanese), an occupational therapist(HM), a medical sociologist (HY), an anthropologist, twonutritionists, seven gerontologists, three dentists (TR andanother two), and three pedagogical experts from bothIndonesia and Japan. We also invited two IndonesianPage 3 of 9care workers who had previously worked in Japan to ourmeeting as observers. Based on the discussions between
the participants, of the 62 items from the original checklist, 42 were selected after adjusting them for the sociocultural conditions in Indonesia and divided into two
domains (Table 1): (1) observation of the care setting
environment and (2) observation of functions and eating
capabilities. The first domain contained nine observational items regarding the safety of the care environment
for older adults’ dietary needs. The second domain was
divided into five periods: (A) overall condition of thepatient before meal (five items), (B) meal preparation
period (three items), (C) feeding period (eight items), (D)swallowing period (13 items), and (E) post-meal period(four items).
Fourth, language appropriateness was discussed toconfirm content validity. Two nurses, two dentists, and acare worker engaged in care work in Japan (including twoof the authors: NS and TR) tested the content validity.
Finally, a confirmatory factor analysis was conducted totest stability. The results derived six factors, which were
almost the same as the originally developed six categories, comprising the first domain and five periods under
the second domain. Internal consistency reliability wastested using Cronbach’s alpha for each category; values
ranged from 0.541 to 0.896.
A self-report questionnaire that included the oral
care checklist and demographic characteristics of the
respondents (i.e., gender, age, years’ experience in carework, and occupation at the care facility) was used andthe respondents were asked to provide yes/no responses(yes = 1, no = 0) to indicate whether they were attentive
to the necessity of care intervention for each item.
Participants

Eligible participants were Indonesian care workers who
worked in public and private care facilities in Indonesia
and Japan. In Indonesia, nonprobability purposive sampling was performed to select the participants. In total,
215 care workers from 18 care facilities (7 governmentowned and 11 privately owned) from four prefectures(Yoghakarta, West Java, DKI Jakarta, and TangerangBanten) were enrolled in the study and 213 completed
the survey. All participants, including 52 nurses, were
engaged in care work. We compared the participants by
the country in which they engaged in care work, after
confirming there were no laws and regulations that
restricted the job description of the nurses engaged incare work in Indonesia. We conducted a separate statistical analysis to test the distribution of attentiveness in careby occupational title. There were no statistical differencesin attentiveness in care between nurses and non-nurses
based on domain/period-based total scores. Therefore, inHirano et al. Hum Resour Health(2021) 19:71

Page 4 of 9

Table 1 Comparison of oral care checklist score between the two study groups
No. Observation item

I

Indonesian care
workers in Japan(n = 110)Indonesian care
workers in Indonesia(n = 213)

P value

Environmental observation

1

There is a separation between the dining room and the bedroom

96%

55%

< 0.0012

Adjustable dining tables or special chairs that can be used according to need areavailable for personal use

91%

47%

< 0.001

3

There are applicable utensils (e.g., spoons and chopsticks) that can be used inaccordance with the impairment of the individual user*

98%

–

4

There are variations in the form of food (e.g., porridge cut into bite-size pieces andsoft chopped food)

98%

64%

< 0.001

5

There is portable mucus suction

77%

54%

< 0.001

6

There is a tool that can be used by care workers or patients to notify other care
workers if there is an emergency (e.g., a bell).

89%

44%

< 0.001

7

Numbers of care workers and older adults are balanced when conducting meal
supervision

66%

52%

0.008

8

There is an allocation of one care worker for every care receiver who requires totalcare**

28%60%< 0.001

9

The care workers understand the dietary needs of each receiver

78%

74%

0.257

Total score

6.2 (SD:1.4)

4.5 (SD:1.9)< 0.001II

Observation of physiologic functions and eating capabilities

A

Overall condition before meal

1

Older adult moves differently than usual

72%

58%

0.009

2

Older adult is in poor condition/sleep deprivation

42%

57%

0.006

3

Older adult has fever

20%

50%

< 0.001

4

Older adult is in a state of coughing.

