The Mental Health Predictors of Indonesian EPA Nurses and Certified Care Worker Candidates in Japan 1

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1 bs_bs_banner Japanese Psychological Research 2016, Volume 58, No. 1, Special issue: Culture-inclusive approaches doi: /jpr The Mental Health Predictors of Indonesian EPA Nurses and Certified Care Worker Candidates in Japan 1 SUSIANA NUGRAHA 2, and YUKO OHARA-HIRANO* Nagasaki University Abstract: This study was performed to identify predictors of the mental health of Indonesian nurse and certified care worker candidates who migrated to Japan under the Japan-Indonesia Economic Partnership Agreement (EPA) 1 year after they migrated to Japan. A total of 92 people participated in this study. Twenty-eight of the study participants were nurse candidates, and 64 of them were certified care worker candidates. Using the mental health status measured by the General Health Questionnaire (GHQ-12) as the dependent variable, this cross-sectional study aimed to identify the most appropriate model of mental health predictors for each occupation in the post-migration stage using multiple linear regression analyses. The results showed that the mental health prediction model was different for the two occupational groups. Each predictor and the characteristics of the occupations will be discussed. Key words: migration, mental health, nurse, certified care worker, Indonesian. The number of international migrants continues to increase in the current mobile world.the international migration of skilled health professionals from developing to developed nations has increased dramatically in recent years, and is becoming a prominent issue in global health. According to Kingma (2006), nurse migration has become a social phenomenon that occurs in the context of increasing global mobility and growing competition for scarce skills, including skills required in the healthcare sector. International migration among Indonesian healthcare workers was initiated in 1996, beginning with the United Arab Emirates as the first destination country (Suwandono, Muharso, Achadi, & Aryastami, 2005). Since then, several efforts have been made by the Indonesian government to promote overseas nursing programs, including improvements in education, recruitment and other mechanisms. Since 2008, the Japanese government has opened its market to Indonesian healthcare human resources. Under the Japan-Indonesia Economic Partnership Agreement (JI-EPA), more than 1,000 Indonesian workers have migrated to Japan to work as nurses or certified care workers. The migration of healthcare human resources under the JI-EPA is the first system that involves government-to-government cooperation. Unlike other migrations, the JI-EPA is *Correspondence concerning this article should be sent to: Yuko Ohara-Hirano, Department of Health Science, Graduate School of Biomedical Science, Nagasaki University, Sakamoto, Nagasaki , Japan. ( hirano@nagasaki-u.ac.jp) 1 This study was made possible by the support from a research grant administrated by Japan Society for the Promotion of Science (JSPS) under the research title Introducing foreign nurse and certified care workers under the bilateral agreement: Friction and Cohabitation (Representative: Dr. Yuko Ohara-HIRANO) funded by KAKENHI (Grant-in-Aid for Scientific Research (B) , fiscal years ). 2 The authors wish to express their sincere gratitude to the sixth batch of EPA nurse and certified care worker candidates and the National Board for the Placement and Protection of Overseas Workers of the Republic of Indonesia (BNP2TKI) Japanese Psychological Association. Published by Wiley Publishing Asia Pty Ltd.

