PONE-D-24-31334Employing foreign caregivers: exploring perspectives of older stroke survivors - a qualitative studyPLOS ONE

Dear Dr. Chang,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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ACADEMIC EDITOR: 

In view of difficulty in securing reviewers, some of whom did not revert after accepting the review, I have taken up the role as one of the reviewers for this manuscript.

Both reviewers have raised pertinent points that require attention. Please address all the comments provided by the reviewers carefully and ensure that all points are addressed in the revision. 

As the authors have claimed that they adhere to COREQ checklist in the manuscript, please upload a completed COREQ checklist to ensure that hte criteria have been met. 

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Please submit your revised manuscript by Nov 08 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Chai-Eng Tan

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: No

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: N/A

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Review ”Employing foreign caregivers: exploring perspectives of older stroke survivors – a qualitative study”

Thank you for the opportunity to review this manuscript with, from my point of view, a problematic topic. The authors themselves mention exploitation and I become very badly affected when reading the results. The expectations of the persons affected by stroke widely exceeds what is reasonable to expect. How can anyone consider it to be ok to expect persons to work 24 hours per day as is stated in line 250? This represent a very dehumanized way of looking at other persons. The researchers make a good discussion of this very problematic issue.

Abstract

In the section for Results, the themes are given, however, not with the correct names. Make sure to use the correct names from the results or re-write the text in the abstract so it is evident that what is written there is not the actual themes, but a summary of what they tell about.

Introduction

A little more about the health care system in Taiwan needs to be described for an international audience to be able to understand the article. Which care services are available for persons who are in need of daily care, but not needing hospital care? What is the cost for such services for the individual person in need?

On p 11, lines 86-87, it is stated that “a” scoping review has highlighted but then two references are given. When using two, the word “a” is not sufficient. However, reference 16 does not seem to be a scooping review.

On p 11, lines 87-90, a statement is given about existing qualitative investigations, where the scoping review is given as one of the references. Are the authors sure that all studies included in the scoping review are performed with qualitative methods?

Method

Setting and participants

It is unclear to me if all patients with a previous diagnosis of stroke are scheduled for outpatient visits at the physical medicine and rehabilitation departments of the included hospitals or if the patients who are scheduled for such visits constitute a special selection in some way? I would not expect that everyone who has got a diagnosis of stroke and live in the catchment area of one of the included hospitals, would still be scheduled for outpatient visits at these departments more than five years after their stroke. This needs to be clarified in order to understand if the available participants in any way constitutes a selected group of patients.

Procedure

On p. 13 the development of the semi-structured interview guide is described. I would suggest to also give the number of questions, not only state that there were “various questions” together with the examples tat are given.

On p 14, line 140, present tense is used, while past tense should be used, on for example “family caregivers are encouraged”.

Data analysis

On p 12, line 102 the study is stated to employ a descriptive phenomenological approach, but in the section for Data analysis, p 14, line 149, it is stated that a thematic analysis was performed. These two statements are not compatible and cannot both be true Please revise this. I cannot find any signs in the text, of this study being a phenomenological study so I would suggest to keep the claim about the thematic analysis and omit the phenomenological claims. This also gives a need to revise the aim. When a phenomenological analysis has not been performed, the results is not “lived experience”.

Ethical considerations

I cannot find any information concerning ethics despite the statement about ethical approval and information given to the participants found on p 12. Information about if informed consent was obtained, how data was handled and stored and how the participants’ identities have been protected are missing. Also information is lacking about the relationship between the researchers who recruited the participants and the researcher who conducted the interviews, and the participants. Were the researchers in any caregiving position for the participants? Can it be assumed that any power relations between the researchers and the participants existed so that the participants could feel forced to participate?

Results

In the method section only patients with a diagnosis of stroke are stated to be participants. I was therefore very surprised to understand from line 181-182 and the very first quotation in the results, that information given by relatives to the participants was included. If relative’s statements are to be part of data, then they also needs to be viewed as participants in the study.

There are multiple problems related to the results, mostly pertaining to the headings of the themes and sub themes.

The sub theme “Severity and complexity”, I do not see nether severity nor complexity in the text that describes what is labelled as this. Please revise.

I am not very sure about the name of the second theme, line 208. Is the use of “survivor” really good? We can assume that no dead person will have the need of a caregiver of any kind. I suggest to use the word participant or the word stroke instead.

I have trouble to understand how anyone hiring a foreign caregiver can view language barrier as an “unexpected consequence”. Is really seen in the interviews or is this a result of a bad heading for the sub theme?

Make sure that this section reports on the results, not discuss them. Discussion has a section dedicated to that. Examples that needs to be removed from the results are for example line 225.

It is not ok to use valuing word in the results section, these should be reserved for the discussion, see for example first word, line 309.

Discussion

Well-written and problematizing the results in a good way. This is really well needed with this kind of problematic and bothering results showing so little respect for other human beings.

Strength and limitations

Discusses the limitations in a proper way. No strengths in the study is reported which I consider would be of value. There cannot only be limitations in the study, there must also exist some good things.

I also do not agree that there would be greater reasons for persons with negative experiences to decline participation, than it would be for persons with positive experiences. Those who are dissatisfied are often not hesitant to tell about it.

Conclusion

Supported by the results.

References

Reference 19 – the title of the publication have been written in a mysterious way: Approaches QIaRDCAF. Similar problem appear in ref 33.