27%

43%

0.004

5

Older adult has different blood pressure (higher or lower) and pulse (bradycardia,
tachycardia) than usual

36%

49%

0.012

Total score

2.0 (SD:1.4)

2.6 (SD:2.0)

0.021

B

Meal preparation period: Waiting time before arrival of food and serving of food1

Older adult cannot sit in a stable position

66%

54%

0.018

2

Older adult is not fully conscious

39%

41%

0.428

3

Older adult appears calm

40%

55%

0.008

Total score

1.5 (SD:1.2)

1.5 (SD:1.2)

0.839

82%

49%

< 0.001C

Feeding period:

1

The dining table cannot be set up in accordance with the bodily positions of older
adult

2

There are difficulties when eating (e.g., cannot use a spoon for food or hold food)

79%

65%

0.007

3

There are problems in paying attention to food and the environment

77%

55%

< 0.001

4

There is a problem when placing food into the mouth (e.g., hand vibrates or food
falls)

72%

67%

0.207

5

There is a speed problem when placing food into the mouth.

72%

55%

0.003

6

There is a problem with the amount of food that is placed into the mouth

68%

55%

0.014

7

Older adult cannot ask for help when having difficulties during the eating process

55%

44%

0.035

8

Older adult refuses to be helped when eating (e.g., does not want to open themouth or feed themselves)

63%

49%

0.014

Total score

5.7 (SD:1.9)

4.4 (SD:2.9)< 0.001

D

Swallowing period:

1

Older adult cannot take in food smoothly (e.g., lips cannot close or food falls out of
the mouth)

58%

54%

0.302

2

There are problems with chewing (e.g., lack of chewing, removing or leaving hardfood, very fond of eating soft food only, or chewing for a long time)

70%

66%

0.287

3

Older adult cannot chew food into appropriate shapes and sizes to be swallowed

59%

59%

0.52

Hirano et al. Hum Resour Health(2021) 19:71

Page 5 of 9

Table 1 (continued)
No. Observation item

Indonesian care
workers in Japan(n = 110)Indonesian care
workers in Indonesia(n = 213)

P value

4

Older adult hoards food in the mouth (e.g., stores food in the mouth but does not
swallow)

65%

57%

0.083

5

There are problems in the process of swallowing food (e.g., cannot swallow food ortakes time to swallow food)

71%

54%

0.002

6

There is a swallowing disorder (e.g., food cannot be channeled into the esophagus)

48%

48%

0.535

7

There is a sound of fluid in the esophagus

43%

47%

0.3

8

Older adult chokes when eating

59%

56%

0.362

9

Older adults does not exhibit coughing when choking

39%

54%

0.009

10

Older adult takes a lot of time from start to finish when eating

81%

60%

< 0.001

11

Older adult looks tired when eating

48%

49%

0.503

12

Older adult looks weak when eating, and cannot maintain proper posture (e.g., thebody position is always slumped)

66%

53%

0.018

13
E

Older adult does not finish one portion of provided food

72%

55%

0.002

Total score

7.8 (SD:3.7)

7.1 (SD:4.5)

0.216

Post-meal period

1

Older adult does not brush teeth after meals

41%

32%

0.07

2

There is shortness of breath after meals

29%

45%

0.005

3

Older adult cannot use toothbrush

66%

40%

< 0.001

4

There is leftover food after brushing teeth

69%

40%

< 0.001

Total score

2.1 (SD:1.3)

1.6 (SD:1.2)

0.001

Scoring system: 1 = yes; 0 = no*This item was omitted from the questionnaire for Indonesian care workers in Indonesia**

This item was translated “There are special nurses who are responsible for older adult with total care” in the Indonesian version to suit the environment of the caresetting in Indonesia

the latter part of this study, all observations from Indonesia (Indonesia-based care workers) were tested, regardless of the occupational title. In Japan, 418 Indonesiancare workers who entered Japan under the certified care
worker track designated by the Japan–Indonesia EPA(Japan-based EPA care workers) were recruited throughsocial networking services (Facebook). In total, 110 completed the survey. Due to EPA regulations, all 110 participants enrolled in the study were nursing graduates
engaged in care work, as follows: 57 (51.8%) in special
nursing homes, 33 (30%) in healthcare facilities for older
adults, and 20 (18.1%) in other types of care institutions,
including hospitals and special care facilities for people
with disabilities.
Data analyses

Scores for each oral care item were added by domain/
period and a within-group analysis of differences between
the added scores was conducted using the demographic
characteristics of the respondents. Mann–Whitney U
tests and Chi-square tests were conducted to compare
the distribution of each item between Indonesia-basedcare workers and Japan-based EPA care workers at ap < 0.05 significance level. We used IBM SPSS Statistics
for Windows version 25J for the statistical analyses.

Results
Descriptive statistics

Among the total 213 (response rate: 99.1%) Indonesiabased care workers and 110 (response rate: 26.3%) Japanbased EPA care workers, the average age was significantly
higher among the former (35.2 years; standard deviation [SD] = 11.2), compared with the latter (27.9 years;
SD = 3.1; p < 0.001), as was the duration of work experience (7.3 years, SD = 6.6 vs. 3.7 years, SD = 2.8, respectively; p < 0.001). There was no significant difference ingender distribution by group.
Cross‑sectional analysis of respondent characteristics
and oral care domain scores

The domain/period-based total scores for Indonesiabased care workers were tested by institution (public or
private) and type of work (nursing or other care work),
and no significant correlations were found. For Japanbased EPA care workers, we tested the domain/periodbased total scores by the type of institution (working
in a special nursing home or not), clinical experienceHirano et al. Hum Resour Health(2021) 19:71

as a nurse prior to entering Japan, completion of a care
worker training course while in Indonesia, and experience as a care worker prior to entering Japan, and foundno significant correlations.
Comparisons between Indonesia‑based and Japan‑based
EPA care workers

Comparisons of each item on the oral care checklist
between Indonesia-based and Japan-based EPA care
workers are shown in Table 1. The results indicate thatthe latter were more likely to perform environmental
observations (p < 0.001), especially during both feeding(p < 0.001) and post-meal (p = 0.001). Conversely, Indonesia-based care workers were more likely to check theoverall condition of the patient before meals (p = 0.021).
This was particularly true for the following items: “older
adult is in a poor condition/sleep deprivation” (p = 0.006),“older adult has a fever” (p < 0.001), “older adult is coughing” (p = 0.004), and “older adult has different bloodpressure (higher or lower) and pulse (bradycardia, tachycardia) than usual” (p = 0.012). To determine whether anursing background contributed to these differences, we
compared the proportions of Indonesia- and Japan-based
EPA care workers with nursing backgrounds, and foundno significant difference between groups.

Discussion
Providing care skills training helps not only care recipients, but also care workers [8]. When training migrantcare workers, it is essential to consider cultural diversityof care [21]. This study statistically demonstrated that,even among care workers of common nationality (Indonesian), how care workers provided care varied, because
the manner in which care is applied is subject to the environment and care setting. Therefore, analyzing discrepancies in attentiveness between Japan-based Indonesian
EPA care workers and Indonesia-based care workers
may bridge the gaps in the provision of care for older
adults between Japan and Indonesia, which could resultin improving good practice guidelines for the transfer ofcare skills.
We compared the quality of oral care provided to older
adults by Indonesia-based care workers and Japan-based
EPA care workers. Although all participants were Indonesian, there were differences between the oral care item
groups checked by them. Apart from the meal preparation and swallowing periods, there were other significant
differences between groups. Specifically, Japan-based
EPA care workers were more likely to make environmental observations during feeding and post-meal, whereas
those based in Indonesia were more likely to make observations about the overall condition of their patients