2 86 S. Nugraha and Y. Ohara-Hirano a special case in terms of the policy and system. This program is governed by a bilateral agreement and is underpinned by the intention to promote free trade (Ogawa, 2012). Therefore, major efforts have been made by the two countries to minimize any negative impact that may exist due to the migration, such as preparing the healthcare workers in terms of language proficiency, establishing minimum allowable wages and introducing Japanese culture. The healthcare workers who migrate to Japan under the EPA program are designated as candidates until they pass the National Board Examination (NBE) for registered nurses and certified care workers (Ohno, 2012). Unlike the nursing profession, which has been a well-known health profession, the certified care worker (or kaigofukushi-shi in Japanese) is a new concept unique to Japan. The concept of kaigofukushi-shi developed because of the long-term care programs implemented in response to the increasing number of elderly people in the population (Ministry of Health, Labour and Welfare, 2010). The long-term care plan involved shifting the place where patients were treated and rehabilitated for chronic illnesses from the hospital to long-term care facilities or home visit nursing. The term kaigofukushi-shi refers to the occupations that provide services to help people develop their capabilities, or their ability to pursue the aspects of their life that they value (Japan Association of Certified Care Workers, 2005). The main role of the kaigofukushi-shi is to provide support to the elderly and/or disabled people who are unable to meet their daily needs independently. Although it does require some nursing skills, this profession is different from the nursing profession, especially in terms of the job description and responsibilities. Care that provides personal services within an intimate relationship is highly necessary in this profession. Therefore, special skills and training are required for this profession. Indonesia does not have such a system, therefore most of the certified care worker candidates are recruited from the diploma of nursing school graduates (Ogawa, 2012). In fact, since 2013, the JI-EPA program has only accepted candidates who have graduated from a nursing school (National Board for the Placement and Protection of Overseas Workers of the Republic of Indonesia, 2013) for both nurse and certified care worker candidates. 3 A minimum of 2 years of work experience is required for the nurse candidates, while there is no minimum working experience currently required for the certified care worker candidates. Living in a different sociocultural setting has been linked to initial cultural shock (Ward & Kagitcibasi, 2010). The differences in the social environment, cultural setting and language barrier have reportedly caused mental health problems among migrants and may reduce the net benefit of the migration (Aprahamian, Kaplan, Windham, Sutter, & Visser, 2011; Berry, 2005; Bughra & Becker, 2005). The effects of migration on individuals, societies and countries are profound and multifaceted, and many of these effects are directly or indirectly linked to the development of the adjustment processes. Numerous research studies have revealed that international migration appears to have a wide range of health impacts on migrants (Gushulak & MacPherson, 2011; Lu, 2010; Stillman, McKenzie, & Gibson, 2006; Vega, Kolody, & Valle, 1987). Mental health is becoming a major health outcome of interest in the migration setting. This is because migration often leads to the loss of one s social structure and culture, which can result in a grief reaction. According to Bughra and Becker (2005), migration involves the loss of the familiar, including language, attitudes, values, social structures and support networks. In point of fact, this situation can be viewed as a healthy reaction and a natural consequence of migration, although in some cases, this situation may cause significant distress or impairment and last for a significant 3 Responding to the EPA, the Indonesian government established a certified training course for care workers in 2009 but it was soon abolished because many graduates did not match the expectations of staff at the Japanese care facilities, who claimed that the Indonesian care workers did not have a sincere caring spirit (interviews with Indonesian government officials in July 2010 and August 2011 by R. Ogawa).

3 The mental health predictors 87 period of time for the migrants. A study among JI-EPA candidates conducted by Alam & Wulansari (2010) and Setyowati, Susanti, Yetti, Ohara-Hirano, & Kawaguchi (2010) examined the numerous sociocultural issues faced by EPA candidates that may lead to job and cultural stress, including the communication barrier due to limited language proficiency, salary and rewards issues, being treated as trainees, feeling lonely, a different working culture and the burden of passing the NBE. This study was conducted 1 year after the candidates migrated to Japan, and was intended to identify factors affecting the mental health condition of the participants post-migration. As mentioned previously, nurses and certified care workers are two different healthcare occupations. Under the JI-EPA program, both occupations require the same educational background, wherein the participants must have graduated from nursing school, despite the fact that they perform different jobs. Identifying the mental health predictors specific to both occupational groups was the goal of this study. Furthermore, this study was also designed to determine the most appropriate prediction model that explains