The journal names are alternately written with initial upper-case and lower-case in each word. Make sure to adhere to the journals guidelines concerning this.

Language

Good

Reviewer #2: Thank you for addressing an important phenomenon in caregiving for stroke patients in an Asian country. In Asian countries, reliance on informal caregivers is common due to the reluctance to institutionalise stroke patients in care homes, related to their local culture of filial piety. The current manuscript still contains many areas that require improvement.

I hope the authors can address the following issues:

The study is being presented as a phenomenological study. Please mention the key characteristics of a phenomenological study in the methods section. Otherwise, it appears that the study is more of a generic qualitative study. Important characteristics include the focus on lived experience, the meaning/interpretation of the phenomenon by the study participants, steps taken to bracket or to limit researcher bias/ influence in the interpretation fo the data etc

Secondly, the introduction needs to provide more information on the local context of the study. Were trained formal caregivers available in the country? How are foreign caregivers employed and what are the laws or restrictions surrounding the employment of these foreign helpers? Do they receive training prior to employment? What is the current long-term care system in Taiwan?

In the introduction section, add justification on why it is important to understand the perspectives of the stroke survivors. Currently it is only briefly and superficially described. What are the possible benefits of knowing their expectations, needs, challenges related to employing foreign caregivers? What expected policy changes are required?

In the methods section, please include a paragraph to represent the positionality of the researchers in the study. This is important for phenomenological studies and is part of the COREQ criteria. What additional steps were taken to minimise personal bias / influence?

Provide more description on the development of the topic guide. Was it based on theory or specific research questions? Please provide the full topic guide.

What language was used to conduct the interview? What language was used for transcription and analysis?

Line 140-141: How does presence of family caregivers influence the interview?

Lines 152: Provide an explanation for textural descriptions with a reference. It is good to provide a sample of the coding process.

Line 153: usually the term used is "thematic saturation"

A total of 23 stroke survivors were recruited for the study. How did the researchers determine when recruitment would be terminated?

For the results section, phenomenological studies usually provide rich description which can illustrate the lived experience.The current results section seem to be inadequate. For example, under Severity or complexity, the provided quotes are inadequate to reflect the severity or complexity of the patient's condition.

Overall, the results section show a more superficial description of the study findings rather than providing an interpretation of the lived experience of the stroke survivors.

The discussion provided a good explanation of the cultural setting of expectations towards foreign caregivers. The authors could provide some conclusion on the ethics or appropriateness of these expectations. Provide some recommendations on policy or education for potential employers of foreign caregivers.

Please complete the COREQ checklist and upload it as a supplementary information for this study.

Thank you.

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6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

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Reviewer #1: Yes: Åsa Rejnö

Reviewer #2: Yes: Chai-Eng Tan

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PONE-D-24-31334R1Employing foreign caregivers: exploring perspectives of older stroke survivors - a qualitative studyPLOS ONE

Dear Dr. Chang,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================

ACADEMIC EDITOR: 

The authors have addressed most of the comments from the reviewers satisfactorily. There are only minor corrections required. I suggest that the manuscript be sent for professional proofreading prior to resubmission as PLOS ONE does not copy edit accepted manuscripts. 

==============================

Please submit your revised manuscript by Dec 27 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Chai-Eng Tan

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: (No Response)

Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: (No Response)

Reviewer #2: N/A

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: (No Response)

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: (No Response)

Reviewer #2: No

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

Reviewer #2: Thank you for addressing most of the comments in the first round of review.

There are still some minor language issues that require revision.

Introduction, line 65: instead of saying "a high number of family caregivers are needed", it would be more appropriate to state that "the caregivers' role is crucial". It is not so much the number of family caregivers, but the availability and quality of care by the caregivers that enables stroke survivors to return to the community safely.

Methods, Design, line 119-120: Please correct the lanugage ".. to understand stroke survivors' experiences in receiving care from..."

Methods, Design, line 124: Please remove the Joanna Briggs Institute Critical Appraisal Checklist from the text. A critical appraisal checklist is meant for evaluating quality of published studies and not to guide reporting. The COREQ checklist is adequate.

Methods, Study Setting and Recruitment, line 132-133: Please describe how you approached potential participants. Were they approached at the waiting area of the rehabilitation services or were they recruited through an advertisement or poster? Who did the recruitment? Were the interviews conducted on the spot or an appointment given for a protected time for the interview?

Study participants, line 140: please replace "Chinese" with "Mandarin" to standardise the manuscript (as mentioned in line 183).

Formatting of quotes, e.g. line 281-283, lines 309-310, lines 343-347, lines 357-358, lines 380-389, lines 394-397. Please separate the quotes from different participants into separate paragraphs.

Discussion, lines 470-473. Please highlight the issue of patient safety when untrained caregivers are used, particularly when one of the quotes mentioned that hte caregiver caused the participant to fall. What does "inadequately treated" mean? Please rephrase for clarity.

References, please ensure references are correctly formatted. Some were incomplete e.g. ref 19, and others used different referencing styles. Referencing for websites should include when the website was accessed.

I suggest that the manuscript undergo professional proofreading prior to resubmission.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Åsa Rejnö

Reviewer #2: Yes: Chai-Eng Tan

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[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Employing foreign caregivers: A qualitative study of the perspectives of older stroke survivors

PONE-D-24-31334R2

Dear Dr. Chang,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Thank you for addressing all the comments posed by the reviewers.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Chai-Eng Tan

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: