ERIA Research Project Report FY2023 No. 08

Resilient Long-term Care under the COVID-19
Pandemic in Indonesia, Japan, and Thailand

Edited by
Takeo Ogawa
Takuma Kato
Asuka Nagatani

Resilient Long-term Care under the COVID-19 Pandemic in Indonesia, Japan, and Thailand

Economic Research Institute for ASEAN and East Asia (ERIA)
Sentral Senayan II 6th Floor
Jalan Asia Afrika No. 8, Gelora Bung Karno
Senayan, Jakarta Pusat 12710
Indonesia© Economic Research Institute for ASEAN and East Asia, 2023
ERIA Research Project Report FY2023 No. 08
Published in July 2023

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, ortransmitted in any form by any means electronic or mechanical without prior written notice to andpermission from ERIA.
The findings, interpretations, conclusions, and views expressed in their respective chapters are
entirely those of the author/s and do not reflect the views and policies of the Economic ResearchInstitute for ASEAN and East Asia, its Governing Board, Academic Advisory Council, or the institutions
and governments they represent. Any error in content or citation in the respective chapters is thesole responsibility of the author/s. Material in this publication may be freely quoted or reprinted withproper acknowledgement.

iiPreface

Since 1988, Keishin Gakuen has conducted research in Japan, Australia, China, Indonesia, amongst
others, on the long-term care insurance system, the qualification system for long-term care workers,
and the training of long-term care workers, which form the foundations of Japan's ageing population
countermeasures, on the theme of the globally advancing ageing of society.
In 2019, a new research project was launched with the support of the Economic Research Institutefor ASEAN and East Asia (ERIA), and research was conducted with the aim of applying the policy of
employing foreign workers in Japan’s long-term care labour market in response to the declining
population and ‘promoting cross-border circulation of long-term care workers’, in accordance withJapan’s Asia Health and Wellbeing Initiative (AHWIN).
Furthermore, in the current project running from 2021, on the theme of ‘resilience’ in the face of thenovel coronavirus disease (COVID-19) pandemic, research has been conducted on how to protect
people's lives and livelihoods, quickly restore businesses, and move on from there.
The global spread of the COVID-19 infection, which began in 2019, has had a tremendous impact onhuman survival and livelihoods. In Japan, where the population is ageing rapidly, many long-term carefacilities for the elderly (especially nursing homes for the elderly, long-term care facilities for theelderly, day services, etc.) have been struggling to find ways to protect lives since the beginning of the
spread of COVID-19.
In order to contribute to these efforts, the Keishin–ERIA project conducted international comparisonsof COVID-19 infections and mortality from the perspective of resilience in long-term care homes forthe elderly, as well as field surveys to identify effective infectious disease countermeasures being usedin the long-term care business, and surveys on the actual situation of business continuity
management and business continuity plans (BCPs) at long-term care facilities for the elderly.
It is envisaged that long-term care facilities for the elderly would be further developed and increasedin number due to the advance in the ageing of societies in the countries of East Asia and the
Association of Southeast Asian Nations (ASEAN) Member States, and consequently it will benecessary to establish resilience against the risk of new infections.
Support is necessary for various activities in the further development of East Asian and ASEAN
countries, and in terms of support for long-term care facilities for the elderly, it is hoped that thevarious findings, analysis results, and data confirmed in this research can help in the development of
new infectious disease control models that can be shared and used internationally.

iii

I would like to express my sincere gratitude to Project Leader Professor Takeo Ogawa, who has madesuch great efforts on behalf of this research, Professor Reiko Hayashi, Professor Shun Ohno, Professor
Kaysorn Sumpowthong from Thailand, and Professor Tri Budi Rahardjo from Indonesia, and otherexperts from many countries, and to Keishin Gakuen faculty staff and everyone involved.

President Mitsutoshi Kobayashi
Keishin-Gakuen Educational Group

iv

Acknowledgements
Originally, this survey was based on collaborative research between ERIA and Keishin Gakuen on theinternational training and circulation of long-term care workers for the elderly based on the ‘Asian
Health and Wellbeing Initiative’. Initially, we envisioned a basic survey with India and the Philippines
to aim for the harmonisation of international professional qualification frameworks, including ademonstration on the training and circulation of long-term care. However, shortly after the survey
was launched, the novel coronavirus disease (COVID-19) pandemic broke out, rendering international
research activities impossible. Therefore, we have decided to conclude the first phase of the research
to a literature survey on the harmonisation between national occupational qualification frameworks
like India’s National Skills Qualifications Framework, the Philippines’ Qualifications Framework, andJapan’s Long-term Care Professional Career Rank System with the International Qualifications
Reference Framework like the ASEAN Qualifications Reference Framework.
In addition, as the second phase of research, we focused on resilient long-term care for the elderly
under the COVID-19 pandemic. Research studies on the impact of tragic events such as infectious
disease pandemics on long-term care for the elderly are often conducted with a view to highlighting
their vulnerability. However, what is important is the ability of the field to respond with resilience.
Therefore, we organised the following research groups to explore how resilience has been embraced
during COVID-19.
-

A basic study of the demographic impact of COVID-19.

-

Measurement of CO2 concentration in terms of measuring ventilation conditions in facilities.

-

Business continuity plan and management and knowledge, attitudes, and practices (KAP)
surveys for long-term care facilities in Japan and the staff working there. The KAP survey is an
integrated platform for users to collect, manage, and analyse data.

-

Interviews with migrant care workers in Japan.

-

KAP survey of caregivers in Thailand.

-

KAP survey of caregivers in Indonesia.

The aim was to summarise the findings obtained from these research studies and makerecommendations to those who will be involved in policymaking in the field of long-term care for theelderly in the future and those who will create training programmes for better care knowledge, skills,
and social attitudes as professionals in long-term care for the elderly.
However, as the spread of COVID-19 made direct surveys difficult, other methods, such as online
interviews, were used to conduct surveys, and monthly webinars were held to share the results ofthe survey and discussions (see Appendices). Based on discussions with ERIA, our schedule was
extended.

v

It was heart-breaking that during our study that Professor Tri Budi Raharjo, the head of the Indonesian
research team, lost her husband, son, and granddaughter in the COVID-19 pandemic. We would liketo offer our condolences to her once again.
The fact that we were able to overcome numerous difficulties and complete the second phase of theresearch is thanks to the tireless efforts of each research team. At the same time, it is thanks to thecooperation of the managers and staff of long-term care service providers. The person in ERIA alsochanged due to personnel changes along the way, with Osuke Komazawa, and Sota Machida in thefirst phase of the survey, and Takuma Kato and Asuka Nagatani in the second phase, who advised
after a smooth handover, gave enthusiastic advice. We would like to express our heartfelt gratitude
to all the people involved.

viList of Project Members and Authorship

Takeo Ogawa, PhD (Leader):Professor Emeritus, Kyushu University and Yamaguchi University. Japan
Executive Summary, Chapter 1, Chapter 8
Katsuhiko Kikuchi, Mr (Co-researcher)
Professor, Seitoku University, Japan
Chapter 3
Hiromi Kinebuchi, Ms (Co-researcher)
Lecturer, Niigata University of Health and Welfare, Japan
Appendix 1
Reiko Hayashi, PhD (Principal Researcher)
Deputy Director-General, National Institute of Population and Social Security Research
Chapter 2, Chapter 4. First AuthorshipTomonari Yashiro, Doctor of Engineering (Advisor)
Professor, Institute of Industrial Science, The University of Tokyo, Japan
Chapter 4. Advisor
Yo Ishigaki, PhD (Advisor)
Project Associate Professor, The University of Electro-Communications, Japan
Chapter 4. Advisor
Minato Nakazawa, PhD (Advisor)
Professor, Graduate School of Health Sciences, Kobe University, Japan
Chapter 4. Advisor
Shun Ohno, PhD (Principal Researcher)
Professor, Seisen University
Chapter 5.1. First Authorship, 6.2, 6.3. Co-author
Yoichi Hiruma (Co-researcher)Specially Appointed Associate Professor, Shizuoka University
Chapter 5.2. First Authorship
Yuko Hirano, PhD (Co-researcher)
Professor, Nagasaki University
Chapter 5.3. First Authorshipvii

Mario Ivan Lopez, PhD (Co-researcher)
Associate Professor, Center for Southeast Asian Studies, Kyoto University
Chapter 5.4. First Authorship
Wako Asato, PhD (Co-researcher)
Associate Professor, Graduate School of Letters, Kyoto University
Chapter 5.5. First Authorship
Reiko Ogawa, Ms (Co-researcher)
Professor, Chiba University
Kazumi Murakumo, Ms (Co-researcher)
PhD graduate student, Graduate School of Humanities and Social Sciences, University of Tsukuba
Kaysorn Sumpowthong, Dr (Principal Researcher)
Assistant Professor, Faculty of Public Health, Thammasat University, Thailand
Chapter 6. First Authorship
Panicha Boonsawad, Dr (Co-researcher)
Assistant Professor, Dr of Fundamental Nursing and Nursing Administration Department,
Srisavarindhira Thai Red Cross Institute of Nursing, Thailand
Chapter 6. Co-authorship
Anantachai Inthiraj, Mr (Co-researcher)
Researcher, College of Sports Science and technology, Mahidol University, Thailand
Chapter 6. Co-authorship
Pimpitcha Kangyang, Ms (Co-researcher)
Public Health Officer, Ministry of Public Health, Division of Health Economics and Health Security,
Thailand
Chapter 6. Co-authorship
Tri Budi W. Rahardjo, PhD, drg.,M Si (Principal Researcher)
Universitus Respati Indonesia
Chapter 7. Co-authorship
Susiana Nugraha, Dr PH SKM, MN (Co-researcher)
Assistant Professor, Centre for Family and Ageing Studies, University of Respati Indonesia
Chapter 7. First Authorship
the Central for Family and Ageing Studies (CeFAS) URINDO
Dinni Agustin, SPd, M Kesos (Co-researcher)
Centre for Family and Ageing Studies, University of Respati Indonesia
Chapter 7. Co-authorshipviii

Asyifa Robiatul Adawiyah, S.Ked, M.Kes (Researcher)
Centre for Family and Ageing Studies, University of Respati Indonesia
Putri Tresna Asih Handayani, SKM (Researcher)
Centre for Family and Ageing Studies, University of Respati Indonesia
Nadratul Laila, SKM (Researcher)
Centre for Family and Ageing Studies, University of Respati Indonesia
Lisna Agustina.,S.Kep.,Ners., M. Kep (Researcher)
Centre for Family and Ageing Studies, University of Respati Indonesia
Sudibyo Alimoeso, Dr, MA (Researcher)
Centre for Family and Ageing Studies, University of Respati Indonesia
Tri Suratmi, Dr, MPd (Researcher)
Centre for Family and Ageing Studies, University of Respati Indonesia
Lili Indrawati, Dr, MARS (Researcher)
Centre for Family and Ageing Studies, University of Respati Indonesia
Biben Fikriana, S.Kep., Ners., M. Kep (Researcher)
Centre for Family and Ageing Studies, University of Respati IndonesiaixTable of Contents

Prefaceiii

Acknowledgementv

List of Project Members and Authorshipiii

List of Figuresxi

List of Tables

xiii

List of Abbreviations and Acronyms

xv

Executive Summary

xvii

Chapter 1

Introduction

1

Chapter 2

COVID-19 Impacts on Long-term Care for Older Persons

27

Chapter 3

Business Continuity Management to Ensure Resilience in the Long-term

35

Care Business
Chapter 4

Environmental Health Resilience: Monitoring CO2 in Health and Long-

56

term Care Facilities
Chapter 5

Navigating Resilience and Vulnerability: Everyday Lived Experiences of62

Migrant Care Workers in Japan During the COVID-19 Pandemic
Chapter 6

Capacity Building for Resilient Long-term Care in Thailand

98

Chapter 7

Capacity Building for Resilient Long-term Care in Indonesia

114

Chapter 8

Recommendations

122

Appendix 1

Research Results on the Vulnerability and Resilience of Care

153

Workers in Japan
Appendix 2

Conferences for Learning and Sharing Results of Our Research

175

Appendix 3

Training Modules of Infection Prevention and Control

177xList of Figures

Figure 1.1

Transmission of COVID-19 Infection in Indonesia, Japan, and Thailand

1

Figure 1.2

Cumulative Deaths: Distribution by Age in Japan

2

Figure 1.3

Global Comparison of COVID-19 Deaths

3

Figure 1.4

Focusing Paradigm of Long-term Care Regime

4

Figure 1.5

COVID-19 Cluster Events by Week in Japan

5

Figure 1.6

Our Research on Paradigm of Long-term Care Regime

8

Figure 1.7

Research Approaches and Methods

8

Figure 1.8

Conceptual Diagram of Resilience10

Figure 2.1

COVID-19 Monthly Cases and Deaths (World)

27

Figure 2.2

Age and Gender of COVID-19 Cases

29

Figure 2.3

Age and Gender of COVID-19 Deaths

29

Figure 2.4

Age and Gender-specific COVID-19 Mortality

30

Figure 2.5

Comparison of Place of Death between Total Deaths and COVID-19 Deaths

31

Figure 3.1

Structure of Crisis Response Capability and Resilience in an Emergency

36(concept diagram)
Figure 3.2

Management Map for the Long-term Care Business

38

Figure 4.1

Avoid the Three Cs

56

Figure 4.2

CO2 Monitoring System

57

Figure 4.3

Examples of CO2 Monitoring

58

Figure 4.4

Well-ventilated Long-term Care Facilities in Indonesia

60

Figure 5.1

Transition of Numbers of Foreign Workers Engaged in Medical and Welfare

63

Services in Japan (October 2016–October 2021)
Figure 5.2

Breakdown of Foreign Workers Engaged in Medical and Welfare Services by

63

Nationality (as of October 2021)
Figure 5.3

Transition of Numbers of Approved Technical Intern Training Plans in Nursing

67

Care (March 2019–March 2021)
Figure 5.4

Transition of Numbers of Specific Skilled Workers in Nursing Care (June2019–March 2022)

xi

68Figure 5.5

Transition of Numbers of Foreign Enrolled Care Students Studying at Schools

68

for Certified Care Workers (2017–2022)
Figure 5.6

Breakdown of Vietnamese Technical Intern Trainee Respondents by Nursing

70

Graduation School
Figure 5.7

Population Changes for Fukuoka Prefecture (2010–2040)

86

Figure 5.8

New Arrivals of Specified Skilled Workers by Country of Origin

Figure 6.1

Model for COVID-19 Prevention and Resilience in Long-term Care, Thailand

109

Figure 6.2

Resilient Care beyond Vulnerability: Institutional-based Long-term Care

110

Figure 6.3

Resilient Care beyond Vulnerability: Community-based Long-term Care

111

Figure 8.1

Infection Prevention and Control of Aerosol Transmission

123

Figure 8.2

Resilient Long-term Care with Environmental Health

125

Figure 8.3

Situations of Family Caregivers and Volunteers during Infection

126

Figure 8.4

Resilient Long-term Care served by Family Caregivers and Volunteers

127

Figure 8.5

Business Continuity Plan of Long-term Care Facilities

129

Figure 8.6

Resilient Long-term Care with Business Continuity Management

130

Figure 8.7

Situation of Long-term Care Workers in Facilities

133

Figure 8.8

Resilient Long-term Care Served by Care Workers in Facilities

135

Figure 8.9

Residential Visas, Job Qualifications, and Working Places in Japan

139

Figure 8.10

Resilient Long-term Care Showcased by Migrant Care Workers in Japan

137

Figure 8.11

Overview of Resilient–Vulnerable Long-term Care

138

Figure 8.12

Environmental Health under Aerosol Infection Control

141

Figure 8.13

Behavioural Contacts and Referral System of Patients in Long-term Care

142

Facilities
Figure 8.14

Social Norms of Long-term Care Workers under an Infectious Disease145

OutbreakFigure 8.15

International Harmonisation of Qualifications Framework of Long-term Care

149

Figure 8.16

Recommendations for Policymakers and Professionals to Support Resilient150

Long-term Carexii

List of Tables

Table 1.1

Status of Residence of Foreign Care Workers in Japan

6

Table 3.1

Agile Response by Leader in Active Role

39

Table 3.2

ICT Utilisation for Process Management

41

Table 3.3

Multitasking of Professional Jobs

43

Table 3.4

Readiness and Prompt and Quick Response

46

Table 3.5

Vulnerability in Long-term Care Facilities

49

Table 3.6

Resilience in the Long-term Care Facilities

50

Table 5.1

Outline of Diversified Statuses of Residence for Migrant Care Workers in

65

Japan
Table 5.2

Details of Focus Group Discussions

71

Table 5.3

Summary of Comparison of COVID-19 Related Responses by Status ofResidence73

Table 5.4

Characteristics of the Participants

75

Table 5.5

Social Support of the Participants (very much/much)

77

Table 5.6

Sense of Coherence Scores and Subscales

78

Table 5.7

General Health Questionnaire Scores and Subscales

79

Table 5.8

Association between Sense of Coherence Score and Characteristics of theParticipants

80

Table 5.9

Association Between Sense of Coherence/Subscales and Social Support

83

Table 5.10

Social Welfare Corporation Special Nursing Home Group in Fukuoka
Prefecture: Changes in Employment of Foreign Staff (October 2020 toAugust 2022)

88

Table 5.11

Employment Status of Foreign Workers across Facilities (by Country)*

88

Table 5.12

Technical Intern Trainee Absconders by Nationality

92

Table 6.1

Demographic Characteristics of the Respondents

103

Table 6.2

Knowledge of the Participants

104

Table 6.3

Practice of the Participants

106

Table 6.4

Resilience Quotient

108

Table 7.1

Characteristic of Study Participants

116

xiii

Table 7.2

Knowledge about Infection Control According to Characteristics of the117

Workplace
Table 7.3

Knowledge, Attitudes, and Practices of the Caregiver in COVID-19

118

Prevention
Table 8.1

Training Outcomes of Resilient Long-term Care (tentative)

xiv

143

List of Abbreviations and Acronyms

AHWIN

Asia Health and Wellbeing Initiative

ASEAN

Association of Southeast Asian Nations

BCI

Business Continuity Institute

BCM

Business Continuity Management

BCMS

Business Continuity Management System

BCP

Business Continuity Plan

CDC

Centers for Disease Control and Prevention

COVID-19

novel coronavirus disease

DCAT

Disaster Care Assistant TeamDMAT

Disaster Medical Assistant TeamDPAT

Disaster Psychiatric Assistant TeamDWAT

Disaster Welfare Assistant Team

EPA

Economic Partnership Agreement

FGD

Focus Group Discussion

GHQ

General Health Questionnaire

HEC

Health and Elderly Establishment Confederation (Thailand)

ICT

Information and Communication Technology

IoT

internet of things

IPC

Infection Prevention and Control

JICWEL

Japan International Corporation of Welfare Services

JLPT

Japanese Language Proficiency

KAP

Knowledge, Attitudes, and Practices

LEDlight-emitting diodeLTC

Long-term Care

LTCF

Long-term Care Facility

LTCW

Long-term Care Worker

MCW

Migrant Care Worker

xv

MHLW

Ministry of Health, Labour and Welfare (JPN)

MOLISA

Ministry of Labour, Invalids and Social Affairs (Viet Nam)

MOPH

Ministry of Public Health (Thailand)

MOU

Memorandum of Understanding

MOC

Memorandum of Cooperation

OJT

On the Job Training

OSHA

Occupational Safety and Health Administration

OTIT

Organization for Overseas Technical Intern Training

PCR

Polymerase Chain Reaction

POEA

Philippine Overseas Employment Administration

PPE

Personal Protective Equipment

SDStandard Deviation

SISKOTKLN

System for Overseas Worker Management Services (Indonesia)

SOC

Sense of Coherence

SSW

Specified Skilled Worker

TITP

Technical Intern Trainee Programme

UNFPA

United Nations Population Fund

VHV

Village Health Volunteer (Thailand)

WHO

World Health Organization

xvi

Executive Summary
One of the common challenges in Asia is population ageing. As the population ages, the elderly
population will increase, and the number of elderly people who need long-term care will increase
accordingly. Long-term care is quoted from the World Health Organization (WHO) website as follows:
Older people continue to aspirate to well-being and respect regardless of declines inphysical and mental capacity. Good-quality long-term care is essential to provide older
persons with the care and support to maintain their functional ability consistent with
their basic rights, fundamental freedom, and human dignity. (WHO, Data Platform,
Ageing-Long-term Care for Older People. https://platform.who.int/data/maternalnewborn-child-adolescent-ageing/ageing-data/ageing---long-term-care-for-olderpeople)
Despite the ageing of the population, the working-age population is decreasing relatively and evenabsolutely in many Asian countries. With industrialisation and urbanisation, the working-age
population would be employed as industrial workers, and older persons might no longer be
dependent on traditional family care and community care. In that case, it would be necessary to ‘defamily’ and socialise long-term care. This would be where it becomes necessary to socially develop
institutional care for the elderly. Originally, public institutional care has been provided only for theelderly who are unable to work, who are poor, and who are without relatives. This is still the same
situation in many countries. However, as the population ages, older persons will seek long-term careservices that anyone can use, even if they are wealthy or have a family, if their daily living ability
declines. This is the reason why we focus on institutional care for the elderly.
The institutional care for the elderly in need of long-term care (LTC) is supported by trained andprofessional staff and equipped with housing facilities. Public institutional care, which only accepts
the poor, people with no relatives and are unable to work, is provided by civil servants, employedworkers, and volunteers. Furthermore, in places like Japan where a long-term care insurance system
has been established, services are provided by a variety of employed workers, mainly long-term care
professionals with national qualifications.
The institutional care for the elderly may be efficient, but it carries the risk of massive damage when
faced with disasters and pandemics. Indeed, the novel coronavirus disease (COVID-19) has posed thatchallenge. In the early phase of COVID-19, clusters and deaths occurred in nursing homes in Italy andthe United States. Compared to Europe and the United States, Japan that has developed institutionalcare to a certain extent has been able to contain the outbreak of infection clusters and the increasein mortality in long-term care facilities to at least the extent of the Omicron variant epidemic. However,compared to Asian countries, it is not always safe for the elderly in Japan.

xviiWhat challenges has the long-term care for the elderly been posed by COVID-19, what vulnerabilities
have it exposed, and what kind of resilience has born? We organised a research team to address andconduct research on this issue. Although our research was extremely difficult due to the pandemic,
the research team conducted a multifaceted survey using each research method.
In Chapter 1, Takeo Ogawa provides an overview of the framework of this research study.
Overviewing long-term care for the elderly in Asia, many countries rely on the care by family members
and by residents. Few countries like Japan have shifted from a family care system to an institutionaland community care system. Therefore, the resilience and vulnerability of LTC needs to be looked atfrom both institutional and community care perspectives. The resilience is defined as the ability torecover again after something difficult or bad has happened. For enhancing resilience of LTC, it isneeded to clarify the conceptual diagram of resilience, he said.
In Chapter 2, Reiko Hayashi made an international comparison of the demographic impact of COVID19 based on demographics. Whilst the infected cases of COVID-19 in older persons is not a particularly
large number, it has shown that the mortality rate amongst the elderly is high. It also showed that therate of COVID-19 deaths in Japanese facilities was extremely low. For understanding such facts, there
needs to be and understanding of the death registration system. Hayashi emphasises such vitalstatistics as more reliable dataset should be disseminated in ASEAN countries.
In Chapter 3, Katsuhiko Kikuchi conducted interviews with managers of LTC facilities on business
continuity planning (BCP) and business continuity management (BCM) in Japan. BCPs set out theresilience to ensure that critical businesses are not interrupted and restored in the short term in theevent of a crisis such as COVID-19. BCM is to ensure the requirements for it. Through interviews withmanagers, it was confirmed that day-to-day management skills are necessary to achieve these issues.
Furthermore, it will be needed to provide agile leadership in the initial response system and themultitasking of LTC jobs and smart care applying information and communication technology, etc. forresilience.
In Chapter 4, Reiko Hayashi's group conducted a survey in Japan and Indonesia to determine theventilation state in a real room by measuring the concentration of carbon dioxide gas from theviewpoint of environmental health. Although telemetry is possible with a simple terminal andcommunication application, it was found that there are problems such as the lack of a Wi-Fi
environment in which it can operate effectively.
In Chapter 5, Shun Ohno and his group conducted interviews with foreign care workers and students
being training as certified care workers residing in Japan, group discussions, and the sense ofcoherence (SOC) survey as an indicator of resilience. In Japan, there are foreigners engaged in longterm care work with various residency status. They are conceptualised as migrant care workers(MCW) together. The author poses the questions: What kind of status of residence is advantageousfor MCWs to engage in LTC jobs? What are the disadvantages? What was the impact of COVID-19?
Was there social support? The chapter examines various aspects of the global market of MCWs.

xviii

In Chapter 6, Kaysorn Sumpowthong's group from Thailand conducted a knowledge, attitudes, andpractices (KAP) survey and interviews with community volunteers and staff of long-term care facilities.
The KAP survey is an integrated platform for users to collect, manage, and analyse data. KAP surveys
originated in the 1950s in the fields of family planning and population research. Also known as
knowledge, attitude, behaviour, and practice surveys, these are now widely accepted for theinvestigation of health-related behaviours and health-seeking practices. In Thailand, village healthvolunteers (VHVs) have been cited as key persons in providing proactive support and havesuccessfully managed COVID-19 outbreak control. Bangkok and Patum-Tani Province were selected
as field survey settings. VHVs had little knowledge of aerosol infections and did not wear masks athome, but they were highly resilient. Strengthened and upgraded VHVs became more involved in thearea of community-based long-term care. Also, the Ministry of Public Health in Thailand launched
new regulations in 2021 for private LTC facilities to monitor and supervise the services. Private
facilities for the elderly have formed a federation to share information with each other. The Healthand Elderly Establishment Confederation provides a variety of support and activities for LTC and works
as a bridge to connect to government sectors. Then, a model for COVID-19 prevention and resiliencefor LTC was proposed.
In Chapter 7, Susiana Nugraha and Indonesian colleagues conducted a KAP survey of caregivers infacilities and in the community. Although caregivers in communities and care workers in facilities do
not have rich literacy for infection prevention and control, they had made efforts for older persons toperform exercise and sunbathing in order to maintain their healthy life. The author recommends thatpolicymakers establish a community based integrated care system, and for researchers to construct
a training module for the infection prevention and control.
In Chapter 8, Takeo Ogawa summarises the findings revealed by these research studies, and basedon the lessons learned, provides recommendations for building resilient care in response to infection
crises. In the short term, policymakers and care professionals need to disseminate existing guidelines
of infectious disease control, to support designing business continuity plans for public and/or private
LTC service providers, and to engage in online training programmes aimed at improving thecompetencies of long-term care workers. In the medium term, policymakers and care professionals
will need to address the challenges that long-term care administration has been unable to respondflexibly to COVID-19. After sorting out issues related to the existing division of labour, the standard ofreferrals, and monopolies of professional services, long-term care facilities and long-term care
workers should be able to respond flexibly and promptly to changes. In the long term, the prolonged
COVID-19 pandemic has highlighted structural weaknesses in existing aged care, including theambiguous positioning of long-term care facilities within the community comprehensive care system,
the unclear job description of care work, complex professional collaboration, the division of theinfectious disease task force over each facility, the qualification framework of migrant care workers
and in career development, deskilling risks, etc. To overcome these vulnerabilities and establish
resilient long-term care, policymakers and care professionals should develop creative and alternative
long-term care solutions.

xixChapter 1
Introduction

1.

Background and Objectives of the Project

1.1.

Daily New Confirmed Covid-19 Cases per Million People

The novel coronavirus disease (COVID-19) caused a pandemic in the world and had a huge impact on
the economy and society as a whole. It has repeated a long-term wavy epidemic since 2020 (Figure1.1). Each country has dealt with policy execution, corporate efforts, and civic behavioural changes
according to each situation.
COVID-19 has seen several waves of outbreaks. Our research covers the first wave up to the fifth waveof β mutants in Japan. It is not subject to research after the spread of the Omicron mutant strain fromJanuary 2022.

Figure 1.1. Transmission of COVID-19 Infection in Indonesia, Japan, and Thailand

Note: Daily new confirmed COVID-19 cases per million people, 7-day rolling average. Due to limited testing, thenumber of confirmed cases is lower than the true number of infections.
Source: John Hopkins University Center for Systems Science and Engineering COVID-19 Data.
https://ourworldindata.org/coronavirus (accessed 31 July 2022).

1

1.2.

The Vulnerability of Older Persons to COVID-19

COVID-19 is causing enormous damage to vulnerable people. The actual situation is different fromcountry to country. In addition, the damage situation according to gender and age is different in eachcountry. According to the United Nations Children’s Fund (UNICEF, 2022), Japan released statistics bygender and age of cases and deaths, Thailand released age-specific and gender statistics only for cases,
and Indonesia has not released any of them.
In Japan, if persons infected with COVID-19 died in the pandemic, the prefecture reported it
statistically as a ‘COVID-19 death,’ whether it was a direct or indirect cause of death in accordancewith the public health law. Therefore, the figure is different from official vital statistics based on the
doctor's death certificate under the Demographic Survey Order. Based on Japanese statistics, which
are reported by prefectures, the age-based composition of COVID-19 deaths shows that more than
80% of the age groups were in their 70s and older, and the elderly were the most vulnerable (Figure
1.2).

Figure 1.2. Cumulative Deaths: Distribution by Age in Japan10s
0%under 10
0%

20s
0%

30s
0%

40s
1%
50s
4%

Over 90
25%

60s
8%

70s
22%

80s
40%

under 10

10s

20s

30s

40s

50s

60s

70s

80s

Over 90

Source: Ministry of Health, Labour and Welfare (MHLW) Japan (2022). https:covid-19.mhlw.go.jp (accessed
31 July 2022).

In the facilities where older patients were hospitalised, provided with day care, or institutionalised,mass infections of the elderly were likely to occur, and the fatality rate was also high. According toJapan's 2020 census, 6.3% of the population aged 65 and over lived in facilities.

2

In welfare facilities for the elderly, infectious diseases are prone to become epidemics because
vulnerable elderly people live in groups. When COVID-19 spread in Europe and the United States,
many elderly people in facilities died, which had a great impact on citizens. In Japan, mass infectionsof COVID-19 occurred in long-term care facilities (LTCF), but the number of deaths were not as highas in Europe and the United States (OECD, 2021).
In addition, the outbreak of such an infectious disease in the ageing population not only caused
excess deaths, but the prevention of infection also hindered existing economic and social activities(Sanchez, 2021).
However, Japan was able to suppress infectious outbreaks amongst the elderly and to keep themortality rate low compared to European and North American countries, even though Japan’s
population is ageing and there are many LTCFs for the elderly.

Figure 1.3. Global Comparison of COVID-19 Deaths

Note: Daily new confirmed COVID-19 deaths per million people, 7-day rolling average. Due to varying protocols
and challenges in the attribution of the cause of death, the number of confirmed deaths may not accurately
represent the true number of deaths caused by COVID-19.
Source: John Hopkins University Center for Systems Science and Engineering COVID-19 Data.
https://ourworldindata.org/coronavirus (accessed 31 July 2022).

On the other hand, compared to countries in East Asia and the Association of Southeast Asian Nations(ASEAN), in Japan infection suppression of COVID-19 has not always been successful. The difference
between East Asia and Japan may be related to the acceptance of lockdown measures in the initial
response to infection, the presence or absence of live-in care staff, and the presence or absence ofstationed doctors and nurses.
In ASEAN countries, care for the elderly is often entrusted to families and communities, so mass3

infections in LTCFs may not be visible as a problem. However, with the ageing of the population, it will
be necessary to develop resilience to prepare for infectious disease risks in the future when LTCFs willbe established in ASEAN countries.
Japanese long-term care providers developed resilience experiences during COVID-19 as business
continuity plans (BCP). There are three major management components of long-term care (LTC) in
BCPs. One element is the management and operation of physical infrastructure such as facilities andequipment. The second element is the management and operation of human relations such as
residents, working people, and visitors. The third factor is the management and operation of money.
In this study, the management of the physical infrastructure and human relations are elements of a
BCP in accordance with international standards. Therefore, this study will focus mainly on these two
aspects.
The Japanese government recommends that BCPs in the situation of COVID-19 infection at the longterm care service providers be prepared with the following components: members of the BCP
promotion task force; contact directory outside facilities and offices; body temperature and physicalcondition checklist of staff, residents and clients; infectious and high-risk contact persons (including
suspected persons) management list; emergency contact network by staff of specified department;
stockpiling list (personal protective equipment etc.); job classification for selecting priority work; andbody temperature checklist at the time of visitor entry (MHLW, 2020).

Figure 1.4. Focusing Paradigm of Long-term Care Regime

LTC = long-term care.
Source: Compiled by authors.

4No matter how much we tried, the risk of mass infection (infection clusters) in elderly facilities washigh. In Japan, some infection cluster occurred in the first wave. However, from the second wave tothe fifth wave, infection cluster in LTCFs was controlled well. Since COVID-19 is a human-based
infection, training is needed to cut off the infection path from the facility staff. Staff members are
required to have knowledge, skills, and attitudes as the basic competency. Also, the maintenance of
LTCFs on the environmental health approach is required much more than community-based care.
Then, LTC service providers should make efforts to design a business continuity plan and management.
It includes the need to not only to manage economic capital but also to manage human, social, andenvironmental capital. Long-term care workers (LTCW) must learn the knowledge, attitudes, andpractical skills for infection prevention and control. Although Japanese certified care workers aretrained as professionals, they were confused about the unknown causes of COVID-19 infection. They
needed to renew their knowledge, attitudes, and practical skills for adapting new normal LTC for theelderly in their workplace, in crowds, and at home. They must prevent not only to be infected but
also not to infect others. Long-term care workers in LTCFs are not nurses. However, they sometimes
work as hospital nurses. They are regarded as essential workers. However, this recognition was
delayed in COVID-19 infection.

Figure 1.5. COVID-19 Cluster Events by Week in Japan

Source: Ministry of Health, Labour and Welfare (MHLW) Japan (2022). Visualising the Data: Information on
Covid-19. https:covid-19.mhlw.go.jp (accessed 31 July 2022).

In addition, there was a problem in the training and use of foreign long-term care workers. In Japan,
many foreign workers for the elderly are already working and learning. Through their eyes, it isnecessary to evaluate how the resilience of long-term care for the elderly towards infectious diseases
was realised in Japan, and to design and to shift it as a training module that can be widely used by5

sending countries. International migrant care workers (MCW) are categorised in the status ofresidence of foreign care workers in Japan (Table 1.1.)

Table 1.1. Status of Residence of Foreign Care Workers in Japan
Status of Residence
Medical Services
Nursing Care
Specified Skilled Worker

ExamplesPhysician, dentist, or
registered nurse
Certified care worker

Technical Intern Training

Foreign nationals engaging inwork requiring skills which
need considerable knowledge
or experience belonging to
specified industrial fields (LTC)
Technical intern trainees (LTC)

Student

Student

Designated Activities

Nurse and certified caretakercandidates under the
Economic Partnership
Agreement
Korean, Japanese, etc.
Article 817-2 of the Civil Code

Permanent Resident
Spouse or Child of Japanese
National
Spouse or Child of Permanent
Resident
Long-term Resident

Japanese, Brazilian etc.

Period of Stay
5 years, 3 years, 1 year, or 3
months5 years, 3 years, 1 year, or 3
months1 year, 6 months, or 4 months

Period designated individuallyby the Minister of Justice (2years or less)
Period designated individuallyby the Minister of Justice (4years, 3 months, or less)
3 years

Unlimited
5 years, 3 years, 1 years, or 6months5 years, 3 years, 1 year, or 6months5 years, 3 years, 1 year, 6months, or a term designatedby the Minister of Justice (5years or less)

LTC = long-term care.
Source: Immigration Services Agency of Japan (2021).

2.

Methodologies of the Project: Frame of ReferenceThis research project is a study using a psychosocial approach on the initiatives for COVID-19.
Biomedical approaches on COVID-19 are interested in high-risk targets that lead to individual deaths,
such as the causes of infection, infection processes, prevention, isolation, and medical treatments(Zamora-Ledezma, et al., 2020).

6

In contrast, the psychosocial approach is interested in the spread of infections by a wide range of
populations, including infected people, and also families who care for the infected, essential workers,
nearby residents, colleagues, the public, and corporate citizens to prevent infection (Dubey, et al.,2020).
When considering Japan's efforts towards COVID-19 using the psychosocial approach, it is necessary
to differentiate the macro-level, mezzo-level, and micro-level factors. The macro-level analysis was
carried out by collecting data from national and international statistics and conducting online
interviews (Wang, 2021).
The mezzo-level action entities are local governments, individual corporate organisations, andvoluntary organisations. In the event of a natural disaster or pandemic, corporations, medical
corporations, welfare corporations, and non-profit organisations, etc. which implement social andeconomic activities, will be forced to suspend their daily activities. It will cause great economic
damage. At the same time, if the period of emergency evacuation is prolonged during a disaster orfrom the time of infection, recovery and reconstruction will be difficult. After such an emergency
occurs, the possibility of business continuity will be questioned. Therefore, it is necessary for businessestablishments to have BCPs prepared in advance (Japan Federation of Kaio Business Providers, 2020;
ILO, 2020; South Australian Government, Office for Ageing Well. 2021; Comas-Herrera, Ashcroft, andLorenz-Dant, 2020; Giri, Chenn, and Romero-Ortuno, 2021.) A BCP will allow critically importantbusiness or work to continue even in the event of unforeseen circumstances.
In a BCP, it is necessary to increase resilience in two main aspects. One aspect is hygiene management
related to the facility environment (improvement of the environment, cleaning of the facility,
treatment of vomit, treatment of blood, and body fluids, amongst others). In the COVID-19 pandemic,
problems such as ventilation, procurement of masks, gowns, and disinfectants, waste disposal, etc.
emerged (UN HABITAT, 2021, WHO, 2017). The second aspect is human-related management such asstaff, the elderly, and their families. With regards to staff management, the COVID-19 pandemic has
been recognised as requiring tougher training and practice than ever before. The staff managementof MCW is also an important issue (ILO, 2020; Periyasamy, 2021; WHO, 2020b; Comas-Herrera,
Ashcroft, and Lorenz-Dant, 2020; Kiyota, 2021).

7

Figure 1.6. Our Research on Paradigm of Long-term Care Regime

LTC = long-term care.
Source: Compiled by authors.

In ASEAN countries, care of the elderly is often handled by the informal sector. Therefore, improving
resilience to pandemic clusters in long-term care facilities for the elderly, as in Japan, is not yet treatedas a problem. However, it is important to share the knowledge of Japanese service providers about
BCPs, as it is expected that the development of LTCFs in ASEAN countries will proceed in the future.
Figure 1.7. Research Approaches and Methods
Research Approaches
Psychosocial Approach

Biomedical Approach

Macro-Level Strategies

Statistical Analysis

Mezzo-Level Strategies
CO2 Density Measurement

Vulnerability/Resilience

Contingency Management
KAP Survey
Narrative Hearing

Micro-Level Strategies
LTC under COVID-19

KAP = knowledge, attitudes, and practices, LTC = long-term care.
Source: Compiled by authors.

8At the micro level, each individual is the subject of action. In Japan, the core human resources that
support the problem-handling of long-term care are professionals. The professions that haveattracted attention since the outbreak of COVID-19 began are those who are directly engaged in carework in addition to doctors, nurses, and co-medical workers. They are people who cannot avoid
physical contact in the course of their duties even if they know that the risk of infection is high andhave to go out to a client's place even if they are asked to stay home. Japanese care workers havebeen trained to deal with infectious diseases such as food poisoning and influenza every year, so they
have been able to take some action. However, there were cases where it was not possible to copewith the new COVID-19 pandemic (OECD, 2020; Ide, 2020; Estevez-Abe and Ide 2021a, 2021b; Abeand Kawachi, 2021; Suzuki, Morikawa, and Wakabayashi, 2021).
People's ability to solve the challenges they face is measured by their knowledge, attitudes, andpractices. A knowledge, attitudes, and practices (KAP) survey is a method (predefined questions
formatted in standardised questionnaires) that provides access to quantitative and qualitative
information. KAP surveys are often used in health surveys. They provide a baseline for family
caregivers, volunteers, and care workers to discover, educate, enlighten, and train what they cannot
do in reality. For enhancing the resilience of caregivers and care workers, we should understand theirknowledge, attitudes, and practices in the current situation. This research aimed to investigate KAP
amongst people involved in the care of the elderly in each country and contribute to the creation oftraining programmes for them.
Several efforts have been made to demonstrate the resilience to infectious disease in various sectors
in each country against the current vulnerable state of long-term care. However, for realising the ideal‘ageing in place’ for older persons, it will be necessary to gather the best practices and to design
strategies and tactics for more effective prevention of infectious diseases (Tsuji, 2021; WHO, 2020d;
Gleckman, 2020).
The COVID-19 pandemic, which has been spreading around the world since 2020, has disrupted
people's daily and normal lives. In the face of this crisis, the vulnerability of people's daily lives andalso the activities of various business establishments were highlighted. Nonetheless, there have been
efforts by individuals and business establishments to overcome this vulnerability and demonstrate
their resilience. Rather, it can be said that such resilience is the first step in building the new normal
standard for the next era.

9Figure 1.8. Conceptual Diagram of Resilience

Source: Compiled by authors.