Page 6 of 9

before meals. We offer three possible interpretations forthese 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 arealso expected to simultaneously provide care for several
older adults. This might have prevented the Japan-based
EPA care workers from focusing on the overall conditionof each patient prior to meals. Conversely, the ratio ofcare 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 the institution-based care of older
adults differ between the two countries. Japan-based EPA
care workers are expected to follow all rules and regulations established in Japan, with care facilities required to
uphold ministerial ordinances. Specifically, Ministerial
Ordinance No. 39 (enacted on March 31, 1999) statesthat food should be provided in a form that meets thephysical requirements of each individual older adult,
which is crucial for dysphagia management (i.e., posturaladjustments, swallowing maneuvers, and diet modifications) [22–24]. This ordinance has directly led to
improvements in the care environment and skill sets ofcare workers in Japan; by contrast, there is no comparable regulation in Indonesia.
Third, the formal job description and employer expectations of care workers differ between Japan and Indonesia. Having no specific legislation to regulate the role ofa care worker in Indonesia, all care workers share common tasks, regardless of their occupational title. Therefore, Indonesia-based care workers were comparatively
more attentive to the overall condition of their older
adult patients, particularly during the pre-meal period,
including checking vital signs such as blood pressure
and assessing sleep deprivation, fever, and cough. In
Japan, such tasks are often under the purview of nurses,
where the job descriptions of nurses and care workers areclearly delineated by law. Under this system, a nurse isdefined as someone who is licensed under the Ministry of
Health, Labour and Welfare of Japan to provide medical
treatment or assist in providing medical care for people
who are injured, ill, or recovering from childbirth [25].
The role of a care worker is broader: a “care worker mustin good faith engage in the services so as to allow thepersons under their charge to maintain personal dignity
and live an independent life in light of their standing at
all times” [26]. In accordance with these laws, the duties
of care workers in Japan are clearly divided: nurses checkvital signs (because this is a form of medical care) andcare workers assist older adults with activities of daily living that are important to maintain quality of life.

Hirano et al. Hum Resour Health(2021) 19:71

The strengths of the institution-based care environment in Japan were reflected in the differences in thepractical application of oral care skills between our two
study groups. The environmental observations made during the feeding and post-meal periods enabled the Japanbased EPA care workers to be more attentive in helping
older adults maintain not only oral functioning, but also
good posture and motion while eating. Care skills to
assist older adults with maintaining a good posture whileeating can help prevent dysphagia and decrease pharyngeal residue, including the “chin down technique” and“head rotation technique”, which minimize dysphagia risk
by changing the angle of the head [27–30]. Further, theauthors have routinely observed Japanese care workers
instructing their Indonesian EPA counterparts on performing these skills.
Another beneficial practice that Indonesian care workers appeared to learn from working in Japan was greaterattentiveness to oral care needs, particularly during thepost-meal period. Post-meal oral care, such as toothbrushing, is also useful for dysphagia prevention, as
reported by Yoneyama et al. [31, 32]. More than 65% of
the Japan-based EPA care workers in this study engaged
in oral care post-meal, regardless of care institution. We
propose that Indonesian EPA care workers could help
their compatriots by transferring these skills to the caresetting in Indonesia.
Currently, older adults represent 9.6% of the Indonesian population (268 million) and the older-age dependency ratio (age 60 + /age 15−59) is 15.01% [33]. The
workload of care is sufficiently low to allow them to beflexible when providing care. However, it has been predicted that, by 2045, the older segment of the Indonesian population will increase to 19.8%, with the older-age
dependency ratio increasing markedly to 24.5% [34].
Therefore, in the near future, Indonesian society may
face some of the issues that Japan is currently experiencing. Our results suggest that Indonesia may benefit fromlearning some of Japan’s recent lessons.
There are important factors to consider whenattempting to transfer care skills and practices between
these two countries. First, we must remain aware thatcare work varies in accordance with the cultural andsocietal setting. As indicated above, there are significant
discrepancies between Japan and Indonesia in terms ofprovision and regulation of care, job descriptions fornurses and care workers, and responsibility distribution between care providers. Our study identified areasthat require focus to bridge the gaps in older-age careprovision between Japan and Indonesia, assuming suchdiscrepancies reflect cultural and societal differences incare work. Accordingly, it is necessary to adopt a multidisciplinary approach to develop a training module