the mental health conditions of the two occupational groups. This study passed the screening from Nagasaki University institutional review board for ethical considerations. Research Methods Study Participants and Procedures The participants of this study were the sixth group of Indonesian EPA nurse and certified care worker candidates who entered Japan in 2013, which included a total of 148 candidates. This study was conducted 1 year after the candidates migrated to Japan. The explanation of the terms and conditions of the study and informed consent for study participation were obtained. All participants were assured of the voluntary and confidential nature of the study. A total of 148 questionnaires were distributed online during 2 15 July The questionnaire was set up with a default one response per respondent to avoid any duplicate responses. Notification of the completion of a questionnaire was automatically sent to the respondent s or private message address. Measures A four-page questionnaire was developed in the Indonesian language and was distributed online, including the General Health Questionnaire (GHQ-12), which assessed the mental health condition selected as an outcome variable in this study. It measures a participant s current mental health by focusing on two major areas: the inability to carry out normal functions and the appearance of new and distressing experiences (Goldberg & Williams, 1988). In this study, the GHQ-12 was used to determine the overarching mental health condition, and was coded as A total score was given after adding all items on the scale, and ranged from 12 to 48, with higher scores referring to a poorer mental health condition. The Indonesian-language version of the GHQ-12 has been tested for reliability and validity, and the Cronbach s alpha ranged from.670 to.776, with a sensitivity of and a specificity of (Idaiani & Suhardi, 2006). The sociodemographic data consisted of the gender, age, EPA course (nurse or certified care worker) and current economic condition, which was measured by a self-rated score. Subsequently, these variables were selected as control variables. Other independent variables selected in this study were self-rated Japanese-language proficiency, self-reported job satisfaction, selfrated satisfaction towards the support given by a preceptor in helping the candidates prepare for the NBE, and the frequency of fatigue in a week. The participants were also asked to rate their burden in struggling with their position at the time, in which they were not allowed to utilize their skills and competency before passing the NBE.The working hrs and study hrs per week were also selected as independent variables. The study participants were also asked to rate their level of focus and level of confidence in passing the NBE. Migration had separated the EPA candidates from their usual sources of social support. Therefore, this study

4 88 S. Nugraha and Y. Ohara-Hirano measured the amount of social support that the candidates felt using a self-rated assessment of their perceived social support, which was measured by the Multidimensional Scale of Perceived Social Support (MSPSS) developed by Zimet, Dahlem, and Farley (1988). The MSPSS was designed to assess the perception of the adequacy of social support from three specific sources: family, friends and a significant other. The responses were in the form of a 7-point Likert-type scale, and ranged from 1 (very strongly disagree) to 7 (very strongly agree). This study employed the sociocultural adaptation scale (SCAS) established by Ward and Kennedy (1993). This scale measures the amount of behavioral and cognitive difficulties experienced by an individual when adjusting to a new culture and society. The following introductory statement was used: Living in a different culture often involves learning new skills and behavior. Thinking about living in Japan, please rate your competence on each of the following behaviors (from 1 = not at all competent; to 5=extremely competent). The total score indicates the level of competency in adjusting to sociocultural differences. This scale measures the amount of behavioral and cognitive skills, reflecting the ability to fit in or effectively interact with members of the host country s society (Ward, 2009). Statistical analysis. This study employed SPSS 19 (IBM Corp., Armonk, NY, USA) for the statistical analysis. Descriptive statistics were used for demographics, and the independent sample t-test was used to compare the mean GHQ scores by gender. Pearson s correlation coefficient was used to test the associations between the outcome variable and each independent variable; multiple linear regression analysis was employed to determine the most appropriate model for the predictors that influence the mental health condition. The level of statistical significance was set at p <.05. Results Table 1 The sociodemographic characteristics of the candidates Characteristics n (%) Age (years) (Mean: ± 2.36 SD, Min.: 21 Max.: 34) a Gender Male 40 (43.50%) Female 52 (56.50%) EPA course Nurse candidates 28 (30.40%) Certified care worker 64 (69.60%) candidates Current economic condition Very difficult to survive 2 (2.20%) Difficult but able to survive 22 (23.90%) Not so difficult to survive 68 (73.90%) Self-rated Japanese-language proficiency Beginner 1 (1.10%) Elementary 23 (25%) Intermediate 66 (71.70%) Advanced 2 (2.20%) a Mean, standard deviation, range. A total of 92 candidates participated in this study, including 64 certified care worker candidates (69.60%) and 28 nurses candidates (30.40%), with a response rate of 62.20%. The sociodemographic profile of the study participants