Therefore, we tried to focus on the world of LTC for the elderly, a common issue in ageing Asia, to
uncover the vulnerabilities exposed by COVID-19 and the resilience explored from that. Let us defineresilience here as the ability to recover again after something difficult or bad has happened.
In considering resilience, as shown in Figure 1.8., depending on whether the risk shock is short-termor long-term, resilient responses to risk can take on various aspects from maintaining stability, flexible
adaptation, to alternative creative innovation. The resilience to maintain stability against short-termrisks will be an effort to mitigate as much as possible the vulnerabilities that arise. The resilience tosustain middle-term risks will be a flexible approach to adapting to unexpected vulnerabilities. The
resilience will be an alternative and transformative approach, which is different from existing
responses, to emerging structural vulnerabilities exerted if risks persist for a long-term.
We researched LTCFs and community-based LTC in Japan, Thailand, and Indonesia. We foundvulnerability and resilience of long-term care for the elderly during COVID-19. From the lessons learnt
based on findings, we summarised the supportive policy for enhancing resilient LTC for the elderly. It
is not only a focus on institutional care but also integrated community-based care. ‘Ageing in Place’ iscommon sense for realising the wellbeing of all citizens. Older people, their families, community
volunteers, and professionals like LTCWs will have to be co-creators of an integrated communitybased care system in ageing Asia.

10

3.

Implementation of our ProjectThis study was conducted in the midst of the prevalence of COVID-19 all over the world. For thatreason, it was not possible to meet with the planned survey subjects, and it was hard to obtaincooperation at facilities that were busy with responses. Professor Tri Budi Rahardjo, who oversaw theIndonesian research team, suffered the misfortune that her husband, eldest son, and granddaughter
died of COVID-19. In Japan, a mass infection occurred at the university where the research members
belonged, and the research activities themselves were restricted. Due to such circumstances, theinvestigation schedule was extended. In addition, when going to an interview, we had to make an
unexpected expense such as performing a polymerase chain reaction (PCR) test. In spite of these
difficulties, each research team implemented the research by repeating the ingenuity as much as
possible. Research studies conducted by each research team will be reported in detail in later
chapters.
Although it was difficult to conduct research, unexpected changes occurred in the world of
information transmission and sharing. With the spread of internet use, even if physical meetings were
not possible, meetings and interviews were able to be conducted online. Therefore, for supervising
the whole team, webinars were held every month with the aim of mutually learning andunderstanding the goals, research methods, and progress of each research. The materials are
summarised as appendices at the end of this report.

4.

Review of Literature

4.1.

Preventing and Managing COVID-19 across Long-term Care Services

The World Health Organization (WHO) published ‘Preventing and Managing COVID-19 across Longterm Care Services’ as a policy brief in 2020. The brief provides 11 policy objectives and key action
points to prevent and manage COVID-19 across long-term care. The 11 policy objectives are:•Include LTC in all phases of the national response to the COVID-19 pandemic.

•

Mobilise adequate funding for long-term care to respond to and recover from the COVID-19
pandemic.

•

Ensure effective monitoring and evaluation of the impact of COVID-19 on LTC and ensure
efficient information channelling between health and LTC systems to optimise responses.

•

Secure staff and resources, including adequate health workforce and health products, torespond to the COVID-19 pandemic and deliver quality LTC services.

•

Ensure the continuum and continuity of essential services for people receiving LTC, including
promotion, prevention, treatment, rehabilitation, and palliation.

•

Ensure that infection prevention and control standards are implemented and adhered to in all
LTC settings to prevent and safely manage COVID-19 cases.

•

Prioritise testing, contact tracing, and monitoring of the spread of COVID-19 amongst people

11receiving and providing LTC services.
•

Provide support for family and voluntary caregivers.

•

Prioritise the psychosocial well-being of people receiving and providing LTC services.

•

Ensure a smooth transition to the recovery phase.

•

Initiate steps for transformation of health and LTC systems to appropriately integrate and ensure
continuous, effective governance of long-term care services.

The WHO report ‘Health Workforce Policy and Management in the Context of the COVID-19
Pandemic Response’ was published in 2020. This guide consolidates COVID-19 guidance for humanresources for health managers and policymakers at national, subnational, and facility levels to design,
manage, and preserve the workforce necessary to manage the COVID-19 pandemic and maintainessential health services. The guide covers the following areas (WHO, 2020b, p. 3):
Supporting and protecting health workers:
Infection prevention and control, including use of and access to personal protective equipment.
Decent working conditions, including occupational health and safety.
Mental health and psychosocial support.
Remuneration and incentives.
Strengthening and optimising health workforce teams:
Building competencies through education and training.
Optimising roles.
Leveraging community-based health workers.
Increasing capacity and strategic health worker deployment:
Improving health worker availability through hiring and redeployment.
Activating partner networks.
Rationalising the health workforce distribution.
Ensuring a supportive work environment, including a manageable workload.
Health system human resources strengthening:
Improving health workforce information systems, including to track health worker infections.
Assessment and planning of health workforce needs.
Licensing and regulation reforms.
Strengthening governance and intersectoral collaboration mechanisms.
The WHO Western Pacific Region published ‘Preparedness Checklist for Long-Term Care Facilities:
COVID-19 Infection Prevention and Control’ in 2020. This checklist can be used by facility

12administrators, infection prevention and control focal points or staff, internal or external professionals.
The seven elements of the checklist are (WHO Western Pacific Region, 2020a):•

Facility information•

Organisation and planning•

Safe and healthy work environment•

Equipment and supplies•

Cleaning, disinfection, and waste disposal•

Education and training (for staff, residents, and visitors)•

Communication

The WHO Western Pacific Region also published ‘Communication Toolkit for Long-Term Care Facilities’in 2020. (WHO Western Pacific Region, 2020b).
The European Centre for Disease Prevention and Control did a surveillance of COVID-19 in LTCFs in
the European Union/European Economic Area in 2021. It discussed limitations include difficulties inpooling or comparing national data due to differences in the national surveillance systems such as
the participating types of LTCFs, testing policy, and surveillance definitions, among other caveats(ECDC, 2021).

4.2.

Review Articles of LTCFs and KAP Survey during COVID-19

The Health and Welfare Bureau for the Elderly, Japan Ministry of Health, Labour and Welfare,published ‘Guidelines for Business Continuity at Care Facilities in the Event of COVID-19’ in 2020
(MHLW, 2020). Achieving resilience for LTCFs during the COVID-19 pandemic is nothing less thanensuring business continuity. Characteristics of COVID-19 measures and the main points for business
continuity are:•••Accurate information collection and quick and accurate decision making
The key to business continuity is mainly adjustments in manning
Prevention of staff infection in order to secure manpower

Therefore, LTCFs need to develop BCPs for infectious diseases. Points for preparing a BCP aredescribed in the following items:
•
•
•
•
•

Information sharing and division of roles with stakeholders, building a decision-making system
Formulation of a response flow in the event of (suspected) infections
Securing support personnel in anticipation of staff shortages
Determining work priorities
Making sure staff are informed and trained on the BCP during normal times so that it can be
implemented when needed (MHLW, 2020).

Dykgraaf et al. published a review article titled ‘Protecting Nursing Homes and Long-term Care
Facilities from COVID-19: A Rapid Review of International Evidence’ in 2021. The report pointed outthat attention to ventilation and environmental management, digital health applications, and acute13

sector support were also considered beneficial, although evidence for effectiveness was lacking. It
also introduced the fact that staff represented substantial transmission risk and workforce
management strategies were important components of pandemic response. Higher-performing
facilities with less crowding and higher nurse staffing ratios had reduced transmission rates. It
concluded that facility-level leadership, intersectoral collaboration, and policies that facilitated accessto critical resources were all significant enablers of success (Dykgraarf, et. al., 2021).
Masoud et al. published ‘KAP-COVID GLOBAL: A Multinational Survey of the Levels and Determinantsof Public Knowledge, Attitudes and Practices towards COVID-19’ in 2021. They concluded thefollowing based on a cross-sectional study that assessed the levels and determinants of KAP towards
COVID-19 in 22 countries (Masoud, et.al., 2021):
The public in those countries had fair knowledge and good attitudes towards COVID-19, but
one-third of our participants did not know that infected individuals can be asymptomatic, which
increases their risk of exposure to the disease.
Almost half of our participants held negative or uncertain attitudes about contacting Chinese
people and more than one-third had similar attitudes towards doctors.
82% of respondents usually wear face masks in crowded places, but only 52% wear masks
outdoors in general.

4.3.

Findings and Lessons Learnt from Research on Long-term Care during COVID-19
Lessons Learnt Internationally
Global Union (UNI) published ‘Most Dangerous Job: The Impact of COVID-19 on Long-Term, Care
Workers in the US, UK, Canada, Ireland, and Australia’ in 2021 and recommended the following:•

The working conditions and pay of LTCWs should be improved in all nations with the goal of
improving employee retention and maintaining institutional knowledge. Reliance on temporary
workers and workers that move amongst multiple care facilities should be minimised as muchas possible by giving people full-time jobs with decent pay.

•

Staff-to-resident ratios should be increased to safeguard the health of both.

•

COVID-19 should be considered an occupational disease for all LTCWs.

•

Investment in the LTC sector should be increased and tied to both worker and resident outcomes,
providing incentives for investors, employers, and governments to follow the strictest safety
protocols and best practices.

•

Robust tracking systems should be developed and implemented to track coronavirus infections,
hospitalisations, and deaths amongst workers on a national level. Ideally, these data should bebroadly comparable internationally.

•

Infectious disease training should be provided to all LTCWs on an annual basis.

•

Health and safety structures, including worker or joint committees, should be used to address
COVID-19 risks and to impose stronger measures that include infectious disease protocols,14

access to personal protective equipment (PPE) and vaccines, among others. If they do notcurrently exist at a worksite, they should be created.
•

Most importantly, workers must have a voice in decision-making in the workplace throughunions and collective bargaining. And as part of the move towards empowering workers, eachnursing home needs a worker health and safety committee and democratically elected worker
safety representatives.

Kiyota published ‘Elder Care Providers and COVID-19: Cross-Cultural Perspectives’ in 2021. It reported
lessons learnt based on interviews. The vulnerability of elder care settings during COVID-19 has
highlighted systemic challenges that this sector faces. Lessons learnt include:•

Fostering Equity
Eliminate global inequity such as tests, PPE, and technology.
Share procedures and educational materials through global network.

•

Learning from Experience
Study experiences and share lessons globally.

•

Protecting Human Rights
Create balance between social interaction and infection control by developing a creative system.

•

Supporting the Workforce
Develop training and education
Develop systems for awarding formal recognition•

Adapting the Physical Environment
Design buildings for infection control: small-scale household units, private ensuite rooms, safe
outdoor spaces, wide corridors, and enhanced ventilation.
Minimise cross-contamination within buildings•

Developing Effective Policies and Guidelines
Ensure that policies are relevant to elder care settings by including elder care providers in thedevelopment of those policies.

•

Advocating for Elders and Caregivers
Develop local support networks of elder care providers

Estévez-Abe et al published ‘COVID-19 and the Long-Term Care system in Japan’ in 2021 forInternational Long-term Care Policy Network. They found some traits of Japan’s response towards
COVID-19 (Estévez-Abe, et al., 2021b).
•

Despite being the most aged society in the world and having a high population density, Japan
maintained low rates of deaths from COVID-19.

•

Japan locked down LTCFs during the first months of the pandemic, several weeks earlier than in

15

Europe and the United States. This helped protect the most vulnerable elderly population from
infection risks.
•

The well-established protocols of prevention and control of communicable diseases such as
influenza and tuberculosis. In LTCFs proved to be effective in containing transmission of SARSCOV-2. The rate of compliance with the protocols has been high.

•

The Japanese government’s response to the pandemic has been primarily a routine bureaucratic
response. The presence of public authorities exclusively devoted to the oversight of LTCFs
contributed to swift institutional responses.

•

The presence of effective channels of communication between the public authorities and LTCFs
contributed to the swift implementation of government guidelines.

•

The national government’s unwillingness to make PCR tests widely available to LTCFs and the
population at large has been a major obstacle in ensuring safety of residents in LTCFs and usersof other LTC services. Japan has almost solely relied on lengthy lockdowns of LTCFs. This is not
an ideal solution to a prolonged pandemic.

•

The government campaign offer subsidies for domestic tourism (GoToTravel campaign) andeating out in restaurants (GoToEat campaign) led to the worst spikes in viral transmission during
the final quarter of 2020.

•

The pandemic has revealed the most vulnerable aspects of the Japanese LTC system. Particularly,
two characteristics of the Japanese LTC system have proved to be highly vulnerable totransmission of SARS-COV-2: Japan’s reliance on day care and homecare services and the large
number of LTC facilities that provide both residential and non-residential care services.

The WHO published ‘COVID-19 and the Decade of Healthy Ageing’ in 2020 (WHO, 2020d). It focusedon four action areas:•

Changing how we think, feel and act towards age and ageing.

•

Developing communities in ways that foster the abilities of older people.

•

Delivering person-centred, integrated care and primary health services responsive to older
people.

•Providing older people who need it with access to LTC.

Sato and Dempster (2022) following recommended the following points:
Support migrants and their families during crisis:•
Ensure remittances are able to flow.
•
Provide social protection for migrant workers abroad.
•
Ensure migrants can access health systems.
•
Focus on accommodation.

16

Help critical workers deploy their skills.
Do more to highlight role of ‘low-skill’ workers.

••

Build sustainable LTC systems:
Take a systems approach which integrates the strengths of each sector.
Implement policies which uplift the LTC sector and attract LTCWs.
Develop robust insurance or financing mechanisms.
Provide more information to choose the appropriate care.
Focus on human resources for LTC, including migrant workers
Collect and analyse data to understand skills shortages, both in quantity and quality, andenhance workforce planning.
Recognise the need for more migration to meet demand.
Take meaningful steps to recognise the qualifications of registered nurses, to prevent downskilling.
Provide LTC workers, including migrant LTCWs, with opportunities and training to advance theirskills.
Promote standardisation of qualifications to enhance migration opportunities for LTC workers.

•
•
•
•
•
•

•
•

•

•

Develop legal migration pathways for LTC:
Countries of destination should create a multi-year visa for LTC work.
Countries of origin should ensure mutual benefit from any legal migration pathways.
Ensure such pathways are built with sustainability in mind.
Enter into BLAs and MOUs which safeguard migrant rights.
Ratify the Domestic Workers Convention and enact legislation to support domestic workers.
Encourage regional collaboration.

•
•
•
•
•
•

Lessons Learnt in JapanThe Japan Care Work Foundation (Kaigo Rodo Antei Center) released a report of the ‘Long-term CareLabour Fact-finding Survey (Special Survey)’ in 2021. The survey found the following results:•

Between December 2020 and January 2011, COVID-19 caused 5.2% of staff in care facilities totake leave.

•

62.2% of institutional and residential care facilities had already formulated infection prevention
measures and infection control policies. In addition, 73.3% of institutional and residential carefacilities had formulated manuals of infectious disease control.

•

34.4% of institutional and residential care facilities started residents meeting with their families
using an online meeting tool. About 19.2% of care facilities had introduced conferences using
online meeting tools.

•

The psychological burden on the staff working at LTCFs was heavy. The degree of burden varies
depending on the job, and the people who felt the most burdened were life support advisors17

(67.2%), physical therapists, occupation therapists, and speech therapists (66.0%), nursing staff(61.5%), care managers (60.3%), and LTC staff (56.4%).
•

As a professional in Japan, certified care workers are trained in infectious disease prevention andcontrol, so they have a certain level of knowledge and practical ability. Nevertheless, many
LTCWs felt anxious about becoming infectious diseases by themselves (90.1%) and worried thatthey would bring the virus into the workplace (88.9%).

•

Among those who work in institutional and residential care facilities, 43.9% said that ease ofcommunication and consultation with superiors has deteriorated under the COVID-19 pandemic,
while 32.0% said that it has actually improved. In addition, there were more people who
improved (32.8%) than those who had a worse ‘ease of communicating with other occupations’(24.3%).

•

Despite experiencing difficult times, 64.2% of care workers expressed a willingness to continue
working.

Lessons Learnt in Thailand
The Asian Development Bank’s report on ‘Country Diagnostic Study on Long-term Care in Thailand’in 2020 recommended the following (ADB, 2020, pp. 55–57):•

A supportive environment, health services, and social services in support of a LTC system forolder persons.

•

Governance and coordination.

•

Financing long-term care.

•

Registration and care standards for LTC establishments.

•

Human resources development.

•

Improvement of LTC service in homes and residential facilities.

The Asian Population and Development Association (2021) pointed out the following vulnerabilities
of LTC in Thailand:•

As the incidence of gender-based violence has risen since the start of the COVID-19 pandemic,
elder abuse must also be monitored as families are increasingly locked down together and more
dependent on one another for social and economic support.

•

The financial impact of significant loss of income on families who are also caring for older
persons can cause added stress.

•

Although older people may be unable to use online resources, posters and public awarenesscampaigns are being disseminated in many different forms of media.

•

Older persons living at home to have one primary carer in order to limit their exposure to
multiple people, and to essentially quarantine together.

18

This report recommended:•

Target advice to older persons to the country-context, whether more older persons live with
their families or live in residential aged care.

•

Utilise public health approaches tailored to the living conditions of older persons—for example,
looking to community health workers to deliver important information, education, and supplies
to older persons living in more rural areas, living with family members, or with less access tohealth information.

•

Consider adopting a tax deduction as compensation for the additional risk healthcare workers
have taken on during the COVID-19 pandemic.

•

Consider classes of persons—especially older persons—who may be left out of stimulus
payment programmes, such as informal workers and farmers, and develop programmes toprovide these groups with cash assistance as well.

•

Short-term and low-interest loans from the government to individuals and businesses can be analternative to direct cash payments where government budgets do not allow for large cash
payment programmes.

Delegates form the WHO and officials from Thailand’s Ministry of Public Health discussed the COVID19 response on 27 May 2022. After several days of consultation, it was concluded that Thailand has
many strengths that contributed to the success of the pandemic response (WHO, 2022). Somehighlights are:•A high level of political commitment was essential and was exemplified by the Prime Ministerleading the response.

•

A robust health system established for decades provided the best platform for an effective
response•

The covid-response involved many sectors and people from all walks of life. Adoption of the‘whole of society’ approach and good collaboration between all sectors were essential.

•

Strong community networks, in addition to the presence of more than 1 million village healthvolunteers ensured bottom-up support.

•

Innovative solutions to problems encountered were developed quickly, such as cardboard beds
in field hospitals. The ‘Bubble and Seal’ approach ensured Thai and migrant workers were kept
safe whilst allowing factories to stay in business.

Areas that could be improved include:•

Better aligning population databases generated by different government agencies to record
health and vaccination status.

•

Addressing barriers in access to health care that were sometimes faced by some vulnerable
populations, such as migrants.

•

Enhancing universal health coverage through primary healthcare in urban areas.

19•Strengthening measures to address pandemic fatigue and complacency.

•

Developing strategies to sustain and share innovations.

•Improving arrangements for medical waste management.

The following recommendations were jointly proposed:•

Continue to invest in innovation and digital technology.

•

Sustain the gains made during the pandemic response.

•

Make healthcare more inclusive, especially for vulnerable populations.

•

Strengthen domestic capacities for self-reliance to produce vaccines, reagents, diagnostics, anddrugs.

•

Further integrate databases.

•

Continue to collaborate across sectors, including the management of medical waste.

•

Share best practices and lessons learned from the pandemic response among different
stakeholders in Thailand and with other countries.

Lessons Learnt in Indonesia
The report by Sani et al. (2020) ‘The COVID-19 Long-Term Care Situation in Indonesia pointed out thefollowing vulnerabilities:•

There is limited data and information on people needing LTC who are affected by COVID-19.

•

Although the government of Indonesia has taken several measures to reduce the spread of thevirus, it was very difficult to coordinate each administration of various side of LTC among several
ministries.

•

There has been no specific guideline or protocol regarding COVID-19 prevention andmanagement or for LTC system users in general.

•

LTC in Indonesia for older people is partially dependent on volunteers’ home-care visits. Since
the end of March 2020, all regular health programmes conducted by local health volunteers(kader) have been stopped.

Sani et al. said that the COVID-19 pandemic has exposed the urgent need for improvements in thehealth and social care systems in Indonesia. As the impact of the pandemic spans over multiple
sectors, inter-programme and inter-sectoral coordination is required to effectively respond to theoutbreak. The WHO and Ministry of Public Health wrapped up lessons learnt as follows:•

Short-term calls for action-

Data from surveillance of COVID-19 cases in institutional care settings (both residents andstaff) is needed to better understand the impact of this outbreak on this population.
An inter-ministry streamlined approach is needed to ensure support for LTC users especiallyduring COVID-19.
Guidelines on self-quarantine and care for COVID-19 patients who live with disabilities areneeded.

20

-•Guidelines on care coordination especially regarding discharge from hospital to community
and institutions are needed.

Longer term policy implications-

There is an urgent need to develop an integrated universal health and long-term careservice based on the existing systems.

-

Surveillance of older people infected with COVID-19 and the availability of free rapid testing
on a large scale is essential to obtain data to support long-term policy decision-making onvulnerable population.

-

Monitoring and evaluation of existing long-term care policy is fundamental to ensure
effective implementation of the policy.

-

There is a strong cultural tendency to care for family members at home in Indonesia.

-

This calls for the strengthening of community and family-based long-term care throughcapacity building of caregivers and ensuring adequate government funding, including for
older people recently discharged from hospitals.

Komazawa et al. reported in 2021 that economic and social support for older people should bemaintained and continued even after the pandemic in Indonesia. It is crucial to minimise the negative
impact of falls in income and social restrictions on the welfare of older people – such as decreasedfood quality, more limited access to healthcare facilities, and greater social isolation (Komazawa,2021). As mandated in the Ministry of Health’s 2020 ‘Guidelines for Older People Health Services in
the COVID-19 Pandemic Era’, the main priority is the prevention of COVID-19 amongst older people
through effective and persistent efforts and collaboration with the government and the community,
including family. However, the mitigation of the impact of economic distress and social isolation is
also crucially important. The quick development of a comprehensive support system for older people
is strongly encouraged. Such efforts would surely contribute to the accomplishment of the goals
stated in the Concept of National Strategy on Ageing, which is to ensure independent, prosperous,and dignified lives of older people.
The report by Mahendradhata et al. (2021) on ‘The Capacity of the Indonesian Healthcare System to
Respond to COVID-19’. noted the following:•

Insufficient numbers of available medical staff.

•

The pandemic has exposed the fragility of medical supply chains. Surges in the number ofpatients requiring hospitalisation have led to depleted medical supplies.

•

The existing healthcare infrastructure is still inadequate to deal with the rise of COVID-19 cases.

•

The COVID-19 pandemic has further exposed the weakness of the patient referral system andthe limited capacity of the healthcare system to deliver essential health services under
prolonged emergencies.

21References
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26

Chapter 2
COVID-19 Impacts on Long-term Care for Older Persons

1.

Background

Three years have already passed since the novel coronavirus disease (COVID-19) pandemic started.
Different variants of COVID-19 and human responses during the period created different disease
impacts. In the first year, the alert was high, and many countries implemented states of emergency
and lockdowns. The number of cases and deaths rose, especially in Europe and America. Vaccines
became available in the second year in 2021, but the number of cases and deaths increased much
more than in the previous year. In the third year in 2022, due to the rapid spread of the Omicron
variant at the beginning of the year, the number of cases rose sharply, but the increase in deaths wasmodest. Throughout the period, from January 2020 to July 2022, several waves occurred, but the
total number of deaths gradually declined (Figure 2.1). It is hoped that the overall trend of the gradualdecline of deaths will continue in line with humans gaining herd immunity.

100

500

90

450

80

400

70

350

60

300

50

250

40

200

30

150

20

100

10

50

0

Monthly deaths in thousands

Monthly cases in millions

Figure 2.1. COVID-19 Monthly Cases and Deaths (World)0
Jan Mar May Jul

Sep Nov Jan Mar May Jul

2020

2021
Monthly cases

Sep Nov Jan Mar May Jul
2022

Monthly deaths

Year Month
Source: WHO Coronavirus (COVID-19) Dashboard (2022a).

Due to the high COVID-19 mortality amongst the elderly, COVID-19 prevention amongst older
persons, especially in a collective living setting is important. However, the living arrangements of older
persons differ from country to country, and the COVID-19 risk should be understood accordingly. This
chapter firstly examines the age-specific prevalence and mortality of COVID-19. Secondly, the place27

of death of COVID-19 will be analysed to verify whether there was a concentration of deaths in longterm care facilities in countries with data.

2.

Age-specific Prevalence and Mortality by COVID-19

Due to the global spread of COVID-19 and raised awareness, almost all countries are conducting
epidemiological surveillance on COVID-19. Thus, the total number of cases and deaths are relatively
easy to get. However, these data are not always gender and age-disaggregated. Amongst reported
cases and deaths of COVID-19 to the World Health Organization (WHO), 48.8% of cases and 38.6% ofdeaths are with age information (WHO, 2022a).
As for the COVID-19 cases, the typical structure is that they are concentrated amongst the younger
age groups, especially those in their 20s. Figure 2.2 shows the examples of Indonesia, Malaysia, andJapan. As for deaths, the concentration is found in older age groups. Amongst those older than 60,
the peak age varies; the 60s in Indonesia and Malaysia, but over 80 in Japan (Figure 2.3). It is due tothe difference in the exposed population; in Japan, older persons are older than in Indonesia or
Malaysia. The smaller number of deaths in the 70s and 80s age groups are due to the smaller
population of those ages. The death rates by age show an increasing trend for all three countries(Figure 2.4).
The level of COVID-19 mortality differs between the three countries. For all ages, the mortality was
57.7 per 100,000 population in Indonesia, 110.1 in Malaysia, and 25.9 in Japan. By age, the mortality
is similarly different; Japan is half of Indonesia, and Indonesia is half of Malaysia. The difference is dueto the severity of the infection or the effectiveness of countermeasures taken in each country.
However, the lower mortality in Indonesia compared with Malaysia could also be due to the deaths
not diagnosed as COVID-19. As the vital statistics based on the registration are absent in Indonesia,
the impact of COVID-19 is difficult to be assessed correctly.

28

Figure 2.2. Age and Gender of COVID-19 Cases

Notes: From 30 December 2019 to 25 July 2022 for Indonesia and Malaysia, to 1 August 2022 for Japan. The
above charts are drawn from data that are gender and age-disaggregated; the coverage amongst the totalreported cases is 79.8% for Indonesia, 95.9% for Malaysia, and 99.1% for Japan.
Sources: WHO COVID-19 Detailed Surveillance Data Dashboard (2022b) for Indonesia and Malaysia, Visualizing
the Data: Information on COVID-19 Infections (Ministry of Health, Labour and Welfare, 2022) for Japan.

Figure 2.3. Age and Gender of COVID-19 Deaths
Age

Indonesia

Age

Malaysia

Age

80+

80+

80+

70s

70s

70s

60s

60s

60s

50s

50s

50s

40s

40s

40s

30s

30s

30s

20s

20s

20s

10s

10s

10s

<10

<10

<10

2,000 1,000
Male01,000 2,000

personFemale

5,000

0
Male

5,000

personFemaleJapan

10,000 5,000
Male05,000 10,000

personFemaleNotes: From 30 December 2019 to 25 July 2022 for Indonesia and Malaysia, to 1 August 2022 for Japan. The
above charts are drawn from data that are gender and age-disaggregated; the coverage (proportion of theseage and sex disaggregated deaths amongst the total reported deaths) is 5.9% for Indonesia, 98.6% for Malaysia,
and 70.0% for Japan.
Sources: WHO COVID-19 Detailed Surveillance Data Dashboard (2022b) for Indonesia and Malaysia, Data on
COVID-19 (National Institute of Population and Social Security Research, 2022) for Japan.

29

Figure 2.4. Age and Gender-specific COVID-19 Mortality

Japan

Malaysia

900
800
700
600
500
400
300
200
100
0

300

1,800
1,600
1,400
1,200
1,000
800
600
400
200
0
<10 20s 40s 60s 80+
Male

Age

Female

250
200
150
100
50
0
<10 20s 40s 60s 80+
Male

Female

Age

<10
10s
20s
30s
40s
50s
60s
70s
80+

Deaths per 100,000 population

Indonesia

Male

FemaleAge

Notes: From 30 December 2019 to 25 July 2022 for Indonesia and Malaysia, to 1 August 2022 for Japan. The
coverage rates of 5.9% for Indonesia, 98.6% for Malaysia, and 70.0% for Japan are applied to the observedmortality (The death rates shown in the figures are calibrated to the level that the gender and age information
are provided for all deaths assuming that missing information are evenly distributed between age groups).
Sources: COVID-19 deaths by WHO COVID-19 Detailed Surveillance Data Dashboard (2022b) for Indonesia andMalaysia, data on COVID-19 (National Institute of Population and Social Security Research, 2022) for Japan.
Population by Age Group, Sex and Ethnic Group, Malaysia (DOSM, 2022) for Malaysia, World Population
Prospect 2022 (UN, 2022) for Indonesia, and Population Census 2020 (Statistics Bureau) for Japan.

3.

COVID-19 Mortality in Long-term Care Facilities

The higher mortality amongst older persons raised the concern of infections in the collective living
setting in long-term care facilities (LTCFs). The media argued that one-third of COVID-19 deaths in the
United States (US) were linked to nursing homes (New York Times, 2021), and 14% of COVID-19
deaths in Japan were happening in LTCFs (47 News, 2020).
The vital statistics based on the registration numbers usually included the information on the placeof death by cause. As of March 2022, such information was available in France, Japan, US, andEngland and Wales (Figure 2.5). According to the data, COVID-19 deaths were not concentrated in
LTCFs in Japan, US, and England or Wales. In Japan, 12% of total deaths occurred in LTCFs, whereas
only 3% of COVID-19 deaths occurred there. The same contrast was found as 22% vs. 19% in the US
and 26% vs. 24% in England and Wales. In France, 21% of total deaths occurred in LTCFs, whereas it
was a bit higher, 25%, for COVID-19 deaths. However, the difference is not large. In all four countries,
there is a common tendency for COVID-19 deaths to occur more in hospitals and less at homecompared to deaths caused by other causes. COVID-19 is the designated infectious disease, andpublic health measures intervene, not the private health sector. The public hospitals were in chargeof the patient, and thus more deaths occurred in the public hospitals. The wide media coverage ofthe abundance of COVID-19 deaths at LTCFs was not confirmed by vital statistics.

30

Figure 2.5. Comparison of Place of Death between Total Deaths and COVID-19 Deaths

France

Japan

100%

100%

Other

90%

90%

80%

80%

70%

43%

Public healthfacility

57%

60%
50%
40%
30%

21%

20%
10%

Private healthfacility

12%

22%

12%

5%

0%
Total deaths

COVID-19
deathsn=877,147 129,608

70%
60%

20%

12%

Home

10%

16%

from March
2020 to June
2021

0%

COVID-19
deathsn=1,372,755
3,466

England and Wales

10%

38%

Other
71%

Total deaths
n=6,295,107

70%

60%

Hospital
Facility

40%

Home

30%
20%

19%
8%

0%

70%

Other
43%

Hospital
Facility

50%

22%

33%

90%
80%

30%
20%

2020

Total deaths

Unknown

60%
40%

3%

100%

90%

50%

Hospital/
ClinicLTC
Facility

30%

100%

70%

96%

50%

United States
80%

70%

40%

Long-termcare facility

25%

Other

COVID-19
deaths2020 and
2021 until
25 Nov.

773,825

10%

Home

26%

28%

24%
6%

0%
Total deaths

COVID-19
deathsn=1,119,379

153,687

From 28 Dec.
2019 to 5
Nov. 2021

LTC = long-term care.
Sources: Vital statistics by CépiDc (2022) for France (2022), Ministry of Health, Labour and Welfare (2022) forJapan, NCHS/CDC (2022) for the United States, and ONS (2022) for England and Wales.

31

4.

Policy Implications

COVID-19 is ongoing and the number of cases is increasing. With the continuous arrivals of newvariants that are more contagious and less lethal than the previous ones, it seems that the virus took
the course to slow down. It is hoped that the severity of the disease will eventually be lowered toordinary influenza or seasonal flu. At the beginning of the pandemic, there were no vaccines andpeople followed the coercive activity limitations. As time passed, vaccines were available and thenumber of people who contracted COVID-19 increased. People are tired and the negative economic
impact due to the activity limitation started to be intolerable. Towards the end of COVID-19, thehealth and long-term care system has to remember the experiences gained through the fight against
COVID-19 and keep in mind how to balance infection control with the economic and social activity ofsociety. COVID-19 infection occurs mostly in active young people but the risk of dying from thedisease is higher amongst older persons. This fact has not changed from the beginning of thepandemic until now. It became compulsory that the health and LTC for older persons are equippedwith a proper infection control system, which is discussed in this research project.
During the time of the pandemic, the COVID-19 case and death data are collected daily in many
countries, but this system will be integrated into the regular weekly updates with other infectious
diseases when the threat is lower. The upgraded surveillance capacities were a side-product of the
COVID-19 pandemic, but at the same time, it was revealed that the existing death registration system
was not sufficient. Those countries without a death registration system suffer from random ‘findings’
by ad-hoc media coverage, making it hard to elaborate a policy needed to avoid COVID-19 deaths
effectively. In the Association of Southeast Asian Nations (ASEAN), some countries, such as thePhilippines and Malaysia, are making progress in producing vital statistics, including data on the causeof death information (Hayashi and Komazawa, 2022). The efforts should be continued and spread tomore countries.

32

References
47 News (2020), ’Kaigo shisetsu de shibou zentai no 14% Shingata Korona, Kyototsushin jichitai chosa’[14% of COVID-19 Deaths in Long-term Care Facility, Municipality Survey by Kyodo Tsushin],
13th May. https://www.47news.jp/4808143.html (in Japanese)
Centre d'épidémiologie sur les causes médicales de décès (CépiDc) (2022), ‘Données sur la Covid-19
du centre d'épidémiologie sur les causes médicales de décès de l'Inserm’ [Data on COVID19 from the Epidemiology Centre on the Medical Causes of Death from Inserm].
https://opendata.idf.inserm.fr/cepidc/covid-19/ (in French)
Department of Statistics Malaysia (DOSM) (2022), ‘Population by Age Group, Sex and Ethnic Group,
Malaysia’.

https://www.data.gov.my/data/en_US/dataset/population-by-age-group-sex-

and-ethnic-group-malaysia
Hayashi, R. and O. Komazawa (2022), ‘Cause of Death Statistics in ASEAN+3 Countries’, in Health andLong-term Care Information in Ageing Asia. ERIA Research Project Report FY2022 No. 07,
Jakarta:ERIA,

pp.1–33.

https://www.eria.org/uploads/media/Research-Project-

Report/RPR-2022-07/06_Part-A-Cause-of-Death-Statistics-in-ASEAN%2B3-Countries.pdf
Ministry of Health, Labour and Welfare, Japan (MHLW) (2022), ‘Vital Statistics’. https://www.estat.go.jp/en/stat-search?page=1&toukei=00450011
Ministry of Health, Labour and Welfare, Japan (MHLW) (2022), ‘Visualizing the Data: Information on
COVID-19 Infections’. https://covid19.mhlw.go.jp/en/
National Institute of Population and Social Security Research (2022), Data on COVID-19.
https://www.ipss.go.jp/projects/j/choju/covid19/index-en.asp
National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention, US (2022),‘Provisional

COVID-19

Deaths

by

Place

of

Death

and

State’.

https://data.cdc.gov/NCHS/Provisional-COVID-19-Deaths-by-Place-of-Death-and-/uggshy5q
New York Times (2021), ‘Nearly One-Third of U.S. Coronavirus Deaths Are Linked to Nursing Homes’,
1 June. https://www.nytimes.com/interactive/2020/us/coronavirus-nursing-homes.html
Office for National Statistics (ONS), UK (2022), ‘Weekly Provisional Figures on Deaths Registered inEnglandandWales’.

https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/de
aths/datasets/weeklyprovisionalfiguresondeathsregisteredinenglandandwales
Statistics Bureau of Japan (2020), Population Census. https://www.stat.go.jp/english/data/kokusei/
United Nations, Department of Economic and Social Affairs, Population Division (2022), World
Population Prospects: The 2022 Online Edition. https://population.un.org/wpp/

33

World Health Organization (WHO) (2022a), WHO Coronavirus (COVID-19) Dashboard.
https://covid19.who.int/(WHO)(2022b),WHO

COVID-19

Detailed

Surveillance

Data

Dashboard.

https://app.powerbi.com/view?r=eyJrIjoiYWRiZWVkNWUtNmM0Ni00MDAwLTljYWMtN2
EwNTM3YjQzYmRmIiwidCI6ImY2MTBjMGI3LWJkMjQtNGIzOS04MTBiLTNkYzI4MGFmYjU5
MCIsImMiOjh9*All internet web addresses (URL) were accessed on 7 August 2022.

34

Chapter 3
Business Continuity Management to Ensure Resilience in the Longterm Care Business1.

Background of Business Continuity Plans and Business Continuity Management forLong-term Care Facilities

Institutional care is an essential service for elderly care. Institutional care is designed to protect the
lives of vulnerable older people. Nevertheless, many older people fell victim to the novel coronavirus
disease (COVID-19) under institutional care. Furthermore, the COVID-19 pandemic has shaken thesustainability of facility management itself. Therefore, the resilience of institutional care in an
emergency was once again questioned.
In response to the COVID-19 pandemic, the Japanese government mandated long-term care facilities
to develop business continuity plans (BCPs) in 2021 to ensure resilient elderly care services even intimes of emergency. Japan’s Ministry of Health, Labour and Welfare (MHLW) required that BCPs oflong-term care facilities (LTCFs) should be accomplished until March 2024 (MHLW, 2020a, 2020b,
2021, 2022). The BCPs formulated the rate for infectious diseases in LTCFs for the elderly was 33.5%
in 2021. If formulating plans in the future are included, the figure was 89.2% in Japan (NTT Data
Institute of Management Consulting, 2022).
A BCP will allow critically important business or work to continue even in the event of unforeseen
circumstances, such as big earthquakes or other natural disasters, the spread of infectious diseases,
terrorist incidents, major accidents, disruption in the supply chain, or other sudden changes in thebusiness environment, and/or policies, systems, or procedures that enable a return to normal
conditions as quickly as possible even if any discontinuation occurs.
However, what is more important is to be able to properly put the formulated plan into practice in an
emergency. To that end, it is important, through the implementation of business continuity
management (BCM), to continuously improve the BCP so that it is effective in practice.
BCM is the management of activities conducted in normal times, including the establishment,
maintenance, and renewal of BCPs, the securing of budgets and resources for achieving business
continuity, the implementation of preparatory measures, the implementation of education andtraining for expediting good practice, the promotion of inspections, and continual improvement.
In order to protect and maintain the lives of their residents, LTCFs have a duty to continue to provide
services even in emergencies such as natural disasters and infectious disease pandemics. Even if theservice is interrupted, it must be restored as soon as possible, and the interruption period kept to aminimum.

35

The World Health Organization’s (WHO) report in 2020 ‘Responding to Community Spread of COVID19’ commented about the maintenance of essential services. Community transmission of COVID-19
may lead to an interruption of essential services in the communities affected unless tested business
continuity plans are in place. The WHO recommended the following actions: adapt and implement
national cross-sectoral emergency preparedness business continuity plans, where existing, to COVID19; and work with United Nations’ agencies and other partners to identify and support thecontinuation of critical functions (i.e. water and sanitation, fuel and energy, food,telecommunications/internet, finance, law and order, education, and transportation), necessary
resources, and essential workforce.

Figure 3.1. Structure of Crisis Response Capability and Resilience in an Emergency(concept diagram)

Source: Authors.

Japanese LTCFs require BCM to enable BCPs to be formulated. In order for the LTCFs to demonstrate
BCM in emergency, it is necessary to determine whether they have sufficient organisational
management skills from normal times.
As shown in Figure 3.1, the formulation of a BCP is one of the processes of business continuity
management (the cyclical process from policy formulation, business impact analysis, selection ofimportant operations to advance measures, education and training, and correction andimprovement) from normal times. Furthermore, it will depend on the management capabilities ofthe organisation itself. The combination of ‘BCM from normal times’ and ‘organisational management
capabilities’ enables LTCFs’ resilience in emergencies.

36However, Japan’s LTCFs have been said to have weak ‘organisational management capabilities’ fromthe beginning. As many social welfare corporations, which are the main players in Japan's LTCFs, havenot been able to transition or convert from ‘institutional management’ under the government
safeguard system to ‘corporation management’ based on a contract system, their management
functions are weak.
It is believed that this is due to the fact that, under the safeguard system, they were placed in agovernment-led business environment with no need for autonomous management. For example,
there are rules that guarantee income based on the number of users at the beginning of the term, orthat if the profit at the end of the term exceeds a certain amount, it must be returned to thegovernment, but the system is such that there is no need for any effort to improve management
efficiency or productivity. In addition, as one factor of the fragile management base, because social
welfare corporations tend to be family-run, problems have been highlighted, such as ‘the board of
directors becoming a mere formality, poor audit functions, the careless diversion of corporate assets,
the monopolisation of major posts by family members, the lack of human resources development,
in-fighting among relatives, lack of ability of successors, etc.’ (Tokyo Metropolitan Social Welfare
Corporation, 2011).
As management challenges faced by LTCFs, a range of organisational and human resource
management issues have been indicated, such as ‘quick staff turnover due to immaturity inorganisational management, personnel management, human resource development, etc.’, ‘a lack oforganizational structuring and no clarification of job roles and responsibilities within the organisation’,and ‘failure to systemise career paths and link expertise with conditions and remuneration’. In
addition, in a research project commissioned by the Ministry of Education, Culture, Sports, Scienceand Technology on the theme of human resource development in the LTC business, in which theauthors participated, the following were extracted as management issues for LTCFs: conservative
organisational climate in the field (resistance to change), principles and values of LTC business
management not permeated, functions and roles of LTCWs not differentiated, failure to foster anorganisational climate that nurtures people, etc. It is believed that these are also factors that have led
to the vulnerability of LTC business management.
In line with Figure 3.2, it has been pointed out that the governance of the core management
philosophy is weak, the management of human resources is particularly weak, and the managementof operations is not well developed. On the one hand, Japan's LTCFs were able to operate stably interms of finance, services, and marketing under the tradition of Japan's elderly welfare administrationand the establishment of a long-term care insurance system. On the other hand, the COVID-19
pandemic forced LTCFs to respond to new challenges in facilities and information and communication
technology with a different dimension of risk response. In other words, LTCFs exposed to the COVID19 crisis are the domains coloured in Figure 3.2 (philosophy, human resources, operations, facilities,
ICT, risks) and management issues are highlighted.