Page 7 of 9

for oral care that involves medical professionals, sociologists, and anthropologists. Second, a discussion on
the governance of returning migrant workers is a prerequisite for the dissemination of such training module.
Indeed, our ultimate goal is to contribute not only to
the well-being of older adults in Indonesia, but also tothat of its returning migrant workers. As recommended
by the Global Forum on Migration and Development[35], bilateral circular labor agreements should include
the country of origin’s responsibility for the recognition of workers’ skills when they return. Accordingly,
as part of the Law on Protection of Migrant Workers(No. 18/2019) [36], the National Agency for the Protection and Placement of International Migrant Workers
of Indonesia initiated a program under which returning
migrants, particularly those who have engaged in carework in Japan, will train local care workers and Japanbound Indonesian care workers. Therefore, establishinga 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.
Limitations

There are some limitations to this study. First, theresponse rate for the Japan-based EPA care workers waslow, which made sampling bias unavoidable. Second,
the sample was limited to institution-based care workers. Further research is required to evaluate the oral careskills of home-based care workers.

Conclusions
A novel oral care checklist was developed that revealed
differences in oral care practices for older adults between
care workers based in Indonesia and Indonesian EPA care
workers based in Japan. Based on these findings, our final
goal is to develop a new training program to help bridge
the gaps in oral care provision between these two countries. Implementing such a training program in Indonesia
would reduce the risk of dysphagia among older adults,
which may be a cause of aspiration pneumonia. This is asmall but significant step to transfer care skills that benefit both the destination and source countries of migrantcare workers.
Abbreviations
EPA: Economic Partnership Agreement; SD: Standard deviation.
Acknowledgements
We thank the study participants and Michelle Kahmeyer-Gabbe, PhD, from
Edanz Group (https://​en-​author-​servi​ces.​edanz​group.​com/) for editing a draftof this manuscript.

Hirano et al. Hum Resour Health(2021) 19:71

Authors’ contributions
HY drafted the manuscript; SH conducted the analysis; HM, NS, RT, and HYdeveloped the questionnaire and conducted the survey; and HM and NS
provided advice to HY. All authors read and approved the final manuscript.
Funding
This research was supported by the Economic Research Institute for ASEAN
and East Asia.
Availability of data and materials
The datasets generated and/or analyzed during the current study are notpublicly available because of ongoing data collection. However, data will be
released upon completion of the study and are available from the corresponding author on reasonable request.

Declarations

Page 8 of 9

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Ethics approval and consent to participate
Ethics approval was granted by the Biomedical Sciences Ethics Board at Nagasaki University (permission number: 19111407).

15.

Consent for publication
Not applicable.

16.

Competing interests
The authors declare that they have no competing interests.
Author details
1
Institute of Biomedical Sciences, Nagasaki University, 1‑7‑1 Sakamoto,Nagasaki, Nagasaki 852‑8520, Japan. 2 Faculty of Health Sciences, University of Respati Indonesia, Jakarta, Indonesia. 3 Department of Occupational
Therapy, Chubu University, Kasugai, Japan. 4 Faculty of Rehabilitation Sciences,
Nishikyushu University, Kanzaki, Japan.
Received: 12 August 2020 Accepted: 20 May 2021

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References
1. Organization for economic co-operation and development. internationalmigration outlook 2020. OECD; 2020. https://​www.​oecd.​org/​migra​tion/​inter​natio​nal-​migra​tion-​outlo​ok-​19991​24x.​htm. Accessed 20 Nov 2020.
2. Ministry of Health, Labour and Welfare: Transition of number of entry.
https://​www.​mhlw.​go.​jp/​conte​nt/​00063​9886.​pdf. Accessed 20 Nov 2020
(In Japanese).
3. Hirano OY, Ogawa R, Ohno S. A comparative study of Filipino and Indonesian candidates for registered nurse and certified care worker coming
to Japan under Economic Partnership Agreements. Jpn J Southeast AsianStud. 2012;49:594–610.
4. Alam B, Wulansari SA. Creative friction: some preliminary considerations
on the socio-cultural issues encountered by Indonesian nurses in Japan.
Bull Kyushu Univ Asian Center. 2010;5:183–92.
5. Hirano YO, Rahardjo TW, Nugraha S. The experience of Indonesian EPA
nurse and care worker candidates in Japan. Chiiki Kearingu. 2016;6:87–91(In Japanese).
6. Ministry of Health, Labour and Welfare: the result of the 31st nationalboard examination for certified care workers on EPA certified care worker
candidates. https://​www.​mhlw.​go.​jp/​stf/​houdou/​00001​99604_​00001.​
html. Accessed 3 May 2021. In Japanese.
7. Ministry of Foreign Affairs. Agreement between Japan and the Republicof Indonesia for an Economic Partnership. Annex 10: Specific Commitments for the Movement of Natural Persons. https://​www.​mofa.​go.​jp/​region/​asia-​paci/​indon​esia/​epa07​08/​index.​html. Accessed 3 May 2021.
8. Hirano YO, Yoneno-Reyes M, Hiruma Y, Nugraha S. Reviewing EPA
programs through the perception of EPA returnees. In: Hirano YO,
Yoneno-Reyes M, editors. Foreign nurses working in Japan: assessment of
the EPA program. Tokyo: The University of Tokyo Press; 2021. p. 211–31 (InJapanese).