of this study is described in Table 1. The average age of the candidates was years, 56.50% of them were female. Approximately 74.0% of the study participants said that their current economic condition was not so difficult to survive. The response toward self-rated Japanese-language proficiency showed that 2.20% of the candidates rated themselves as advanced, 71.7% rated themselves as intermediate, 25% rated themselves as elementary and 1.1% rated themselves as beginners. The average GHQ score was 25.7 ± 5.57 SD, with a range of 13 43; the SCAS was 3.12 ± 0.45 SD, with a range of ; and the MSPSS was ± SD, and ranged from 28 to 83. The average length of working hrs in a week was 37.8 hrs, and the average length of study hrs in a week was 10.5 hrs. Approximately 60% of the study participants said that they were somewhat satisfied with the support given by

5 The mental health predictors 89 Table 2 The description of variables n = 92 Variables n (%) GHQ-12 (M, SD) 25.7 ± 5.57 SD, range MSPSS (M, SD) ± SD, range SCAS (M, SD) 3.12 ± 0.45 SD, range Working hrs in a week (M, SD) 37.8 ± 8.97 SD, range Study hrs (M, SD) 10.5 ± 8.2 SD, range 0 32 Satisfaction with support given by the preceptor in preparation for the NBE Not satisfied at all 3 (3.3) Not very satisfied 14 (15.2) Somewhat satisfied 55 (59.8) Very satisfied 20 (21.7) Degree of focus toward the NBE Not at all focused 4 (4.3) Not very focused 54 (58.7) Somewhat focused 33 (35.9) Very much focused 1 (1.1) Degree of confidence in passing the NBE Not at all confident 3 (3.3) Not very confident 40 (43.5) Somewhat confident 47 (51.0) Very confident 2 (2.2) The frequency of feeling physical fatigue Always 21 (22.8) Sometimes 61 (66.3) Seldom 10 (10.9) Job satisfaction Not satisfied at all 2 (2.2) Not very satisfied 20 (21.7) Somewhat satisfied 67 (72.8) Very satisfied 2 (2.2) Unknown 1 (1.1) The extent of struggle against the current condition Struggling very much 6 (6.5) Somewhat struggling 57 (62.0) Not struggling so much 27 (29.3) Not struggling at all 2 (2.2) Note. GHQ-12 = General Health Questionnaire; MSPSS = Multidimensional Scale of Perceived Social Support; SCAS = sociocultural adaptation scale. the preceptors. Regarding the degree of focus on the NBE, 58.7% of the study participants were not very focused on the examination. With respect to the degree of confidence in passing the NBE, 51.0% of the participants said that they were very confident in their ability to pass the examination. In terms of the frequency of fatigue, 66.3% of the respondents said that they sometimes felt fatigue. Regarding the level of job satisfaction, 72.8% of the participants reported that they were somewhat satisfied with their current job. In terms of the extent of struggle with respect to not being allowed to utilize their competency until they passed the NBE, 62.0% of the participants said that they were somewhat struggling against the current conditions.the details of the descriptions can be seen in Table 2. A bivariate analysis was employed to determine the direct correlation between each variable and the GHQ score, with the participants divided by the EPA course (nurse and certified

6 90 S. Nugraha and Y. Ohara-Hirano Table 3 Variables The correlation coefficient between the GHQ-12 scores and independent variables Correlation coefficient Nurse Care worker Age Current economic condition a * Satisfaction with the support from the preceptor in preparing for the NBE b ** Working hrs Total study hrs Focus for the NBE c Confidence about passing the NBE c Fatigue d.382*.418** Job satisfaction b ** Struggle against the current working status as a candidate e ** Self-rated language proficiency f Expectations about the length of stay SCAS.707**.404** MSPSS.625**.373* Note. GHQ-12 = General Health Questionnaire; NBE = National Board Examination; MSPSS = Multidimensional Scale of Perceived Social Support; SCAS = sociocultural adaptation scale. Terms of measurement: a 1=Very difficult to survive, 2=Difficult to survive and 3 = Not so difficult to survive. b 1=Not satisfied at all, 2=Not very satisfied, 3=Somewhat satisfied and 4 = Very satisfied. c 1=Not at all, 2=Not very, 3=Somewhat, 4=Very. d 1=Always, 2=Sometimes, 3=Seldom and 4 = Never. e 1=Not struggling at all, 2=Not struggling so much, 3=Somewhat struggling, 4=Struggling very much. f 1=Beginner, 2=Elementary, 3=Intermediate, 4=Advanced. *p <.05. **p <.01. care worker candidates). Pearson s correlation coefficients are shown in Table 3. For the nurse candidates group, the results showed that there were three independent variables that had a significant correlation with the GHQ-12. In brief, the values were: SCAS, r =.707, p <.01; MSPSS, r =.625, p <.01; and fatigue, r =.382, p <.05. For the certified care worker candidates group, we identified seven variables that showed significant correlations with the GHQ-12. These were the current economic condition (r =.312, p <.05), satisfaction with the support from the preceptor on preparing for the NBE (r =.325, p <.01), fatigue (r =.418, p <.01), job satisfaction (r =.522, p <.01), the extent of struggle against their current working status as a candidate, in which they were not allowed to utilize their skills and competency before passing the NBE (r =.380, p <.01), the SCAS (r =.404, p <.01) and the MSPSS (r =.373, p <.05). The independent sample t-test showed that there were no significant differences in the mental health status between the gender groups among nurse candidates. In contrast, among the certified care worker candidates, there were statistically significant differences in the GHQ-12 scores, where female certified care worker candidates were more likely to have a higher GHQ-12 score, which reflected poorer mental health (t = 2.244, p <.05). Finally, a multiple linear regression analysis was conducted for the nurse and certified care worker candidate groups, as indicated in Table 4. The prediction model for the nurse candidates shows statistical significance (p <.01) with F = ; the model was able to predict the mental health condition of the nurse candidates in 79% of the cases (adjusted R 2 =.726). Their mental health condition was primarily predicted by the SCAS (β =.606, p <.01), MSPSS

7 The mental health predictors 91 Table 4 The mental health prediction model, stratified by occupation Predictive variables Nurses Care workers β β Gender.325**.045 Age Economic condition Satisfaction with the support from the preceptor in preparing for the NBE.008 Fatigue Job satisfaction.306* Struggle against the current working status.23* SCAS.606**.25* MSPSS.364** 0 R F ** 5.570** Note. MSPSS = Multidimensional Scale of Perceived Social Support; NBE = National Board Examination; SCAS = sociocultural adaptation scale. *p <.05. **p <.01. (β =.364, p <.01) and gender (β =.325, p <.01). On the other hand, the prediction model for the certified care worker candidates was statistically significant (p <.01) in only 48% of the cases (adjusted R 2 =.399). Their mental health condition was primarily predicted by job satisfaction (β =.306, p <.05), followed by the SCAS (β =.25, p <.05) and the extent of struggle against the fact that the candidates were not allowed to utilize their skills and competency (β =.23, p <.05). Discussion This study showed that the mental health conditions of the EPA candidates differed by occupational group whereby the mental health conditions of the certified care worker candidates were influenced by more varied factors compared with the nurse candidates. In addition to gender, which distinguishes the mental health condition among the certified care workers, another seven variables showed a significant correlation coefficient with mental health. These were: job satisfaction, fatigue, SCAS, the extent of struggle against being unable to utilize their skills and competency before passing the NBE, the MSPSS, their satisfaction with the support given by the preceptor for preparing to take the NBE, and economic condition. The mental health prediction model showed that job satisfaction is the strongest predictor of mental health, followed by competency in sociocultural adaptation and the extent of their struggle against not being allowed to utilize their skills. For the nurse candidates, we identified three variables that showed a significant correlation coefficient with mental health: SCAS, MSPSS and fatigue. The prediction model showed that the mental health condition of the nurse candidates was mainly predicted by their competency in sociocultural adaptation, followed by perceived social support and gender. Regardless of occupation, the competency of the participants in sociocultural adaptation was an important predictor of mental health status in this study. Competency in sociocultural adaptation positively affects psychological wellbeing (Aprahamian et al., 2011; Ward & Kennedy, 1993). This finding indicated that the study participants who had lower competency in sociocultural adaptation tended to have poorer mental health. Sociocultural adaptation is also defined as acculturation, which refers to the process of adopting the cultural traits or social patterns of another group. A study among foreign migrants in Japan conducted by Mahmud and Masuchi (2013) revealed that competency in acculturation was beneficial for the migrants in enhancing their psychological well-being. Psychological adaptation refers to

8 92 S. Nugraha and Y. Ohara-Hirano personal well-being and good mental health, while sociocultural adaptation refers to individuals social competence in managing their daily lives in the intercultural setting (Ward & Kagitcibasi, 2010). The process of sociocultural adaptation involves psychological adaptations that may affect an individual s psychological and physical well-being. Those who have good competency in sociocultural adaptation will be able to easily fit in and effectively interact with the host country s community. Excellent integration and acculturation with the host country s community would be beneficial for improving mental well-being (Kirmayer et al., 2011). Supporting the results of the previous studies, the present results indicated that competency in sociocultural adaptation was an important component for maintaining the mental health of nurse and certified care worker candidates. One may assume that the capability of integrating with the host country s community and adjusting to the sociocultural differences is indispensable for the candidates. Those who are competent in adapting to sociocultural differences tend to have better mental well-being compared to those who are less capable. In the nurse candidates, competency in sociocultural adaptation was found to be the strongest predictor of mental health, followed by the amount of social support and gender. The prediction model explained approximately 79% of the mental health condition, which means that the mental health condition of the nurse candidates can be simply defined by these three predictors. The reason for this is likely that the Indonesian nurses came to Japan to work as registered nurses, which is a similar job to what they had already done for at least 2 years in Indonesia. Aside from sociocultural adaptation, social support and gender were the other predictors that explained the majority of mental health conditions of the nurse