37

Figure 3.2. Management Map for the Long-term Care Business

BCP = business continuity plan, BCM = business continuity management, ICT = information communicationand technology.
Source: Keishin Gakuen Vocational Education Research and Development Center (2021).

In this study we listened, learned, and made recommendations by the managers of LTCFs in Japan,
who developed advanced BCPs, and how they behaved amidst the COVID-19 pandemic.

2.

Interview Research on LTCF Managers

2.1.

Research Outline

For investigating business continuity management and the actual application of business continuity
plans for COVID-19 infection in LTCFs for the elderly, and for clarifying effective efforts andimprovement challenges, we conducted semi-structured interview surveys face-to-face and online
during October 2021 to March 2022.
An interviewer was able to contact four corporations operating LTCFs for the elderly in Japan (in Tokyo,
Saitama, Niigata, and Fukuoka) that matched the purpose of the survey. The subjects of theinterviews were the persons responsible for COVID-19 infection control at each facility. Ethics
applications were submitted to Keishin Academy and approval received (approval number: Keishoku
21-02). A request for research cooperation was presented in advance, and consent was obtained forthe interview content, method, etc. before conducting the research.
Questions were asked about the following:1) COVID-19 infection status
2) Effective measures to prevent infection3) Improvement challenges for infection prevention384) BCP formulation status
5) Efficacy and effects of BCP
6) Advance preparation for BCP operation in an emergency7) BCP/BCM improvement challenges

2.2.

Research Results

Facility A: Niigata Prefecture. Social Welfare Corporation
Table 3.1. Agile Response by Leader in Active Role
Item

Confirmed Details

1) Basic information,such as businessoverview andinterviewee details,
etc.

Type of business: Special care homes for the elderly, short stay, andresidential long-term care support business

2) COVID-19 infection
statusNo infections at time of interview

Interviewee: Facility manager (Principal)
Interview date: 22 October 2021

3) Effective measures to ・ Raise awareness and take infection control measures by promptly
prevent infection
disclosing and sharing information according to changes in theinfection situation (cluster outbreaks, instructions from theauthorities, best practices of other companies to prevent
infection, etc.).
・ Arouse awareness of infection prevention amongst staff. It is
important to be conscious of ‘not being too scared and being
appropriately concerned’.
・ Thorough implementation of standard precautions. Since nurses
have knowledge and skills of infection prevention measures thatcaregivers do not have, infection prevention guidance by nurses iseffective.
・ No interaction with infection response teams. If support staff fromother departments return to their original departments, there is arisk that infection may spread. Red zone staff and green zone staff
shall be separated without interaction.
・ Use of ICT (online meetings, remote guidance, etc.). ICT literacy
enables a quick and efficient response in administrative processing
in emergencies.

39

Item

Confirmed Details

4) Improvement
challenges for
infection prevention

・ Each site leader cascaded down the response policies and measures
decided by the organisation to their subordinates, but there wereinconsistencies in the levels of subordinates' understanding.
・ In the event of an emergency, the presence of site leaders who cantake command is important, but they are also afraid of infection.
They too need care.

5) BCP formulation
statusMay 2021

6) Efficacy and effects of The actual response process was determined based on the BCP
BCP
framework. The BCP was effective as a basis for deciding emergency
responses.
7) Advance preparation ・ It is necessary to routinely train site leaders to make judgements. In
for BCP operation inan emergency, judgement is required for atypical/irregular cases. In
an emergency
addition, the strength to stick to a decision is necessary.
・ BCP training was conducted using actual outbreak cases.
8) BCP/BCM
improvement
challenges

・ The wording of the BCP template prepared by the government isdifficult and needs to be simplified.

■Key insights

Necessity of autonomous decision-making and action by groupleaders in an emergency

Findings recognised byinterviewers asimportant for
demonstrating crisis
response capabilities
and resilience

In response to emergencies, in addition to the judgement and actionof the chief executive, there are also situations where prompt
judgement and action by site leaders is required. In the event of an
emergency, the situation was changing and problems arise one after
another, so it is difficult for the chief executive to make all decisions
quickly. Group leaders often had to make decisions autonomously intheir respective posts. For this reason, it is necessary to make efforts
to foster and strengthen the leadership, judgement, and autonomy ofgroup leaders in normal times.

BCP = business continuity plan, BCM = business continuity management, ICT = information communication andtechnology.
Source: Compiled by authors.

40Facility B: Saitama Prefecture. Private Sector Company
Table 3.2. ICT Utilisation for Process Management
Item1) Basic information,such as businessoverview andinterviewee details, etc.

Confirmed Details
Type of business: Private senior long-term care home
Interviewee: Deputy Principal
Interview date: 12 November 2021

2) COVID-19 infection No infections at time of interview
status3) Effective measures to ・The experience of having conducted field surveys when clusters
prevent infection
occurred at other facilities within the corporate group was effective.
Simulation of the outbreak of infection, such as dividing the redzones and green zones, successfully gave some hints on how to
respond.
・In response to the personnel shortage, managers were sent onsite,
support was provided from other departments, and staff worked
overtime.
・Long-term care schedule management software was introduced,
and we use the system to manage care plans for users, staff workduties, shift schedules, etc. and we are trying to provide visibility to
our care work. Staff use their smartphones to keep track of theirown work schedules and administer care to the users based on thatschedule. It is linked with the long-term care work record system andthe details of the care are also input, so the administrator can check
whether care is being provided according to the care plan, whether
the service is appropriate, and whether there are any problems at
the site, etc., and can understand and manage the work status of all
staff.
・Based on this, it has also been confirmed that there are many tasks
being done other than those that strictly should be performed,
resulting in a situation of excessive workload. For example, excessive
care was confirmed, such as providing Level 3 care to users with
Level 1 care needs. We plan to identify and address these issues.
・During the coronavirus crisis, being able to trace what kind of carework was provided in which room and at what time was effective in
identifying routes and blocking the spread of the virus in the case of
infection.

41

Item

Confirmed Details

4) Improvement
challenges for
infection prevention

・Nothing confirmed

5) BCP formulation
status・Formulated by corporate headquarters and started operation in April
2020.

6) Efficacy and effects of
BCP

・BCP allowed us to build a framework for emergency response. In
accordance with the BCP, new measures will be added as needed as
notices from headquarters.
・Any time a person develops a fever, the response procedures arerevised and improved repeatedly, in accordance with commentsfrom staff at the site, thereby increasing their effectiveness.

7) Advance preparation ・We regularly conduct infection control training at monthly staff
for BCP operation inmeetings, regardless of whether there is an emergency or not (e.g.
an emergency
thorough hand washing, how to remove gloves, masks, aprons, how
to transport items to be discarded, etc.)
・Simulation of infection is performed to improve processes.
8) BCP/BCM
improvement challenges■Key insights
Findings recognised byinterviewers asimportant for
demonstrating crisis
response capabilities
and resilience・ The amount of work that is different from normal times has
increased, exceeding the allowable capacity.
In response to this, we are studying the priority of tasks and reviewing
what work is essential in an emergency.
Utilisation of ICT for long-term care staff work management andschedule management
By introducing a system in normal times that links the management oflong-term care work and schedules with the input of long-term carework records, we can stay up to date on the work duties and action
history of the long-term care staff as data. With this system, it ispossible to visualise when, where, and what kind of work the longterm care staff performed, and to understand their actions, thus
contributing to the prevention of the coronavirus infection within thefacility. The system also makes it possible to optimize operations andimprove operational efficiency during normal times.

BCP = business continuity plan, BCM = business continuity management, ICT = information communication andtechnology.
Source: Compiled by authors.

42Facility C: Fukuoka Prefecture. Social Welfare Corporation
Table 3.3. Multitasking of Professional Jobs
Item

Confirmed Details

1) Basic information,such as businessoverview andinterviewee details,
etc.

Type of business: Special care home for the elderlyInterviewee: General Manager

2) COVID-19 infection
status

A total of three facility staff and users tested positive in July 2021.

3) Effective measures toprevent infection

・Increased opportunities for information sharing amongst employees(normally once per day increased to 3 times per day)Interview date: 23 December 2021

・The use of the intercommunication system (intercom) was effective
in sharing information. Used more than usual.
・Since June 2020, the Corona Countermeasures Committee has held
online meetings twice a month. At these meetings, we decide on
what action to take.
・ In the pre-revision BCP, it was stated that a countermeasures
headquarters consisting of managers would be established.
However, as a practical response, it was judged that the committee
should include staff members also, and the Countermeasures
Committee was set up.
・Assuming that there will be foreign care workers, we have prepareda guide for staff that illustrates the precautions to be taken toprevent infection. We tried to raise awareness by handing these out
when we handed out the monthly salary slips.
・We conduct online meetings with users and their families.
・Fukuoka Prefectural Council of Elderly Welfare Facilities has a systemof ‘goods accommodation’ through intra-regional cooperation. First,
goods are procured via your own facility ⇒ if they are difficult to
procure at your own facility, procure within the regional block ⇒ if
difficult even in the regional block, procure from all blocks.
・Online conference system was introduced in May 2020 after the
spread of COVID-19.
・Mental care for employees is important (for concerned employees,
the supervising facility director provides individual consultations as
and when necessary)

43

Item

Confirmed Details

4) Improvement
challenges for
infection prevention

・Nothing confirmed

5) BCP formulation
statusFormulated before the coronavirus pandemic. Revised September–
October 2020.

6) Efficacy and effects of
BCP

・It proved realistic and effective to decide on rough guidelines without
making too many detailed decisions in the BCP, and then leave therest to an on-the-spot judgement according to circumstances.
・Information communication routes and the division of roles for highpriority tasks have been clarified.
・Effectiveness was improved by reflecting the details of the actual
coordination with the competent administrative authorities andpublic health centres (e.g. the implementation of PCR tests) in the
BCP, and by revising and making it more detailed.

7) Advance preparation ・The organisational management policy implemented during normal
for BCP operation in antimes was ‘total cooperation’. This eliminates sectionalism andemergency
builds a collaborative system that transcends occupations.

8) BCP/BCM
improvement

・Promote multitasking in the process of reducing personnel numbers
within the organisation.
- Rather than support and help, care is positioned as a job incharge even in non-care jobs. Therefore, nurses are included incare.
- Long-term care, nursing, and rehabilitation are all connected,
and when other occupations are involved in long-term carework, they will be able to have a better understanding of whatcare work is.
- Since multitasking is explained to applicants at the time ofrecruitment selection, they accept it before joining thecompany.
- Promoting the creation of relationships within the organizationthat ‘acknowledge each other’, ‘accept each other’, and‘respect each other’. Good relationships remain effective intimes of emergencies.
- Conduct training to spread the annual policy amongst all
employees and review that training for all employees,
including part-timers. Eight to nine people per group. 2 hours
per session. These will lead to strengthening organisational
management and affect resilience in the event of an
emergency.
・There is an issue about support from other nearby facilities when
there is a staff shortage due to an infection amongst staff or a staff

44

Item
challenges

Confirmed Details
members has been in close contact with an infected person. This isbecause there is a risk of infection for supporters, and there is asimilar shortage of personnel in all facilities in the area.
・There is a challenge in how to handle users with dementia while
dealing with infection. There are no accommodation type medical
institutions that can provide special care for dementia.
・It is necessary to develop site leaders and supervisors. In the eventof an emergency, site leaders are required to make decisions
autonomously. (Currently conducting leader training to reacknowledge roles, identify workplace issues, and think about
solutions.)*Other・Utilisation of YouTube is effective for activities targeting users. Very
good user reaction.
・Communication within the organisation became very active throughthe response to the COVID-19 pandemic. Normally, we assume thatmatters are understood, and we often perform our duties without
sharing problems. Since this is not possible in the coronavirus
situation, communication will naturally become pro-active.
・In managing subordinates, ‘listening’ is especially important.
・ Nursing emphasises ‘logic’, and long-term care emphasises‘emotion’. According to one general manager of a facility, who was
originally a nurse, if nursing placed more value on emotion andlong-term care more value on logic, a better relationship could bebuilt between the two. I think that it is an important viewpoint in
the human resource management of the long-term care welfare
business.

■Key insights
Findings recognised byinterviewers asimportant for
demonstrating crisis
response capabilities
and resilience

Cross-disciplinary collaborative system and multitasking introduced
during normal times
In the situation of a pandemic infection, there will be a shortage of
personnel due to the increase in care workers being designated as
infected or as having been in close contact with infection, as well as theincrease in irregular duties, but in response, a system has been
established to assign other staff (from nursing, clerical work, etc.).
Moreover, it is important to note that this is not positioned as helping
with long-term care work, but that multitasking is part of their original
duties.
In many long-term care welfare facilities, roles are clearly divided
according to occupation and section, but it is a big advantage in termsof organisational management that the spread and acceptance of

45

Item

Confirmed Details
multitasking facilitates the smooth re-allocation of personnel, one ofbiggest challenges in an emergency situation.

BCP = business continuity plan, BCM = business continuity management, ICT = information communication andtechnology.
Source: Compiled by authors.

Facility D: Tokyo. Social Welfare Corporation
Table 3.4. Readiness and Prompt and Quick Response
Item

Confirmed Details

1) Basic information,such as businessoverview andinterviewee details,
etc.

Type of business: Special care home for the elderlyInterviewee: Chief Operating Officer and General Manager
Interview date: 31 March 2022

2) COVID-19 infection
statusInfection amongst users occurred for the first time after the Omicronstrain appeared in 2022. Until then, we had taken measures to ensure
zero corona infections, but after this, we set a maximum number ofpeople we could handle and switched to measures that did not exceedthat limit.

3) Effective measures toprevent infection

・With regard to corona, from the time the unidentified virus was
discovered in Wuhan, a surveillance system was implemented.
・On 7 January 2020, the Risk Management Office was established. In
response to the confirmation of the first infections in Japan on 27
January, we started restricting visits by family members, nonessential contractors, and related parties. No outsiders wereallowed in, and the staff inside the facility had as little contact withthe outside as possible.
・In February, after receiving reports that a taxi driver had been
infected with the coronavirus in a neighbouring area, staff wereprohibited from using taxis from 14 February, and they were allowed
to commute by private cars, which is not normally permitted. Backoffice staff transitioned to telework.
・Crisis management experts were placed within the organisation. In
addition, we had an expert on infectious diseases as an advisor andacted as we received their advice.
・The response manual was updated as needed, based on information
related to the coronavirus.

46

Item

Confirmed Details
・ For infection prevention measures, we generally follow the
instructions and guidance of the public health centre, but since it
may take time for the authorities to send information and makecontact, we set our own stricter conditions and made our own
judgements.(e.g. criteria for certifying close contacts, etc.)
・After the outbreak of the Omicron strain, devices were deployed tonegatively pressure users' rooms. By creating a negative pressure in
the room, bacteria were prevented from exiting.
・Not only dividing the area, zoning is also implemented, and when
personnel move from the red zone to the yellow zone, adecontamination constructed from plastic sheets is set up, where
personal protective equipment, gloves, etc. are removed before
going out into the green zone.

4) Improvement
challenges for infection
prevention

・Medical facilities have a hardware structure that allows them to beisolated in order to deal with infectious viruses and bacteria. The
problem with long-term care facilities is that that their main purpose
is to provide daily life support, and they are structured so that users
may freely access them and may use shared areas. Therefore, if an
infection occurs in a long-term care home, the infected person mustbe transferred to a medical institution immediately. Otherwise, theinfection will spread rapidly within the facility.
・In a situation where mutations occur continuously, it is difficult toincorporate the response for each mutation in the manual in atimely manner, and it takes time to update the information andspread it amongst the staff.

5) BCP formulation
statusFormulated around 2009.

6) Efficacy and effects of ・The necessary items and their quantities are specified in the BCP.
BCP
Against the backdrop of the gradual shortage of masks anddisinfectants, as of February 2020, we made estimates for items thatwere likely to be in short supply and items whose prices were
expected to rise and procured hygiene items such as masks,
antiseptic solutions, and gowns and food that can be stockpiled forabout 3 months.
7) Advance preparation ・ Even before the coronavirus crisis, we established a crisis
for BCP operation in an
management countermeasures office and have been conducting
emergency
risk management in normal times. Risk monitoring is carried out
from a global perspective.
・ Ever since the outbreak of the H1N1 strain of influenza, small

47

Item

Confirmed Details
amounts of chlorine dioxide have been sprayed inside the facility
regularly to create a sterilised environment.
・Efforts are being made to develop management personnel evenduring normal times. In addition to in-house training, employees are
required to attend training related to critical thinking andmanagement at external educational institutions.
・Although there is no serious shortage of personnel, if there is a
shortage of personnel in the future, administrative staff will bedispatched to the facility. So that they are able to do not only
administrative work but also care work, we try to perform
multitasking during normal times, and our employees understandand accept this.
・It is generally said that the ratio of effort required to formulate a BCP
is 8:1:1, but in order to make it an effective BCP in practice, we feelthe ratio should be revised to 20% documentation, 40% training andimprovement, and 40% review.
・There are two types of training methods: desktop training andpractical training. The former is to actually, physically move, confirm
the need for any necessary equipment, etc., and make
improvements. The latter is to discuss at the desk whether thecountermeasures work. These are carried out by site leaders andabove.
・In addition, when categorising by training content, there is event
training and scenario training.
・We manage training participation on an individual basis, and record
who received which training and when, and enable regularparticipation. Training should also be evaluated.

8) BCP/BCM
improvement
challenges

The Tokyo metropolitan government is trying to promote cooperation
amongst local facilities in the case of emergency, but it is not realistic.
It is not easy to go to the different facilities of other corporations andprovide care for different users. There is also the risk of bringing in
infections from other facilities. Another issue is the content of thepartnership agreement that needs to be concluded in advance.

■Key insights

Speedy initial response and fully functioning crisis management
system during normal times

Findings recognised byinterviewers asimportant for
demonstrating crisis
response capabilities

・The initial response, presumed to be the fastest in Japan, even before
the corona pandemic was recognised, and the crisis management
system routinely implemented to make it possible are unparalleled.
Robust business continuity management systems are being built.

48

Item

Confirmed Details
・Risk management experts are being appointed, the cooperation of
infectious disease experts enlisted, and BCM initiatives, formulationof BCP, training of staff, etc. are being carried out.

and resilience・In terms of infection prevention measures, we established our own
standards, which were stricter than the government's andimplement these thoroughly.
・We reckon that all efforts to ensure our crisis response capabilities
and resilience to the coronavirus crisis are at the highest level both
domestically and internationally.
BCP = business continuity plan, BCM = business continuity management, ICT = information communication andtechnology.
Source: Compiled by authors.

3.

Lesson Learnt from the Research

Based on the interview results, vulnerabilities of risk management, human resource management,
facility and equipment management, ICT management, operation management, and governancewere summarised. Table 3.5 shows the results.

Table 3.5. Vulnerability in Long-term Care Facilities
Target Area

Main Vulnerabilities

Risk management

Human resources

・ The organisation has not been properly structured (structures forallocating roles and responsibilities have not been developed).

(personnel andorganisation)
management

BCP has not been formulated
Insufficient BCM effort
Although risks related to natural disasters, infectious diseases,
information security, etc. are increasing, the risk awareness of
employees is low.

・ Chronic shortage of personnel. As a result, many employees workovertime, and the workload is heavy.
・ Insufficient management and leadership education for managers andfront-line leaders・ Personnel evaluation and treatment based on it are not functioning
properly

Facility andequipment
management

・ The facility structure is not based on the premise of isolation, as inmedical care (all users can access the common areas)
・ The facility structure is not user-oriented
・ Preparatory inventory of necessary goods is not secured

49

ICT management

・ Little progress in the application of ICT in clerical work (employees' ICT
literacy is low, and clerical work such as work recording, informationtransmission and sharing is inefficient.)
・ Little progress in the use of robots in care work.

Operation
management

・ There is no task assignment or division of roles based on expertise・ Poor collaboration with other departments

Governance・ Weak management skills of top management and administrators
・ Management philosophy and management policy are not fully spreadamongst employees(philosophy,
structure, andsystem)・ There is a discrepancy between the notion and the actual practice ofcare
・ Front line opinions are not reflected due to the top-down approach

BCP = business continuity plan, BCM = business continuity management, ICT = information and communication
technology.
Source: Compiled by authors.

Similarly, resilience based on each domain is summarised in Table 3.6.

Table 3.6. Resilience in the Long-term Care Facilities
Target Area

Main Resilience

Risk management

・ Mutual support between nearby facilities as a countermeasure for staff
shortages
・ However, in an emergency, all facilities will be understaffed, and it will
not be easy to dispatch staff to other facilities. In advance, it is necessary
to discuss the rules for dispatching support staff at local facilities, anddetermine the work duties, roles, duration, remuneration, andcompensation for damages in the event of infection.
・ To be thorough about business continuity management (BCM)・ Formulation of a business continuity plan (BCP) is one of the processesof BCM. How realistic and effective a response system can be built for
BCP execution in an emergency depends on the thoroughness of BCM
in normal times.
・ Importance of initial response
countermeasures.

and timely

modification of・ In emergency management, the most important thing is a quick initial
response. If the initial response is delayed, the damage will spread. Since
the situation changes from moment to moment, it is also necessary tomodify the response in a timely manner. Review while practicing
emergency responses and make corrections as needed.

50

Target Area

Main Resilience

Human resources

・ Create a collaborative system during normal times to deal with anincrease in the amount of work in emergencies and staff shortages. ex,a system supported by occupations other than long-term care staff suchas administrators, nurses, and administrative staff, introduction ofmultitasking during normal times, etc.

(personnel andorganisation)
management

・ Strengthen the management system during normal times and develop
front line leaders
・ If management is strong during normal times, they will be able to takeappropriate measures even in times of emergency. Particularly, it isimportant to train front line leaders to assist the director of the facility.
・ In an emergency, it can be assumed that the front line leader will needto make decisions quickly for the unit they are in charge of, and thatdecisions will need to be made on behalf of the facility director if they
are unable to work due to infection or some other reason.
Facility andequipment
management

・ Pre-emptively procure goods to prevent shortages of necessary goods.
・ In BCP, set sufficient spare inventory.
・ Recognise the effectiveness of ventilation in preventing infection andimplement thorough ventilation measures.
・ Implement negative pressure countermeasures, sterilisation and sterile
environment creation, etc., as seen in survey cases.

ICT
management

・ Promotion of smart care: ex, use of robots for monitoring,
communication support, transfer and movement support, toilet
support, etc., and ICT utilisation for contactless care.
・ Digitisation of long-term care work management: for example,
introduction of a system that digitises work schedules, management ofservices provided, and work records, as seen in the survey cases. This
makes it possible to visualise the work and fully understand the status ofcontact with the user.
・ Video conferencing systems (e.g. Zoom meetings) are effective fordecision making, transmission of instructions, information sharing, etc.
It is also possible for isolated managers to give instructions andparticipate in meetings from home.

Operation
management

・ Prioritise the services to be provided, for example, based on the staff
availability rate (ex. 30%, 50%, 70%, 90%, etc.). Determine the services
to be provided according to the service priority.
・ Introduction of contactless care, for example, using sensors in living
spaces and on beds to monitor the users' movements, bodytemperature, pulse rate, etc., and to control room temperature,humidity, etc. remotely.
・ To be thorough about zoning.

51

Target Area
Governance(Philosophy,
structures andsystems)

Main Resilience・ Leadership of top management, quick and accurate judgement.
・ Clarification of the chain of command, prompt decision-making(system), and clear instructions to staff.
・ Thorough communication and sharing of information within theorganisation.
・ Clarification of the substitution order in an event when the person in
charge is absent.

BCP = business continuity plan, BCM = business continuity management, ICT = information communication andtechnology.
Source: Compiled by authors.

4.

Recommendations for Long-term Care Businesses to Prepare the Future Pandemic

In any case, during the pandemic, it is easy to fall into a reactive response by focusing only on LTCFs
vulnerabilities and thinking about workarounds. However, it is well known in Japan that proactive
responses are necessary in the event of a crisis such as a natural disaster. It can be said that thisproactive response is also required when responding to an unknown infectious disease pandemic
such as COVID-19.
The principle of proactive response is said to be the following three actions:•

Act when in doubt. Waiting until the situation becomes clear can make things worse. Even when
the situation is unclear, we should start responding whenever there is a ‘situation that triggers
action’, based on prior knowledge.

•

Act assuming the worst situation. Wishful thinking will solve nothing. By always thinking about
the worst in some corner of your head and act, you can expand your ability to respond.

•

Trying and failing can be forgiven, but inaction cannot be. We should act proactively with‘inspiration from necessity’, asking ourselves ‘what is it that we should be doing now? even if itturns out that there was no actual damage or effect to be dealt with, our experience value
increases and our capacity for action is improved. (Kimura, 2018).

Proactive response is the key to the operation of a resilient LTCF. To apply the lessons learned fromthis study to crises such as future pandemics, LTCF administrators should focus on the following:
4.1.
•

Risk Management
It should be reaffirmed that the creation of BCPs to take emergency response measures is partof BCM. BCM should make more efforts not only in the preparation of documents like BCPs, butalso in training and improvement of risk response. Since BCM and BCPs are part of risk
management in organisational management, BCM should focus on training and improvement
to raise and maintain the level of knowledge, attitudes, and practice of staff regarding infectious
diseases in normal times.

52

•

4.2.

Agile initial response and timely tuning are important. Proactive measures should be taken.
Human Resource Management•

Employees should be instructed to avoid risks not only in the workplace but also outside theworkplace. Staff are also worried about not just getting infected, but infecting others (Appendix1). Efforts should be made to raise awareness of the attitude of ‘not being too scared, but to beappropriately scared’ against infectious diseases, and to care for those who care for the elderly.

•

Staff should be prepared to become infected or close contacts and be unable to perform theirduties. The possibilities and limitations of support agency measures from other departments,
occupations, managers, and other facilities should be examined. Based on the reconfirmation of
the job regulations, staff should be trained to understand and practice multitasking (performing
multiple tasks simultaneously and simultaneously while switching between them in a shortperiod of time) in crisis situations.

•Inspections should be carried out on the minimum tasks that should be secured and those thatshould be omitted as excessive in an emergency.

•

Emphasis should be placed on mental health care for staff.

4.3.

Facility Management•

Unlike medical institutions, LTCFs are considered to be places of life, so they are not supposed
to have facilities and equipment such as quarantine spaces, zoning, negative pressure rooms,
and ventilation equipment, but they should be able to respond to situations where they cannot
transport patients to hospitals, accept discharged patients, and isolate and follow up for those
who are close contact with patients.

•

Especially, LTCFs should share knowledge that COVID-19 is transmitted through aerosol
transmission and train in correct equipment installation and operation to control ventilation (SeeAppendix 1).

•

Stockpiling of equipment necessary for infection prevention and mutual accommodation ofequipment between facilities should be ensured.

4.4.

ICT Management•

During the COVID-19 pandemic, advanced LTCF s experienced the effectiveness of online
interviews, intercom communication, online meetings, telework, and YouTube utilisation.
However, many LTCFs have not yet introduced ICT or care robots. Digital transformation of careshould be promoted as soon as possible.

•

Software for long-term care schedule management should be used to track actions inemergencies to identify infection routes and prevent infection.

53

•

4.5.

For establishing contactless care, efforts should be made to spread ICT literacy, job redesign, andbuild an ideal image of smart care.
Operation Management•

Cascade down on infectious disease control (the process of strategically breaking down the goals
set by the person in charge of a company or organisation and assigning them to subordinate
groups and individuals) should be clarified. To this end, the job descriptions of each level of staff
should be clarified, the scope of responsibility and discretion for each position should be clarified,
and training should be conducted with clear output of the knowledge and skills necessary toachieve the competency.

•

Efforts should be made to develop onsite leaders (core specialists) in normal times.

•

For responding to the increased workload due to infectious disease control, the priority of workin normal times should be considered and essential operations should be reviewed.

•

The introduction of contactless care using sensor technology should ease the burden andconcerns on staff.

4.6.

Governance•Risk management is an important strategic activity in the management of LTCFs. BCM, which isone of them, requires the efforts of the entire organisation. To this end, all employees shouldraise their risk awareness.

•

Since top management is entrusted with the greatest responsibility and discretionary authority,
they should make agile and accurate judgements on unexpected risks.

•

Thorough cascade down procedures should be ensured.

•

Information should be shared by all staff so that it does not become just a top-down approach.

•For making quick decisions, the substitute ranking in the absence of the top management should
be clarified.

Since Japanese LTCFs are controlled under the public long-term care insurance system, this study did
not discuss the impact of COVID-19 on the management of finances, services, and marketing. Of
course, these remaining issues are important for BCM of LTCFs. However, due to the different politicaland economic backgrounds of each country, it is difficult to share the financial, service, and marketing
challenges of Japanese LTCFs at this time. On the other hand, LTCF managers in each country canshare lessons learnt from the experiences of Japanese LTCFs during COVID-19 regarding risk, humanresources, facilities, ICT, operations, and governance.

54References
Keishin Gakuen Vocational Education Research and Development Center (2020), ‘Training Module forManagers of Long-term Care Provider. A Project to Build a Modular Learning System by
Utilizing E-learning to Train Managers of Long-term Care and Welfare Services’. Reiwa FY2Specialized Training School Recurrent Education Comprehensive Promotion Projectcommissioned by the Ministry of Education, Culture, Sports, Science and Technology (MEXT).
https://keishin-group.jp/pdf/report34.pdf (in Japanese)
Keishin Gakuen Vocational Education Research and Development Center (2021), ‘Training Module forManagers of Long-term Care Provider. A Project to Build a Modular Learning System by
Utilizing E-learning to Train Managers of Long-term Care and Welfare Services. Reiwa FY2Specialized Training School Recurrent Education Comprehensive Promotion Projectcommissioned by the Ministry of Education, Culture, Sports, Science and Technology (MEXT).
https://keishin-group.jp/pdf/report40.pdf (in Japanese)
Kimura, R. (2018), ‘How to Increase 'Personal Awareness' of Disasters - Focusing on Evacuation
Behavior’. No. 2 Research Information Magazine ECPR.
Ministry of Health, Labour and Welfare (2020a), ‘Guidelines for Business Continuity at Long-term Care
Facilities and Providers in the Event of COVID-19.’
Ministry of Health, Labour and Welfare (2020b), ‘FY2019 Subsidies for Work Preparation Support for
Those in Need. Social Welfare Promotion Project Survey and Research Project on the
Usefulness of BCP in Social Welfare Facilities.’ MS&AD InterRisk Research & Consulting, Inc.
Ministry of Health, Labour and Welfare (2021), ‘Points for Creating a Business Continuity Plan (BCP)in the Event of a New Coronavirus Infection Outbreak at Long-term Care Facilities andProviders -Common Matters’. https://www.mhlw.go.jp/content/000744335.pdf (accessed 31
July 2022). (in Japanese)
Ministry of Health, Labour and Welfare (2022), ‘Guidelines for Business Continuity at Long-term Care
Facilities
andProviders
in
the
Event
of
COVID-19’(revised).
https://www.mhlw.go.jp/content/000922077.pdf 1 Aug.2022 (accessed 31 July 2022). (inJapanese)
NTT Data Institute of Management Consulting, Inc. (2022), ‘Survey and Research Project on Business
Operators' Efforts on Infectious Disease Countermeasures and Business Continuity’.
Tokyo Metropolitan Social Welfare Corporation Management Optimization Study Group (2011),‘Towards Optimal Management of Social Welfare Corporations’.
World Health Organization (WHO) (2020), ‘Responding to Community Spread of COVID-19’.
https://apps.who.int/iris/bitstream/handle/10665/331421/WHO-COVID-19Community_Transmission-2020.1-eng.pdf (accessed 31 July 2022).

55

Chapter 4
Environmental Health Resilience: Monitoring CO2 in Health andLong-term Care Facilities

1.

Background

Ventilation is one of the crucial elements of the novel coronavirus disease (COVID-19) prevention.
The Japanese government launched the ‘Avoid the Three Cs (Sanmitsu-Kaihi)’ (crowded places, closecontact settings, and confined and enclosed spaces) approach at the beginning of the pandemic in
March 2020, which was further endorsed by the World Health Organization (WHO) in July 2020.
Through this approach, it was recommended to open windows and doors for ventilation (Figure 4.1).
With the growing awareness of the mode of transmission of COVID-19, in December 2021, the WHO
acknowledged that COVID-19 spreads not only by droplet transmission but also by airborne
transmission (WHO, 2021). In a closed place where many people stay, such as in classrooms, meetingrooms, buses, trains, airplanes, or restaurants, the virus, if present, would remain in the air and infectothers who are in the same closed space. Ventilation to evacuate contaminated air eliminates COVID19 and prevents infection.

Figure 4.1. Avoid the Three Cs

Source: WHO (2020).

56

In this research project, a system to monitor the carbon dioxide (CO2) level as the proxy of air
ventilation was implemented in health and long-term care facilities, and the system installation
process was observed.

2.

Methods and Findings

The CO2 monitoring system comprises a CO2 monitor, smartphone/PC, and an internet of things (IoT)
service (Figure 4.2). A ‘pocket CO2 sensor’1 was chosen because it is small and lightweight, has inbuilt Wi-Fi, is relatively affordable, and has multiple data handling systems in cloud storage,
smartphones, and with an attached light-emitting diode (LED) panel. ‘Ambient Free Cloud’2 wasused for data storage and visualisation if the sensor was successfully connected to Wi-Fi and theinternet. If not, the sensor was connected to a smartphone, and the data are stored in the app
together with location information obtained from the smartphone’s global positioning system (GPS).
If the sensor could not be connected to the internet or smartphone app, the CO2 level was checkedfrom the LED display on the sensor.

Figure 4.2. CO2 Monitoring System

IoT = internet of things, LED = light emitting diode.
Source: Authors.

The CO2 level of outside air is around 400 parts per million (ppm), and exhaled air from a person isaround 45,000 ppm. Thus, when the number of people increases and the length of stay becomes
longer, the CO2 exhaled from persons in the space will increase the CO2 level if there is no ventilation
mechanism. The CO2 level is recommended to be below 1,000 ppm by the Japanese Ministry of

1
2

The detailed explanation of the sensor is available at https://sites.google.com/view/pocket-co2/
The service is accessible from https://ambidata.io/57

Health, Labour and Welfare (MHLW, 2022) and the United Kingdom’s Health and Safety Executive(HSE, 2022).
The CO2 monitoring system was prepared by the research team to be implemented in health andlong-term care facilities in Japan, Thailand, and Indonesia. Amongst the 19 locations contacted, two
in Japan successfully implemented the IoT data cloud system, 10 in Indonesia stored the data in thesmartphone app, and seven in Japan and Thailand used an LED display only. The example of the dataobtained in the cloud or app is shown in Figure 4.3. In charts A and B, several different patterns areobserved. It is because the sensors were carried from room to room to check the ventilation. Chart
C only shows data in one location, but the CO2 level fluctuates. When the number of people increases
in the monitored room, or when the exhaled air hits the sensor, the CO2 level increases. The CO2 level
fluctuates according to the situation. No location recorded a CO2 level exceeding 1,000 ppm.

CO2 ppm hourly average, ppm

Figure 4.3. Examples of CO2 Monitoring
800
750
700
650
600
550
500
450
400
350
300

A

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Hour

2021/9/15

CO2 ppm hourly average, ppm

1000
900

2021/10/15
2021/10/16
2021/10/17
2021/10/18
2021/10/19
2021/10/20
2021/10/21
2021/10/22
2021/10/23
2021/10/27
2021/10/28
2021/10/29
2021/10/30
2021/10/31
2021/11/1
2021/11/2
2021/11/3

2021/9/16

B

2021/9/17

8002021/9/18

700

2021/9/19

600

2021/9/20

500

2021/9/21

400

2021/9/22

300
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Hour

58

2021/9/23

Figure 4.3. Continued
900
850

CO2 level in ppm

800

C

750
700
650
600
550
500
450
400
09:59:02 09:59:46 10:00:29 10:01:12 10:01:55 10:02:38 10:03:22 10:04:05 10:04:48
Hour Minute Second

CO2 = carbon dioxide, ppm = parts per million.
Source: Authors.

3.

Lessons Learnt

Monitoring the CO2 level continuously and automatically via IoT is the optimal way. However, it is noteasy to implement without a specialised technician. Under the high alert of COVID-19, many facilities
restricted the entrance of non-residents, and it became difficult to install and configure the sensors
to be connected by Wi-Fi to IoT. The android app was easier to implement and adds geographicallocation information but will be used only when the smartphone is available. The LED display is a
simple but quick way to check the CO2 level, but it does not record cumulative data. For the
dissemination of CO2 monitoring, easy-to-install devices, such as built-in monitors attached to the airconditioning switches, would be helpful.
In this experiment, no locations recorded CO2 levels of more than 1,000 ppm. There are biases, suchthat those who participated in this experiment were well aware of the importance of ventilation andmight have responded quickly to a rising CO2 level. Also, in Indonesian long-term care facilities, therooms are not equipped with air-conditioning; thus, they keep windows and doors open (Figure 4.4).
It must have reduced cluster infection in long-term care facilities in Indonesia.

59Figure 4.4. Well-ventilated Long-term Care Facilities in Indonesia

Source: Authors.

4.

Recommendation to Policymakers and Long-term Care Professionals

Before COVID-19, the importance of ventilation was somewhat neglected. With COVID-19,
ventilation has become a crucial component for infection control, and CO2 monitoring has become
an effective tool. This time, we conducted a trial experiment on how the CO2 monitoring system
would be accepted and used in health and long-term care facilities in Asian countries. Like
temperature and humidity, the level of CO2 should be monitored regularly in a space where humans
live, especially in health and long-term care facilities. The system needs to be simple so that it would
be utilized widely. The small sensor that is easy to carry could detect the CO2 in different rooms in
different locations instantly, raising awareness of air quality and ventilation.

60

References
Health and Safety Executive (HSE) UK (2022), ‘Ventilation in the Workplace. Using CO2 Monitors’.
https://www.hse.gov.uk/ventilation/using-co2-monitors.htm
Ministry of Health, Labour and Welfare (MHLW), Japan (2022), ‘Kenchikubutsu Kankyou Eisei Kanri
Kijun ni Tsuite’ (On the building environmental hygiene management standards).
https://www.mhlw.go.jp/bunya/kenkou/seikatsu-eisei10/
World

HealthOrganization(WHO)(2020),‘Avoid

the

Three

Cs’.

https://www.who.int/brunei/news/infographics---english
WHO (2021), ‘Coronavirus Disease (COVID-19): How is it Transmitted?’ https://www.who.int/newsroom/questions-and-answers/item/coronavirus-disease-covid-19-how-is-it-transmitted

All internet web addresses (URL) were accessed on 7 August 2022.

61

Chapter 5
Navigating Resilience and Vulnerability: Everyday Lived Experiencesof Migrant Care Workers in Japan During the COVID-19 Pandemic

1.

Background of Migrant Care Workers in Japan

In recent years, the number of foreign workers in Japan has rapidly increased, especially in health andwelfare services. According to the Japanese Ministry of Health, Labour and Welfare (MHLW), as ofthe end of October 2021, the number of foreign workers in Japan stood at 1,727,221, 1.6 times larger
than that at the end of October 2016. Amongst those, 17,434 foreign nationals were engaged in
medical and social welfare services at the end of October 2016, increasing to 57,788 at the end of
October 2021 in the same sectors: 3.3 times more than in the past 5 years (Figure 5.1). Amongst these,
Filipinos and Vietnamese (Figure 5.2) constitute the majority engaged in the field of elderly care.
The residence status of these workers is diverse. They comprise permanent residents, long-term
residents, the spouses or children of Japanese nationals, designated activities, technical interntraining, nursing care, and specific skilled workers (hereafter, abbreviated as SSW), amongst others.
The latter visa categories were established after 2016 in response to a severe shortage of elderly-care
workers in Japan (Figure 5.3).
In February 2020, the novel coronavirus disease (COVID-19) pandemic spread within Japan andsignificantly impacted long-term care facilities located across the country, many of which employ
migrant care workers. Within these, cluster infections occurred in a substantial number.
Most long-term care facilities restricted visits, including the relatives of elderly residents and required
staff to constantly wear masks and other personal protective equipment (PPE) in the workplace andmaintain frequent disinfection and ventilation. This ‘new-normal’ led to the rise of new workstylepatterns that were accompanied by transformation in the lives of the elderly and those employed tocare for them.
To ascertain what kinds of transformation occurred, our research team (Shun Ohno, Yuko O. Hirano,
Mario Ivan Lopez, Wako Asato, Yoichi Hiruma, and Reiko Ogawa) conducted fieldwork and researchjust after COVID-19 was declared a ‘pandemic’ by the World Health Organization (WHO) on 11 March
2020.

62

Figure 5.1. Transition of Numbers of Foreign Workers Engaged in Medical andWelfare Services in Japan (October 2016–October 2021)
70,000.00

persons
57,78860,000.00
50,000.00
43,44640,000.00

34,261

30,000.00

26,086
21,73420,000.00

17,43410,000.00
0.00
2016

2017

2018

2019

2020

2021

Source: Drafted by the authors based on data obtained from the Ministry of Health, Labour and Welfare(MHLW) (2022a).