22.
23.

24.
25.
26.
27.
28.
29.

30.
31.

Hewko SJ, Cooper SL, Huynh H, Spiwek IL, Carleton HL, Reod S, et al. Invisible no more: a scoping review of the health care aide workforce literature. BMC Nurs. 2015;14:38. https://​doi.​org/​10.​1186/​s12912-​015-​0090-x.
Puffer ES, Annan J, Sim AL, Salhi C, Betancourt TS. The impact of a familyskills training intervention among Burmese migrant families in Thailand: arandomized controlled trial. PLoS ONE. 2017;12(3):e0172611.
World Health Organization. WHO Global Code of Practice on the International Recruitment of Health Personnel. https://​www.​who.​int/​hrh/​migra​
tion/​code/​WHO_​global_​code_​of_​pract​ice_​EN.​pdf. Accessed 20 Nov
2020.
Sumida T. Current conditions of foreign care workers entered Japan
under EPA. http://​www.​mcw-​forum.​or.​jp/​image_​report/​DL/​20170​420-1.​
pdf. Accessed 20 Nov 2020 (In Japanese).
Azarpazhooh A, Leake JL. Systematic review of the association between
respiratory diseases and oral health. J Periodontol. 2006;77(9):1465–82.
https://​doi.​org/​10.​1902/​jop.​2006.​060010.
Liu C, Cao Y, Lin J, Ng L, Needleman I, Walsh T, et al. Oral care measures forpreventing nursing home-acquired pneumonia. Cochrane Database Syst
Rev. 2018;9:CD012416.
Ministry of Health, Labour and Welfare. Demographic statistics in Japan
2011. https://​www.​mhlw.​go.​jp/​toukei/​saikin/​hw/​jinkou/​kakut​ei11/​dl/​10_​
h6.​pdf. Accessed 4 Dec 2019. (In Japanese).
Teramoto S, Fukuchi Y, Sasaki H, Sato K, Sekizawa K, Matsuse T. Highincidence of aspiration pneumonia in community- and hospital-acquired
pneumonia in hospitalized patients: a multicenter, prospective study inJapan. J Am Geriatr Soc. 2008;56:577–93.
Higashijima M. Influence of age and bolus size on swallowing function:
basic data and assessment method for care and preventive rehabilitation.
Am J Occup Ther. 2010;64:88–94.
Shiozu H, Higashijima M, Koga T. Association of sarcopenia with swallowing problems, related to nutrition and activities of daily living of elderly
individuals. J Phys Ther Sci. 2015;27:393–6.
Higashijima M, Murata J, Ueda T, Han M. Clinical advantages of eating
positions of the mid-neck on swallowing function. J Phys Ther Sci.
2012;24:837–40.
Leopold NA, Kagle MC. Swallowing, ingestion and dysphagia: a reappraisal. Arch Phys Med Rehabil. 1983;64:371–3.
Davis BH, Smith MK. Developing culturally diverse direct caregivers forcare work with older adults: challenges and potential strategies. J Contin
Educ Nurs. 2013;44(1):22–30.
Sura L, Madhavan A, Carnaby G, Crary MA. Dysphagia in the elderly: management and nutritional considerations. Clin Interv Aging. 2012;7:287–98.
The Oto-Rhino-Laryngological Society of Japan. Clinical practice guidelines for diagnosis and management of dysphagia; 2018. http://​www.​jibika.​or.​jp/​membe​rs/​guide​lines/​enge_​shoug​ai_​2018.​pdf. Accessed 31
Jan 2020.
Japanese Society of Gerontology. Manual of oral care management
addition; 2010. http://​www.​gerod​ontol​ogy.​jp/​publi​shing/​file/​manual.​pdf.
Accessed 31 Jan 2020 (In Japanese).
Japanese Law Translation. Act on public health nurses, midwives, andnurses. http://​www.​japan​esela​wtran​slati​on.​go.​jp/​law/​detai​l/?​id=​2075&​
vm=​04&​re=​01. Accessed 25 Dec 2019.
Japanese Law Translation: Social Worker and Certified Care Worker Act.
http://​www.​japan​esela​wtran​slati​on.​go.​jp/​law/​detai​l/?​id=​2693&​vm=​&​re=. Accessed 25 Dec 2019.
Shanahan TK, Logemann JA, Rademaker AW, Pauloski BR, Kahrilas PJ.
Chin-down posture effect on aspiration in dysphagic patients. Arch Phys
Med Rehabil. 1993;74:736–9.
Rasley A, Logemann JA, Kahrilas PJ, Rademaker AW, Pauloski BR, Dodds
WJ. Prevention of barium aspiration during videofluoroscopic swallowing
studies: value of change in posture. Am J Roentgenol. 1993;160:1005–9.
Logemann JA, Gensler G, Robbins J, Lindblad AS, Brandt D, Hind JA, et al.
A randomized study of three interventions for aspiration of thin liquids
in patients with dementia or Parkinson’s disease. J Speech Lang Hear Res.
2008;51:173–83.
Logemann JA, Kahrilas PJ, Kobara M, Vakil NB. The benefit of headrotation on pharyngoesophageal dysphagia. Arch Phys Med Rehabil.
1989;70:767–71.
Yoneyama T, Yoshida M, Matsui T, Sasaki H. Oral care and pneumonia.
Lancet. 1999;354:515.

Hirano et al. Hum Resour Health(2021) 19:71

32. Yoneyama T, Yoshida M, Ohrui T, Mukaiyama H, Okamoto H, Hoshiba K,
et al. Oral care reduces pneumonia in older patients in nursing homes. J
Am Geriatr Soc. 2002;50:430–3.
33. BAPPENAS (Ministry of National Development Planning/National Development Planning Agency), BPS (National Statistics Bureau), and UNFPA(United Nations Fund for Population Activities). 2018. Proyeksi PendudukIndonesia 2015–2045 (Indonesia Population Projection 2015–2045).
Populasi. Jakarta. https://​indon​esia.​unfpa.​org/​en/​publi​catio​ns/​indon​
esia-​popul​ation-​proje​ction-​2015-​2045.​html. Accessed 23 July 2020 (InIndonesian).
34. National Statistic Agency: Statistics of Elderly Population 2019. Jakarta,
2019. https://​www.​bps.​go.​id/​publi​cation/​2019/​12/​20/​ab17e​75dbe​630e0​5110a​e53b/​stati​stik-​pendu​duk-​lanjut-​usia-​2019.​html. Accessed 7 June
2020 (In Indonesian).

Page 9 of 9

35. Global Forum on migration and Development. Sixth meeting of the
global forum on migration and development, Report of the proceedings.
https://​www.​sem.​admin.​ch/​dam/​sem/​en/​data/​inter​natio​nales/​inter​nat-​zusar​beit/​multi​later​ales/​gfmd/​gfmd-​report-​6-​2012-e.​pdf/. Accessed 8
Aug 2020.
36. International Labour Organization: Law on Protection of Migrant Workers(No. 18/2019). https://​www.​ilo.​org/​dyn/​natlex/​natle​x4.​detail?​p_​isn=​10927​9&p_​lang=​en. Accessed 29 Jun 2020.

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