candidates. In line with other studies among foreign migrants in Japan (Asakura & Murata, 2006; Ikeguchi, 2007; Mahmud & Masuchi, 2013), the present study showed that gender was a predictor of mental health among the nurses. Although equal treatments are applied for the EPA program, regardless of gender, there were still gender-related differences in mental health among the nurse candidates, where the female nurse candidates tended to have a lower level of mental health compared to the males. A previous study by Mahmud and Masuchi (2013) examined the relationship between gender and social connectednesss with the main society among foreign residents in Japan and found that gender differences indicate that males have a stronger degree of social connectedness with the main society than females. One may assume that the process of integration with the Japanese community in the work environment and society may easily lead to conflict for female candidates with the social norms in their home country, as well as threats and/or a loss of identity, which may burden their mental health. This study also found that the perceived social support was a predictor of mental health. According to Lassetter and Callister (2009), migration can significantly affect the migrants social support network, which can lead them to feeling lonely in their new location. Compared with the male candidates, females with a lack of social support who are exposed to stressful life events, such as migration, are more vulnerable to psychological disorders than males (Afifi, 2007; World Health Organization, 2004). This finding suggests that separation from the sources of social support as a result of migration has a greater impact on female nurse candidates compared with male nurses candidates. On the other hand, the mental health condition of the certified care worker candidates was explained by different variables from those in the nurse group. As shown in the bivariate analysis, the variables that showed a significant correlation with the GHQ-12 were more varied in care worker candidates. The nurse group had only three variables that showed a significant correlation with the GHQ-12 score (the SCAS, MSPSS and fatigue). Whereas the certified care worker candidates had those three variables but also gender, job satisfaction, the struggle against the current working status as a candidate, satisfaction with the support from the preceptor in preparation for the NBE and the current economic conditions. Although the

9 The mental health predictors 93 t-test showed that mental health was distinguished by gender and social support showed significant correlations in the bivariate analyses, those two predictors did not show any significant correlation with the GHQ-12 in the mental health prediction model. This finding suggests that the certified care worker candidates may face a similar situation as the nurses: female candidates tended to have poorer mental health, and those who had less social support had poorer mental health. Nonetheless, there were some other predictors that had a greater influence on the mental health conditions of the care worker candidates, such as job satisfaction and the struggle against the fact that they are not allowed to utilize their skills and competency before passing the NBE. Job satisfaction was the strongest predictor explaining the mental health condition in the post-migration care worker candidates. Job satisfaction is defined as the degree of contentment of a person with his or her job (Iecovich, 2011; Lee, Lee, Liao, & Chiang, 2009). According to Boundless (2014), feelings of job satisfaction are mainly based on the individual s perception of satisfaction, which can be influenced by the person s ability to complete the required tasks, the level of communication in an organization and the manner in which management treats the employees. As mentioned previously, all of the certified care worker candidates have an educational background in nursing, which may be benefial for adjusting to the certified care worker s job, including the use of basic nursing skills. Their ability to complete the required job may lead to job satisfaction. Additionally, the clean and comfortable working environment in long-term care facilities, sufficient support from the institution and considerable income may make them satisfied with their current job and lead to better mental health. In line with the findings of this study, a previous study conducted among medical center staff showed that the level of satisfaction positively correlates with the psychological well-being (Lee et al., 2009). The certified care worker candidates who were not satisfied with their current working condition tended to have poorer mental health. On the other hand, the extent of the struggle against the fact that the candidates were not allowed to utilize their skills and competency before they passed the NBE significantly correlated with the mental health condition among the certified care worker candidates. Those who were struggling more with their current condition tended to have poorer mental health. This finding suggests that the certified care worker candidates may not be well informed about the actual job responsibilities of the certified care worker candidates, and they therefore struggled against their working condition, which may be a burden on their mental health. Since there is no certified care worker system in Indonesia, the term certified care worker (kaigofukushi-shi) was unfamiliar to most Indonesians. Compared with the profession of nurse, which is an occupation defined almost universally, the skills required for the certified care