Figure 5.2. Breakdown of Foreign Workers Engaged in Medical and Welfare Services by
Nationality (as of October 2021)

9,238, 16%944, 2%

14,704, 26%

2,015, 3%
2,726, 5%

4,943, 9%
12,722, 22%

9,823, 17%
Filipinos

Vietnamese

ChineseIndonesians

Koreans

Brazilians

Nepalese

Others

Source: Drafted by the authors based on data obtained from MHLW (2022a).

63

1.1.

Outline of Research

Research team members investigated the multiple problems that migrant care workers encounteredworking in long-term care facilities during the pandemic and conducted interviews on a wide range
of issues such as transformation in employment; changes that impacted daily private life and mental
health; individual resilience, and future plans under the prolonged pandemic.
Onsite and online interviews were conducted with a total of 60 migrant care workers. These included
certified care workers (Kaigo-fukushishi in Japanese) technical intern trainees, specific skilled workers,
and part-time working ‘care students’ studying at vocational schools for certified care workers.
Interviews were also conducted with long-term care facility employers, Japanese co-workers, city
government officials as well as the directors of the Japan International Corporation of Welfare
Services (JICWELS) who nationally coordinate projects concerning the movement of care and nursing
workers under Japan’s economic partnership agreements (EPAs) with Indonesia, the Philippines, andViet Nam.
As Vietnamese workers occupy the largest group of migrant care workers in Japan, our team paid
particular attention to their conditions. From December 2021 to January 2022, Hiruma and his
partner scholars conducted questionnaire surveys with 54 technical intern trainees in the Chubu
region including follow-up interviews. Additionally, in July 2022, focus group discussions wereconducted with technical intern trainees as well as care students from Viet Nam in the Kansai region.
These discussions intended to clarify Vietnamese participants’ awareness of problems they faced
during the pandemic and identify any differences between the experiences of technical interntrainees and care students. The outcomes of these surveys are reported in the following sections.
An additional focus of research was to examine the resilience and vulnerability of migrant care
workers during this pandemic. To this end, in July 2022, our team conducted questionnaire surveys
with 219 international students studying at three vocational schools for certified care workers locatedin the Kanto and Kansai regions. The surveys assessed a range of factors, including respondents’ social
demographic characteristics, sense of coherence (SOC), and a general health questionnaire (GHQ).
Results and analyses are presented in Section 3.
To gain a deeper understanding of the experiences of migrant care workers, employees and local
officials in Fukuoka City and its surrounding areas, research members – consisting of Ohno, Lopez,and Hirano – conducted a series of onsite interviews in October 2020 and December 2021. As one of
the cities in northern Kyushu that has actively recruited foreign care workers in response to a shortageof Japanese care workers, Fukuoka provided a particularly informative site for our study. Throughintermittent surveys, we sought to document changes in employment conditions and shifts inawareness of critical issues amongst migrant care workers during the pandemic. Our findings, whichshed light on the lived realities of these workers and their communities, are presented in Section 4.

1.2.

Diversification of Migrant Care Workers in Japan

In this section we examine the changing landscape of migrant care workers and how they have started
to diversify in Japan in recent years. Since 2008, through EPAs concluded with three Southeast Asian64

countries – Indonesia, the Philippines, and Viet Nam – Japan has been accepting ‘candidates’1 forcertified care workers (Indonesia 2008, Philippines 2009, and Viet Nam 2014). The Japanese
government has allocated a substantial budget for training candidates, who are granted a ‘designatedactivities’ status to let them pass the national licensure examination for certified care worker. Each
year, respective sending countries can send no more than 300 care workers. Candidates are required
to return to their country if they do not pass the examination within 4 to 5 years after arrival in Japan.
As of 2022, 2,950 EPA candidates have passed exams (Ministry of Health, Labour and Welfare, 2022b).
However, it is worth noting that due to various reasons, a substantial number of those who havepassed the exam have already left Japan. Our analysis sheds light on these trends and theirimplications for the field of migrant care work in Japan.

Table 5.1. Outline of Diversified Statuses of Residence for Migrant Care Workers in Japan
Status of
Residence

Aim

Beginning
Year

Designatedactivities

Japan’s economic
partnership agreements(EPAs) – including theprovision of movement ofcare and nursing workers– with Indonesia, thePhilippines, and Viet Nam
aim to strengthen theireconomic partnerships,
but do not intend torespond to Japan’s labour
force shortage in the
sectors concerned.

2008 inthe caseof EPA
projects

Nursingcare

Aims to grant stable2017
working status in Japan tomigrants who graduatedfrom CCW training schools
or who obtained CCW
licensure by othermethods.

1

Certified Care
Worker (CCW)
Qualification

Future Prospect

The aim is to pass
the national
licensure exam for
CCWs and obtain
CCW qualifications
within 4–5 years
after arrival in
Japan.

CCWs under the
EPAs can extend
their status ofresidence as manytimes as they wantas long as they
continue to work
as CCWs. They
have the right tohave family
members
accompany themto Japan.
Permanent
residency ispossible.

Training school
graduates who wish
to work as CCWs formore than 5 years
are required to pass
the national exam
for CCWs within 5
years after their

Nursing care visa
holders can
extend their statusof residence as
many times as
they want as longas they continue
to work as CCWs.

Japan’s EPAs with Indonesia, the Philippines, and Viet Nam allow Southeast Asian care workers to become
certified care workers after they pass the national licensure examination in Japan. Before they pass the exam,
they are called ‘candidates for certified care workers’.

65graduation. They
can hold a CCW
licensure even if
they fail the examand they cancontinue to work as
care workers formore than 5 years.

They have theright to havefamily membersby accompany
them to Japan.
Permanent
residency ispossible.

Technical
interntraining

The aim is to transfer their 2017
skills obtained in Japan totheir home country.
Basically, trainees are notallowed to change
workplaces. Family
members are notpermitted to accompany
them to Japan.

If the trainees fulfill
some requirements,
they can take the
CCW exam. If they
pass, they canchange status fromresidence to nursing
care worker.

The total length ofstay in Japan is 5
years in length.
Those who passed
the CCW exam canchange status ofresidence tonursing care
worker andcontinue to workin Japan.

Specifiedskilledworker(i)2Aims to fill labour force
2019
vacancies in selectedindustrial sectors. Granted
to certain-level skilledworkers. EPA candidates
who could not pass the
CCW exam within 4–5
years can receive thisstatus as long as they
fulfill some requirements.
Family members are notpermitted to accompany
them to Japan.

If the workers fulfill
some requirements,
they can take the
CCW exam. If they
pass, they canchange status ofresidence to nursing
care worker.

The total length ofstay in Japan is 5
years at length.
Those who pass
the CCW exam canchange status ofresidence tonursing care
worker andcontinue to workin Japan.

Source: Prepared by the authors based on data from Ministry of Health, Labour and Welfare (MHLW).

Despite the EPAs that Japan has established, the flow of care workers has not ameliorated the serious
shortage of workers. In 2016, the Japanese government took active measures, introducing new
initiatives to increase the number of foreign workers. This included the addition of nursing care for2

The ‘Specified skilled worker’ has two types: Specified Skilled Worker (i) and Specified Skilled Worker (ii). The
latter is a status of residence for foreign nationals engaged in jobs that require proficient skills in specified
industry fields. These fields do not include nursing care.

66technical intern training programmes, the creation of a new residency status for graduates of schools
for certified care workers called ‘nursing care’, and the establishment of a ‘specified skilled worker’(SSW) category for those who have higher skills and Japanese language proficiency than technicalintern trainees (Table 5.1).
Following the introduction of new residency status and training programmes, there has been asignificant increase in the number of foreign care workers in recent years. Notably, this trend
continued even after the COVID-19 pandemic was declared by the World Health Organization (WHO)in March 2020 (Figures 5.3 and 5.4), with a substantial increase in technical intern trainees and SSWs.

Figure 5.3. Transition of Numbers of Approved Technical Intern Training Plans
in Nursing Care3 (March 2019–March 2021)

Source: Drafted by the authors from data of the Organization for Technical Intern Training (OTIT) (2021).

3

The number of approved technical intern training plans is not exactly same as that of technical intern trainees
residing in Japan since the former includes the number of approved trainees who did not enter Japan.

67

Figure 5.4. Transition of Numbers of Specific Skilled Workers in Nursing Care
(June 2019–March 2022)
Persons

WHO = World Health Organization.
Source: Drafted by the authors based on date obtained by the Immigration Services Bureau of Japan (2022).

Another group of foreign workers in the care industry, known as ‘care students,’ those international
students studying elderly care at schools for certified care workers, have also seen an increase from2017 since the introduction of the ‘nursing care’ residency status for graduates of those schools.
However, due to the impact of the pandemic, this growth showed a slight decrease in fiscal years
2021 and 2022 possibly due to the pandemic (Figure 5.5).

Figure 5.5. Transition of Numbers of Foreign Enrolled Care Students Studying at Schools for
Certified Care Workers (2017–2022)

Source: Drafted by the authors from data of the Association of Educational Facilities for Certified Care Worker(2022).

68

In recent years, the number of Vietnamese care workers entering Japan has increased significantly,
making them one of the largest groups of new foreign care workers. As of March 2021, 43% of all
nursing care trainees (out of 12,068) were Vietnamese technical intern trainees (5,152) (OTIT, 2021).
Moreover, as of September 2021, 52% (2,062) of all SSWs engaged in nursing care (3,947) wereVietnamese (Immigration Services Bureau of Japan, 2022). Additionally, they constitute the largest
group amongst enrolled foreign students studying at schools for certified care workers accounting for34.3% (750) of the total registered international students studying at schools for certified care
workers all over Japan (2,189) (Association of Educational Facilities for Certified Care Worker, n.d.).
As a result of the diversification of residential statuses, our research team decided to concentrate on
the dynamics and experiences of this growing group of care workers. In section 2, we clarify what
problems they faced as well as their aspirations for the future during the pandemic as categorised bystatus of residence (visa category) through focus group discussions. In Section 5, Wako Asato
examines the reasons behind the popularity of technical intern trainee projects and the less popular
EPA projects amongst Vietnamese and other migrant care workers during the pandemic.
The accounts of care migrants reveal that most of them were able to overcome those difficulties they
faced relating to COVID-19 and these seem to indicate their mental resilience. Given the relative
stability of the elderly care industry, employment insecurity did not emerge as a major problem under
the pandemic. As such, many migrant workers have remained in Japan to work longer than their initialplans. The following sections present their narratives.

2.

Vietnamese Technical Intern Trainees in Nursing Care and International Students
Studying at Vocational Schools for Certified Care Workers

2.1.

Research on Vietnamese Technical Intern Trainees and International Students

As noted in the opening section of this chapter, Vietnamese technical intern trainees and care
students studying at certified care worker schools make up a significant proportion of migrant care
workers in Japan. There is a need to pay more attention to this population and identify the challenges
they face to improve the current acceptance and training system in Japan.
This section sheds light on the perceptions of technical intern trainees based on a questionnaire
survey conducted by Hiruma, and subsequent in-depth interviews in the Chubu region from February
to May 2022 (Survey 1). The survey aimed to understand the trainees’ reasons for choosing to work
as technical intern trainees, and the problems they encountered 2 years after their arrival in Japan.
Data obtained from focus group discussions with Vietnamese technical intern trainees and care
students (conducted by Ohno and Hiruma) in the Kansai region in July 2022 (Survey 2) present the
impact of the pandemic on both groups’ everyday lives and other issues.
Every year the Ministry of Health, Labour and Welfare and the Organization for Overseas TechnicalIntern Training conduct a large-scale questionnaire to gather information on the number of approved
technical intern training programmes throughout Japan. However, there is limited information on
the technical intern trainees’ conditions and problems by nationality. To respond to this, we
conducted a survey of Vietnamese technical intern trainees. Whilst there is one report dealing with
the impact of the COVID-19 pandemic on migrant workers in Japan (Sasaki 2020), other similar
studies remain scarce.
69

2.2.

Questionnaire Survey with Follow-up Interviews with Technical Intern Trainees

Hiruma conducted Survey 1 by administering a questionnaire to 110 Vietnamese technical interntrainees at 55 care facilities employing trainees in the Chubu region. These were distributed to eachfacility and collected via mail between December 2021 to January 2022, with a collection rate of 49%
resulting in 54 valid responses) (Figure 5.6). To follow up on the results, in-depth online separate
interviews were conducted with four respondents in May 2022.
According to the results (54 respondents), many technical intern trainees (30 respondents) were
graduates of nursing colleges and universities, similar to EPA-certified care worker candidates, and amajority of them (51 respondents) were willing to take the national examination and obtain acertified care worker licence (Figure 5.6).

Figure 5.6. Breakdown of Vietnamese Technical Intern Trainee Respondents by
Nursing Graduation SchoolNA
1, 2%
University
10, 18.5%

Nonnursing
school13, 24%

Secondary
10, 18.5%

College20, 37%NA = no answer.
Source: Drafted by the author based on dataobtained from Hiruma et. al. (2022).

During the follow-up in-depth interviews with four Vietnamese technical intern trainees, four reasons
emerged regarding their choice of technical intern trainee programme over the care student
programme:
1.

They wanted to start working sooner as they had already graduated from a nursing college oruniversity in Viet Nam.

2.

They wished to send money to their family sooner.

3.

They were unable to shoulder high costs associated with studying in Japan (it costs
approximately twice that of the cost for coming to Japan as a technical intern trainee).

70

4.

The programme for care students usually requires approximately 9-years stay in Japan, whichis too long for them. Care students usually have a contract with their financial sponsor who
requires them to work at a facility for at least 5 years after graduation from their school for
certified care worker.

Interviews (with three females and one male, average age 25 years) indicated that, overall, their levelof Japanese language proficiency and knowledge in nursing care amongst Vietnamese technicalintern trainees in nursing care was lower than that of the Vietnamese care students.
2.3.

Focus Group Discussions with Care Students and Technical Intern Trainees

On 11 July 2022, face-to-face focus group discussions (hereafter, abbreviated as FGDs) were also
conducted with six Vietnamese care students studying at a vocational school in the Kansai region andfive technical intern trainees (including one former technical intern trainee who recently changed hervisa to specified skilled worker [SSW]) working at care facilities in the same region (Table 5.2). These
were done to compare the two groups’ experiences and future plans during the pandemic. The
vocational school and care facilities are owned by a social welfare corporation.

Table 5.2. Details of Focus Group Discussions
FGD 1

FGD 2

No. of participants(maximum lengthof discussions)6(70 minutes)

5(60 minutes)

Status of residence

studenttechnical intern training (4)specified skilled worker (1)Gender3 females, 3 males

all females

Age range(Average age)
No. of participants who
graduated from nursing
college or university

21–33 years old(24.8 years old)

23–32 years old(25.6 years old)1

5

FGD = focus group discussion.
Source: Original data of the authors.

During the FGD 1, six care students stated that the impact of the pandemic was more severe on care
students than on technical intern trainees. This is because care students are typically part-timeworkers and were viewed as expendable when employers needed to make employment
adjustments. As a result, when employers experienced lost income and had to reduce their labour
force, they tended to layoff part-time and irregular workers, including foreign students.
In one interview, a 33-year female student related, ‘If we were infected (with COVID-19), we would
be fired and lose our income.’ This understanding was commonly shared by other students ofdifferent nationalities studying at the same vocational school. In contrast, a 32-year female SSW

71

stated, ‘when I became positive after the corona infection broke out at our workplace, I wasquarantined at a nearby hotel. During that time, our corporation (her employer) always helped me’.
Vietnamese technical intern trainees were also safeguarded as regular workers through the labour
contracts they had with their employers. Three technical intern trainees who participated in the FGD
2 stated that the risk of infection was higher for care students because they moved around a lot anddue to the large pool of people who they came in contact at school or through part-time jobs.
However, the risk was lower for technical intern trainees as their workplaces were fixed and thus
movement limited. Moreover, their care facilities took relatively strict infection control measures
including frequent PCR tests for workers whereas care students had less opportunities to receive
them (as narrated by a 32-year female SSW). Whilst Sasaki’s previous study suggested that the overall
economic impact of the pandemic on care students was limited (Sasaki, 2020), our FGD data
highlighted the vulnerability of care students, not only in terms of economic impact, but also in termsof infection risk.
One distinctive aspect relates to care workers’ inability to go back to their home country for
temporary visits during their stay in Japan. A 24-year male student shared his experience stating that‘during my stay in Japan for the last 5 years, I was not able to return to Viet Nam. So, I feel so lonely.
I long to go back this summer, but there is still a risk to not return to Japan due to corona (strict
border controls).’
On the other hand, one 23-female technical intern trainee stated that she had no changes to her plandue to the pandemic. She related that she knew that she could not return home during her 3-year
contract with her employer. This defines that technical intern trainees have basically no rights toreturn for a temporary visit. When asked if their expectations had been disappointed due to the
COVID-19 pandemic, three technical intern trainees replied with a spontaneous no.
During the FDGs, participants were also asked about their future plans after experiencing difficulties
due to the pandemic. All of them kept their initial plans to work for a least 5 years after graduationfrom the vocational school since they had agreements with sponsors paying schooling fees and thatthese would be not required to be repaid on the condition that they have worked at care facilities
for more than 5 years. Moreover, after getting used to the ‘new normal,’ most of them expressed adesire to stay in Japan beyond the 5-year work at their sponsors’ facility. For example, one 25-year
male related, ‘I wish to live in Japan for a long time since I found that Japan to be a comfortable place
to stay. We can earn our livelihood even by working part-time.’ Another 26-year female expressed,‘I wish to be a manager of a care facility after living and working in Japan.’
These desires were shared by other technical intern trainee participants. All five expressed a desire
to reside and work in Japan even after 3-year work experience as technical intern trainees No.1 andNo.2. If they wish to continue to work in the same workplace for more than 3 years, they are required
to change their visas to technical intern trainee No.3 or specified skilled worker. One participant had
already changed hers to SSW and others also expressed a desire to work as technical intern trainee
No.3 or SSW. Additionally, a 23-year participant also stated that she would like to sit the national
examination for certified care worker during her stay in Japan. Table 5.3 presents the differences
between both groups in terms of their experiences during the COVID-19 pandemic.

72

Table 5.3. Summary of Comparison of COVID-19 Related Responses by Status of Residence

Employment

International Students

Technical Intern Trainees

Unstable and sometimes no

Stable (treated as regular staff)

income（treated as‘adjustment valve’）
Responses to COVID-19
infection

No or a little support(sometimes given by theirschool)Full support given by theiremployer

Inability to return home fortemporary visit

Beyond expectations

Within expectations

Future life plan

Longer stay and work inJapan than their initial plans
in most cases

Longer stay and work in Japan
than their initial plans in allcases

Source: Original data of the authors.

2.4.

Findings and Lesson Learnt from Vietnamese Migrant Care Workers

The research enabled us to identify multiple patterns amongst Vietnamese migrant care workers(including care students) under the pandemic.
1.

The risk for infection and loss of stable income tended to be higher for Vietnamese and othermigrant care students during infectious disease outbreaks due to their unstable employment
and higher mobility. This is an important lesson learnt from their past and current problems.

2.

Some technical intern trainees who have been in Japan for 2–3 years now realise that their
Japanese language skills and nursing care knowledge are lower than those of foreign care
students. They expressed that they would have chosen the care student programme if they had
the financial ability to pay for tuition before coming to Japan. This highlights an important lesson
for future migrant care workers planning to come to Japan.

3.

It is important to address and give serious consideration to the gap between theimplementation of the purpose of the technical intern trainee system (skill acquisition andtransfer) and the career aspirations of technical intern trainees (taking the national examinationand obtaining a certified care worker licence).

This survey has some limitations. First, in Survey 1, the pool of in-depth interviewees was small (twowere from the same nursing college), which resulted in sampling bias. Second, Survey 2 was limited
to FGD participants only from ‘good workplaces.’ Therefore, more research is needed to include caremigrants employed in facilities that are considered to not be good workplaces.
4.

One of the most important needs amongst technical intern trainees is to improve not only theirskills, but also their level of Japanese language proficiency and knowledge in nursing care, as
well as to obtain a certified care worker licence as soon as possible. Public support should be73

considered to help host institutions, corporations, and supervising organisations to meet theseneeds, such as through cooperation with schools for certified care workers.
5.

An important need amongst foreign care students is to ease the stressful situation of balancing
school activities and part-time work. Due to their positions as part-time workers, they are more
vulnerable than technical intern trainees and tend to be easily laid off as a ‘employment valve’
under economic recession triggered by the pandemic. For this reason, the government and their
Japanese sponsors need to support financially distressed care students more than before
realising their desires to become certified care workers.

In conclusion, we strongly advocate for the establishment of a new system for accepting migrant care
workers that maximises the advantages and minimises the drawbacks of current residency statuses.
This system should also enhance resilience against disasters such as pandemics.

3.

Resilience of International Students Enrolled at Vocational Schools for Certified
Care Worker in Japan during the COVID-19 Pandemic

3.1.

Research Agenda of International Students

Previous studies have indicated that COVID-19 increases perceived stress and health outcomes(Tanaka et. al., 2021). Therefore, strengthening the resilience of individuals has been key to a
successful coping strategy to survive under a ‘new normal’ where everyone is required to adjust to
daily life under a pandemic. However, to date, no studies on the resilience of non-Japanese
healthcare providers who provide care in Japan have conducted.
In this study, we investigated the resilience of international students enrolled at vocational schools
for certified care workers in Japan by testing the association between sociodemographic
characteristics, social support, and mental health outcomes. We employed the Sense of Coherence(SOC) framework, conceptualised by Antonovsky (1987), as a marker of resilience. SOC is defined as‘a global orientation that expresses the extent to which one has a pervasive, enduring though
dynamic feeling of confidence that (1) the stimuli deriving from one’s internal and external
environments in the course of living are structured, predictable, and explicable; (2) the resources areavailable to one to meet the demands posed by the stimuli; and (3) these demands are challenges,
worthy of investment and engagement’ (Antonovsky, 1987).
3.2.

Methodology

An eight-page questionnaire was developed in Japanese and distributed to 219 international
students studying at three vocational schools for certified care workers in the Kanto and Kansai
regions in July 2022. Out of these, 217 replied (respondent rate: 99.1%). The questionnaire contained
the following items: social demographic characteristics of the student, SOC, and a general healthquestionnaire (GHQ). SOC comprised 13 items, which are categorised under the three subcategoriesof meaningfulness, manageability, and comprehensibility. The higher they mark, the stronger
resilience they have. The GHQ consisted of 12 items. The higher they mark, the lower mental healththey have had in the last 2 to 3 weeks.

74

3.3.

Results

3.3.1.

Participant Characteristics

Sixty-six of the participants were male (24.4%) and 199 female (73.4%). By nationality, Thai students(32.5%) comprised the largest group, followed by Vietnamese (28.4%) and Chinese (14.4%) (Table
5.4). The mean age of the participants was 26.03 (SD:4.53) years old. The average length of stay inJapan was 23.1 (SD:15.34) months. The average length of education prior to Japan was 14.51(SD:2.53) years. On average, the length of working in care facilities in Japan was 14.77 (SD:10.36)
months.

Table 5.4. Characteristics of the Participants
NumberGenderCountry of origin

Nursing education

JLPT level

Enrolled school year

MarriedMale

66 (24.4)

Female199 (73.4)

NA

6

Thailand88 (32.5)

Viet Nam

77 (28.4)

China

39 (14.4)

Philippines

34 (12.5)

Other countries

30 (11.1)

NA

3

Yes

29 (10.7)No

242 (89.3)

(2.2)

(1.1)

N1

7

N2

56 (20.7)N3

83 (30.6)N4

47 (17.3)

N5

17

Have not taken yet

59 (21.8)

NA

2

(2.6)

(6.3)

(0.7)

Freshman

145 (53.5)

Sophomore

126 (46.5)

Yes

24

No

240 (88.6)

NA
Living with others

(%)

Yes

75

7

(8.9)

(2.6)

170 (62.7)

NumberHave lived with COVID-19 infected
person(s)Type of care facilities

Have cared COVID-19 infected person(s)Have been infected by COVID-19

Level of COVID-19 impact on daily life

Level of worried about pandemic

(%)

No

94 (34.7)

NA

7

Yes

42 (15.5)

No

127 (46.9)

NA
Intensive Care Home for the
ElderlyLong-Term Care Health Facilities

102 (37.6)

Others121 (44.6)(2.6)

77 (28.4)
52 (19.2)

Not working in care facilities

5

(1.8)

NA

16

(5.9)

Yes

42 (15.5)

No

213 (78.6)

Not working in care facilities

5

(1.8)

NA

11

(4.1)

Yes

55 (20.3)

No

209 (77.1)

NA

7

(2.6)

Not affected at all

10

(3.7)

Not affected

15

(5.5)

Neither affected or not

17

(6.3)

Affected

82 (30.3)

Strongly affected

139 (51.3)

NA

8

(3.0)

Not worry at all

5

(1.8)

Not worried

17

(6.3)

Neither worried or not

25

(9.2)

Worried110 (40.6)

Worried very much

107 (39.5)

NA

7

(2.6)

Level of difficulties in adapting online class Not difficult at all

16

(5.9)

Not difficult at all

24

(8.9)

Neither difficult or not

29 (10.7)

Difficult87 (32.1)

Difficult very much

107 (39.5)

76

Number

(%)

8

(3.0)

NA

JLPT = Japanese Language Proficiency Test, M = mean score, SD = standard deviation, NA = no answer.
Source: Original data of the author.

3.3.2. Source of Participants’ Social Support
More than 80% of participants answered that family or friends were the main source of social support,
regardless of type (Table 5.5).

Table 5.5. Social Support of the Participants (very much/much)
Number (%)
Can frankly speak to
1.Instructors in care worker school

148 (54.6)

2.Superiors in workplace

141 (52.0)

3.Colleagues in workplace

167 (61.6)

4.Family/friends

233 (86.0)

Can rely on when in trouble
1.Instructors in care worker school

147 (54.2)

2.Superiors in workplace

109 (40.2)

3.Colleagues in workplace

121 (44.6)

4.Family/friends

229 (84.5)

Can ask for advice for personal problems
1.Instructors in care worker school

134 (49.4)

2.Superiors in workplace

79 (29.2)

3.Colleagues in workplace

96 (35.4)

4.Family/friends

233 (86.0)

Source: Original data of the author.

3.3.3. Distribution of SOC and Subscales
The mean score of SOC was 54.17 (SD:10.73) points, which was closer to that of Japanese healthcare
workers’ study (Tanaka et. al., 2021) (Table 5.6).

77

Table 5.6. Sense of Coherence Scores and Subscales
M

SD

SOC total score (range: 13–91)

54.17 (10.73)

Meaningfulness (range: 4–28)

17.98 (3.86)

1. Do you have a feeling that you really don't care about what is going onaround you?
4. Until now your life has had: no clear goals or very clear goals andpurpose
7. Doing the things you do every day is: a source of deep pleasure andsatisfaction or a source of pain and boredom
12. How often do you have the feeling that there is little meaning in thethings you do in your daily life?
Manageability (range:4–28)

4.12 (1.60)
5.15 (1.48)
4.31 (1.61)
4.40 (1.87)
16.12 (4.16)

3. Has it happened that people whom you counted on disappointed you?

4.09 (1.65)

5. Do you have the feeling that you are being treated unfairly?

3.84 (1.75)

10. Many people, even those with a strong character, sometimes feel likelosers in certain situation. How often have you felt this way in the past?

4.39 (1.71)

13. How often do you have feelings that you are not sure you can control?

3.79 (1.64)

Comprehensibility (range: 5–35)

20.07 (4.86)

2. Has it happened in the past you were surprised by the behaviour ofpeople whom you thought you knew well?
6. Do you have the feeling that you are in an unfamiliar situation and do
not know what to do?
8. Do you have very mixed-up feeling and ideas?
9. Does it happen that you experience feelings that you would rather nothave to endure?
11. When certain events occurred, have you generally found that you
overestimated or underestimated their importance – you assessed thesituation correctly?

4.19 (1.58)
3.85 (1.57)
3.81 (1.69)
3.77 (1.54)
4.45 (1.45)

M = mean score, SD = standard deviation, SOC = Sense of Coherence.
Source: Original data of the author.

3.3.4.

Distribution of GHQ and Subscales

The mean score of GHQ was 27.12 (SD:4.95) points. The highest items marked by the participants
was ‘felt constantly under strain’, whose average was 2.72 (SD:.899) points, followed by ‘been losing
confidence in yourself’, which was 2.68 (SD:.804) respectively (Table 5.7).

78

Table 5.7. General Health Questionnaire Scores and Subscales
MSD

1.Been able to concentrate on what you are doing

1.98(.744)

2.Lost much sleep over worry

2.57(.907)

3. Felt you were playing a useful part in things

1.93(.752)

4. Felt capable of making decisions about things

2.02(.713)

5. Felt constantly under strain

2.72(.899)

6. Felt you couldn't overcome your difficulties

2.57(.764)

7. Been able to enjoy your normal day-to-day activities

1.96(.797)

8. Been able to face up to your problems

1.84(.707)

9. Been feeling unhappy and depressed

2.51(.880)

10. Been losing confidence in yourself

2.68(.804)

11. Been thinking of yourself as a worthless person

2.22(.877)

12. Been feeling reasonably happy, all things considered

2.12(.671)

Total GHQ score (range: 12–48)

27.12(4.95)

GHQ = general health questionnaire, M = mean score, SD = standard deviation.
Source: Original data of the author.

3.3.5. Association with SOC Scores
There was a gender variance in SOC and comprehensibly mean scores. Male students scored higher
with SOC 56.09 (SD:12.45) for comprehensibility 21.00 (SD:5.68) higher than females 53.56(SD:10.17) and 19.80 (SD: 4.58), respectively (Table 5.8).

79

Table 5.8. Association between Sense of Coherence Score and Characteristics of the Participants
SOC (range: 13-91)
M
GenderNursing education
JLPT level

Enrolled school year
MarriedLiving with others
Have lived with
COVID-19 infecteesSDpmeaningfulness (range: 4-28) manageability (range: 4-28) comprehensibility (range: 5-35)
M

SD

18.30

(4.18)

17.91(3.76)

18.55(3.09)

17.92(3.94)

p

M

SD

16.79

(4.64)

15.86(4.00)

15.79(4.21)

16.15(4.17)

p

M

SD

21.00

(5.68)

19.80(4.58)

19.76(4.60)

20.11(4.90)

Male

56.09 (12.45)

Female53.56 (10.17)

Yes

54.10 (9.77)

No

54.18 (10.86)

N165.00 (10.49)

21.43(2.37)

19.57(4.58)

24.00(4.69)

N2

56.71 (12.08)

19.25(3.90)

16.64(4.72)

20.82(5.59)

N3

55.21 (9.95).009 18.62(3.44)

16.35(3.97)

20.23(4.63)

N4

55.85 (8.85)

17.70(3.67)

16.83(3.33)

21.32(4.28)

N5

48.76 (9.97)

15.53(3.20)

15.76(3.94)

17.47(4.32)

Freshman

53.25 (10.64)

17.97(4.01)

15.52(4.04)

19.76(4.84)

Sophomore

55.22 (10.77)

18.01(3.69)

16.79(4.22)

20.43(4.88)

Yes

62.22 (12.50)

20.30(4.35)

18.52(4.59)

23.39(5.17)

No

53.23 (10.25)

17.69(3.73)

15.83(4.05)

19.75(4.76)

Yes

53.34 (10.34)

17.57(3.89)

15.82(4.12)

19.95(4.58)

No

55.34 (11.37)

18.55(3.71)

16.51(4.22)

20.28(5.43)

Yes

53.05 (10.19)

17.29(3.70)

15.37(4.22)

20.39(4.70)

17.67(3.98)

15.97(4.11)

19.83(4.56).406 18.32(3.68)

16.69(3.86)

19.91(4.83)No
Type of care facilities Intensive
Care Home

53.48 (10.46)
54.92 (9.86)

.015
.159

.914
.068
.322
.625

80

.142
.032

.000

.271
.265
.834
.427
.470

.065
.605

.302

.407
.256
.733
.840
.243

p
.028
.392

.018

.608
.368
.205
.943
.472

SOC (range: 13-91)
M

SD

p

meaningfulness (range: 4-28) manageability (range: 4-28) comprehensibility (range: 5-35)
M

SD

p

M

SD

p

M

SD

for theElderlyLong-Term
Care HealthFacilities
Others

52.33 (11.70)

17.49(4.19)

15.47(4.13)

19.37(5.46)

54.17 (10.96)

17.88(3.74)

15.93(4.44)

20.36(4.76)Have cared COVID19 infectees

Yes

53.50 (10.51)

17.83(4.14)

15.76(3.91)

19.90(4.98)

No

54.18 (10.89)

17.93(3.81)

16.14(4.25)

20.11(4.93)Have been infectedby COVID-19

Yes

51.67 (10.27)

17.56(3.55)

15.02(4.03)

19.09(5.05)

No

54.68 (10.80)

18.02(3.93)

16.34(4.17)

20.32(4.83)

.395
.066

.922
.432

JLPT = Japanese Language Proficiency Test, M = mean score, SD = standard deviation, SOC = Sense of Coherence, p = p value.
Source: Original data of the author.

81

.644
.037

p

.871
.100

The older the participants, the higher the SOC, meaningfulness, manageability, andcomprehensibility were marked (r=.206, p=.001, r=.122, p=.046, r=.233, p<.001, and r=.159, p=.009),
respectively. In particular, the length of stay in Japan was significantly associated with manageability(r=.153, p=.012). The longer the stay in Japan, the higher SOC was registered.
The level of COVID-19 infection impact on daily life was negatively associated with SOC,
meaningfulness, and comprehensibility (r=-.185, p=.003, r=-.147, p=.017 and r=-.189, p=.002). There
was no significant association observed between SOC and its subscales, and level of difficulties in
adapting to online classes.
The level of Japanese Language Proficiency Test (JLPT) was significantly associated with SOC,
meaningfulness, and comprehensibility (p=.009, p<.001, and p=.018 respectively). The higher their
Japanese proficiency, the stronger their SOC registered (Table 5.6).
Those who were infected by COVID-19 marked a lower manageability score of 15.02 (SD:4.03) thanthose who had not being infected; 16.34 (SD: 4.17) (p=.037). However, no significant association wasobserved between those who have cared person infected with COVID-19 and those who didn’t haveany association of SOC and its subscales scores, nor whether they had lived with those infected by
COVID-19 or not (Table 5.6).
Regarding the source of social support, participants who were able to speak frankly with instructors
in care worker schools, had significantly higher scores in SOC (55.05, SD:9.50) and a meaningful score(18.21, SD: 3.44) compared to those who were not able to (52.87, SD:12.17) and 17.53 (SD:4.32),
respectively. Supervisors at the workplace whom the participants could talk to frankly, was anothersource of social support, which strengthened the SOC and comprehensibility score (54.60, SD:9.38)
and 20.52 (SD:4.42), respectively, than those who could not 53.61 (SD:12.24) and 19.61 (SD:5.38),
respectively (Table 5.9).

82

Table 5.9. Association Between Sense of Coherence/Subscales and Social Support
SOC(range: 13-91)
M

SD

Yes

55.05

(9.50)

No

52.87(12.17)

Yes

54.60

(9.38)

No

53.61(12.24)

Yes

54.94

(10.08)No

52.72(11.83)

Yes

53.76

(10.69)No

56.83(11.03)

Yes

54.92

(10.52)

No

53.01(11.10)

Yes

54.68

(10.72)

No

53.75(10.85)

Yes

54.67

(10.53)No

53.68(11.03)

Yes

54.00

(10.83)

No

54.76(10.34)

meaningfulness(range: 4-28)
p

M

SD

18.21

(3.44)

17.53(4.32)

17.93(3.70)

17.92(4.05)

18.20(3.73)

17.43(4.05)

17.89(3.82)

18.34(4.22)

18.40(3.80)

17.30(3.87)

17.86(3.92)

17.98(3.83)

17.87(3.79)

17.99(3.94)

17.91(3.92)

18.12(3.50)

manageability(range: 4-28)
p

M

SD

16,44

(3,81)

15.65(4.58)

16.14(3.86)

16.08(4.52)

16.17(4.13)

16.02(4.25)

15.97(4.20)

17.00(3.84)

16.45(4.08)

15.64(4.28)

16.49(4.13)

15.85(4.20)

16.26(4.13)

15.99(4.23)

15.98(4.21)

16.79(3.86)

comprehensibility(range: 5-35)
p

M

SD

20.39

(4.53)

19.69(5.33)

20.52(4.42)

19.61(5.38)

20.57(4.51)

19.27(5.45)

19.90(4.87)

21.48(4.91)

20.07(4.84)

20.08(5.01)

20.33(4.94)

19.93(4.88)

20.55(4.83)

19.70(4.95)

20.11(4.92)

19.85(4.77)

p

Can frankly speaking toInstructors in care
worker school
Superiors in workplace
Colleagues in workplace
Family/ friends

.033
.017
.177
.760

.018
.362
.249
.286

.126
.289
.854
.568

.070
.017
.054
.689

Can rely on when in trouble
Instructors in care
worker school
Superiors in workplace
Colleagues in workplace
Family/ friends

.296
.704
.518
.626

83

.822
.632
.609
.206

.922
.928
.938
.367

.516
.939
.742
.551

SOC
(range: 13-91)
MSD
Can ask advice for your personal problems
Yes
55.88
Instructors in care
worker school
No
52.23
Superiors in workplace
Colleagues in workplace
Family/ friends(10.47)(10.77)

Yes

55.57

(10.69)No

53.53(10.77)

Yes

54.55

(10.70)No

53.91(10.83)

Yes

54.40

(11.02)

No

51.57(8.15)

p

.684
.991
.663
.149

meaningfulness(range: 4-28)
M
SD
p

18.73

(3.97)

17.11(3.58)

18.77(3.95)

17.55(3.76)

18.17(3.89)

17.78(3.84)

17.98(3.92)

17.39(3.24)

M = mean score, SD = standard deviation, p = p value, SOC = Sense of Coherence.
Source: Original data of the author.

84

.099
.638
.824
.368

manageability(range: 4-28)
M
SD

16.59

(3.99)

15.55(4.30)

16.52(4.18)

15.94(4.16)

16.06(4.15)

16.15(4.20)

16.16(4.25)

15.54(3.49)

p

.550
.901
.955
.270

comprehensibility(range: 5-35)
M
SD
p

20.57

(4.81)

19.56(4.94)

20.28(5.25)

20.03(4.75)

20.32(5.05)

19.98(4.82)

20.26(5.00)

18.64(3.76)

.682
.411
.558
.093

A strong negative association was found between SOC and GHQ scores (r=-.511, p<0.01),
meaningfulness (r=-.410, p<0.01), manageability (r=-.430, p<0.01), and comprehensibility (r=-.435,
p<0.01) (Table 5.7).
3.4.

Findings and Lesson Learnt on International Students

SOC and its subconstructs were associated with some sociodemographic characteristics of foreign
students enrolled at schools for certified care workers, such as gender and Japanese language abilities,
whilst marriage and residence status were not significantly associated with SOC. Rather, SOC and its
subconstructs are likely to be influenced by social support, such as the one given by instructors at
school for certified care workers and superiors in the workplace, whom the students can speak to
openly. Thus, it is crucial to establish support systems for foreign students to strengthen SOC andlower health risks associated with stress and loss of confidence.

4.

Diversified Strategies for Procurement of Migrant Care Workers under the
Pandemic: A Case Study in Fukuoka

Fukuoka Prefecture was chosen as a research site as it has some of the worst shortages in the caresector and subsequently in response to this has seen a diversification of migrant streams for carework. Fieldwork in Fukuoka Prefecture was conducted in October 2020 and December 2021 when
COVID-19 infection rates were relatively low and aimed to understand the current situation andconditions and how different actors, institutions, and care workers themselves responded under the
pandemic.
4.1.

Current Welfare Conditions of Fukuoka

Fukuoka Prefecture has been ageing in line with the national trend and by 2040 the population is
expected to decrease by just under 14% and the proportion of the elderly (65 years old and above) is
projected to continue to grow, increasing to 35.3% (image shown in Figure 5.7). By 2025, there will
be a forecast need of 95,246 care workers. During the pandemic, the prefecture experienced asignificant reorientation in the procurement and placement of different types of workers as coveredin the following sections.

85

Figure 5.7. Population Changes for Fukuoka Prefecture (2010–2040)

Source: English draft by the author based on data from Fukuoka Prefecture (2017, p.15).

4.2.

Local Government Initiatives

At present, both the prefecture and city suffer from chronic shortage of care workers, 9,500 within
the prefecture and 5,500 within the city (Fukuoka City, 2020, p.30). To respond to this, the city isdeveloping a three-point plan and wants to (i) promote the entry of caregivers into the market, (ii)prevent the turnover of workers and aim for retention of care workers, and (iii) improve the overall
quality of care. To foster a higher degree of retention, through collaboration with academics, nonprofit organisations, and other stakeholders, another approach has been to introduce the idea of‘kanryu’ (a form of circulation), to cultivate Fukuoka as a model city where workers can come, train,
work, and learn. Those who leave would circulate knowledge via their networks bolstering therecognition of the city within Asia.
In order to achieve this, the local government has instituted a working group of different
organisations and stakeholders to promote the appeal of nursing care, increase workers, improvebusiness efficiency, and the quality of workers. This also led to a campaign to further the visibility of
the city within Asia through a promotional video targeting international students4 and implement aplatform to circulate information between different stakeholders who require help in securing care
workers, especially those from overseas (Fukuoka City, 2022).

4Internal figures were provided by the Department of Human Resources for Long-term Care, Elderly Affairs
Policy Section, Fukuoka City.

86

4.3.

Parallel Private Sector Initiatives: International Student Recruitment

Within the prefecture, there are presently 15 vocational schools and other institutions for training
foreign students. These have a degree of flexibility in that they can switch their residence status to‘nursing care’ upon graduation and obtain a nursing care worker visa. Research ascertained that theongoing impact of the pandemic led to a collapse of work opportunities in the food, retail, and hotelindustries where many worked part-time. A recent trend before the pandemic saw migrant working
students (dekasegi ryūgakusei in Japanese) come to train and work in Japan as part of a temporary
floating buffer workforce, but this did not tackle the concrete issue of how to secure a more longterm source of care labour. Some trainers at college offering packages shared their frustration on
Japan’s current migration regime a ‘halfway measure’ and expressed a desire for an open discussion
on migration policy in Japan. Research clarified that there was a rise in foreign students and technicalintern trainees despite the impact of the pandemic. The research clarified the following:•••

A number of schools and vocational training colleges that were training international students forcare picked up the slack from other industries where demand for workers stalled during the
pandemic.
Some students were shuffled around within the economy for an undersupplied market byrecruiting students.
A public–private nexus between businesses, care facilities, schools, and local government
collaborated to assure a diversifying stream of care workers into the prefecture to ameliorate ashortage of workers.

What can be inferred from these trends is a diversification of strategies to procure workers during
this a period of instability between 2019–2021.

4.4.

Migrant Care Workers Appraisal under the Pandemic

A number of care facilities we visited presented the challenges they faced under the pandemic but
provided some lessons on what is happening on the ground. One care facility A, part of a group homelocated just outside Fukuoka City, has employed care workers actively from four different streams andvarious nations (Table 5.10) with different employment status across the group (Table 5.11).

87

Table 5.10. Social Welfare Corporation Special Nursing Home Group in Fukuoka Prefecture:
Changes in Employment of Foreign Staff (October 2020 to August 2022)

EPA

Vocational School
Graduates(certified care
workers)

ForeignStudents

Internship
Programme***Technical Intern
Trainees***

Facility A

3 (-1)**

4 (+1)

1 (-2)

2

3 (+4)

Facility B

0

2

0

Facility C0

1 (+1)

1 (-1)

1 (+2)
4 (+2 Pending
Entry)

1

EPA = Economic Partnership Agreement.
Notes: + - Change from previous year including entries in 2021 and 2022. Current as of August 2022.
**1 with approved caregiver certification; ***pending entry; *** care workers on internship programme with
Vietnamese Nursing University.
Source: Juseien, Imayama-kai Group Home.

Table 5.11. Employment Status of Foreign Workers across Facilities (by Country)*
Myanmar Philippines
Certified Care Worker

1

EPA Certified Care Worker
CandidateSpecific Skills Care Worker

1

Technical Intern Care
WorkerInternship Programme

Nepal

Sri Lanka

5

4

5
6

4
3

Foreign Student
TotalsVietnam

1
11

2

9

4

4

EPA = Economic Partnership Agreement.
Note: * Current as of August 2022.
Source: Juseien, Imayama-kai Group Home.

At some elderly-care facilities, foreign care staff, especially those with nursing educational
background and clinical knowledge, were highly appraised for the professional capacity that they
displayed whilst the pandemic played out. It provided a positive opportunity to reappraise the role ofmigrants as essential key workers who have fulfilled some vacancies of shift work caused by theabsence of Japanese co-workers due to the pandemic, and thus sustained the healthcare system of
their workplaces during a time when it was tested.
Additionally, to diversify care worker streams, the above-mentioned facility A is fostering apartnership with a Vietnamese nursing college through an internship exchange programme, increaseknowledge cultivation and circulate human resources within the group home with a secure supplier.

88

Several findings from this case study were identified:•

The pandemic provided an opportunity for Japanese staff to acknowledge and appraise migrantco-workers as valuable and essential workers. Migrant care staff’s presence has been evaluatedpositively more than before. Such recognition was commonly shared with key officials of theInternational Welfare Service Corporation (JICWEL) that is responsible for the EPA projects fornurses and care workers from Southeast Asian countries.5•

The facility’s experience provides an example of the challenges that care homes face inmaintaining and training a diverse pool of workers from different countries and migration
streams.

•

A pragmatic approach aligns with a model of knowledge circulation that local government has
been fostering in the hope of creating a system which can be replenished by future migration
streams.

4.5.

New Trends of Employment and Mobility under the Pandemic

Facilities such as those mentioned above, are part of an information sharing network, the Kyushu
Committee for Development of Overseas Human Resources, set up and coordinated by a local
training company for care work. The authors (Ohno and Lopez) are both active members of thecommittee, a broad coalition comprising nursing care facility directors and managers based in
Fukuoka, technical training supervision organisations, the heads of non-profit organisations,executives of the Fukuoka Prefecture legal specialists, and academics (Japanese and foreign). One
online discussion meeting with other participating members that took place on 4 December 2021
clarified several important issues for committee members.
•

There exists great difficulty in procuring professional migrant care workers to work in semi-rural
areas far from larger urban areas.

•

Skilled workers who already have a national licensure for certified care worker such as EPA
workers are difficult to retain for a long time due to lower wages in Fukuoka. Many have moved
to higher paying regions such as Tokyo and Osaka.6•

The pandemic exacerbated a shift from EPA professionals to technical intern trainees as part ofa strategy to diversify the pool of available workers to avoid the ‘brain drain’.

•

Career paths in care work have concrete limitations. With migrant care workers who switch overto the specified skills worker visa, the system offers flexibility, but it means that employers run
the risk of a high turnover of workers.

Several participants related the challenges that they face, including a turnover of workers due tostagnation. One social welfare provider instituted their own criteria for evaluating work and language

5

Our research team hosted an online meeting with three directors of the JICWEL in charge of EPA projects on
13 January 2022. They noted that EPA personnel and other foreign care staff had filled vacancies due to theresignation of Japanese staff and the latter’s absence due to their fear of corona infection.
6
Tokyo Metropolis ranks its highest annual income for care workers affiliated with social welfare facilities inJapan (¥4.01 million=$34,870). On the other hand, Fukuoka Prefecture ranks 31st (¥3.29 million= $28,610)
amongst 47 prefectures in Japan and is 82% of the annual income in Tokyo. Data are based on surveys conductedby Japan’s Ministry of Health, Labour and Welfare (MHLW) in 2019.

89

proficiency and created an appraisal system that reflects in the salaries workers receive as well as
introducing a mentor system where more experienced workers (Vietnamese) help those who are stilltraining to communicate. Some organisations are developing more dynamic approaches to thecirculation of knowledge, but only at the initiative of the organisation, rather than that built into thecriteria of the specified skilled worker visa. Such an approach presents a pragmatic strategy that
acknowledges the limits of visa system in place. Due to this, in the long term, shifts to different
streams may ultimately impact the quality of care in facilities.
4.6.

Findings and Lessons Learnt from Fukuoka’s CaseOur research found that Fukuoka provides a clear case of issues that are converging and require
attention. First, to recognise the current ways in which migrant streams were reorganised due to thesocioeconomic impact of the pandemic. Second, to further evaluate and appraise the local initiatives
that care providers have taken to secure care labour streams. Third, to not only recognise theappraisal of foreign migrant care workers in care facilities, but also rethink what kind of systems canallow more upwards career mobility and more incentives to retain professional migrant care workers
at their workplaces in reginal cities and towns. Finally, this will provide a clearer career path
opportunities for highly skilled workers and improve the visibility of industry needs and opportunities
domestically and overseas.

5.

Failure of the International Labour Market: Examining the Case of Migrant Care
Workers

5.1.

International Market and Migrant Care Workers

In 2015, there was a significant transformation in the migration patterns of care workers in Japan.
During that year, housekeepers began to be accepted as one migrant stream and ‘nursing care’ wasestablished as a new status of residence for elderly care. In 2017, the Technical Intern Training
Programme (TITP) was extended to nursing care, then subsequently the Specified Skilled Worker(SSW) programme was introduced in 2019. The latter programme aimed to recruit a substantial
number of care workers and was intended to accept a maximum of 350,000 people across 17 selectedindustry sectors. However, the significant expansion caused several problems within the international
labour market resulting in a process called ‘adverse selection,’ where an appropriate recruitment
system was not implemented. Adverse selection can occur due to information asymmetry in themarket, negatively impacting rational choices. This is what is happening in the contemporaryinternational labour market of care workers in Japan. The following section will focus and illustrate
this point.
5.1.1.

Zero Placement Fees Less Selected

Let us begin by examining the recruitment process across different recruitment channels. One suchchannel is the acceptance of care workers under the EPA implemented in 2008. A basic requirement
for accepting care workers from Indonesia and Viet Nam is graduation from a nursing school, and for
the Philippines, graduates must have completed 4 years of university study and hold caregiver
qualifications. The EPA aims to facilitate candidates to obtain a certified care worker license in Japanand provides about 1 year of training in the Japanese language and multiple subjects on elderly care90

before and after their arrival in Japan at the expense of the Japanese government. Moreover,accepting facilities are mandated to provide education assistance for the licensure examination,
which is financially supported by local governments. JICWEL handles the matchmaking andcoordination for EPA without imposing any financial burden on the workers.
For this section, the author (Wako Asato) estimates that the total public support per care worker isaround ¥2.5 million based on the government’s total budget. The EPA regulations stipulate thatplacement fees should not be charged to incoming workers but should be shouldered by theaccepting organisation. The organisation that accepts applicants for EPA may have implemented aneffective recruitment system, leading to high levels of satisfaction amongst accepted candidates.
Additionally, Vietnamese applicants may have a high passing rate of the national licensure
examination, exceeding 90%, which is higher than the passing rate for Japanese applicants. This could
be attributed to the effective recruitment system in place. However, the number of applicants for thisframework continues to decline, particularly those from Viet Nam, which has a high reputation
amongst accepting organisations. As a result, the EPA quota of 300 persons per country per year is
not being met and the accepted number of care workers peaked at 773 persons in 2018.
5.1.2. Money Attracts People and Politics
Let us examine TITP trends. Of the four migrant care worker streams that exist such as the EPA,
international care students, the TITP, and the SSW programme, the number of incoming care workers
coming through the TITP have increased greatly. There were less than 2,000 entrants 2,000 in 2018,
but the number shot up to 12,000 by 2020.
Out of the total number of TITP participants, Viet Nam comprises the largest number of 653 in 2018
to 5,142 in 2020, accounting for 43%, an overwhelming popularity amongst receiving facilities.
Despite the Philippines having a long history of providing workers for domestic work, elderly care,and nursing in the international labour market, they have only accepted 13 to 917 under the TITP.
This is noteworthy as the Philippines bans the collection of placement fees from workers under the
TITP, whereas in Viet Nam the legal placement fee is US$3,600. According to the author’s calculations
examining TITP applicants to Japan in 2019, the actual payment of workers reached US$7,000. There
are several reasons behind the negative impact of high placement fees. One is the high rate of‘absconding’7 trainees, which stands at about 2.79% amongst Vietnamese technical intern trainees,
whilst the ratio was less than 0.47% amongst Filipinos in 2019 (Table 5.12).

7

The term ‘absconding’ or ‘abscondence’ is controversial amongst scholars and activists who sympathise withtechnical intern trainees as in general, they are not allowed to change their workplace under related laws. The
Japanese government has confirmed numerous cases of labour law violations and human right violations at
workplaces in the past. Therefore, some scholars argue that abscondence should be referred to as an‘emergency evacuation’ to better capture their situations and circumstances.

91

Table 5.12. Technical Intern Trainee Absconders by Nationality
Ratio ofabscondence
Nationality
bynationality

Ratio ofabscondence
in 2019(estimate)Amount of legal
placement fee

Average of placement
fees for absconding
migrants (¥ thousand)Philippines

NA

0.473%

zero

222

Indonesia

3.50%

0.867%

no upper ceiling

408

Myanmar

3.90%

2.65%

US$2,800---

Cambodia

5.30%

4.85%

no upper ceiling

700–800

China
Viet Nam

15.10%
69.40%

1.61%
2.79%

no upper ceiling
US$3,600

837
1,028

NA = not available.
Note: The ratio of abscondence is determined by the number of absconders in 2019 divided by the number oftechnical intern trainees in 2019. Even though the Philippines is included with the others, the author applied
the number of absconders of other countries divided by technical intern trainees from the Philippines. Legal
placement fees are noted from the governments of sending countries and interviews with stakeholders. Also
see Mekong Migration Network (2019a 2019b).
Source: Ministry of Justice (2022).

There are two points of importance here. First, the annual quota of 900 workers in the placementfee-free EPA has not been met, whilst the number of technical intern trainees, which typically comewith higher costs, increased by 10,000 over the past 2 years. Second, although the Philippine
government prohibits the collection of placement fees, the number of interns from the Philippines
remains low. In summary, the higher the placement fee onto the worker, the greater the number ofplacements. This can be interpreted as a higher placement fee becoming the recruitment incentive
force in the labour market. In Viet Nam, each placement has a direct economic impact of at least
US$3,600, whilst the ripple effect in the sending country is extremely limited as with the case of EPA
personnel and technical intern trainees from the Philippines due to the lack of a recruitment fee.
The average placement fee for those who abscond is an estimate from the surveys on those
absconding from accepting organisations. The average placement fee for Cambodian absconders is
not available from the survey. However, according to the Manpower Association of Cambodia (MAC)
the typical placement fee is more than US$6,000. Therefore, the placement fee for absconders is
considered higher than this.
The EPA and the TITP are under the jurisdiction of Viet Nam’s Overseas Labor Administration of the
Ministry of Labor, Invalids and Social Affairs and the Department of Migrant Workers8 respectively.
TITP sending agencies authorised by the Viet Nam government receive a minimum of US$3,600 from
one to-be-worker and are motivated to attract people to work in Japan by providing extensive

8

The Philippines’ Department of Migrant Workers was created in February 2022. It now assumes and performs
all the powers and functions of seven merged agencies of the Department of Labor and Employment (DOLE)
and Department of Foreign Affairs such as the Philippine Overseas Employment Administration (POEA) of the
DOLE (Department of Migrant Workers, 2022).

92

Japanese language training, prompt procedures, welcoming hospitality, and kickbacks to satisfy
clients from Japan. In contrast, the EPA programme cannot expect any economic effect on sending
agencies and government bodies since the agreement prohibits the collection of any placement fee.
Furthermore, since there is no economic incentive to do so, popularity has been gained by the TITP.
The slow progress in sending technical intern trainees from the Philippines to Japan is due to the factthat the sending agency, without charging a placement fee on workers, does not have enough capitalfor Japanese language education and no services and kickbacks are provided to Japanese clients due
to strict regulations. The zero-placement fee, in turn, signifies that the cost of migration is relatively
borne by receiving organisations.
This suggests that the higher the economic spillover effect, the stronger the centripetal force of
attracting accepting organisations through the provisioning of a series of incentives. In fact, newsending countries such as Cambodia and Myanmar, have increased their popularity and share in theinternational labour market by increasing the burden on workers, whilst alleviating the share of thecosts on accepting organisations.
5.2.

Unpopular Specified Skilled Worker Programme

The specified skilled worker programme is unique in that it allows job-seeking activities directly withJapanese companies without sending agencies if certain requirements are met, such as passing theN4-level examination of the Japanese Language Proficiency Test (JLPT) and skills proficiency tests
conducted in Japanese. This programme enables applicants to apply without paying a placement fee.
However, this is not popular in sending countries such as Viet Nam and Cambodia, where highplacement fees are common. There are two reasons for this. First, governments point out that thisprogramme without a mediating sending agency cannot protect workers since responsibility in thesending country is unclear. Second, the economic ripple effect is limited without a charge on thepotential worker within the sending country.
For these reasons, most sending governments require registration with a sending agency, claimingthat the programme is flawed. In other words, the alleviation of the placement fee is not in line with
the intention of the Japanese government. Indonesia is an exception in that, unlike others, it does not
require registration with sending agencies. Workers simply register online with the System forOverseas Worker Management Services without the collection of a large fee.
Figure 5.8 illustrates the number of new arrivals in Japan under this programme. Looking at themonths of March and April in 2022 when the restrictions on movement due to COVID-19 infection
were greatly eased, the largest number of new arrivals is not from Viet Nam, but from Indonesia. This
could suggest the reluctance of sending specified skilled workers from Viet Nam, whilst relatively
smooth procedures are ongoing in Indonesia. However, it does not mean the registration system is
not flawed since the level of language requirement is as low as the N4 level of the JLPT; it may bedifficult for applicants to conduct job-seeking activities without an interpreter service or broker tohelp with the job search.

93

Figure 5.8. New Arrivals of Specified Skilled Workers by Country of Origin

VN = Viet Nam, PH = Philippines, IN = Indonesia, CH = China, MM = Myanmar, KH = Cambodia.
Source: Immigration Services Agency of Japan (2022).

5.3.

COVID-19 and Migrant Care Workers in Japan

According to a series of surveys that the author conducted mainly in the Kansai region during the firstwave of COVID-19 infections, which had a substantial economic impact on migrant workers at thenational level, workers were able to maintain financial stability. However, despite this, there are stillsome points of concern, specifically regarding family members in the country of origin. Care work
amidst the COVID-19 infection had a strong employment absorption capacity, and many foreigners,
regardless of their status of residence, have been entering as new workers. Although some care staff
left their employment due to concerns over the transmission of COVID-19, more migrant care
workers, mostly non-certified care workers, have begun to engage in elderly care. They often seemto be able to fulfil their positions as care workers, whilst in the condition of being infected (theinfected care for the infected). However, only very few are engaged in managerial positions, and manyof them are placed on the frontline where they tend to be exposed to cluster infections within theirworkplaces.
5.4.

Findings and Lesson Learnt on Placement Systems of Migrant Care Workers

Japanese society displays an ethical double standard when it comes to accepting migrant workers,
even in the field of elderly care. Japanese laws prohibit the collection of fees from job seekers in Japan.
However, collecting fees from overseas job seekers particularly in the TITP is a common practiceabroad. It is not uncommon for Vietnamese under the TITP to pay in excess of ¥1 million before theirarrival in Japan. Ironically, the higher the placement fee, the more popular the programme.
Zero placement systems such as the EPA and the TITP from the Philippines are on the decline. This
could be because of less lucrativeness from sending governments and fewer applicants from sending
countries or because of fewer accepting organisations in Japan.

94

The high ratio of abscondence amongst TITP workers is closely linked to the high placement fees andlow wages the workers face, which represents a contradiction between the programme's popularity
and the abscondence ratio. In other words, the institutional framework of migration is a major
contributor to this problem, and as a result individual workers are the ones who suffer. Withoutchanges to the institutional framework, this vicious cycle will persist. This can be seen as the social
construction of vulnerable workers.
The abscondence ratio amongst technical intern trainees who provide care for the elderly is currently
very low. This could be because the programme is new to the care sector. However, if placement fees
continue to be overcharged, the ratio will likely increase, given the current institutional setup. To
break the vicious cycle of the failure of the international labour market, multilateral politicalintervention is essential. There are several suggestions that can help improve current conditions. First,
a memorandum of understanding on the TITP and the SSW programme should be raised to the levelof an international agreement that binds domestic laws for the cost management of placement fees.
Second, the creation of a transparent and accessible information platform should be established toprovide accurate information about the recruitment process. The programme run by the Philippines’
Department of Migrant Workers.can be seen as a successful case. Finally, more stringent permit
restrictions should be imposed on organisations that hire foreign workers if they violate labour laws.

95

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Antonovsky, A. (1987), Unraveling the Mystery of Health: How People Manage Stress and Stay Well.
San Francisco: Jossey-Bass Publishers.
Association of Educational Facilities for Certified Care Worker (2022), ‘Kaigo-fukushishi Yosei-shisetsu
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facilitiesforcertifiedcare
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students’].
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(in Japanese)
Department of Migrant Workers, 2022, ‘Department ofhttps://www.dmw.gov.ph/about-dmw (accessed 4 May 2023).

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Kaigo
Hoken
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Fukuoka Prefecture (2017), ‘Fukuoka Ken Chiiki Iryo Koso, Fukuoka. Dai 2 Sho, Iryo Keikaku, Koreisha
Hoken Fukushi Keikaku Nado to Chiiki Iryokoso no Kankeisei’ [Prefecture Regional Medical
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Hiruma Y., F. Michigami and M. Sone (2022), ‘Shizuokaken-nai no Betonamu-jin Kaigo Ginou-jisshusei
no Jittai ni- kansuru Chousa Repoto’ [Report on Survey of Vietnamese Technical Intern
Trainees for Nursing Care in Shizuoka Prefecture]. http://www.shizuoka-wel.jp/wpcontent/uploads/2022/06/report-research.pdf (accessed 27 June 2022). (in Japanese)
Immigration Services Agency of Japan (2022), ‘Shutsunyukoku Kanri Tokei Tokei-hyo’ [Statistics for
immigration
andemigration,
tableofstatistics].
https://www.moj.go.jp/isa/policies/statistics/toukei_ichiran_nyukan.html (accessed 10
July 2022). (in Japanese)
Immigration Services Bureau of Japan (2022), ‘Tokutei Ginou Zairyu Gaikokujin-suu no Kohyo’[Releaseof
numbersofforeign
specifiedskilledworkers].
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Mekong Migration Network (2019a), ‘Social Protection Across Borders: Roles of Countries of Origin
in Protecting Migrants’ Rights’. Chiang Mai: Mekong Migration Network.

96Mekong Migration Network (2019b), ‘Labour Migration from Mekong Countries of Origin to Japan’.
Chiang Mai, Thailand: Mekong Migration Network.
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Matome, Reiwa 3-nen 10-gatsu-matsu Genzai’ [Roundup for reports on employment offoreigners as of the end of Oct. 2021]. https://www.mhlw.go.jp/stf/newpage23495.html(accessed 25 July 2022). (in Japanese)―― 2022b, ‘Dai-34-kai Kaigo-fukushishi Kokka-shiken Kekka no Uchiwake [Breakdown of the resultsof the 34th national licensure examination for certified care worker].
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Ministry of Justice (2022), ‘Ginou-jisshusei no Shissosha-suu no Suii, Heisei 25-nen Reiwa 3nen’[Transition of numbers of absconders among TITs in 2013-2021].
www.moj.go.jp/isa/content/001362001.pdf (accessed 10 July 2022). (in Japanese)
Mizuho Research & Technologies, Ltd. (2021), ‘Kaigo Gyoshu ni Kakaru Ginoujisshusei no Ukeire no
Jittai ni Kansuru Chosa Kenkyu Hokokusho’ [Report on Survey Research on the Actual
Conditions of Acceptance of Technical Intern Trainees for Nursing Care Occupations].
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20 July 2022). (in Japanese)
Organization for Technical Intern Training (OTIT) (2021), ‘Reiwa 2-nendo Gyomu Toukei’ [Businessstatistics of fiscal year 2020] https://www.otit.go.jp/gyoumutoukei_r2/ (accessed 26 July2022). (in Japanese)
Sasaki A. (2020), ‘Korona Ka ga Nihon no Kaigo Ryoiki ni Okeru Imin ni Ataeta Eikyo’ [The Impact of
COVID-19 pandemic on Immigrants in the Japanese Nursing Care Area]. IDE Article
http://hdl.handle.net/2344/00051868 (accessed 20 July 2022). (in Japanese)
Tanaka, K., M. Tahara, Y. Mashizume, and K. Takahashi (2021), ‘Effects of Lifestyle Changes on the
Mental Health of Healthcare Workers with Different Sense of Coherence Levels in the Eraof COVID-19 Pandemic’, International Journal of Environmental Research and Public Health,18(6), 2801. https://doi.org/10.3390/ ijerph18062801

97Chapter 6
Capacity Building for Resilient Long-term Care in Thailand

1.

Introduction

The novel coronavirus disease (COVID-19) pandemic brings challenges to both government andprivate sectors in order to ensure adequate care for elder citizens and persons with disabilities. Bothlong-term care workers and those that they care for have revealed vulnerability or resiliency,
depending upon certain factors. This study of Thailand explored the knowledge, attitudes, andpractices (KAP) amongst caregivers and village health volunteers (VHVs) and investigated thecatalysing factors leading to vulnerability or resiliency regarding the COVID-19 pandemic.
Recommendations are also formulated based on evidence found from this study.
1.1.

COVID-19 and Older People in Thailand

Thailand transitioned to an aged society in 2020, with approximately 12 million people that are aged,
about 19.2% of Thailand’s population (NSO, 2017). One report (UNFPA, 2021) has mentioned that
almost one out of every five people is aged over 60 years and one out of 10 people is aged over 80
years. While almost 2 million older persons are not in good physical health, with some 250,000 being
in extremely poor condition, more than 80% of them are still active and productive in some way.
However, Thai society itself is going through a significant transition, moving away from a traditional,
nuclear family-oriented pattern. The family structure now seems to be fragmented, with physical andpsychological distances amongst its members. Further, there are more older persons today that arepoor, many of whom live alone and lack family and other socioeconomic support, and that was the
picture before the COVID-19 pandemic in Thailand.
When the COVID-19 pandemic occurred in China and other countries in the region in 2019, Thailand
was attacked by the disease beginning in 2020, and the crisis became more serious in 2021 during
the third wave of the pandemic. In the early days of the pandemic, the Thai government gave serious
attention to controlling the pandemic situation. A state of emergency was declared on 26 March 2020,
right after new COVID-19 cases spiked to 111 in one day. This was followed by curfews and various
public health measures to contain the spread of the virus. These measures have proven successful;the death toll as of the 23 April 2020 was 50, and the total number of confirmed COVID-19 cases
amongst Thai citizens was 2,521, of which 10.1% were older persons aged 60 years and over
(Department of Disease Control, 2021). However, during this third wave of the COVID-19 pandemic,
a new high rate appeared in early May of 2021, and that made people frightened and stressed.
Daily reports find that many new cases are older persons that are living with their family, some areliving as couples, and some are in age-care facilities. Therefore, this shines light on the fact that older
persons need special attention, as their infections are more serious than other age groups; themortality rate amongst them is also higher. Not only have serious problems emerged in terms of their
physical health, but also in terms of their mental health and economic problems. One report98mentioned that almost 90% of the weak elderly in Thailand do not have a caregiver. They must takecare of themselves and therefore the risks to them during the COVID-19 pandemic are obvious.
A survey in Thailand exploring the impact of COVID-19 on older persons was conducted in July 2020
by the College of Population Studies, commissioned by the United Nations Population Fund (UNFPA,2020). It was the very first COVID-19 survey directly focusing on older persons aged 60 years and over.
The survey explored information on economic status, living arrangements, and the physical andpsychological health of the respondents before and during the COVID-19 outbreak. It was found fromthe report that overall, 80% of the participants indicated that their health was about the same as
before COVID-19, and about one-fifth felt that their health was worse than before. This proportion
was higher in urban than in rural areas. Only small percentages (4% to 8%) reported that their healthproblems became worse during the COVID-19 pandemic; their income was either sometimes oralways inadequate before the COVID-19 outbreak. In terms of living arrangements, 67% co-resided
with at least one child, whereas 5.5% lived alone and 12% lived with their spouse only. One-quarterof older persons experienced one of the selected psychological symptoms, either sometimes oralways during the COVID-19 pandemic. The most common symptom was feeling worried, loss ofappetite, loneliness, and unhappiness. The percentages varied little by gender but were significantly
higher in urban areas than in rural areas. Older persons living alone were more likely to feel lonely
than those in other living arrangements. However, very little was mentioned about the elderly in longterm care (LTC) facilities, which seems to be a worse situation than those living with family members.
In early 2022, severe COVID-19 infections seemed to have decreased because of high vaccination
rates in Thailand. However, the Omicron variant has begun to spread around the country in the
middle of 2022 and decreased in late 2022. Since then, most of the infected persons have been
asymptomatic or have had only mild symptoms.
1.2.

Long-term Care in Thailand and the COVID-19 Pandemic

The World Health Organization (WHO) defined long-term care as ‘services to ensure that people with,or at risk of, significant loss of physical and mental capacity can maintain a level of functional ability
consistent with their basic rights, fundamental freedom, and human dignity’ (WHO, 2020, p.9). In
Thailand, there are about 800 LTC facilities, and most of them are small and medium sized. There are
only 40 large LTC facilities within central Thailand and in some large cities. With regard to thedefinition of LTC by the WHO (2020, p.9) ‘long-term care facilities vary by country. Nursing homes,
skilled nursing facilities, assisted living facilities, residential facilities, and residential long-term carefacilities are collectively known as long-term care facilities that provide a variety of services, including
medical and assistive care to people that are unable to live independently in the community’.
However, this study focuses on long-term care facilities that include only nursing homes andcommunity care facilities organised by the private and public sectors in Thailand.
It has been mentioned in many reports that COVID-19 has disproportionately affected long-term carefacilities. Evidence shows that what is needed is to mitigate the impact across all aspects of long-termcare, including institutional-based and community-based care, given that most users and providersof care are vulnerable to severe COVID-19. The Thai government therefore is paying attention to andis concerned about long-term care both in the community and in the institutional sector. Guidelines
for COVID-19 prevention developed by the Ministry of Public Health in Thailand have been distributed
to LTC facilities. Many social media and announcements concerning COVID-19 have been distributed.

99

At present, long-term care facilities such as private nursing homes receive support from the Healthand Elderly Establishment Confederation (HEC) in terms of a range of information related togovernment programmes, training, and advocacy. Those facilities are encouraged to be a member ofthe HEC. At present, the HEC covers more than 50 % of LTC facilities in Thailand (HEC, n.d.). During
the COVID-19 pandemic, the HEC has played important roles in assisting the facilities by providing
knowledge and skills to prevent COVID-19. High coverage of COVID vaccines amongst the elderly infacilities were also supported by the HEC.
1.3.

Volunteering in Thailand

In the context of community-based LTC, the essential support has come from the Local Administrative
Organization, public health centres, and hospitals and local networks. VHVs have been cited as key
persons providing proactive support and have successfully managed COVID-19 outbreak control byplaying a huge role. There are approximately 1,055,000 active VHVs in Thailand (Department ofProtocol, Thailand, 2020) and each province contains around 104,000.
VHVs have been recognised as valuable assets for the primary healthcare system in Thailand for many
decades, and they have begun to play an important role in line with the concept of community
participation since 1977 (Chuengsatiansup and Suksuth, 2007). This group of people come from avariety of careers and backgrounds; however, most of them are females with low and middle incomes.
Their roles in primary care services have been accepted and are trustworthy, and they perform very
well on short-term tasks such as taking ad hoc health surveys, collecting periodic data, and conducting
disease prevention campaigns by collaborating with health personal.
At the beginning phase of health volunteering, VHVs are very involved with maternal and child health,family planning, and infectious disease control. Recently, as Thailand has approached an aged society,areas of work are needed with long-term, continuous dedication, such as caring for chronically illpatients and dependent elderly. Further, health issues have become more complicated, and digital
literacy is needed, and therefore VHVs have been equipped by the Ministry of Public Health and othersectors, such as the local administrative organisation that runs many training programmes for VHVs.
During the time of COVID-19, VHVs have been very active and have provided a lot of support to thepeople in their villages.
According to the changing contexts in Thai society, the relevance of the conventional model of VHVs
has been called into question. The Ministry of Public Health (MoPH) currently therefore has launched
new mechanisms for primary healthcare services that increase the roles of VHVs called ‘three doctors
for primary health care’. The VHV is so called the ‘first doctor’ in the village and works collaboratively
with the second doctor, who is a member of the public health personnel or nurse practitioners at the
local health centres; and the third doctor is the family physician. VHVs are expected to communicate
more with their villagers, use basic tools for health assessment, and then report the results to thesecond doctors. This strongly indicates that health volunteering has been progressively more
accepted and plays an increasing role in Thai society.
1.4.

Capacity Building of the Long-term Care Team for COVID-19 Prevention in Thailand

The unique challenges that have affected the ability of long-term care systems to respond to the
COVID-19 pandemic are currently presented by the WHO (2020). The 11 key actions for addressing

100these challenges in the short and longer term seem to be beneficial to LTC if all stakeholders arecollaboratively implementing these key actions. This study focuses on three of the 11 key actions asfollows: (i) ensuring that infection prevention and control standards are implemented and adhered
to in all long-term care settings to prevent and safely manage COVID-19 cases, (ii) providing support
for family and voluntary caregivers, and (iii) prioritising the psychosocial well-being of people
receiving and providing long-term care services.
In early 2021, the Thai Health Foundation granted funding to an academic group to carry out a project
for the infection prevention of COVID-19 for LTC facilities across the country. Fifteen facilities havebeen included in the training programme, and it is expected that acceptable guidelines will be
produced through learning and sharing across settings. However, significant factors relevant to theeffectiveness of the programme have not been explored yet. Regarding the statement, ‘truly leave noone behind in the response to COVID-19, Thailand needs to do more in terms of prevention,
preparation, and response to the COVID-19 pandemic’, and to mitigate its impact across long-termcare services, including care providers.
Recently the MoPH in Thailand launched new regulations for private LTC facilities to monitor andsupervise services. Private LTC facilities in Thailand have been informed to register with the MoPH
and have to follow the new regulations; for example, caregivers must be trained by certified
institutions with a total of 420 hours and a completed self-assessment report submitted to the MoPH,
along with an application form. The MoPH will then send auditor teams to visit the LTC facilities toensure that adequate quality standards are met and that licenses of owners and care workers arerecorded.
In conjunction with the LTC network, the researchers of this study continued to utilise the existing
programme and used evidence gained from previous studies to make refinements and to ensure theeffectiveness of the training programme and recommendations.

2.

Objectives of the Study•

To explore the situations and factors related to the prevention of COVID-19 in institutional andcommunity LTC for the elderly during the COVID-19 pandemic.

•

To develop a model for a training programme for the caregivers in nursing homes, family
caregivers, and village health volunteers using existing evidence and media.

•

To utilise the training programme and collect feedback about on COVID-19 prevention in
institutional and community care settings.

3.

Research Procedures

3.1.

Field Survey (observational study)

Bangkok and Patum-Tani Province were selected as field survey settings. The situations and factors
related to the prevention of COVID-19 in institutional and community care for the elderly were
explored in December 2021. A KAP survey and resilience quotient questionnaire were applied inorder to obtain the factors related to the prevention of COVID-19 infection. The essential documents,
such as business continuity plans (BCPs), and infectious disease control manuals used in LTC facilities
during the COVID-19 pandemic were also explored.
101

3.2.

Development of a Model for a Training Programme (meetings and consultation activities)

The results from the KAP survey and the existing programme used for LTC capacity building developedby the Thai Health Foundation were brought together, analysed, and synthesised. The redesigned
model for training emerged from a research team meeting and consultations with the LTC facility
leaders and the chair of the VHVs. The model is presented in Figure 6.1. The researchers selected
existing media for the training and applied them to the training programme (the media used areshown in Appendix 3).
The research team carried out focus group discussions with home nursing staff and VHVs in order toexplore the details of the developed model and to extract the essence of each factor, and then used
this information in the workshop on capacity building for LTC facilities. At this stage the model has
been refined and adjusted to suit each type of LTC. Lastly, we obtained two models, as shown in
Figures 6.2 and 6.3.
3.3.

Implementation of the Model and Collecting Feedback

The workshops to implement the model of capacity building for resilient LTC were carried out in the
middle of June 2022 and approximately 30 VHVs and 10 caregivers participated. Online group
discussions and individual interviews were carried out after the implementation of the programme
to collect feedback on the programme in terms of satisfaction with it, and self-efficacy amongst thecare workers and caregivers in terms of the prevention of infection and the impacts on resident care.

4.

Results of the Survey

A cross-sectional survey was carried out in December 2021 at the time of the pandemic crisis in
Thailand. Online responses were obtained through google form application with 126 participants thatwere involved in LTC activities. The study areas were Pathum-Thani Province and Bangkok, as
indicated above. The data for this study were collected using a KAP survey questionnaire and a
resilience quotient scale and were analysed by adopting descriptive statistics: percentage, mean, andstandard deviation. In addition, two focus group discussions were carried out from January to
February in 2022 in order to collect qualitative data illustrating the situation of LTC and the factors
related to COVID-19 prevention. The first group of participants were LTC facility staff and the owners,
and the second group participants were VHVs and community leaders working with communitybased LTC in Pathum-Thani Province.
4.1.

The Knowledge, Attitudes, and Practice (KAP) Survey

The KAP survey obtained 126 participants with the response rate of 85%. The results were divided
into four parts: (1) the demographic characteristics of the participants, (2) the knowledge of theparticipants, (3) the practice of the participants, and (4) the resilience quotient, which reflected
attitudes towards their life during the pandemic.

102

Demographic Characteristics of the Respondents
Table 6.1 shows the characteristics of the respondents; the majority were female (88.10%), theaverage age was 64.65, the value of the standard deviation (SD) was 8.42, the maximum age was 79
years, and the minimum age was 48 years. Half of them had one to two family members that wereover or equal to 60 years of age (including the respondents), one person (32.54%), and two people(29.37%). Most of them did not have COVID-19 patients (92.86%) or a bed-ridden person (95.24%) in
their family.

Table 6.1. Demographic Characteristics of the Respondents
Demographic characteristics
1. Gender
Male
Female2. Age (years)
3. The number of family
members that were over or
equal to 60 years of age.
(Including the respondents)
0 persons
1 person
2 people3 people4 people5 people
6 people
8 people
4. COVID-19 patients in family
YesNo
5. Bed-ridden person in family
YesNo

Frequency(n = 126)

Percentage
(%)

15
111

11.90
88.10

30
41
37
8
5
3
1
1

23.81
32.54
29.37
6.35
3.97
2.38
0.79
0.79

9
117

7.14
92.86

6
120

4.76
95.24

Average

SD

Max.

Min.

64.65

8.42

79.00

48.00

SD = standard deviation.
Source: Developed by researchers.

Knowledge of the Respondents
After the data collection and analysis, the participants that were VHVs and caregivers in LTC facilities
were found to have relatively high KAP scores, as shown in Table 6.2. The participants seemed to haveclear knowledge about COVID-19. Some unclear knowledge was related for example to how long thecoronavirus can survive on a surface and in the air and frequently-touched areas (do notknow=18.25% and 9.52%, respectively), the duration of the infection (do not know=7.94%), and103

asymptomatic pathogen holders (do not know=11.11%). These four points were discussed andexplained in greater detail with the participants in the capacity-building training session.

Table 6.2. Knowledge of the Participants (n=126)
AnswerStatements

No
n (%)

I know that infection with COVID-19 causes
fever, respiratory symptoms (cough, sorethroat, nasal discharge, nasal closing, etc.),
headache, malaise, etc.
2. I know that COVID-19 has similar initial
symptoms to influenza and colds.
3. I know that COVID-19 make people lose senseof taste and smell.
4. I know that COVID-19 was initially thought tospread with contact or droplet infections, but
has now been proven to spread with aerosol
infections.
5. I know that the underlying diseases (chronic
respiratory diseases, diabetes, cardiovasculardisease, etc.) are high-risk factors for COVID19.
6. I know that the COVID-19 virus remains in the
air for about 3 hours in aerosol form, about 72
hours on plastic and stainless steel surfaces,
about 24 hours on cardboard surfaces, and 4
hours on copper surfaces.
7. I know that the COVID-19 virus is more
attached to patients’ pillows, telephoneanswering machines, TV remote controls,
doorknob and toilet environments.
8. I know that most COVID-19 patients are thesources of infection transmission.
9. I know that COVID-19 is transmitted before
onset (2 days before onset) or fromasymptomatic patients.
10. I know that COVID -19 is most infectious
before and after the onset.
11. I know that COVID-19 causes aerosol infections
in enclosed spaces.

Yes
n (%)

1.

104

2 (1.59)

7 (5.56)
4 (3.17)124(98.41)
119(94.44)122(96.83)1 (0.79)125(99.21)1 (0.79)125(99.21)23 (18.25)

103(81.75)12 (9.52)

114(90.48)9 (7.14)117(92.86)6 (4.76)120(95.24)

11 (7.94)
4 (3.17)115(92.06)122(96.83)

AnswerStatements

No
n (%)

12. I know how COVID-19 becomes more severe
with symptoms associated with pneumonia
and respiratory failure.
13. I know that in COVID-19 severe cases, theprogression after pneumonia progresses
quickly and the condition deteriorates rapidly,
so careful observation and quick response are
required.
14. I know that the close contact person is one
who comes into contact with the COVID
patients between 2 days before a term fromthe onset.
15. I know that the patients here include‘asymptomatic pathogen holders’.

Yes
n (%)
9 (6.35)

117(93.65)6 (3.97)120(96.03)4 (3.17)122(96.83)14 (11.11)

112(88.89)Source: Developed by researchers.

Practice of the Respondents
Table 6.3 shows the practice of the respondents divided into two parts: the first part was COVID-19
preventive behaviour for themselves, and the second part was COVID-19 preventive behaviour forthe elderly in the household, community, or nursing home. The results of the first part show that the
majority would wear a mask when going out (97.62%), wash their hands before and after meals,
coughing, and using the toilet (95.24%), and having a hot meal or just cooked food (95.24%). However,wearing a mask in their own house when doing things with the family was the lowest level of practice.
The results of the second part show that the majority would stop contacting the elderly when they
have a fever, cough, or sore throat (85.71%), wash their hands with soap or alcohol gel before andafter touching the elderly (83.33%), and wear a mask anytime they were taking care of the elderly(79.37%). While the behaviour that the participants practiced for themselves was appropriate, one
item that was found at a moderate level was having a meal with the elderly during the pandemic.
Almost 50% did not apply this recommendation to their daily life.
This might be because of the strong Thai culture to have meals at the same time and to share meals
in the family, even if they know that this might cause the spread of the virus from one to another.

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Table 6.3. Practice of the Participants (n=126)
Level of practiceStatements

COVID-19 preventive behaviour for yourself
1. I wash my hands before and after meals, coughing,
and using the toilet.
2. While having a chat with others, I create a 1 to 2
metre distance.
3. I do not use any personal items with others such as
bath towel, dishes, glasses, spoons.
4. I avoid doing things in crowded places.
5. I wear a mask in my house when I do things withfamily members.
6. I wear a mask when I go out.
7. I have a hot meal or just cooked food.
8. I follow up on the news about COVID-19 and avoid
going to places where there are COVID patients.
9. I do exercise at home during the COVID pandemic.
10. I try not to travel or visit any places or activities if notnecessary.
COVID-19 preventive behaviour for the elderly in thehousehold/community/nursing home
1. When I return home, I change my clothes and have a
shower before I see the elderly.
2. I wash my hands with soap or alcohol gel before andafter I touch the elderly.
3. I wear a mask anytime I take care of the elderly.
4. I wear gloves anytime I take care of the elderly.
5. If I have a fever, cough, or sore throat I stop
contacting the elderly.
6. I avoid close contact with the elderly for example byhugging or kissing.
7. I avoid having meals with the elderly.
8. If it is not urgent, I avoid taking the elderly to thehospital. I postpone the appointment with thedoctor for them.
Source: Developed by researchers.

106

Almostalwaysn (%)

Rarely/nevern (%)

Sometimesn (%)

1 (0.79)

5 (3.97)120 (95.24)

2 (1.59)

33 (26.19)

91(72.22)

5 (3.97)

13 (10.32)

108 (85.71)

4 (3.17)19 (15.08)

103 (81.75)

19 (15.08)

48 (38.89)

58 (46.03)

0 (0.00)
2 (1.59)

3 (2.38)
4 (3.17)123 (97.62)
120 (95.24)

1 (0.79)

13 (10.32)

112 (88.89)

8 (6.35)

46 (36.51)

72 (57.14)

4 (3.17)46 (32.54)

72 (64.29)

14 (11.11)

24 (19.05)

88 (69.84)

11 (8.73)

10 (7.94)

105 (83.33)

14 (11.11)
24 (19.05)

12 (9.52)
24 (19.05)

100 (79.37)
78 (61.90)

15 (11.90)

3 (2.38)108 (85.71)

15 (11.90)

12 (9.52)

99 (78.57)

21 (16.67)

36 (28.57)

69 (54.76)

20 (15.87)

27 (21.43)

79 (62.70)

Resilience Quotient of the Respondents
Resilience has been defined as the ability to plan and prepare for, absorb, recover from, and adapt toadverse events (Chavapattanakul, Wongkumsin, and Kongkasuwan, 2020). In addition, the resilience
quotient is the capability of a person to adjust or adapt oneself and recover when facing crises. Some
articles have proposed that resilience comprises the coping capacity of the individual. Resilient
individuals seem to have optimistic attitudes and positive emotions, which can be protective factors
during the COVID-19 crisis. This study applied a set of questions from the Department of Mental
Health in Thailand (2009), which covers three elements: emotional stability, hope and morale, andproblem management. The definitions of three element are as follows:•

Emotional stability refers to being emotional stable, and not easy to be stressed in pressure
situations and having techniques to manage one’s emotions to be peaceful and to become
emotionally stable.

•

Hope and morale refer to having a determined mind to achieve one’s goals and to be undaunted
and having a consultant when facing hardships or perturbations.

•

Problem management refers to having positive thinking, not wanting to escape one’s problems,and finding information and having techniques to solve the problems.

Table 6.4 shows the results of the resilience quotient of the respondents, where the average score
was 46.76 from the total of 60, and the value of the standard deviation was 8.24. The results of eachelement show a high level of resilience quotient, which means that they have flexibility in their lives andcan adapt themselves and handle problems during crises. The ability to manage and cope withproblems, crises, and pressure would help them to be productive caregivers working in LTC. Whilst
the resilience quotient was shown to be at a good level, the problem management element was thelowest amongst these three. This result needs to be responded to as LTC facility owners, caregivers,
and volunteers play an important role in protecting the vulnerable elderly people, especially thoseneeding long-term care from COVID-19 infection. It was also evident during the pandemic that theolder a person is and the presence of co-morbidities were the key risk factors that require proper
management, especially infectious disease control in facilities, enough space, clean physicalenvironment, and sufficient workforce in LTC facilities. The key limiting factors in LTC at the early stageof the pandemic in Thailand were the lack of support and appropriate communication between
private LTC facilities and responsible organisations, and the lack of BCPs, which leads to insufficient
care workers when infected staff have to quarantine. It is a fact that there are some inter-related
reasons why the elderly in long-term care facilities and communities are vulnerable in COVID-19
pandemic situations. At the basic level, the high and close-contact nature of care leads to frequent
opportunities for infection (Florek, 2021). This nature requires appropriate attitudes and positive
concerns amongst the staff and volunteers working in this area.

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Table 6.4. Resilience Quotient•••

Resilience Quotient
OverallEmotional stability
Hope and morale
Problem management

Total scores
60
30
15
15

Mean
46.76
23.39
12.83
10.55

S.D.
8.24
4.65
2.57
2.54

Source: Developed by researchers.

4.2.

Model for COVID-19 Prevention and Resilience in LTC

The focus group discussions revealed that the pandemic has brought with it physical and emotionalburdens for care workers. Many of them lack time to take care of themselves and their family, oreven provide the basic care for residents. Some care workers mentioned that their work relies heavily
on moral commitment. These combined effects have led to widespread fear, hopelessness, anddepression amongst care workers for those that work in institutional care. In contrast, the VHVs in
LTC services seem to obtain strong support from local networks, families, and charity organisations,which helps them to work effectively and to be acknowledged.
Because closing nursing homes to families and other visitors was the most common emergency
measure carried out to limit the risk of infection, care workers were also separated from their families
and outer society in order to prevent the transmission of the virus to the facilities. At one nursing
home where many care workers were infected with COVID-19 during the crisis, it was expressed that
because of the owner’s kindness and leadership, they were able to cope with their stress andsymptoms. They were provided with food, material, emotional, and financial support. The leadershipof the LTC owners was therefore mentioned as a significant factor relevant to coping with the stressand resiliency amongst the care workers. After collecting both quantitative and qualitative data, theresearchers had a brainstorming meeting to extract solid results that could answer the researchquestions concerning what factors influence LTC in terms of vulnerability and resiliency. A model for
COVID-19 prevention and resilience for LTC was proposed (Figure 6.1). This model was then utilised
in a workshop as capacity building for LTC facilities.

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Figure 6.1. Model for COVID-19 Prevention and Resilience in Long-term Care, Thailand

Institutional Policy
Social Media
andTechnology

Local Policy

COVID-19
Knowledge
Attitude

Empowerment
andCooperation

Environment/Housing
Community
Based

Services

Institutional
BasedStandard of Care for VHVSupport From
LAOs
Community Hospital
FamilyVolunteer

Environment/Building
ServicesStandard of Care
Personnel
Supporting Staff

COVID-19 Prevention Practice

Culture, Family, and Community
Spirit of Volunteer

Social Support andSupport of Local
Government
Supportive Organisation(Association)

1. Pre-COVID Health Promotion and Distress Prevention and Observation
2. COVID-19 Infection Curative and Care
3. Post COVID-19 Prevention and Rehabilitation

LTC = long-term care, LAOs = local administrative organisations, VHV = village health volunteer.
Source: Developed by researchers.

4.3.

Resilient Long-term Care Beyond Vulnerability: Institutional-based and Community-based
LTC

Focusing on institutional-based LTCs (Figure 6.2), which were private nursing homes, it was revealed
that the catalysing factors leading to vulnerable or resilient LTC were (i) the environment, (ii)
networking, (iii) KAP, (iv) digital literacy, and (v) business continuity plan (BCP). All were significant
factors derived from the interviews and discussions. In this report, clear pictures and details aredescribed.
Due to the closure of nursing homes to families and visitors, researchers were unable to conduct site
visits; however, the environment both in and outside the building were explained by the facility
owners. As most private nursing homes in Thailand are small and medium size with 30 to 50 beds,
some facilities are in small buildings and are crowded, without green areas surrounding the facilities.
Ventilation was therefore of concern. This would lead to vulnerability when one is infected, and it istherefore difficult to do zoning or to retain social distancing. In addition, if nursing homes are notcohorting patients, where the staff are caring for both infected and uninfected residents, this presents
a risk of outbreak. It was found in one nursing home where researchers conducted an interview, thata group of caregivers and residents were infected with mild symptoms.
The manager decided and applied a guideline for COVID-19 management of those requiring LTC bysetting up an isolation room for this group. This decision seemed to help them get through the crisis,
and the family members of the residents were satisfied as they preferred not to have their parents in
hospital. However, this needs to be revised and well prepared in order to prevent complications that109

may occur; especially care workers may suffer with physical and emotional breakdowns in their own
health.

Figure 6.2. Resilient Care beyond Vulnerability: Institutional-based Long-term Care

KAP = knowledge, attitudes, and practices, LTC = long-term care, PPE = personal protective equipment.
Source: Compiled by researchers.

The network of the private nursing home was revealed as a resilient factor. The Health and Elderly
Establishment Confederation (HEC) is one of the most important sources of support for private
nursing homes in Thailand. Its mission is the commitment to elevating the healthcare and ageing
business to the international level with creativity, innovation, and the highest quality management
for mutual success with healthcare business sectors and elders. Whilst the crisis of COVID-19 was
ongoing in Thailand, the HEC provided material, information, and emotional support to members
such as COVID vaccine distribution to cover most members. Another activity which is relevant to the
HEC mission is to prepare members to meet the new regulations of the Thai government. The rolesof the HEC and its activities are a resilient factor in providing positive impacts for institutional LTC.
One more factor relevant to vulnerability is the BCP. Without a BCP, this sector would be in difficulty
as some owners mentioned that they faced staff shortages and the remaining workers increased
their work hours, creating unsafe conditions for staff and residents. BCPs have been developed in
Thailand but are not used by private nursing homes.
Special mention needs to be made of community-based LTC (Figure 6.3). The results from the survey
and focus group discussions show that the catalysing factors leading to vulnerable or resilient LTC
were as follows: (i) housing and the environment, (ii) government and local authority organisations,(iii) the spirit of volunteering, local wisdom, and the attitudes and culture amongst the volunteers
and family, (iv) digital literacy and accessibility of information, and (v) private and public networks,
such as charity organisations and the business sector. In this summary, the most important factors to
help community LTC gain resiliency were strong volunteering work and community support. In

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Thailand, health volunteers are recognised as an important sector to drive public health services for
local people. The stronger the volunteering work in the community, the more resilient the elder carecan be found. Health volunteers are familiar with the local people in the catchment areas (onevolunteer takes care of 10–15 families). This creates effective support by the health volunteers for the
dependent elderly and their families during the pandemic crisis. Local wisdom, such as Thai herbs
and traditional therapy, were widely used by the volunteers. Some charity organisations received
donations and transferred those materials and money to the community assisted by VHVs. Most VHVs
expressed the idea that they were motivated to do volunteer work and found benefits returned tothem and their families in terms of recognition, privilege, and health benefits. However, a few VHVs
contracted COVID-19 infection, but they were able to access treatment and care easily as they are
accepted as a member of public health team.

Figure 6.3. Resilient Care beyond Vulnerability: Community-based Long-term Care

KAP = knowledge, attitudes, and practices, PPE = personal protective equipment.
Source: Compiled by researchers.

5.

Conclusions

To conclude, the WHO proposed key actions to address the challenges of COVID-19 in the LTC sector.
This study discussed three key actions in this regard: (i) ensure that infection prevention and control
standards are implemented and adhered to in all long-term care settings to prevent and safely
manage COVID-19 cases, (ii) provide support for family and voluntary caregivers, and (iii) prioritise
the psychosocial well-being of people receiving and providing long-term care services. These three
key actions were demonstrated through the research activities. The survey revealed that KAP
amongst the caregivers both in the community and institutions were satisfactory. They may not havebeen able to understand some of the points regarding COVID-19, such as the duration oftransmission and asymptomatic holders; however, the resilience quotient, which can be referred toas one’s attitude towards life, was appropriate. Problem management was re-skilled through thecapacity-building workshop, and prevention and protection skills were found to be positive.
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However, some practices, such as having meals with the elderly during high rates of infection, were
not in compliance with standards due to Thai culture and lifestyle. The study identified the catalysing
factors that lead to resilient or vulnerable LTC. It was also found that the vulnerability and resiliency
of both types of LTC were different. Community-based LTC seems to be better in terms of resilience
than institutional-based LTC: for example, there is less work burden in community settings, as theelderly live with their family. VHVs play important roles in visiting and giving specific care to theelderly with the family support. The volunteers also gave advice by consulting with the community
nurses or care managers and received positive support from local organisations and some charity
groups in the community. In contrast, caregivers working in private nursing homes seem to face thecomplicated problems of heavy workloads and high expectations. Private nursing homes, which are
members of the HEC, had strong support from this network and seemed to cope with the crisis
successfully. The HEC members are deemed to demonstrate resilient LTC in Thailand. In addition,
facility owners with health science backgrounds and strong connections with public and private
networks demonstrated sound coping skills and resiliency.

6.

Lessons Learnt•

Regularly provide and update knowledge and skills regarding COVID-19 to LTC staff and VHVs
via an effective route using appropriate technology. Digital literacy amongst caregivers needs
to be developed.

•

Improve health monitoring in LTC by establishing systems of surveillance to monitor COVID19 outbreaks in LTC across the country.

•

Implement an integrated approach to health and social services in LTC, both institutional
based and community based. Charity organisations and the business sector should be
encouraged more to support LTC services in general and during the crisis.

•

Encourage all private nursing homes to become involved with a strong trade union orconfederation so that sharing information, learning from each other, and providing support
amongst members will be effectively carried out. The confederations of LTC in Thailand, suchas the HEC, provide a variety of support and activities for LTC and work as a bridge to connect
to government sectors.

•

Improve occupational health and safety in LTC facilities in order to protect all staff working inthis area, focusing on holistic health (physical, mental, environmental, and spiritual health).

•

Strengthen and upgrade VHVs to become more involved in the area of community-based LTC.
Financial mechanisms to support VHVs need to be considered.

112

References
Chavapattanakul, P., T. Wongkumsin, and R. Kongkasuwan (2020), ‘The Relationship between
Resilience Quotient, Social Support and Spiritual Well-Being of Caregivers of Patients with
Hemiplegia’,
Siriraj
MedicalJournal,72(3),
pp.245–52.
https://he02.tcithaijo.org/index.php/sirirajmedj/article/view/240124 (accessed 22 June 2022).
Chuengsatiansup, K. and P. Suksuth (2007), ‘Health Volunteers in the Context of Change: Potential
and Developmental Strategies’, Journal of Health Systems Research, 1( 3-4 Oct.-Dec).
Department of Disease Control (2021) Situation of COVID-19
https://ddc.moph.go.th/covid19-dashboard (accessed 15 March 2021).

inThailand.

Department of Mental Health (2009), ‘From Bad to Good RQ Resilience Quotient’. Nonthaburi:
Ministry of Public Health, Thailand.
Department of Protocol, Ministry of Foreign Affairs, Kingdom of Thailand (2020), ‘Thailand's
Ungowned and Unsung Heroes Play Significant Roles in Battling COVID-19’, 30 June.
https://protocol.mfa.go.th/en/content/119261-thailands-ungowned-and-unsung-heroesplay-s?cate=5f069ee272a783584326eb0d (accessed 10 January 2022).
Florek, K. (2021), ‘Resilience of the Long-term Care Sector Early Key Lessons Learned from the COVID19 Pandemic’. The European Federation of Public Service Unions (EPSU).
https://www.epsu.org/sites/default/files/article/files/Resilience_of%20the%20LTC%20secto
r_V3.pdf (accessed 12 June 2022).
Health and Elderly Establishment Confederation. https://www.hec.or.th/ (accessed 20 May 2022).
National Statistics Office of Thailand (NSO) (2017), ‘The 2017 Survey of Older Persons in Thailand’.
http://www.nso.go.th/sites/2014en/Survey/social/domographic/OlderPersons/2017/Full%2
0Report_080618.pdf (accessed 15 September 2021).
United Nation Population Fund (UNFPA) (2020), ‘COVID-19 and Older Persons: Evidence from theSurvey in Thailand’. https://thailand.unfpa.org/sites/default/files/pub-pdf/covid-19_reportonline-revised_2021.pdf (accessed 15 December 2021).
World Health Organization (WHO) (2020), ‘Preventing and Managing COVID-19 Across Long-term
Care Services’. Policy Brief. https://apps.who.int/iris/handle/10665/333074 (accessed 10
December 2021)

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Chapter 7
Capacity Building for Resilient Long-term Care in Indonesia

1.

Background of COVID-19 Infection in Indonesia

The novel coronavirus disease (COVID-19) pandemic has had an unprecedented effect on the lives ofpeople, irrespective of social demographics. This trend is common all over the world. In terms of thenumber of confirmed cases and deaths from COVID-19 in member countries of the Association ofSoutheast Asian Nations (ASEAN), Indonesia is the most affected country (Komazawa, et al., 2020).
During the COVID-19 pandemic, older adults face significant fallout with regard to their physical andpsychological wellbeing. Indonesia’s older population has much higher COVID-19 fatality rates than
younger generations. National data reported that by March 2022, as many as 12% of the total
confirmed cases of COVID-19 were residents aged 60 years or over. However almost half of the total
mortality (49.4%) in the country come from the population aged 60 years and over and put thispercentage as the highest amongst other age groups (Satgas Penanganan COVID-19, 2022).
According to the National Health Survey (2018) one in four older people suffer from one or moredegenerative diseases whereas hypertension, cardiovascular disease, diabetes mellitus, chronic
respiratory disease, and stroke are the major degenerative diseases suffered by Indonesian older
people (Ministry of Health Republic of Indonesia, 2018). On the other hand, the ageing process
induces the deterioration of immune system in older people (immunosenescense) and is anotherfactor that puts older people in higher risk of mortality. An appropriate measure in COVID-19
prevention is highly needed to prioritise protection for older people especially those living in longterm care facilities and communities.
Several studies have identified various negative impacts arising from the COVID-19 pandemic on theelderly, from economic, health, and psychosocial points of view (Kaligis, Indraswari, and Ismail, 2020;
Komazawa, et al., 2020; Muhtar, et al., 2020; Nugraha, et al., 2022; Saito and Cicih, 2022; Smeru
Research Institute, et al., 2021).
The devastating impact of the COVID-19 pandemic not only caused suffering of older people living in
the community but also those living in nursing homes. The pandemic has created enormous pressure
on the entire health care system, but possibly the most tragic impact has been on the long-term caresystem for both younger and older people in long-term care facilities (LTCF). Although data on
mortality due to COVID-19 in long-term care facilities are not well documented, attention to theimportance of preventing transmission is very important. More than 85% of the residents in LTCFs areamongst the most vulnerable part of the population. Given their congregate nature and resident
population served (e.g., older adults often with underlying chronic medical conditions), nursing home
populations are at high risk of being affected by COVID-19.

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As demonstrated by the COVID-19 pandemic, a strong infection prevention and control (IPC)
programme is critical to protect both residents and caregivers. Even as nursing homes resume morenormal practices and begin relaxing restrictions, nursing homes must sustain core IPC practices andremain vigilant for COVID-19 infection amongst residents and caregivers in order to prevent spreadand protect them from severe infections, hospitalisations, and death. Caregivers can get confused
when facing the elderly, since they need to keep their distance as well as the need to support older
people at the same time. As an essential worker in supporting older people, it is important to identify
the knowledge, attitudes, and practices of caregivers in long-term care facilities and the community
on how to directly interact with the elderly respond to COVID-19. This study investigated theresilience of older people in facing the pandemic of COVID-19, by investigating the current situationof long-term care for older people living in nursing homes and homebound in the community during
the pandemic.

2.

Findings of Study on the Resilience of Long-term Care Facilities

In order to figure out the resilience of Indonesian caregiver in supporting older people during the
pandemic of COVID-19, we conducted two consecutive studies – a focus group discussion and survey
on the knowledge, attitudes, and practice in COVID-19 prevention in LTCFs.
2.1.

Qualitative Study

To figure out the resilience of the LTCF and community based LTC in dealing with the pandemic of
COVID-19, in-depth interviews and focus group discussions (FGD) were conducted in September 2021.
The informants of this qualitative study are LTCF managers and caregivers in Jakarta city andcommunity caregivers in West Java Province.
The results of interviews and FGDs with LTCF staff showed that during the COVID-19 pandemic, LTCFs
strived to make significant changes in budgeting and policy regulation to avoid transmission of COVID19 in their facilities as they noticed that most residents are in the high risk group. This regulation is
stipulated by the National Taskforce for Covid-19 (Ministry of Health Republic of Indonesia, 2020).
LTCF staff were trained by the Ministry of Social Affairs and the Ministry of Health on how to manage
the LTCF facing the COVID-19 pandemic. Several policies were undertaken by the LTCFs to prevent thetransmission of COVID-19, including restricting visitors for residents, restricting other visitors, and theimplementation of strict health protocols by requiring all residents to wear masks, wash their hands,
and avoid crowds. In addition, the LTCF also carried out routine disinfection to all facilities, changing
the working shift for caregivers, and allowing officers to work from home to minimise their mobility.
To monitor the COVID-19 transmission, the LTCF performed regular rapid tests, especially for themobile staff. The caregivers try to take preventive measures by implementing health protocols whileat the facility and when traveling to and from home. They explained to the older people that there
was currently a pandemic so they had to take care of their health. The residents were encouraged toperform physical exercise while sunbathing to increase their immunity.

115

2.2.

Survey on Knowledge, Attitudes, and Practices of Caregivers

A field survey for identifying knowledge, attitudes, and practices of caregivers in LTCFs and thecommunity were conducted from September to December 2021. Prior to the study, Indonesian
researchers conducted field visits and performed interviews to capture the entire situation andcondition of the older people in institutionalised care and the community. A knowledge, attitudes,
and practices (KAP) survey is a quantitative method (predefined questions formatted in standardised
questionnaires) that provides access to quantitative information. KAP surveys reveal misconceptions
or misunderstandings that may represent obstacles to the activities that we would like to implement
and potential barriers to behaviour change.

Table 7.1. Characteristic of Study Participants (n=292)
Variables

Number

Percentage (%)

Provinces
DKI Jakarta

136

46.6

Jawa Barat

156

53.4

Public nursing home

86

29.5

Private nursing home

90

30.8

Community

116

39.7

Male

66

22.6

Female226

77.4

College degree

104

36

Non-college degree

188

64

Living with older adult

154

52.7

Close contact living with older adult

196

67.1

Diagnosed COVID-19 positive

137

46.9

Family member diagnosed COVID-19 positive

130

44.5

Location

Gender

Education

Living Arrangement

History of Those Contracted with COVID-19

Source: Drafted by the author based on the research findings in the current study.

A total of 292 caregivers in West Java and Jakarta participated in this study, with the average age of39, the age range from 17–64 years old, and most of them female. They consist of 29.5% caregivers
from public LTCFs, 30.8% are caregivers from private LTCFs, and nearly 40% are caregivers incommunity dwellings, most of them are educated with a non-college degree. About 52% of the
caregivers are living with an elderly family member. Nearly half of them had been diagnosed with
COVID-19, and had contact with a family member who had been diagnosed positive (Table 7.1).
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Table 7.2. Knowledge about Infection Control According to Characteristics of the Workplace
Characteristics of Long-term Care Clients

Frequency Percentage (%)

Elderly people in need of long-term care have a declining IADL/ADL
or have a basic disease and are less resistant to infection.

212

72.4

187

63.8

It is common for a single staff to be in charge of multiple clients,
and infectious diseases may spread through the staff.

257

87.7

There are high risks of contact infection because of common use ofmany facilities and equipment.

171

58.4

LTC workers are at risk of infection during commuting hours andoff-hours because they are employees.

197

67.2

In a workplace engaged by multiple professionals, it is required tounderstand the division of roles in measures and common
initiatives.

177

60.4

Everyone has a certain training in infectious disease control as aprofessional.

121

41.3

Mastered the basic concept of infection control and how to wear
personal infection protective equipment.

71

37.8

Actively participate in training, planning, and management of
infection control in a long-term care facility, service provider, or
corporation.

196

66.9

Understanding the location of the manual in occurring infectious
disease.

165

56.3

Sharing information with doctors, nurses, and managers whenclients are suspected of infecting.

92

48.9

Understand that caregivers provide advice and support onchecking the elderly’s health conditions, reporting to doctors, andmeasures to prevent the spread of infection.

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63.8

Elderly people in need of long-term care have cognitive decline andare difficult to cooperate in infection control.
Characteristics of Long-term Care Services

Characteristics of Long-term Care Workers

Competency of Caregiver

IADL = instrumental activity of daily living, ADL = activity of daily living, LTC = long-term care.
Source: Drafted by the author based on the current research findings.

The knowledge of the caregiver according to the characteristic of the workplace are averagely good,with the highest understanding in the staff to be in charge of multiple clients, and infectious diseases
may spread through the staff. However, when they have to face the pandemic situation, they likely
find difficulties in understanding the basic concept of infection control and how to wear personal
infection protective equipment. The limited facilities in the institution could become another hurdle

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for the caregiver to provide appropriate care to the elderly during the Pandemic of COVID-19 (Table
7.2).

Table 7.3. Knowledge, Attitudes, and Practices of the Caregiver in COVID-19 Prevention
To what extent do you understand the following issues?

Knowledge

The types of infectious diseases?

56.0%

How infectious diseases occur?

65.9%

How to perform test for infectious diseases?

36.2%

The symptoms of COVID-19?

60.4%

The meaning of close contact?

54.6%

What is your perspective towards the following issues?

Positive attitude

Air infection preventive

44.0%

Droplet infection preventive

49.1%

Contact infection preventive

84.6%

Maintaining health protocol at home

21.2%

Maintaining health protocol when commuting

58.4%

Basic actions to prevent COVID-19 infection

68.6%

Take a move to COVID-19 spread

56.7%

Maintaining health protocol during shopping

43.7%

Maintaining health protocol during meal

47.1%

Maintaining health protocol during enjoying entertainment, sports, and events

49.8%

Human contacts control during the COVID-19 pandemic

43.7%

How to respond the long term care residents/community elderly who infectedby COVID-19

29.7%

To what extend do you practice the following activity?

Practices

Avoid the pathogens

65.9%

Infection routes responses

62.1%

Host resistance improvement

64.5%

Take a standard precaution to prevent the infectious diseases

61.4%

Hand hygiene performs

53.2%

Cautions on how to use gloves

51.2%

Share the infection information

51.5%

Carry out disinfection and hygiene

51.5%

Cooperative to epidemiological studies for the infection suspect

17.7%

Caring the elderly with dementia under COVID-19

41.3%

Facilitate the infected person to the hospital

24.9%

Source: Drafted by author based on the research findings in the current study.

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The results of the KAP survey and caregiver behaviour both in nursing homes and in the community
show that most respondents have basic knowledge about COVID-19, modes of transmission,
prevention, and definition of close contact. Caregivers have a poor understanding of various COVID19 examination methods; this is possible because generally in Indonesia only rapid antigen tests and
PCR are used (Table 7.3).
In relation to attitudes in preventing the transmission of COVID-19, more than 50% of respondents
have a positive attitude in an effort to prevent the transmission of COVID-19, maintain health whentraveling from home to nursing homes or other facility. Most respondents find it difficult to maintainhealth protocols while at home, and how to shop in a healthy and safe way to avoid COVID-19. Most
respondents do not understand how to make referrals if someone is sick, and how to handle people
who are infected with COVID-19.
In the practice of preventing the transmission of COVID-19, most respondents have implemented
practices to avoid pathogens, infection route responses, host resistance improvement, takeprecautions to prevent infectious disease, perform hand hygiene, use gloves, share infection
information, carry out disinfection, and personal hygiene implementation. The majority of study
participants stated that they were less competent in working with the epidemiology team to carryout tracking and tracing of people suspected of being infected with COVID-19. They also do not havesufficient knowledge in the efforts to prevent and manage COVID-19 in older people with dementia.
It is assumed that most of the respondents are caregivers who do not have a good medical
background, so they have very little experience in collaborating with epidemiology officers. Handling
patients with dementia is a challenge for caregivers. Many caregivers do not have good experienceand ability in caring for the elderly with dementia.
In Indonesia and several ASEAN countries, care for the older people is often entrusted to families andcommunities, so mass infections in long-term care facilities may not be visible as a problem. Therefore,
the problem of improving resilience to pandemic clusters in long-term care facilities for the older
people not yet becoming a big concern. However, in order to realise the ideal ‘ageing in place’ forolder persons, it will be necessary to gather the best practices and to design strategies for more
effective prevention of infectious diseases.

3.

Findings and Lessons Learnt

3.1.

Constructing Resilient Care System under the Pandemic

Resilience is described as the capacity to cope with difficult situations, which usually fluctuates acrossthe lifespan and is often interrelated with some psychological conditions. With better resilience, older
adults may compensate their loss of functional capacity and physical health. Resilience has strong
impacts on the recovery of physical, cognitive, and mental health during the COVID-19 pandemic .
The COVID-19 pandemic has had a significant impact on the lives of Indonesia’s older people who
generally experience ageing in place. Older people used to receive various home or community
services and were encouraged to interact with their relatives, friends, or neighbours in daily living,
but the COVID-19 pandemic suspended most of these activities due to lockdowns and social
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distancing. Unlike the elderly who live in long-term care facilities, numerous uncontrollable variables
can trigger the transmission of COVID-19 to the elderly in the community.
There is a need to construct a community-based integrated care system that can demonstrate theresilience a pandemic situation such as the COVID-19 pandemic. This research identifies various
efforts in the community that are carried out independently and collectively led by community
leaders that have proven to reduce the risk of transmission of COVID-19. The community has a crucialrole in controlling, protecting, and accompanying the elderly in dealing with this pandemic. Material
and psychosocial support is carried out by the community for vulnerable groups such as the elderly.
This effort is carried out in collaboration with care providers to assure and provide an adequate
referral system and comprehensive protection. This system enables the elderly to remain resilient
during the pandemic and enjoy a life of prosperity and dignity.
The providers of long-term care for the elderly in social institutions for the elderly, as well as social
welfare institutions for the elderly need to pay serious attention to the safety and security aspects forboth the elderly and caregivers, especially in the current pandemic situation. Universal precaution
guidelines should always be emphasised in the development of long-term care facility management
policies.
3.2.

Training Programmes of Infection Prevention for Caregivers

Caregivers who work in long-term care facilities and in the community have similar characteristics ofbeing essential workers as care providers. As a result, there is a high risk of COVID-19 infection and at
the same time a high risk of each infection source of infected clusters. Therefore, an infection
prevention programme is critical.
According to the findings of this study, researchers have developed a module for infection prevention
LTCFs. This module is expected to become a guideline to increase the knowledge, attitudes, andpractices for prevention of infectious diseases. Based on the findings of this study, it is highly
recommended for all care providers both in the community and LTCFs to encourage caregivers toattend training programmes for infection prevention not only for COVID-19 but also for othercommunicable diseases.

120

References
Kaligis, F., M.T. Indraswari, and R.I. Ismail (2020), ‘Stress during COVID-19 Pandemic: Mental Health
Condition in Indonesia’, Medical Journal of Indonesia, 29(4), pp.436–41.
https://doi.org/10.13181/mji.bc.204640
Komazawa, O., N.W. Suriastini, E.D. Mulyanto, I.Y. Wijayanti, and D.D. Kharisma (2021), Older People
and Covid-19 in Indonesia. Economic Research Institute for East Asia and ASEAN (ERIA),
Bappenas, and SurveyMETER.
Ministry of Health Republic Indonesia (2020), ‘Guideline for Prevention and Control of Corona Virus
Diseases (COVID-19)’. https://covid19.go.id/p/protokol/pedoman-pencegahan-danpengendalian-coronavirus-disease-covid-19-revisi-ke-5
Ministry of Health Republic Indonesia (2018), ‘Riskesdas 2018’ [National Basic Health Research 2018].
In Riset Kesehatan Dasar.
Muhtar, M., A. Kurniasari, A. Jayaputera, and Husmiati (2020), ‘Perlindungan sosial lanjut usia masa
pandemi COVID-19’ [Social Protection for the Elderly During the COVID-19 Pandemic: At
Government Social Institutions for Elderly and Elderly in Community].
http://puslit.kemsos.go.id/upload/post/files/24d4dfb918f9d78c57f5f2fa0d0470aa.pdf
Nugraha, S., A.R. Adawiyah, Y.T. Aprilia, L. Agustina, T.P.A. Handayani, and T.B.W. Rahardjo (2022),‘Pandemic in Indonesian Older People: The Implication for Sleep Deprivation, Loss ofAppetite, and Psychosomatic Complaints’, Jurnal Ners, 17(1), pp.67–73.
https://doi.org/10.20473/jn.v17i1.33885
Saito, Y. and L. H. M. Cicih (2022), ‘Studi Nasional Tentang Dampak Pandemi COVID-19 Terhadap
Kelompok Lansia (termasuk penyandang disabilitas) di Indonesia’ [National Study on the
Impact of the COVID-19 Pandemic on Elderly Groups (including persons with disabilities) in
Indonesia].
Satgas Penanganan COVID-19 [COVID‑19 Response Acceleration Task Force] (2022), ‘Situasi Terkini
Virus COVID-19’ [Current situation of Pandemic of COVID-19]. Peta Sebaran COVID-19[COVID-19 Distribution Map]. https://covid19.go.id/peta-sebaran-covid19
Smeru Research Institute, Australia Indonesia Partnership for Economic Development (Prospera),
UNDP, and UNICEF (2021), ‘Executive Summary: Socio-Economic Impact of COVID-19 on
Households and Strategic Policy Recommendations for Indonesia’. SMERU Research Institute.

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Chapter 8
Recommendations

1.

Findings

1.1.

Differences for Defining Concepts and Holistic Explanation based on National Data

In international comparative studies, we often analyse quantitative data of each country. In that case,it should be noted that the terminology can be the same word or words, but the definition can differ
depending on the institutional background of each country. For example, in the case of theterminology of ‘death from COVID-19,’ even in Japan, the definition under the Infectious Diseases Act
differs from the definition in vital statistics.
In terms of the concept of ‘place of death’, since welfare facilities, etc. are defined in Japan as placesof living, they were treated the same as homes, but they are now separate. In Japan, the number ofdeaths registered at facilities for the elderly is extremely low compared to facilities for the elderly inEurope and the United States, which often have hospice functions, so deaths at facilities for theelderly also appear frequently. On the other hand, in Japanese long-term care facilities (LTCFs),
hospice functions are limited, and in many cases, if a resident is infected, they are often quarantined
and hospitalised, and if death is subsequently confirmed, the death is reflected in the statistics as‘death at the hospital’.
For strengthening the international response to the pandemic, it is necessary to renew the basic
definition of the terminology in each country and the method of harmonisation of internationalcommon understanding and methodology. (WHO, 2022.)
1.2.

Vulnerability and Resilience of Environmental Health

According to the World Health Organization (WHO), the route of infection of COVID-19 was initiallyconsidered as a contact or droplet transmission. To prevent these transmissions, hand washing andmasks were considered effective. Later, aerosol infection close to airborne infection as an infection
route of COVID-19 attracted attention. In March 2020, Japan’s Ministry of Health, Labour and Welfare(MHLW) announced ahead of the rest of the world that the risk of mass infection increases in
enclosed spaces with poor ventilation. On 9 July 2020, the WHO recognised aerosol transmission,and as a countermeasure, it translated and adopted Japan’s slogan ‘Avoid 3 Mitsu’ into ‘Avoid 3Cs’
(crowded places, close-contact settings, and confined and enclosed spaces). (Japan Society for Air
Conditioning and Sanitary Engineering, 2020).

122

LTCFs for the elderly need to be especially careful about ventilation as many vulnerable people live
together. Especially, in Japanese LTCFs, to make the indoor temperature comfortable, rooms are often
closed and air conditioning is used, so ventilation tends to be poor, and a carbon dioxide (CO2)concentration measurement for ventilation was not widely used. (Figure 8.1)
In addition, LTCFs in Japan are places of daily life, not hospitals or for clinical treatment. Therefore, it
is assumed that LTCFs are not designed for zoning or to have decompression rooms for quarantining
infected people. Also, long-term care workers (LTCWs) wear surgical masks and gowns. However,
COVID-19 has revealed that in an emergency, facilities and equipment will need to be put in place toenable medical treatment in LTCFs.
Compared to Japan, facilities for the elderly in Thailand and Indonesia are well ventilated because
they were built as open facilities, i.e. without air conditioning. However, if facilities with air
conditioning are developed in the future, there is a concern that ventilation problems will worsen,
just like in Japan. In the future development of facilities, it is necessary to pay attention to themeasurement method of ventilation management, especially, since some LTCWs did not know that
COVID-19 infection was aerosol infection or airborne infection. It is necessary to emphasise theimportance of COVID-19 aerosol transmission and the importance of ventilation as a skill in theprevention of infections through training programmes for LTCWs.

Figure 8.1. Infection Prevention and Control of Aerosol Transmission

Source: Ishigaki, Y., et al., 2021. A Guidebook for Practical Ventilation Measures in Hospitals and Long-term Care
Facilities. [Iryo, Kaigo-shisetsu no tame no Jissen Kanki Taisuku Guidebook]. Dimensionsjapan.org/share/kanki2.pdf (in Japanese)

In Japanese LTCFs for the elderly, which tend to be enclosed spaces, ventilation measures are
extremely important. In addition, LTCFs in Japan are places of daily life, not places like hospitals or
clinics.

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People tend to assume that everyone knows about the need for ventilation, but that no one knows
what to do. This sociopsychological state is called ‘pluralistic ignorance’. Indeed, ventilation measuresagainst COVID-19 were in a state of pluralistic ignorance. In response to infectious diseases, people
tended to be sceptical about the effectiveness of measures that ‘cannot be helped’.
In LTCFs, efforts to improve the environment have not been implemented thoroughly. Therefore, thefollowing vulnerabilities of environmental health have occurred:•

Infection clusters in LTCFs might be caused by aerosol transmission of COVID-19.

•

Mal-knowledge, attitudes, and practices of infection prevention and control might cause
infection clusters. For example, an inappropriate partition caused a mal-ventilation environment.

•

LTCWs felt the operation of ventilation as burdensome.

•

Impossible utilisation of the internet of things (IoT) because of the digital divide andunderdeveloped infrastructure.

However, some resilience is challenged:•

Measuring CO2 concentration for evaluation of ventilation.

•

Online control for measuring CO2 concentration without LTCWs.

•

Redesigning rooms and ways of control by checking ventilation conditions.

•

Using natural ventilation.

•

Training employees in ventilation work.

For establishing resilient LTCFs, the maintenance issues of environmental health, such as ventilation,
zoning, and decompression room maintenance have been highlighted. Policymakers and care
professionals should focus on disseminating and training scientific measurement methods andimproving skills for environmental health (Figure 8.2).

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Figure 8.2. Resilient Long-term Care with Environmental Health

IoT = internet of things, LTC = long-term care.
Source: Compiled by authors.

1.3.

Vulnerability and Resilience of Family Caregivers and Volunteers

Unlike in Japan, in Thailand and Indonesia LTC for the elderly is largely provided by family members
and residents. No matter how much institutional care is put in place, only 3% to 4% of the elderly are
eligible for institutional care in Asia, and nearly 90% live under the care of their families.
It is also characteristic of both countries that the care activities of volunteers are flourishing as acomplement to family care. In Thailand, 50,000 rural health volunteers watching over elderly people
at home. In Indonesia, community health activities (Posyandu) are responsible for health activities incooperation with the community health centres (Puskesmas) and volunteers (Cadre) who areresponsible for these activities. Originally, maternal and child health was their main activity, but inrecent years the activities of community health for the elderly (Posyandu Lansia) have increased.
When COVID-19 began, volunteers’ health efforts came to a complete halt.
Public health centres in Thailand and Indonesia have initial medical care functions, unlike healthcentres in Japan. For this reason, when a person is suspected of being infected in a household or thecommunity, the function of the public health centre is first activated. However, when quarantine issought, health centres in Thailand and Indonesia must work with the health volunteers and healthposts (Posyandu) to perform a smooth referral function.
The referral system is a system that smoothly transitions between testing, arranging admission toisolation facilities or hospitals depending on the severity, follow-up, rehabilitation after treatment,
returning home, and long-term care. If this does not go smoothly, the health centre will triage andrequest that patients stay at home. Even if institutional care is maintained to a certain extent as inJapan, if infectious diseases overshoot, similar situations will occur, and there will be cases where the125seriously ill are not treated. In addition, if a path to care after treatment is not created, the patient
may not be discharged from the hospital and the hospital may not be able to accept new patients.
As the concept of LTC means a service for people who live with disabilities after an injury or illness, if
there are no institutional care facilities, families and communities and also hospitals will become
dysfunctional. In addition, when family members and residents care for infected people, close
contacts, and people cured of infectious diseases, appropriate knowledge, attitudes, and practices(KAP) standards are required.
In Thailand and Indonesia, religious activities are deeply rooted in daily life. For this reason, it isconsidered meritorious for families and volunteers to care for elderly people. But at the same time,
religious behaviour sometimes runs the risk of creating problems such as outbreaks of infection
clusters at religious gatherings, family sacrifice, abuse within families, and caregiver burnout (Figure
8.3).