workers at long-term care facilities are relatively unclear. A study conducted by Hirano-Ohara and Wulansari (2009) noted that the job description of the certified care workers is not well recognized even by the EPA candidates. The authors presumed that the question How much do you struggle against the fact that you cannot utilize your competency (ability, skills, knowledge, experience, etc.) before you pass the NBE? may reflect a different type of struggle for each occupation. Nurse candidates can expect to be treated equally to Japanese nurses after passing the NBE, which they are allowed to take a maximum of three times, and may thus experience less of a struggle. In contrast, the certified care workers candidates are given only one chance to take the NBE after 3 years of experience working at the care facilities. The length of time before passing the NBE may be a source of struggle, which may burden the mental health of the care worker candidates. Another possibility is that the certified care worker candidates may not be well informed about the job responsibilities of the certified care worker candidates, and therefore may misunderstand their occupation as a certified care worker, who mainly takes care of the daily needs of patients, rather than performing nursing interventions. This interpretation is

10 94 S. Nugraha and Y. Ohara-Hirano in accordance with the findings of research conducted by Alam and Wulansari (2010) and Kreasita (2010), who found that the care worker candidates who had a nursing background often struggled against their current working condition as kaigofukushi-shi, because it did not meet their expectations. According to a previous study conducted by Hirano-Ohara, Ogawa, & Ohno (2012), approximately 98% of Indonesian certified care worker candidates migrate to Japan under the JI-EPA program to develop their professional career. The fact that they will not work as a nurse, and are thus unable to improve their skills and competency in the clinical setting, makes them struggle against their current working conditions, and thus burdens them psychologically. Finally, this study identified that there are differences in the mental health prediction models between the nurse and certified care worker candidates, which may be explained by the two occupations differences under the EPA regulation. Although the nurse candidates were required to pass the NBE and are treated as candidates until they pass the examination, they realize that it is a process that must be followed to become a registered nurse in Japan. They thus hope that they can pass the NBE, and they will then be designated as a registered nurse. In contrast, the certified care worker candidates are often not well-informed about their job responsibilities, and may be dissatisfied by their inability to develop their nursing career as a certified care worker. Therefore, they struggle against their condition. As shown in the premigration study of the sixth group of JI-EPA candidates conducted by Nugraha and Hirano-Ohara (2014), knowledge about the working conditions is the main predictor of mental health in the pre-migration stage. That study indicated the importance of providing precise information to the candidates, which is in accordance with the results of the present study, especially for the certified care worker candidates who may not understand the responsibilities and status of the job. Certified care work has emerged as a unique profession in elderly care in Japan due to the super-aging of society, because these patients require different types of care from the non-aged society. Therefore, a proper understanding of the role of certified care workers and the working conditions at long-term care facilities is indispensable for the Indonesian certified care worker candidates. Although this study makes contributions to identifying the mental health predictors based on occupations in the EPA program, certain limitations should be taken into consideration when interpreting the results of this study. The first limitation is related to the sample size of the study, especially for the nurse group, which included only 28 participants; statistical biases may have influenced the results of this study. Despite the limitation of the study participants, this study was able to figure out the predictors that influence mental health condition by each occupation. Another limitation is that the measurements in this study were obtained using self-rated scores, and the objectivity of responses to a questionnaire is questionable. Moreover, this study had a cross-sectional design, and was therefore unable to identify the trends in all aspects of mental health over time. Conclusion This study found that the mental health predictors of Indonesian EPA candidates differed by occupation. The nurse model showed that the mental health condition was mainly explained by the competency of the participants in terms of sociocultural adaptation, followed by their perceived social support and gender. On the other hand, the mental health condition of the certified care worker candidates was mainly predicted by job satisfaction, followed by their competency in sociocultural adaptation and the extent of their struggle against the fact that they were not allowed to utilize their skills and competency before they passed the NBE. These findings are expected to be utilized by both countries, especially in the evaluation of the program implementation. Appropriate information for the candidates about the working conditions is necessary to help the candidates adapt to their work. Information should

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