Figure 8.3. Situations of Family Caregivers and Volunteers during Infection

LTC = long-term care.
Source: Compiled by authors.

When the COVID-19 pandemic hit, societies dependent on care by the family and volunteers showed
the following vulnerabilities:•

In general, there is a sense that infection transmission is through insects such as mosquitoes andsmall animals such as rats, but there is a low sense of infection transmission through droplets
and aerosols.

•

Older people are at greater risk of transmission through young family members who workoutside.

•Infection cannot be prevented due to faith in religious gatherings, traditional medicine, andscepticism of government policies.

126

•

Infected elderly people are quarantined together with their primary family caregivers.

•

There are risky situations of family sacrifice, abuse, discrimination, and burnout.

•

KAP of COVID-19 infection amongst family caregivers is not widespread.

•Households with infections are at high risk of losing their breadwinners.

•

Social distancing was called for and volunteering was suspended.

•

Since the infrastructure for information communication and technology (ICT), IoT, etc.
information transmission is not in place, it cannot be used for long-term care.

•

Because appropriate information cannot be delivered, families and residents are placed in asituation of so-called pluralistic ignorance, believing that ‘someone must be doing something’or ‘no one knows what to do’, and the response is delayed when a person becomes infected .

•The referral system of testing, isolation, treatment, healing, rehabilitation, and back home for
infected people does not work smoothly.

However, even during the COVID-19 pandemic, attention was drawn to the resilient activities ofvolunteers in supporting family care (Figure 8.4). In Thailand, health volunteers conducted contact
tracing surveys, communicated information, distributed relief supplies, and helped with polymerase
chain reaction (PCR) testing.

Figure 8.4. Resilient Long-term Care served by Family Caregivers and Volunteers

LTC = long-term care.
Source: Compiled by authors.

Indonesia’s Rama Lancia (friendly to the older adult) West Java chapter launched comprehensive andsustainable assistance efforts to support older persons in communities. Volunteers monitor vital signs(blood pressure, temperature, etc.) and record health complaints, which are then reported to healthworkers for further action. In cooperation with the Puskesmas, they work to ensure that older

127persons with chronic diseases are getting the medicine they need, and they distribute multivitamins
recommended by geriatric doctors. They also provide additional nutrition for those older persons
who are physically weak. The visits also include guidance on how to do at-home exercises to improve
immunity, balance, and physical fitness. These visits also offer an opportunity to educate thecommunity about the pandemic and how to prevent the spread of COVID-19. Volunteers distributeeducational flyers and masks, and they teach older people how to wear masks correctly. They also
use social media platforms that are popular amongst older people to provide education and dispel
erroneous information circulating in the community. Volunteers have used WhatsApp to solve theproblem of not being able to watch over social distancing. Then, the Ministry of Health, incollaboration with the Ministry of Home Affairs, launched the challenge of service standardisationand digitisation in Puskesmas and Posyandu in 2022. Attempts at tele-medicine have been madewhere human contact is avoided, highlighting the need for legal arrangements to disseminate these
new initiatives (AHWIN, 2021).
Resilient care through volunteer work by families and residents can be summarised as follows.
•A dedicated family caregiver cared for the daily lives of the infected elderly.

•

Abundant health volunteers in Thailand and Indonesia were responsible for activities that
reduced the work of public health centres, such as watching, assisting with PCR testing,research of contact tracing, information transmission, and delivery of relief supplies for older
residents.

•

Volunteers can prevent rumours and misunderstandings amongst residents.

•

Family caregivers and resident volunteers who received professional guidance and training
were able to contribute to infection prevention and control.

In this way, resilient LTC that utilises the bonds of family and local communities as social capital is an
issue that should be developed not only in Thailand and Indonesia but also globally, including Japan.
Policymakers and LTC professionals should develop the support measures for family caregivers andvolunteers.
1.4.

Vulnerability and Resilience of Long-term Care Facilities

In Japan, where LTCFs for the elderly have been developed, the COVID-19 pandemic threatened theirbusiness continuity. The risk of business continuity has increased due to the outbreak of infection
clusters in facilities, the suspension of attendance and securing substitute personnel due to infectionof LTCWs, the suspension of recruiting new residents, the lowering of the level of services, and the
securing of infection prevention management goods.
Before COVID-19, LTCFs in Japan had begun working on measures against known infectious diseases
and business continuity plans for natural disasters such as earthquakes and floods that would cometo an end in the short term. However, LTCFs’ responses to COVID-19 were much more difficult
because it attacked repeatedly and for longer.
In LTCFs, communication with various agencies became frequent and complicated according to128

various stages, such as the stage where it occurred in a foreign country, the stage when an infected
person appeared in the community, the stage when a close contact appeared amongst the staff andresidents, the stage when an infected person appeared in the facility, the stage where a person
discharged from quarantine was accepted, etc. Figure 8.5 conceptualises and illustrates how LTCFs
respond to the COVID-19 pandemic to ensure business continuity.

Figure 8.5. Business Continuity Plan of Long-term Care Facilities

Source: Compiled by authors.

LTCFs were unable to demonstrate effective business continuity management, exposing the following
vulnerabilities:•

Outbreak of COVID-19 infection cluster•

Progress of resident frailty due to prolonged prevention of COVID-19 infection•

Restrictions on the acceptance of elderly people who need long-term care•

Turnover of LTCWs and difficulty in securing a labour force•

Medical response to residents during the period of rapid increase in infections•

Deterioration of management, etc.

LTCFs in Japan are considered as places to live. Therefore, as a rule, residents with injuries andillnesses are transferred to hospital for treatment. However, due to the rapid increase in COVID-19
infections, it has become an issue to strengthen the health care functions of LTCFs; they need to beable to give health care to infected residents who are recuperating in facilities and accept elderly
people who have completed treatment in hospital.
Under such circumstances, business continuity plans were advanced at LTCFs for the elderly in Japan.
In addition to simply preventing and controlling COVID-19 infections, many care service providers
have introduced devices for contactless care, such as online visitor interviews, and communication

129

devices to reduce unnecessary conversations. In terms of employee management, various efforts
were also made, such as securing substitute personnel, support personnel, and foreign migrant care
workers. In terms of facility management, zoning in the event of an outbreak of an infected person,
introduction of decompression equipment, allocation of LTCWs, and securing of accommodation
facilities were also planned.
Although the formulation of business continuity plans for LTCFs for the elderly is mandatory in Japan,
it is important for Asian countries that are likely to develop LTCFs in the future to formulate businessplans and to the actual management methods. Thailand has adopted this idea and published amanual of business continuity plans (BCPs) for LTCFs in the Thai language.
Institutional care in LTCFs has the following vulnerabilities:•

Confused responses to infections were occurring because there was not shared consensus
amongst staff.

•

Disabilities for assessing primacy of job competencies because of vague job descriptions.

•

LTCFs do not have isolation functions or space for isolation treatment. Also, the shortage of PPE
supplies occurred, because LTCFs are not recognised as medical institutions.

•Overload of work caused by LTCW shortage, no leadership, and poor treatment of employees.

•

Impossibility of digitalisation because of low literacy of ICT and care robots, digital divide of staff,
and under-developed infrastructure of information.

•

Failures of risk management such as business continuity, infection prevention and control, andineffective referral system of infected residents.
Figure 8.6. Resilient Long-term Care with Business Continuity Management

BCP = business continuity plan, BCM = business continuity management, ICT = information and communication
technology, LTC = long-term care, PPE = personal protective equipment.
Source: Compiled by authors.

130However, our research in Japan revealed the following resilience:•

Clarifying information channels and decision-making structure in emergency based on a BCP.

•

Instructing staff and sharing of information within the organisation.

•

Prioritising the services according to the staff attendance rate. Ordering priority of care jobs.

•

Redesigning job places: zoning, installation of a decompression chamber, ventilation control, andsmooth supply chain of PPE.

•

New style of working such as a multitasking is available for long-term care in the emergency. For
actualising new work styles, training of management leaders is a prerequisite.

•

Coping with increased workload and staff shortages: Utilising ICT, smart care, video conferencing
systems (e.g. ZOOM), digital work by staff.

•

Dispatching workers amongst facilities, agile responses, and timely modification of services
onsite in emergencies. Strengthening of management system and staff training from ‘normal
times’ for risk management.

The government has instructed LTCFs in Japan to develop business continuity plans. The BCP
considers infectious diseases as well as natural disasters. While each LTCF needs to act immediately
on this plan, they also need to respond to events that could not have been anticipated in the plan,act quickly, and later verify their actions and provide feedback to the BCP.
Policymakers and LTC professionals need to address structural issues (building standards, staffing
standards, emergency support systems, new technological innovation, etc.) related to the resilient
LTC system in a medium- to long-term manner.
1.5.

Vulnerability and Resilience of Care Workers in Facilities

In Asian countries where the population is ageing, it will be necessary to establish certain LTCFs in thenear future. Already, in Thailand and Indonesia there are welfare facilities for the elderly who haveno relatives, who are poor, and who cannot work. There are also private fee-based assisted facilities
that provide residential care for the wealthy elderly.
However, facilities that provide LTC services in line with the living functions of the elderly (activities
of daily living [ADL], instrumental activities of daily living [IADL], and dementia) regardless of income
or family structure are still a long way off in Asia, except for Japan, Singapore, the Republic of Korea,
and China. That said, Thailand is considering it. For example, in July 2020, the Thai Ministry of Healthissued a ‘Ministerial Ordinance on Elderly Care Business Outside Medical Institutions’ and has begun
issuing licences to long-term care providers. In the future, securing the quality and quantity of care
workers responsible for institutional care will become a policy issue.
For improving LTC in facilities, it is important to ensure a certain level of quality and quantity of work.
Japan has been promoting institutional improvements such as a public long-term care insurance131system, standardisation of training for LTC professionals, the establishment of national qualifications,staffing standards for LTC facilities, and career paths for LTC positions. Even so, it is difficult to secure
LTCWs. Disparities in working conditions with other occupations are a constant problem.
For ensuring the quality of LTCWs, a comprehensive support system of administrative agencies isnecessary. However, in reality, there is a risk that multiple administrative agencies related to longterm care will fall into a lack of coordination. Measures against infectious diseases that occur
internationally and regionally require mechanisms to complement community-based medical care,health, and welfare systems. When LTCWs in institutions are exposed to unknown infectious diseases,
they might burnout if proper guidelines are not presented. The Ministry of Social Development is
responsible for managing public facilities for the elderly, the Ministry of Health tackles measuresagainst infectious diseases, and the Ministry of Family Affairs takes responsibility for the elderly withina family. It is said that such inter-ministerial coordination did not work well at first. In addition, private
residential care homes had no choice but to completely cut off contact with the outside world.
With the spread of COVID-19, care workers have become recognised as essential workers. However,unlike medical professionals such as doctors, nurses, and pharmacists, the position of LTCWs is by nomeans high. Usually, a job description of an LTCW for the elderly is a service that deals with frailty orlife impairment from non-communicable diseases. For this reason, the knowledge, attitudes, andpractices of emergency response work such as the spread of infectious diseases are required.
Our research adopted a methodology, the KAP survey. The survey is a method to measure the abilityof LTCWs to achieve their competencies. It is a method of checking whether they have the knowledge,
attitudes, and practices necessary for achieving the task or not. Knowledge, attitudes, and practicesof LTCWs in Japan (Appendix 1), Thailand, and Indonesia were investigated in their respective KAP
surveys, and the following vulnerabilities were revealed.
In terms of knowledge, the following vulnerabilities were concerning:•

Lack of knowledge of aerosol transmission•

Lack of knowledge of ventilation control•

Lack of knowledge of professional response to infectious diseases•

Lack of knowledge of intersectoral coordination of administrative information

In terms of attitudes, the following vulnerabilities were worrying:•

Apathy of self-management of health conditions•

Apathy of preventive health in home•

Apathy of quarantine/hospitalisation•

Apathy of contact tracing•

Apathy of alternative care for residents with COVID-19•

Apathy of professional teamwork•

Apathy of the essential worker

Figure 8.7 illustrates the infection mechanism that care workers in LTCFs must know. Care workers
must act based on this knowledge to prevent and control infection diseases.

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Figure 8.7. Situation of Long-term Care Workers in Facilities

Source: Compiled by authors.

In terms of practices, the following vulnerabilities were concerning:•

Unskilled implementation on how to take responsibility during a crisis. No job redesign on
discretionary acts, immunity from responsibility, agile response, and inevitability.

•

Unskilled implementation on how to use PPE. Lack of equipment, unsuitable use of masks, andcareless dumping of equipment.

•

Unskilled implementation on how to control ventilation. Undeveloped ICT environment, malutilisation of equipment, and layout of room.

•

Unskilled implementation on how to contact the infected, close contact, and/or asymptomatic
persons physically. Diffuseness of quarantine, yellow zone, and physical distance.

•

Unskilled implementation on how to care for dementia residents. Dis-communication withpatients, easy physical restraint, and abuse.

•

Unskilled implementation on how to improve work. Normal shortage of labour force, andlabour-intensive business.

•

Unskilled implementation on how to prevent frailty. No alternative idea of onsite preventive LTC
exercise and oral care.

•

Unskilled implementation on how to refer infected residents. Inefficient referral system, andnothing to do.

•

Unskilled implementation on how to work for infected clients. Co-stay in institutions, behaviour
restrictions not only in the business place, but also in public places and at home.

However, these vulnerabilities are mostly avoided. By tackling COVID-19, care workers in institutions
have demonstrated the following resilience:133

In terms of knowledge•

Strengthen knowledge of environmental health.

•Frequent ventilation and introduction of CO2 concentration measurement equipment.

•

Job description for infection risk management. Clarification of job descriptions for medical care
workers and LTCWs.

•

Agile response to risks and immunity from responsibility.

In terms of attitude•

Self-health management. In the workplace, in public places, and at home.

•

Positive attitudes to infection prevention. Acceptance of PCR tests and vaccination.

•

Cooperative attitudes to contact tracing. Willingness to collaborate with other professionals
beyond the division of labour.

•

Innovative willingness to build a new normal LTC. Utilising hotline, information platform,
directory organisation, smart phone, social networking services, and other complementary LTC
technologies.

•

Awareness of a professional and an essential worker. Staff members in institutional care wererequired to stay in LTCFs and engaged in LTC work, their quarantine was designed together withthe elderly residents of the facility.

In terms of practices•

Managing infection prevention in the working place, in public places, and at home.

•

Competency of long-term care. Take responsibility, use own discretion on the job.

•

Handmade PPE. Masks, face shields, gowns, and partition goods.

•

Frequent ventilation. Diligent control of natural ventilation and operating mechanicalventilation.

•

Implementation of contactless care. Follow zoning, keep physical distance, avoid 3 Cs, andapply new technologies.

•

Dementia-friendly care. Effective non-verbal communication with clients.

•

Partnership with other facilities and organisations. Requiring human replacement from other
LTCFs and outsourcing of operations.

•

Development of diverse preventive care programmes. Online training exercise.

•

Awareness of the integrated community-based care system. Improving referral system,
development of new back-referral programme, seamless care, intersectoral coordination,
collaboration of medical and LTC and social welfare staff.

Figure 8.8 summarises catalysing factors of vulnerability and resilience imposed on Care Workers in
LTCFs during the COVID-19 pandemic.

134

Figure 8.8. Resilient Long-term Care Served by Care Workers in Facilities

KAP = knowledge, attitudes, and practices, LTC = long-term care, DCAT = Disaster Care Assistant Team.
Source: Compiled by authors.

1.6.

Vulnerability and Resilience of Migrant Care Workers in Japan

In Japan, the number of workplaces where foreigners are caring for the elderly is increasing. Theirstatus of residence is diverse, such as nursing care (it does not mean nurse but certified care worker
who engages in long-term care for the elderly and the disabled), economic partnership agreement(Indonesia, Philippines, Viet Nam), international students (permission to engage in activities outside
the status of residence), technical intern trainees, specific skilled workers, and permanent residents.
However, in Japan, except for ‘permanent residents’ and ‘nursing care’, it is considered that mostforeigners will eventually return to their home countries.
In the future, countries with advanced population ageing will face a situation such as an increase in
the number of elderly people who need long-term care, and a shortage in the labour force. Therefore,
the introduction of migration care workers (MCW) will be planned. However, there are a lot ofunresolved issues internationally. Is it possible for each country to provide LTCWs as a profession by
regulating it internationally? How should we nurture and send them out? What kind of residence
permit system should be used to accept the applicant? How do you evaluate their careersinternationally? How can we develop their smooth career paths domestically and internationally?
Several other issues remain unresolved.
Unable to return home due to COVID-19, MCWs will once again be considering what categories ofvisa to extend or change. Figure 8.9 shows the different status of residence in Japan and the change
between them. The relationship between the status of residence, vocational status, and theworkplace where MCWs can work is illustrated, but it is complicated. If MCWs themselves do notknow what kind of career path they are aiming for, they will have a risk of losing way.

135

Figure 8.9. Residential Visas, Job Qualifications, and Working Places in Japan

LTC = long-term care, MD =medical doctor, RN =registered nurse, LVN =licenced vocational nurse, EPA =economic partnership agreement,
Source: Compiled by authors.

The global COVID-19 pandemic has exposed the vulnerability of foreign care workers as follows:•

When international students work shorter hours at LTCFs, they may be placed at a disadvantage
as an ‘employment safety valve.’ In occupations other than LTC, the risk of contract cancellation
increased.

•

COVID-19 has forced MCWs to leave and be unable to return home.

•

There was a concern that technical intern trainees and international students from Viet Nam
would be forced to carry a large amount of debt in the sending country for arranging
employment and study in Japan, so they would be forced to exploit the intermediate fee.

•

There was a risk of becoming an illegal resident due to the length of stay for each complicatedstatus of residence and the procedure for change.

•

In order to get an LTC job in Japan, a high level of education and work experience such as auniversity degree and a nursing qualification were required, but in practice there was no
appropriate treatment and was exposed to the risk of the deskilling.

•

The risk of being left unskilled in an LTC job achievement and language learning has increased.

•

When measured by sense of coherence as one of the indicators of resilience, social support,
short-term stay, and language ability were strongly related.

•

Without the support of a manager at workplace, an instructor at an educational institution, or apreceptor for a countryman, MCWs will be lonely and prone to homesickness.

•

The matching method between technical intern trainees and LTCFs under the broker systemcaused over debt cases such as in Viet Nam.

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Figure 8.10 summarises catalysing factors of vulnerability and resilience imposed on migrant care
workers during the COVID-19 pandemic.

Figure 8.10. Resilient Long-term Care Showcased by Migrant Care Workers in Japan

LTC = long-term care.
Source: Compiled by authors.

COVID-19 has forced many businesses to scale back or abolish operations in areas other than LTC.
Many foreign workers were left behind with nowhere to go. Even so, Japanese LTCFs had a public
responsibility to secure business continuity, and LTCWs were guaranteed work opportunities as
essential workers. As a result, even during COVID-19, foreign care workers have been able to continue
to be employed. In addition, some people who worked under a different status of residence switched
their status of residence and were hired at LTCFs.
Therefore, foreign care workers demonstrated the following resilience:•

Conditions of employment for MCWs, which were stable under COVID-19, were protected by
the public long-term care insurance system.

•

Efforts were made to deregulate the terms of residence for MCWs, who are unable to return totheir home countries, and to change their status of residence.

•In the Philippines and Indonesia, a zero placement fee system was worked on for MCWs.

•

The recognition of MCWs as essential workers and the need to improve them internationally as
the amount of decent work has increased.

•

The career path as the LTC professional from the unskilled to the highly skilled has beenhighlighted for MCWs.

•

The acquisition of knowledge, attitudes, and practical skills in LTC work progressed, and thenecessity of an international LTC qualification framework was realised.

137

•

MCWs’ Sense of Coherence as a resilience index was found to correlate with long periods of stayand language proficiency in the destination countries.

•

MCWs were highly esteemed in the workplace, school, and community, and social support wasprovided.

•

The need to build a platform for international matching, rather than relying on a brokeragesystem, began to be discussed.

In the near future, international training and circulation of LTCWs will be a common issue for ageing
Asia. Within the professional qualifications’ framework of each country, LTC-related competencies
have a diverse position. For this reason, the smooth international occupational migration of LTCWs
tends to be hindered. The qualifications of LTCWs in Japan does not exist in other countries'
professions. For unlocking the potential of foreign LTCWs reaffirmed by COVID-19, efforts should bemade to define long-term care internationally in the professional qualifications’ framework.

2.

Lessons Learnt and Recommendations for Policymakers and Long-term Care
Professionals

2.1.

Lessons Learnt on our Research Framework

A summary of the revealed vulnerability of LTC for the elderly and the resilience to overcome it isshown in Figure 8.11.

Figure 8.11. Overview of Resilient–Vulnerable Long-term Care

KAP = knowledge, attitudes, and practices, PPE = personal protective equipment.
Source: Compiled by authors.

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When LTC for the elderly is entrusted to family members and residents, there is a high risk ofvulnerability appearing as age discrimination, abuse, household breakdown, family sacrifice, burnout,and segregation. All relevant agencies have not only taken infection prevention and control measuresagainst COVID-19 but have also taken immediate action against such vulnerabilities.
When LTC for the elderly is entrusted to institutional care, its vulnerability manifests in the following
phenomena: lack of efficient control due to lack of data on LTCFs as the basis of scientific research,susceptibility to infection clusters, burnout of care workers, workforce shortages, lack of literacy ininfectious diseases, lack of guidelines, collapse of medical care occurred due to confused referral
systems and lack of intersectoral coordination, no legal basis for introducing new technologies,
interruption of service provision, inadequacy of PPE supplementation, etc. For alleviating thesevulnerabilities in institutional care, facility managers and care workers will need to respond flexibly
and ask regulators for alternatives and mitigation measures.
However, there is resilience seen in institutional care: possibility of data collection and analysis by
preparing LTCF-related statistics, management technology of environmental health such as
ventilation, business continuity planning, necessity of back-referral programmes, and thedevelopment of training programmes based on KAP surveys, etc. Such resilience will be ensured not
only by the discretionary management of facility managers and care workers, but also by thegovernment's legal arrangements.
In addition, there is resilience demonstrated in terms of community care. Everywhere there are manyelderly people who are being cared for by their families. Activities by residents serve ascomplementary family care. Some of the resident volunteers use social networking services to watch
over the residents. There is a widespread perception that not only facility managers but also
community healthcare and social care businesses need business continuity management skills.
Governments and medical, health, and welfare stakeholders recognise the need for a referral system
and intersectoral coordination within the region. In the future, based on such knowledge, skills andattitude, a comprehensive regional care system should be constructed.
2.2.

Recommendations for Standardising Statistical Procedures InternationallyIn the event of an unknown infectious disease such as COVID-19, data collection methods tounderstand the actual situation should be standardised internationally. The number of new infections
is affected by the number of cases that have undergone PCR testing. However, the number of people
who are seriously ill or die is greatly influenced by other factors, such as age, chronic illness, and thetime required for referral. The definition of statistical concepts and the methods of collecting theirdata should be standardised internationally. In particular, the concepts of LTC, LTCFs, and LTCWs varyfrom country to country. The challenge is to share international concepts amongst countries.
Contact tracing is an important health methodology, but there have been cases where public healthcentres in Japan suspended their practice temporarily due to disruption to the spread of the virus.
Contact tracing methods, as in Thailand, need to be improved, such as the mobilisation of health139

volunteers and the use of smartphone applications. Policymakers and care professionals should seek
legislation to innovate research methods.
2.3.

Recommendations for Promoting Ventilation Strategies in Urbanised Environment

COVID-19 is said to have become a pandemic when a bat-derived virus mutated to the point where
it caused ‘human-to-human’ transmission. The WHO advocates the concept of ‘One Health’, which
integrates animal health and human health. COVID-19 is a prime example. COVID-19 is a series ofmutations that will hit humanity for a long time in waves of epidemics. In the ‘animal-to-human’ stage,
COVID-19 spreads by the transmission route of contact infection, but when it enters the stage ofhuman-to-human infection, it spreads by droplet infection and/or aerosol infection. It is also worth
noting that COVID-19 has changed its infectivity and mortality rate with mutation.
The WHO initially said COVID-19 was spread through contact and droplet transmission. However, inJapan, it was pointed out from an early stage that it spreads due to aerosol transmission, and abehaviour regulation called Avoid 3Cs (crowded places, close-contact settings, and confined andenclosed spaces) was announced. Particularly, for LTCFs where it is easy to create enclosed spaces, it
is important to undertake ventilation control to prevent aerosol infection. In urban environments
where not only LTCFs for the elderly but also various facilities are being developed, the risk of virus
infection increases if ventilation is not good.
Regarding ventilation, there is a method for measuring the CO2 concentration as an index. The
application of ICT technology to telemetry to contribute to its implementation may be developed in
the future. However, for making this possible, there are issues such as improving the information andcommunication situation of facilities and legal development that makes it possible to operate fromthe outside.
In addition, environmental health such as wearing highly-functional masks, face shields, and gowns;
zoning facilities and installing decompression rooms; and sealing waste will be important to combat
aerosol infection with COVID-19.
In this area of environmental health, policymakers and LTC professionals should sort out the issues
surrounding COVID-19 and contribute to advancing the concept of One Health in the future (WHO,2022). Policymakers and LTC professionals should introduce scientific control of environmental healthtechnologies (remote sensors of CO2, photocatalytic coating, etc.). Figure 8.12 illustrates theenvironmental health aspects under infection control.

140

Figure 8.12. Environmental Health under Aerosol Infection Control

Source: Compiled by authors.

2.4.

Recommendations for Supporting and Empowering Long-term Care Service Providers

In China, the share of LTC is said to be ‘973’. This means that 90% of the care will be provided byfamilies, 7% of the remaining 10% in communities, and 3% in institutions. Even in a society like Japan,
where institutional care is conspicuous, the ratio of sharing is almost same. However, once
institutional care is put in place, measures against new infectious diseases peculiar to facilities are
required.
An LTCF is a home for elderly people with weakened ADL and IADL and cognitive decline. They are
extremely vulnerable to infectious diseases. Therefore, elderly care facilities have been working on
measures against infectious diseases in their normal work. But when it comes to responding to
unknown infections like COVID-19, challenges have come to light.
Even if LTCFs are not medical institutions, similar efforts must be taken during periods of COVD-19
outbreaks such as PCR testing of elderly residents in the facility, onsite zoning for quarantine,
mechanical ventilation, maintenance of decompression rooms, etc.
In terms of human resources, if residents or staff are identified as infected or close contacts, it will benecessary to select persons in charge of caring for such people. Even for PPE, personnel guidelines as
essential workers are necessary, such as when wearing high-performance masks etc. equivalent tothose of medical workers and shortening the quarantine period in case of close contact.
Figure 8.13 illustrates whether a chain of behavioural changes occurs between care workers andrelated people when an infected person appears in a LTCF.

141

Figure 8.13. Behavioural Contacts and Referral System of Patients in Long-term Care Facilities

Source: Compiled by authors.

With the spread of COVID-19, LTCFs will have increased liaison work with health centres, medical
institutions, and various government departments. However, such intersectoral coordination tends
to be confusing and dysfunctional. Rapid information sharing is necessary for referrals and quarantine
in the event of an infected person or close contact in LTCFs, or for a back referral from the hospital to
LTCFs after treatment is completed.
In order to enable the business continuity of LTC in response to such infectious diseases, policymakers
and LTC professionals should not only support service providers in formulating a BCP, but also takemeasures to strengthen the power of business continuity management (BCM), as well as to improve
the referral system and intersectoral coordination. These findings should also be utilised in thedevelopment of institutional care in Asian countries (UN-HABITAT, 2020).
2.5.

Recommendations for Supporting and Empowering Long-term Care Workers

Family caregivers and volunteers provide normal care in line with customs. However, under the social
imperative of social distancing, normal care has become impossible. Family caregivers had no choice
but to confine themselves at home with the elderly, and residents had no choice but to stop
volunteering. In addition, rules such as customs and traditional ways of life unique to families andcommunities were excessively applied, leading to family sacrifice and abuse. Nonetheless, family careand care by resident volunteers will be able to provide a powerful support function for infected
people and close contacts who tended to live in isolation.
Employed LTCWs are subject to a workplace’s regulations, and, in some cases, norms based onnational qualifications. If the profession is well established, the knowledge, skills, and professional
ethics necessary to satisfy the competency are known, and those who have mastered it are certified.

142

For example, core LTCWs in Japan are trained as professionals and certified with a national
qualification. Therefore, standard KAP was provided for measures against non-communicablediseases and known infectious diseases on the elderly requiring LTC.
However, Japan's LTCWs are vulnerable to new infections like COVID-19. Nonetheless, LTCWs were
working to create resilient LTC in the workplace. For confirming such a movement, a KAP survey will
be useful. The KAP survey is designed to clarify the competency of LTCWs, for example, how much‘knowing’ about infectious diseases and how much ‘accepting’ the attitudes required for them, andspecifically how much ‘doing’ the skilled practices. Table 8.1 shows examples.

Table 8.1. Training Outcomes of Resilient Long-term Care (tentative)
Level

Competency

Knowledge

Resilient Attitude

SkillsLevel 6 Manage
complextechnical or
professional
activities or
projects,
takingresponsibility
for decisionmaking in
unpredictablelong-term care
contexts; takeresponsibility
for managing
professional
developmentof individuals
and groups.

Advanced knowledge ofa field of long-term care,involving a criticalunderstanding oftheories and principles.
e.g. understanding
business continuity planand management,
understanding
environmental health,job descriptions, referral
system, recruitment ofcare workers, etc.

Transformative
attempts towards
creativity/alternativityof long-term care in
long-term risks.

Level 5 Exercise
management
andsupervision incontexts oflong-term care
activities
where there isunpredictablechange; review
and develop

Comprehensive,
specialised, factual andtheoretical knowledge
within a field of longterm care and anawareness of theboundaries of thatknowledge. e.g.
understanding priority oflong-term care services,
Inter-sectoral

Adaptive attempts
towards flexibility oflong-term care in
mid-term risks.

Advanced skills,
demonstrating
mastery andinnovation,required to solve
complex and
unpredictableproblems in a
specialised fieldof long-termcare. e.g.
enhancing smart
care, contactlesscare, ventilation
systemarchitecture,comprehensive
care system,
harmonisingqualifications
framework, etc.
A comprehensive
range ofcognitive andpractical skills
required todevelop creative
solutions toabstract
problems. e.g.
outsourcing jobs,
accepting143

LevelCompetency

Knowledge

performanceof self andothers.

coordination amongst
long-term care, nursing
care, medicine, publichealth and social work,etc.

Resilient Attitude

SkillsLevel 4 Exercise selfmanagement
within theguidelines oflong-term care
contexts thatare usually
predictable
but are subject
to change;
supervise theroutine workof others,
taking some
responsibility
for theevaluation andimprovementof long-termcare activities.
Level 3 Take
responsibility
for completionof tasks inlong-termcare; adapt
own behaviour
tocircumstancesin solving
problems.

Factual and theoreticalknowledge in broad
contexts within a field of
long-term care. e.g.
understanding selfhealth control, anger
management,
mindfulness, etc.

Mitigative attempts
towards stability
and/or persistency oflong-term care.
Measured on thesense of coherence
and/or resilience
quotient score.

assistant humanresources,
possible agile
decisions,deregulation ofcare, practicalquarantine
management,etc.
A range ofcognitive andpractical skills
required togenerate
solutions to
specific
problems in afield of longterm care.
Possibility ofmultitasking,self-regulation of
everyday life,
quick awarenessof emergency,
etc.

Knowledge of facts,
principles, processes,
and general concepts ina field of long-term care.
Understanding longterm care ascomplementary of
ADL/IADL, etc.

Level 2 Work or studyof long-termcare under
supervision

Basic factual knowledgeof a field of long-termcare. e.g. understanding
older persons those who

Maintain universal
precaution against
infection. Avoid
crowded places,
close-contact
settings, and confinedand enclosed spaces(3 Cs). Respecthuman rights.
Support for older
persons to act in anautonomous or
independent way.
Response to
expectations as an
essential worker.

A range ofcognitive andpractical skills
required toaccomplish tasks
and solve
problems by
selecting andapplying basic
methods, tools,
materials andinformation.
Basic cognitiveand practicalskills required touse relevant144

LevelCompetency
with someautonomy.

Level 1 Work or studyof long-termcare under
directsupervision ina structured
context.

Knowledge

Resilient Attitude

are living with some
disfunctions.

Basic general knowledge.

Skillsinformation inorder to carryout tasks and tosolve routine
problems using
simple rules andtools.
Basic skills
required to carryout simple tasks.

ADL = activities of daily living, IADL= instrumental activities of daily living.
Source: Compiled by authors based on European Qualifications Framework and ASEAN Qualifications Reference
Framework and Japan’s Qualification Framework of Professional Long-term Care (Kaigo Professional Dan’i Seido)(in Japanese).

Figure 8.14. Social Norms of Long-term Care Workers under an Infectious Disease Outbreak
Care Worker
Long-term Care Facility(Job Place)With Clients (the Elderly),
Manager,
Other Professionals,
Colleagues, andClients’ Family
Norms of Association
Competency,
Job Description,
Responsibility andDiscretion,
Knowledge, Skills, andAttitudes
Formal Training
Regulation
Qualification

Home(Living Place)

Crowd(3rd Place)With Partner
ChildrenOlder Parents andRelatives

In Public Transportation
Shopping Stores
Restaurants, Cafés, andBars
Leisure Places andSocialisation with Friends

Norms of Family

Norms of Citizen
Laws
OrdersRules and
Other Regulations

Source: Compiled by authors.

145

Folkways
Customs
HabitsManners
Etiquette
Fads
CultureLTCWs working in institutions move back and forth between workplaces, home, and crowds. For them,
the risk of infection lies not only in the workplace, but also at home and in crowds. How to observesocial norms in such places of commuting should also be dealt with in training programmes (Figure8.14).
Considering the above, policymakers and care professionals should once again appropriately position
support for family caregivers in the integrated system of community healthcare, and health andwelfare systems.
As for volunteers, there were examples such as in Thailand where they actively played a part in healthservices, and in Indonesia, where they used social networking services apps to watch over the elderly.
For disseminating such activities, it is necessary to develop legislation that makes it easy to do so.
Policymakers and care professionals should pave the way for the challenges of protecting personal
information and sharing public health and welfare information.
To establish the decent work of care workers, policymakers and LTC professionals should share thesituation in Japan. This is because, in Japan, LTC is socially recognised as a specified business, LTCFs
have been established, and the vocational qualifications of LTCWs employed there have been
established. Considering the lessons learnt from Japan's COVID-19 response, support should be given
for LTCWs to sharing infectious disease prevention and control training programmes not only ininstitutions but also in crowds and training in contactless care and smart care.
•

The concept of LTC will be systematically established, and a referral system will be put in placeso that people can return to their families and communities after receiving treatment after being
quarantined from their families and communities.

•

Researching and optimising delivery system of long-term care services, whether older persons
live with their families or live in residential aged care.

•

Disseminating the right knowledge, attitudes, and practices of resilient long-term care forfamily caregivers, community volunteers, and leaders.

•

Income compensation should be provided to family caregivers.

•

Developing infection-free environments for caring older persons.

•

Aligning health systems and welfare systems to the LTC needs of older persons.

•Developing sustainable and equitable systems for LTC.

•

Developing and qualifying LTC training programmes for family caregivers and community
volunteers.

For enhancing the power of KAP against infectious diseases amongst LTCWs, policymakers and care
professionals should clarify the job descriptions of LTCWs, and then enhance the knowledge, skills,
and attitudes necessary through recurring education to fulfil their competency (responsibility,
discretion) as following:

146

-

Enhancing the competency of environmental health against infection disease.

We recommend that care workers in facilities strengthen their environmental health KAP, such as
knowledge of aerosol infection, attitude of avoiding 3Cs, and practice ventilation.
-

Clarifying the discretion during infection emergency for LTCW.

In the LTC workplace, each job is usually carried out by a strict division of labour and cooperation
amongst professionals. However, in the event of an emergency, not only facility managers but also
professionals will not be able to overcome the situation unless a certain degree of deregulation andvoluntary discretions are recognised. We recommend that the disclaimer in such cases be clearly
indicated by improving the wide-area support system such as the disaster care assistant team (DCAT),the disaster medical assistant team, and the disaster psychiatry assistant team.
If care workers are certified with a national qualification as in Japan, they should consider mobilising
the DCAT in the event of an infectious disease pandemic on a broad scale. Even when associations ofprivate nursing homes are organised, as in Thailand, a system of mutual support by dispatching the
DCAT to each other would be effective. We propose that a system be put in place to register LTC
workers trained in infectious disease control as reservists and to dispatch them in the event of an
emergency.
2.6.

Recommendations for Supporting and Empowering Migrant Care Workers

In Asia, where the population is ageing, it will no longer be possible to leave elderly care to family
members and resident volunteers alone. If that happens, it will be necessary to develop institutionalcare on a certain scale and cultivate LTCWs who will work professionally there. However, since thedegree of population ageing in each country is different, there is a time lag in the development of
LTCFs for the elderly. Therefore, the issue of training and circulation of migrant care workers becomes
an issue.
This challenge has already been recognised all over the world. In Asia, Singapore, Japan, and Thailand
are host countries for such migrant care workers, whilst countries such as the Philippines, Indonesia,
and Viet Nam have gained experience as sending countries. However, the education, training, andqualification of migrant care workers vary from country to country. In addition, the guidelines forstatus of residence, evaluation of occupational qualifications, and career paths in the host country
are also different. As a result, issues such as deskilling and status of residence issues in the event of asituation such as COVID-19 will surface.
The European Qualifications Framework, which was developed with the integration of the European
Union, an attempt to harmonise international vocational qualifications, has led to the establishmentof the ASEAN Qualifications Reference Framework in Asia as well. However, the work of LTC for theelderly has not been harmonised internationally in accordance with this framework. In the first place,it can be said that job descriptions for LTC for the elderly are not also shared internationally.

147

Japan has established a qualification system for LTCWs which are certified national qualifications andis building an LTC system that uses certified care workers as a core specialised human resource. The
career path within LTC called the LTC professional career rank system based on the European
Qualifications Framework has also been clarified. In addition, Japan accepts a variety of migrant care
workers such as certified care worker candidates through bilateral economic partnershiparrangements, technical intern trainees, international students who have obtained the ‘Japancertified care worker’ qualification, and specified skilled workers. COVID-19 made it impossible totravel to and from the sending countries, measures such as extending the period of stay and switching
the status of residence were taken in Japan.
COVID-19 has confirmed the reputation of LTCWs as essential workers. It was also strongly recognisedthat migrant care workers are indispensable in Japan, the host country, as the labour force
responsible for essential workers. Despite the challenges they faced, migrant care workers
demonstrated their KAP abilities that were appreciated by those around them.
Japan's unique vocational qualification system, which is centred on certified care workers, is fraught
with various misunderstandings with nurse qualifications in other countries. In Japan, certified care
workers are positioned as social (welfare) workers, and there is a clear distinction between nurses inmedical professions. Even within the same workplace, the responsibilities and discretionary powersof both groups are different. However, in response to COVID-19, attention has focused on theactivities of migrant care workers, who received nursing education in the sending country and workas LTCWs in Japan. In the future, as collaboration between medical care, health, and welfare isstrengthened and efforts to engage in medical practice by welfare professionals are fostered in society,expectations for migrant care workers who have received nursing education will increase.
Considering this reality, policymakers and LTC professionals in sending and receiving countries of
migrant care workers have positioned LTC in the international qualifications’ framework towards theestablishment of decent LTC work and career paths in which deskilling should not occur. Also, without
a placement fee, MCWs should get employment information directly through an international
platform that is managed by an authorised organisation on bilateral or multilateral memorandum ofagreements.
Figure 8.15 illustrates the mechanism of harmonising the qualification framework for MCWs. There
are various coordination issues between the qualification framework of each home country and theinternational qualification framework and the status of residence in Japan. A future issue will be toharmonise qualifications frameworks and exchange MOUs so that direct employment matching canbe conducted.

148

Figure 8.15. International Harmonisation of Qualifications Framework of Long-term CareEQF = European Qualifications Framework, AQRF = ASEAN Qualifications Reference Framework, MD = medical
doctor, RN = registered nurse, LVN = licensed vocational nurse, EPA = economic partnership agreement, MOU =memorandum of understanding.
Source: Compiled by authors.

2.7.

Recommendations for Policymakers and LTC Professionals to Promote Resilient Long-term
Care for the Elderly

Overcoming the vulnerabilities of LTC for the elderly that have emerged under COVID-19, themovement to showcase resilience is certainly beginning to take shape. From now on, policymakers
and LTC professionals will be asked how to establish and disseminate these movements as ‘the newnormal’ of LTC. Therefore, towards the establishment of resilient LTC against infection disease
pandemic, we recommend the following to policymakers and professionals in LTC for the elderly inAsia.
In the short term, policymakers and care professionals need to disseminate existing guidelines ofinfectious disease control, to support designing business continuity plans for public/private LTC
service providers, and to engage in online training programmes aimed at improving the competenciesof LTCWs. Specifically, policymakers and care professionals in each country should work on thefollowing for international collaboration:•

Standardisation of statistical methods related to basic infectious diseases on long-term care.

•

Scientific measurement method of environmental health maintenance issues in LTCF settings(e.g. remote-controlled CO2 concentration measurement) and improvement technology (e.g.
mechanical ventilation) and training of ventilation methods.

149

•

Development of LTC training programmes tailored to the pandemic.

•

Formulation of business continuity planning guidelines for LTCFs against infectious diseases andmeasures to improve management capabilities.

•

Sharing knowledge, skills, and attitudes of LTC learned from best practices for the COVID-19
response.

•

Exploring the regional realities of the referral systems and intersectoral coordination of families,
volunteer organisations, facilities, and medical institutions involved in LTC and medical care.

•

Spread of literacy of infectious disease control not only in the workplace but also in families andregional areas.
Figure 8.16. Recommendations for Policymakers and Professionals to Support ResilientLong-term Care

LTC = long-term care.
Source: Compiled by authors.

In the medium term, policymakers and care professionals will need to address the challenges that LTC
administrations have been unable to respond flexibly to COVID-19. After sorting out issues related tothe existing division of labour, standards of references, and monopolies of professional services, LTCFs
and LTCWs should be able to respond flexibly and promptly to changes.
•

Sorting out cases where existing LTC standards could not be met and considering room for
deregulation and exemption. (e.g. facility standards, staffing standards, work arrangements, andthe length of stay at home for LTCWs who have become infected or close contacts, etc.).

•

Establishment of various measures to respond to situations in which quarantine of infected
residents and close contacts must be implemented in the facility. (e.g. securing dormitories for
LTCWs, installing compulsory ventilation systems, outsourcing of environmental sanitation and150waste disposal work, changing the layout of zoning in the facility, additional measures to thezoning, etc.)•

Standardisation of temporary measures for health management and work capacity
improvement for LTCWs (e.g. infectious disease testing and vaccination in the facility, additional
measures for the work of care workers in charge of infected people and close contacts, relaxationof monopoly on work of professionals, remuneration for external human support, etc.)•

Arrangement and legal development of issues related to the status of residence of MCWs (e.g.
measures to extend the period of stay, change of status of residence, etc.).

In the long term, the prolonged COVID-19 pandemic has highlighted structural weaknesses in existing
aged care. The ambiguous positioning of LTCFs within the community comprehensive care system,
the unclear job description of care work, complex professional collaboration, the division of theinfectious disease task force in LTCFs, the qualification framework of migrant care workers and in
career development deskilling risks, etc. To overcome these vulnerabilities and establish resilient LTC,
policymakers and care professionals should take the following steps:•

Establish a comprehensive continuous and seamless system amongst medical care, healthcare,
LTC, and welfare for the elderly.

•

Strengthen medical functions in elderly care facilities (e.g. test, quarantine, visiting medical care,tele-medicine, hospice, etc.).

•

Support for the development and implementation of ICT and robot technologies to enablecontactless care in the field of LTC.

•

Clarify grading of job descriptions of competencies of care workers and systematisation oftraining programmes.

•

Promote common national efforts to harmonise the Occupational Qualifications Framework tofacilitate the career paths of migrant care workers. Also, for enhancing MCWs’ career paths
without placement fees, develop an international platform for introducing LTCFs and job seekers.
Develop memorandums of cooperation for employing migrant care workers beyond
memorandums of understanding.

151References
Asia Health and Wellbeing Initiative (AHWIN) (2021), ‘Accompanying the Elderly to Face the COVID19 Pandemic’. https://www.ahwin.org/accompanying-the-elderly-to-face-the-covid-19pandemic/
Japan Society for Air Conditioning and Sanitary Engineering (2020), ‘Operation of Air Conditioning
and Sanitation Equipment as a Countermeasure against New Coronavirus Infection’,
http://www.shasej.org/oshirase/2103/covid19-%EF%BC%94.pdf
UN-HABITAT(2020),

COVID-19

Response

ReportofActivities.

https://unhabitat.org/sites/default/files/2020/10/covid19_response_report_web26.10.20.pdf
World Health Organization (WHO) (2022), ‘Better Health with Better Information ICD 11 2022
Release’, 11 February. https://www.who.int/news/item/11-02-2022-icd-11-2022-release152

Appendix 1
Research Results on the Vulnerability and Resilience of Care Workers
in Japan1.

Interviews with COVID-19 Infection Control Managers

1.1.

Methods

Semi-structured interviews were conducted with managers at four facilities.
1.1.1. Interview subjects and periods(i)Niigata Prefecture, Social Welfare Corporation A
Type of business: Special care homes for the elderly, short stay, and residential long-term care
support businessOccupation: Principal
50s, Male
Interview date: 22 October 2021(ii) Saitama Prefecture, Company B
Type of business: Private senior long-term care home
Occupation: Deputy Principal
30s, Female
Interview date: 12 November 2021(iii) Fukuoka Prefecture, Social Welfare Corporation C
Type of business: Special care home for the elderly
Occupation: General Manager
Interview date: 23 December 2021(iv) Tokyo, Social Welfare Corporation D
Type of business: Special care home for the elderly
Occupation: Chief Operating Officer and General Manager
Interview date: 31 March 2022
1.1.2. Interview questions(i)What do you to take care of yourself to prevent infection by COVID-19?

(ii) Has the division of roles and tasks at your office or facility changed?
(iii) If so, how did it change?
(iv) Have you made any changes or innovations in the way of care or support?
(v) If so, what changes or innovations did you make?
(vi) Please tell us about any experiences or difficulties you have had in caring for or supporting
others, and any problems or worries you are currently facing.

153

(vii) What do you think is important to prevent the transmission of COVID-19 in long-term carefacilities?
1.1.3. Interview method
Face to face semi-structured interview
1.1.4. Ethical considerations
An ethics review application was filed with Keishin Group, and an ethics review application was also
filed with the reporter's university and approval obtained (Reception number: 18749).
Prior to conducting the interviews, a ‘request for cooperation in research’ was presented, andsignatures on the consent forms were obtained.
1.1.5. Results of interviews with managers
Summary
Table A1.1. Results of Questionnaire to Managers
Question
What do you totake care ofyourself toprevent infection
by COVID-19?

Has the divisionof roles and tasks
at your office or
facility changed?
If so, how did itchange?

A
Thorough physicalcondition
Not to be more
informed thannecessary
Try to forget
about work
during privatetime
All staff do care
work
Remove the usual
system ofseparate stovepiped directions
and commands

B
Not going out
Thorough physicalcondition
Stop work when
having a fever of
37°C

Reviewing theoperations
Developing andusing an iPhonebased staff work
management
systemAll staff, including
administrative
staff, do care
work

Have you madeany changes orinnovations in
the way of careor support?
If so, whatchanges orinnovations did
you make?

Separate
entrances andexits for each day
service andresidential facility
When coming
and going, go
outside once (notIf infection issuspected, switch
to infection
control.
All residents must
not leave theirrooms.

154

C
Thorough physicalcondition
Bathe as soon as
getting home
Not drinking
alcohol

All staff, including
nurses, do carework
A task force
committee
meeting is held
twice a month,where nurses andcare workers
work together todecide onpolicies.
Explain thecautions decided
by the task force
when handingout paychequesto staff.
Demonstrate how
to handle gowns,
etc. in addition toD
Not going out
Thorough physicalcondition
Not eating
outsideOriginally, there isa riskmanagement
office andresearch institute,so not changed.

Negative pressuredevices wereincorporated into
the facility.
Zoning devices‘ZENSHITSU-KUN’
wereincorporated into
the facility.

QuestionA
through thefacility)B
Meals are carried
to their room bystaff.
Use disposabledishes.
When finishedeating, have thefood taken to thebalcony of eachroom and cleaned
up by staff.

Please tell us
about anyexperiences ordifficulties you
have had incaring for or
supporting
others, and any
problems or
worries you are
currently facing.

Do not judge by
feelings but
persuadetheoretically

What do you
think isimportant toprevent thetransmission of
COVID-19 in longterm carefacilities?

Widen
perspective
Know who to ask

Shut out contact.
Mental healthcare・Recreational
activities
・Radiocalisthenics
・Events online
・Fireworks
Oral care
Dementia
patients who
cannot brushtheir teeth rinse
with tea.
Awareness of all
staff members
Workenvironment for
immediate
reportingC
explaining inwords.
Put off bathing,etc. and put
priority on
keeping life.

Mental healthcare for staff
・Choosing adaily lunch box
・Eating theirfavourite snacks
・Building aculture of
acceptanceEstablish
relationships oftrust
Communication
with all staff
members
Leading staffs tobe professionallyaware

D(Use oftechnology,
introduction of
ICT was done
before COVID-19.)

Not having any
problems in theiroperations
because they hadtaken measures
before theoutbreak of theinfection.
Boredom due tolack of directcommunication→present gifts toworkers
Think and act on
one's own
according to thesituation
Moving theorganisation
forward by
oneself.
Never stop doing
what younormally do.
If you wait foradministrative
instructions, youwill not make it intime.

Source: Compiled by author.

155

Some topics mentioned by each long-term care facility(i)Niigata Prefecture, Social Welfare Corporation A

There are two entrances and exits, one for the special care home for the elderly and daytime-carefacility and another for the short stay. If infected people pass through the facility, the infection will
spread. There are 89 clients and 100 staff, and PCR tests are conducted on all persons passing throughthe facility. Therefore, it was decided that any movement between wings would require the person
to exit the facility and then re-enter, without using the internal connecting passageway. During
January and February (winter months in Niigata), there were many complaints from the staff. We
were able to reply to such emotional statements as ‘It's such a shame’, ‘It's so cold out, ‘We have to
put on our coats and use our umbrellas just to go out in the snow and come back inside’, etc. withpersuasive infection prevention information.
Subsequently, there was agreement that the relaxation areas and lockers, which had previously only
been on one side, should be installed on both sides, thus reducing the amount of back-and-forth
traffic, and that the relaxation facilities should be improved.

Figure A1.1. Physical Distancing for Using Relaxation Areas and Lockers

Source: Compiled by author.

At one point there was some discrepancy in opinion and perception between ‘nursing staff who know
very well how the slightest difference can mean life or death’ and long-term care staff who are‘responsible for patients' happiness’, and the director who came down on the side of prioritising
infection control and was able to prevent the spread of infection by making the opinion of the nursing
staff the instructions for the entire organisation.
(ii)

Saitama Prefecture, Company B

The company developed an iPhone application, and each employee started doing their work on
iPhones. Everyone's work is scheduled by the app and displayed on the iPhone such as ‘whose
mobility care is to be done at what time’. When an employee finishes the work, they just need to tap
a button onsite to register ‘job completed’. In order to promote self-reliance support, the purpose of
the initiative is to provide the necessary services to those who cannot speak for themselves at the156

time when they (probably) need assistance. Furthermore, by linking with long-term care record
systems, we were able to reduce the burden of recording work. It may be said that providing visibility
to long-term care work can lead to the optimisation of service content and the discovery of problems
on-site.
(iii)

Fukuoka Prefecture, Social Welfare Corporation C

Since the company had already established a workplace culture in which nurses also provide care ona daily basis, there was no resistance to having all employees (who could come to work) provide careafter the outbreak of COVID-19.
First, it was discovered that a staff member had become infected. This was followed by infections
amongst three clients.
At that time, public health centres were trying to reduce the number of PCR tests as much as possible,
but we requested testing for everyone (130 persons in 2 days). The infected staff member usually
travelled to work by train, but 2 or 3 days before had ridden in a car with a friend, so it was surmisedthat the infection had originated there. However, the friend tested negative, so the route of infection
could not be determined. The three clients were asymptomatic, so if their infections had not been
detected by the PCR testing, there is a high possibility that a large cluster infection could haveoccurred.
This experience highlighted the importance of thinking for oneself and taking the initiative, rather
than simply following the instructions of the authorities and public health centres.
In addition, since we have always had an open workplace culture, even trivial disputes between
employees are heard by their managers. By sharing information within the office and deciding whoserole it is to deal with which issues, trouble has been avoided. From the point of view of stress care forthe employees, we have set aside time for the staff to choose their lunch boxes so that they can relax
by creating time to talk about things other than work. Since it is stressful for technical interns to stayovernight, these technical interns from Myanmar were asked to help prepare meals to help take theirminds off work.
Regarding the improvement of knowledge about infection prevention, we try to hand out pay slips
directly to the staff, and at that time provide both printed and verbal information.
In addition, we have posted information using diagrams and illustrations so that the non-Japanesetechnical interns can understand.
(iv)

Tokyo, Social Welfare Corporation D

Even before the emergence of COVID-19, we had a risk management countermeasure team andlaboratories, with virus monitoring being carried out from an early stage, and negative pressure
ventilation devices and zoning devices introduced. Because we had already had systems in place tohelp out if something happened, there was no need for us to change the divisions of duties or roles
because of COVID-19. In addition, we have been leveraging technology by the introduction of sensing
equipment and care robots. These measures allowed us to spend more time with the facility clients.
The implementation of ICT does not mean that long-term care will lose its human touch, but rather
that more time can be spent with the clients.

157

Regarding COVID-19, zoning and re-allocation had been decided before there were any cases ofinfected people, and we were able to switch as soon as there were any close contact cases. Whenactual cases of infection appeared, we immediately implemented zoning and other measures, andcalmly brought the infection to an end.
Findings with managers of long-term care facilities-

The facility managers took every possible measure to manage their physical condition andrestricted their activities, such as not going out or eating out. This is because caregivers are
exposed to the risk of infection not only in the workplace but also in their private lives (whencommuting, returning home, and in daily life at home), and are required as professionals toperform self-management. This is discussed in detail in the knowledge, attitudes, and practices(KAP) survey in Section 2.

-

Most facilities switched the division of roles and duties of their professional and other staff toan emergency system. All staff, including nursing staff and clerical staff, are involved in
caregiving, thereby compensating for the number of caregiving staff self-isolating at home. In
these circumstances, the normal chain of command has been abolished, with responsibilities
assigned to personnel according to the situation, and the system designed so that it is clear whoto ask about what.

-

In the provision of long-term care, we pay particular attention to zoning. By separating
entrances and exits, having dishes placed on verandas after meals to avoid contact with clients,
and the introduction of zoning devices and negative pressure devices, etc. we have been able
to thoroughly prevent contact between infected persons and close contacts and other clientsand staff.

-

All of our facilities are paying careful attention to the mental wellbeing of our staff. They provide
recreational opportunities as well as confectionary and small gifts to prevent the decline ofmorale.

-As the manager in charge of a facility, I try to build a relationship of trust with the employees
and staff, and to think and act on my own according to the situation. If we wait for instructions
from the government or public health centres, our response will be delayed and may not be intime to deal with the situation. To that end, it is important to broaden one's horizons on a daily
basis and know who to ask when one is in difficulty.

2.

KAP Survey in Japan

2.1.

Methods

2.1.1. Survey subjects
Employees and staff of the interview subjects (ii), (iii) and (iv) (facilities) of Section 1, above.
(breakdown shown in results)158

2.1.2. Survey period
November 2021 till end June 2022
Staff were asked to participate in the survey at the time of the interviews in Section 1, above.
2.1.3. Survey items
Survey questions were set using the checklist of the Ministry of Health, Labour and Welfare.
2.1.4. Survey method
For facilities (ii) and (iii): self-administered questionnaire survey (responses collected by mail)For facility (iv): responses by entry into Google form
Check ☑ entered for ‘I know’, ‘I do’, and ‘applicable’.
2.1.5. Ethical considerations
An ethics application was filed with Keishin Group, and an ethics application was also filed with thereporter's university, and approval obtained (Reception number: 18749).
A ‘Request for cooperation in research’ was presented, and responses obtained on an opt-out basis.
2.1.6. Subjects of KAP Survey of Care Workers in Japan
A total of 114 responses was obtained.
2.1.7 Attributes of Respondents

Figure A1.2. What Type of Business do you Serve?

10.5

14.4

16.7

Welfare Facility for LTC
Health Facility for LTC
Day Care
No Answer
68.4

Source: Compiled by author.

159

Figure A1.3. What is your Age?
0.8
11.4

13.2
20s
30s
40s

20.2

50s
31.6

60s+
No
Answer

22.8

Source: Compiled by author.

Figure A1.4. What is your Tenure?

2.7

10.5

18.4

23.7

21.9

22.8

Source: Compiled by author.

160

Less than 1 year
1-3 yrs
3-4 yrs
5-9 yrs
Over 10 yrs
No Answer

2.2.

Results of KAP Survey

2.2.1. Knowledge of Care Workers in Japan
Table A1.2. Knowledge of Care Workers in JapanYes

Do you know the following about COVID-19？
I know that infection with COVID-19 causes fever, respiratory symptoms(cough, sore throat, nasal discharge, nasal closing, etc.), headache, malaise,etc.
I know that many COVID-19 patients complain of olfactory and taste
symptoms.
I know that COVID-19 was initially thought to spread with contact or droplet
infections but has now been proven to spread with aerosol infections.
I know that in the elderly, underlying diseases (chronic respiratory diseases,
diabetes, cardiovascular disease, etc.) are high-risk factors for COVID-19.
I know that the COVID-19 virus remains in the air for about 3 hours in aerosols,
about 72 hours on plastic and stainless-steel surfaces, about 24 hours on
cardboard surfaces, and 4 hours on copper surfaces.
I know that COVID-19 viruses are more attached to patient pillows, telephoneanswering machines, TV remote controls, chair takers, and toilet
environments.
I know that most COVID-19 patients are the subject of infection transmission.
I know that COVID-19 is transmitted before onset (2 days before onset) or fromasymptomatic patients.

No

114

0

100%

0%

114

0

100%
92

0%
22

80.7%

19.3%

113

1

99.1%

0.9%

61

53

53.5%

46.5%

92

22

80.7%

19.3%

101

13

88.6%
106
93.0%

11.4%
8
7.0%

Source: Drafted by author based on the research findings in the current study.

2.2.2. Attitude of Care Workers in Japan
Table A1.3. Attitude of Care Workers in Japan
Please tell us about yourself.

Yes

I like to do to new things, and to go to new fields.
I think I am more curious.
I think I am contributing to society.
I am a better fit in my new environment soon.
I get to know people and become friends as soon as I get to know them.

161

No
66

48

57.9%

42.1%

55

58

48.7%

51.3%

60

54

52.6%

47.4%

53

61

46.5%

53.5%

33

81

28.9%

71.1%

I can tell people my thoughts and thinking right away.
I will not maintain even if I am unreasonable.
I have three or more hobbies.
I am the type who does not give up things easily.
I like to try various things.
I think I am happy.
I have friends and family who I can consult on anything.
I am the one who switches feelings quickly.
I am excited to think about my future.
I believe that adversity is an opportunity to grow myself.
I try to challenge difficult events.
I think that I will tackle the next opportunity even if I fail.
I switch my feelings and act optimistically.
I can find goodness and appreciate even those who are not good at it.
I can work hard towards my goal.
I think there are good things in the future.
I like to engage with people as a supporter.
I have a family who listens to my troubles and advises me.
I have someone to support me.

162

38

76

33.3%

66.7%

45

69

39.5%

60.5%

40

74

35.1%

64.9%

53

61

46.5%

53.5%

59

55

51.8%

48.2%

80

34

70.2%

29.8%

86

28

75.4%

24.6%

56

58

49.1%

50.9%

24

90

21.1%

78.9%

44

70

38.6%

61.4%

49

65

43.0%

57.0%

75

39

65.8%

34.2%

69

45

60.5%

39.5%

64

50

56.1%

43.9%

74

40

64.9%

35.1%

71

43

62.3%

37.7%

82

31

72.6%

27.4%

81

33

71.1%

28.9%

95

19

93.3%

16.7%

I have a friend who can consult with me.

92

22

80.7%

19.3%

60

54

52.6%

47.4%

79

34

69.9%

30.1%

81

33

71.1%

28.9%

63

51

55.3%

44.7%

65

49

57.0%

43.0%

77

37

67.5%

32.5%

66

48

57.9%

42.1%

80

34

70.2%

29.8%

75

37

67.0%

33.0%

77

37

67.5%

32.5%

59

53

52.7%

47.3%

Yes

No

28
25.0%
3
2.7%
30
26.8%
16
14.2%
8
7.1%
19
16.8%
8
8.0%

84
75.0%
110
97.3%
82
73.2%
97
85.8%
104
92.9%
94
83.2%
104
92.0%

I can take myself positively.
I can control my emotions moderately.
I can analyse the causes of stress.
I can ask a person for help.
I am aware of myself.
I can be a distraction, such as being passionate about hobbies.
I have a boss who can support me.
I can rely on peers and seniors who can help each other in the team.
I can use the means and resources necessary to work as a supporter.
I analyse the situation and work on solving the problem.
I have encouragement and support from many professions.

■ Please tell us about the changes in yourself since the outbreak of
COVID-19.
I cannot sleep or my sleep is shallow.
I have lost my appetite.
I eat more than usual.
I have been suffering from physical problems such as headaches andabdominal pain.
I am suffering from dizziness.
I am overly frustrated.
I am becoming restless and not concentrating in my work.

163

I cannot get out the helpless thinking and the worry about anxiety of mythoughts.
I am not motivated and am becoming hesitation to go to work.
I am uneasy about the response to the infected person.
I have an ‘excessive fear’ of viral infection.
I feel lost and anxious in the working place because there are no clear
instructions, scientifically based explanations.
I spend my days with the thought that we have to work hard.
I am suffering because I am told to ‘avoid’ the functions and relationshipsthat have been required so far in the long-term care field.
I have a strong sense of anxiety that I will carry the infection.
I have anxiety about the future with no exit.
I feel that the amount of work due to infection prevention measures isincreasing more than normal.
I feel that there is no environment for providing safe and secure long-termcare.
I have an anxiety against infection because I have an overwhelming
shortage of supplies such as masks, disinfectant alcohol, and protective
equipment.
I am worried about when I am going to get an infection.
I am worried that I am going to infect with a family.
I am afraid I will spread infectious diseases in the workplace.
Even if I thought that there was ‘no choice’ in my mind because I refrained
from going out, there was a psychological burden.
Source: Drafted by author based on the research findings in the current study.

164

14
12.4%
24
21.2%
42
37.2%
17
15.0%
20
17.7%

99
87.6%
89
78.8%
71
62.8%
96
85.0%
93
82.3%

61
54.0%
25
22.1%

52
46.0%
88
77.9%

41
36.3%
43
38.1%
59
52.2%

72
63.7%
70
61.9%
54
47.8%

36
31.9%
7
6.2%

77
68.1%
106
93.8%

58
51.3%
52
46.0%
56
49.6%
63
55.8%

55
48.7%
61
54.0%
57
50.4%
50
44.2%

2.2.3. Practice of Care Workers in Japan
In this regard, I did a cross tabulation with years of service.
Table A1.4. Practice of Care Workers in Japan■ Can you prevent droplet
infection?

If a client has symptoms (fever,etc.) that are suspected to be a
droplet infection, I will refrainfrom providing the service inprinciple.
I do not go to work as a rule if I
suspect a droplet infection.
When I contact with a patient, I
must wear a high-performancemask (N9512, etc.).
If I cough or sneeze withoutwearing a mask, cover my mouthand nose with a tissue, etc., anddiscard it after use.
If I use a handkerchief, towel,
etc., I do not share that
handkerchief or towel withanyone.
I wash handkerchiefs and towels
with saliva and runny noses in myhands with soap under the flowof water.
I help clients wear surgicalmasks.
I do enough ventilation.
Since contact infections can also
occur with droplet-infected
pathogens, I disinfect common
facilities with a lot of contact(handrails, doorknobs, computer
keyboards, etc.)
In principle, I provide care forclients in a private room.
If it is not available, I will care forpatients in a group-isolated
room.

Less
than
1 year

1–3
years

3–5
years

More
than 10years

NoAnswer

3

More
than
5
years
5

6

19

9

0

1

34

24

23

22

18

3

99

7

17

10

10

3

2

49

12

25

24

21

20

3

105

12

27

24

23

19

3

108

8

16

15

10

5

2

56

4

13

7

8

5

1

38

11

26

25

21

16

3

102

7

21

18

20

16

1

83

6

17

15

15

10

1

64

4

13

9

13

6

2

47

165

TOTAL

If the patient and other clientscannot be isolated, I will make a
distance such as 2 metres ormore of the bed space orpartitioning the bed withcurtains, partitions equipment,etc.
I keep the window open as muchas possible, although I need not
set up special air conditioners.
■ Can you help client’s diet?

I have done hand hygiene before
meal support.
I wear a mask, an apron, goggles,
a face shield, and disposable
gloves.
I wipe the table with wet tissue
with alcohol (alternatively, usedwith diluted sodium
hypochlorite).
I help with meals one by one
separately.
I have double-worn gloves tohelp the next client’s meal
support quickly and safely. I willremove one of gloves when one
person ends, and I will be able tohelp the next person
immediately.
I sit diagonally behind the user
and watch the swallowing tosupport the meal.
I am careful not to get too close
to a client.
I pull my upper body back so that
I do not get bathed in the client's
saliva etc.
I am always positioning on theright or left side of a client to help
him/her stay out of the way ofthe coughing client.

6

14

13

13

11

2

59

9

25

25

21

16

2

98

Less
than
1
year
8

1–3
years

3–5
years

TOTAL

22

More
than
10
years
21

No
Answer

21

More
than
5
years
21

3

96

6

16

15

17

9

1

64

7

22

20

20

18

3

90

3

14

9

9

6

1

42

3

9

2

3

1

1

19

2

11

10

11

6

2

42

4

15

12

9

10

1

51

5

13

16

10

8

2

54

7

17

22

17

17

3

83

166

I avoid verbal conversations asmuch as possible during meals.
I am communicating with nonverbal signs (e.g. nodding sign,
gesture, and body language).

3

14

6

9

7

2

41

7

14

7

8

7

1

44

■ What are you doing with theapron after use?

Less
than
1
year
6

1–3
years

3–5
years

TOTAL

13

More
than
10
years
9

No
Answer

17

More
than
5
years
15

3

63

6

18

17

16

13

3

73

5

16

11

11

4

2

49

5

15

13

12

4

2

51

7

17

14

14

12

2

66

5

14

12

12

2

2

47

Less
than
1
year
3

1–3
years

3–5
years

More
than 5years

NoAnswer

TOTAL

17

12

8

More
than
10
years
1

3

44

4

14

8

9

4

1

40

7

16

16

13

9

2

63

I am slowly taking off so that theoutside of the apron does nottouch my face, hair, or clothes.
I am taking off the apron awayfrom me and folding it outside in.
I put the folded apron in a plastic
bag and close the mouth of the
bag tightly.
I am going to spread out theplastic bag to put the apron in
before I start caring.
I always wash my hands after I
put away my apron.
I take care not to touch the apron
directly and wash it promptly
after take home.
■ How do you communicate withthe client?

I am standing shoulder toshoulder and talking with client
who speak loudly, avoiding faceto-face conversations.
I request the client to wear amask, and I avoid the face to facegetting in close contact directly.
I am talking with the client in awell-ventilated place.

167

■ Are you preventing the spread of
infection to clients?

I do not touch my eyes, nose, or
mouth when I touch water faucets,
doorknobs, and electric switches
that everyone touches.
In the event of an infectious disease,
I will thoroughly perform suchhygiene appropriately as handwashing, vomit, excrement, etc.
I take particular care not to spreadthe infection through my own or mycolleagues.
I urge customers to wash theirhands.
If I have symptoms or suspect aninfection, I will report it to mysupervisor and consult with them
about how to respond.
I will seek instructions from doctors
and nurse and disinfect our facility ifnecessary.
I intend to follow directions by adoctor, if necessary, for isolating
infected client into the private room.
I pay attention to the healthmanagement not only for clients
who are suspected of infection, butalso for all clients, because there areno symptoms now, physicalcondition may change suddenly inthe future.
■ What are you doing when you
leave?

I am changing clothes between
commuting and working.
I am wearing a mask and keeping
my distance from other people.
I do not touch my face when I
touch the straps and handrails.

Less
than
1
year
10

1–3
years

3–5
years

More
than 5years

NoAnswer

TOTAL

16

More
than
10
years
12

23

22

2

85

10

24

25

19

18

3

99

9

26

24

21

18

3

101

5

19

22

19

15

3

83

10

24

25

21

20

3

103

9

22

19

19

17

2

88

10

19

22

19

15

2

87

9

20

23

21

15

3

91

Less
than
1
year
7

1–3
years

3–5
years

More
than 5years

NoAnswer

TOTAL

23

23

20

More
than
10
years
18

3

94

11

27

25

20

19

3

105

11

25

20

16

9

2

83

168

When I am done cleaning up, I am
doing hand hygiene before I gohome.
I try not to touch things after handhygiene.
I am wearing a jacket just before I
leave the front door or after I leave
the front door.

11

25

23

20

20

3

102

7

19

19

15

10

1

71

4

17

11

13

11

1

57

■ Are you mindful of thefollowing when taking a break?

Lessthan 1
year
10

1–3
years

3–5
years

TOTAL

17

More
than 10
years
14

No
Answer23

Morethan 5
years
15

2

81

9

24

22

21

14

3

93

9
11

24
25

19
23

16
22

9
13

2
3

79
97

9

23

20

15

14

2

83

8

17

13

14

12

1

65

10

26

23

24

21

3

107

12

22

25

20

17

2

98

11

26

21

20

13

3

94

12

25

24

22

18

3

104

10

18

19

17

9

2

75

I have taken more than 2 minuteswith others.
I have opened several parts of theroom and ventilated the room.
I am refraining from chatting.
I try not to talk loudly at
mealtime.
I have enough sleep, and a solid
diet.
I am consulting someone when I
am mentally cornered.
I do physical condition checks
such as body temperature
measurement before going towork, and do not go to workwhen I have symptoms.
I avoid gathering in groups in aspace with poor ventilation, evenoutside the rest area or outside of
the workplace.
When eating meals, I willthoroughly devise ways to sit as
far away as possible, and to sit
one by one so as not to face eachother.
I am trying to avoid 3 C’s andenjoy.
I take particular care ofconversations loudly when I takealcohol.

169

■ How do you take meals when
COVID-19 is prevalent?
I avoid congregational meals asmuch as possible.
I am serving small meals,
avoiding platters for share.
In the case of platters for share,
I change chopsticks for
distributing foods and for eatingthem.
I do not eat at restaurants anduse take-home style anddelivery system instead.
When I have meals together, I
sit side by side, not face-to-facewith the other person.
I stop chattering during meals.
I avoid sharing of a drinking
glass.
■ Can you take basic actions toprevent infection?
I have intervals of as much as 2
metres (minimum 1 metre)with others.
I try not to be directly in front of
the other person when I talkwith them.
I wear a mask as much as
possible even if I do not haveany symptoms.
Even when I must put on themask, I take it off appropriately
so as not to become
hyperthermia when climate ishot.
I always wash my hands andface after I get home.
When I go to a crowded place, Ichange clothes as soon as I gethome.
I am washing my hands withwater and soap for 30 seconds.

Less
than 1
year
10

1–3
years

3–5
years

More
than 10
years
17

No
Answer

TOTAL

25

More
than 5
years
22

26

3

103

12

22

22

20

11

3

90

10

22

18

22

15

3

90

7

19

15

12

9

3

65

5

20

12

14

7

2

60

6
12

16
25

14
24

13
21

13
21

3
3

65
106

Less
than 1
year
9

1– 3
years

3– 5
years

TOTAL

16

More
than 10
years
14

No
Answer23

Morethan 5
years
17

3

82

7

23

16

14

1

2

63

12

25

24

23

19

2

105

9

16

15

18

10

3

71

9

24

21

19

8

3

84

7

21

21

15

12

3

79

7

19

21

17

12

2

78

170

I have done alcohol disinfectionof my fingers.
I keep protecting coughetiquette.
I control ventilation frequently.
I check my health such asmeasuring body temperature in
every morning.
I am refraining from going out if
I have symptoms such as fever
or cough.
I am avoiding 3C's.
I exercise self-control ofentering or leaving areas where
COVID-19 is prevalent.
I check where and when I met
with someone.
I am using a contact
confirmation app.
I try to know the infection
situation in various places.
I avoid traveling when public
transportation is crowded.
I move as much as possible bybicycle or on foot.
I try to keep my distance when I
go by with people.
■ How are you shopping when
COVID-19 is prevalent?
I am shopping using mail order.
When I go shopping, I go by
myself or with a small group.
I am shopping at a time when
the store is not crowded.
I am using electronic payments.
I am planning to get my
shopping time finished quickly.
I do not touch the samples on
display.
I take the distance back andforth when I line up at the cash
register.

9

23

21

22

17

2

94

12

23

24

22

20

3

104

11
10

24
24

24
23

20
23

13
17

2
2

94
99

12

25

24

22

20

3

106

12
12

25
26

25
24

22
22

19
18

3
3

106
105

9

19

13

15

7

2

65

6

12

8

6

13

1

46

10

22

17

16

13

2

80

7

22

18

17

11

2

77

10

20

19

14

9

2

74

7

19

17

14

7

3

67

Less
than 1
year
9
12

1–3
years

3–5
years

TOTAL

14
25

More
than 10
years
9
21

No
Answer19
25

Morethan 5
years
12
23

2
3

65
109

7

20

18

17

11

1

74

8
9

19
22

11
22

11
19

7
12

2
2

58
86

6

20

12

13

2

1

54

11

25

26

23

20

3

108

171

■ How do you enjoy
entertainment, sports andevents when COVID-19 wasinfested?
I do not go to the full-service
restaurant.
I do not go to karaoke.
I enjoy the entertainment
programme using online asmuch as possible.
I use the reservation system.
I do not stay longer in a smallroom.
I use times and places where
people are few.
I utilise the contact
confirmation app.

Lessthan 1
year

1–3
years

3–5
years

More
than 5years

Morethan 10years

NoAnswer

TOTAL

7

23

19

16

8

3

76

9
8

24
20

23
14

21
14

17
8

3
3

97
67

9
9

15
19

12
21

14
17

7
13

3
3

60
82

9

18

19

18

13

2

79

5

10

8

5

7

1

36

Source: Drafted by author based on the research findings in the current study.

2.3. Findings
2.3.1. Knowledge of Care Workers in JapanThe response was ‘I know’ to almost all questions, and it can be said that those surveyed havesufficient knowledge about COVID-19 as LTCWs. However, in response to the item ‘I know that the
COVID-19 virus remains in the air for about 3 hours in aerosols, about 72 hours on plastic andstainless-steel surfaces, about 24 hours on cardboard surfaces, and 4 hours on copper surfaces', only
about half (53.5%) answered that they knew this.
2.3.2. Attitude of Care Workers in Japan
Overall, the responses indicated that many employees have a positive attitude. While approximately
70% answered ‘No’ to items related to sociability, such as 'I get to know people and become friends
as soon as I get to know them.' and 'I can tell people my thoughts and what I am thinking right away',about 70% of respondents answered ‘Yes’ to questions related to optimism, such as 'I think I am
happy' and 'I think there are good things in the future.'
In addition, about 70% of the respondents answered positively to questions related to their
qualifications as a caregiver, such as 'I like to engage with people as a supporter.' This is thought to be
due to the above-mentioned facility managers taking care to provide mental health support for theiremployees, and more than 80% answered ‘Yes’ to 'I have someone to support me.' In terms ofquestions about changes in themselves since the outbreak of COVID-19, physical changes(deteriorating physical condition) were less than 30%, but more than 50% responded with 'I spend
my days with the thought that we must work hard.' and 'I feel that the amount of work due to172infection prevention measures is increasing more than normal', indicating that staff are working hardto prevent infection. The fact that so few responded with ’I feel lost and anxious in the working placebecause there are no clear instructions, scientifically based explanations.’ Or ‘I have an anxiety against
infection because I have an overwhelming shortage of supplies such as masks, disinfectant alcohol,and protective equipment’ may be taken as an indication that infection control measures are being
implemented in the workplace.
2.3.3. Practice of Care Workers in Japan
Working on the hypothesis that care workers who have worked over 5 years are likely to be morethorough in infection control, we cross-tabulated by the length of tenure and the practice. The results
show that infection control measures are being taken regardless of the tenure, and many employees
who have fewer years of service answered ‘Yes’, indicating that they are reacting to the situation
seriously.
Regarding meal assistance, the number of respondents who answered ‘Yes’ was low, as was thenumber of actual care workers. As a result, in many facilities, one care worker attends to two (ormore) clients, with the result that it is not possible to provide such assistance from behind or tomaintain distance. Also, such assistance is often provided alternating between clients, which meantthat only a few respondents were able to answer ‘Yes’ to items such as I wear two pairs of gloves tohelp the next client’s meal support quickly and safely’. I remove one pair of gloves when the first client
is finished, so I can assist the next client immediately.’
Also, it can be seen that care workers are careful of their activities in their daily lives outside of work.
Almost all respondents answered ‘Yes’ when asked whether they were avoiding eating out or sharing
food and drink, wearing masks, having consideration for others when coughing, avoiding crowded
places, closed spaces, close contact (3Cs), restricting their activities, shopping in small numbers andin a short space of time, avoiding amusement facilities, etc. In addition, they appear to be taking
careful precautions when traveling to and from work and during rest breaks, as well as changing theirclothes and masks, ventilating room and eating without speaking.
Since essential workers such as care workers are also citizens engaged in ordinary daily life, thoroughinfection control measures must be taken even outside the workplace (at home, when commuting,when going out). The extent of the professional awareness affects the prevention of infection, and it
shall cause the suppression of the occurrence of infection cluster at LTCFs.

173

Figure A1.5. COVID-19 Risks of Long-term Care Workers

Source: Compiled by authors.

3.

Lessons Learnt

LTCWs had made efforts by:-Thorough implementation of infection control measures in daily life (avoid eating out andsharing food or drinks, wear masks, have consideration for others when coughing, avoid the 3Cs,
restrict activities, shop in small numbers and within a short space of time, avoid amusement
facilities).

-

Thorough self-management on a daily-life basis.

Facility managers had made efforts:-

Working to build a relationship of trust with staffs on a daily-life basis.

-

In an emergency such as COVID-19 infection, provide LTC that prioritises life and create aworkplace environment that allows for nurses to make and carry out medical decisions. Also,
there should be a comprehensive LTC structure throughout the workplace, so that nurses arealso able to provide long-term care.

-

Clarify the chain of command in the event of an emergency.

-

Waiting for instructions from the government or public health centres may cause to delay
emergency responses under the risk of a cluster outbreak, so facility managers should makedecisions and implement them by themselves.

-

Take measures to prevent the spread of infectious diseases, focusing on zoning within thefacility (see chapter 3 on business continuity plans for details).

-

Pay attention to the care of the mental health of all staff.

-

For mitigating the undue pressure and stress on daily work, it needs to provide the time andspace for the relief of tension, or to give small presents, etc. in order to relieve stress (small
considerations such as allowing staff the time to choose their own lunch boxes, can be effective).

It is important to have a broad perspective on a daily-life basis, build personal connections, and know
who to ask when in trouble so that the above actions can be implemented instantly.
(Reported by Hiromi Kinebuchi)

174

Appendix 2
Conferences for Learning and Sharing Results of Our Research

Figure A2.1. Figure Volunteers Group Discussions on 17 June 2022

Source: Faculty of Public Health, Thammasat University/Srisavandhira Thai Red Cross Institute of
Nursing/Kealth and Elderly Establishment Confederation, 2022.

175

Figure A2.2. Institutional Staff Group Discussions on 18 June 2022

Source: Faculty of Public Health, Thammasat University, 2022.

176

Appendix 3
Training Modules of Infection Prevention and Control

Existing Media for Training in Thailand
Episode 1: How to build a workplace that cares for the elderly to be safe from COVID-19. Healthcare
facilities need to manage a clean and safe indoor environment and reduce the spread of the virus.
Focus on the entrance screening point, ventilation in the building, and the cleanliness of thecafeteria.

Figure A3.1. Guidelines for Private Nursing Homes to Manage COVID-19 (Clip VDO)

Source: Thai Health Promotion Foundation (2021).

177

Episode 2: Establish a self-management system for staff and caregivers, including getting a vaccine,observing yourself regularly, using protective equipment, and hand washing.

Figure A3.2. Guidelines for Care Workers to Prevent COVID-19 (Clip VDO)

Source: Thai Health Promotion Foundation (2021).

Episode 3: New residents, before entering the nursing home, visitors, and senior citizens must follow
guidelines. Get vaccinated and use antigen test kits and protective equipment before joining theactivity.

Figure A3.3. Guidelines for Visitors to Nursing Home (Clip VDO)

Source: Thai Health Promotion Foundation (2021).

178

Episode 4: How to dispose of garbage infected with COVID-19 as safely as possible.
Figure A3.4. Guidelines for Waste Management in Nursing Home (Clip VDO)

Source: Thai Health Promotion Foundation (2021).

Episode 5: describes the use of an antigen test kit test kit that provides accurate and safe results.
Figure A3.5. Guidelines for Using Antigen Test Kit (Clip VDO)

Source: Thai Health Promotion Foundation (2021).

179

Figure A3.6. Training Module of Infection Prevention

BUKU PANDUAN
Person Responsible: Prof Dr Tri Budi W.
Pengendalian COVID-19 di Instansi Perawatan Rahardjo, drg., M. Si
Jangka Panjang
Editor: Dr Susiana Nugraha, SKM., MN
Source: Center for Aging and Family, University of Respati, Indonesia, 2021.

180

Book Title: Guidelines for COVID-19 Control in Long-term Care Institutions (English translation)
Book description:
This book was developed in 2020–2021 during the COVID-19 pandemic based on the results ofresearch conducted by the Center for Ageing and Family team. The book covers various aspects oflong-term care, including efforts to prevent the spread of infectious diseases, especially in the elderly.
With the publication of this book, it is hoped that it can become a reference in making efforts toprevent infectious diseases, especially COVID-19.
The book consists of:
•
•
•
•
•
•
•
•

Background and the concept of long-term care
Principles of infectious diseases prevention
Prevention of infectious diseases transmission
Caring for elderly infected with infectious diseases
The COVID-19 pandemic and its impact on the health of the elderlyManagement of COVID-19 transmission prevention in long-term care institutions
The resilience of the elderly in the face of the COVID-19 pandemic
The role of informal leaders in tackling COVID-19

181