Difficulties in Caring for the Older Adults: Perspective of Brazilian and Portuguese Caregivers

Round 1

Reviewer 1 Report

Thank you for the opportunity to review this article. For the beginning - the term "elderly" is no longer in use in professional gerontological language. Also' paragraph must include more than 1-2 sentences.

It is not clear why the authors choose Brazil and Portugal - is it because convenience? their state of birth? other reasons? is there a clear basis for comparing those two countries and not others?

The study uses the Theory of Social Representations. 1. The authors should explain this theory. 2. there is no mention of it or referring it in the discussion and conclusions. 

Lines 56-57 - the authors tackle the limitations of family caregiving. What about benefits? there is a lot of literature dealing with it and although the findings show only negative things in caregiving (which is strange), it should be mentioned in the literature review. 

Lines 59-76 - those two paragraphs are not coherent. The reader can't understand whether the authors refer to caregiver or care reciever. The authors themselves get confused with it. Also, in line 73 - "home environment" - who's? the caregiver? care reciever?

The paragraph between lines 141-149: authors mention family caregivers and informal caregivers (lines 141-142). What is the difference? and if there is no difference? why using different terms? Also, what is inclusion criteria for informal caregivers?

Theme 3.2: What does the authors refers to in "support network"? family? services? it is not the same and the benefits from both of them are different. 

To conclude: Authors should consider using the "Family Solidarity Theory" and "Conflict Model" to try and explain why people are giving care to aged family members even with all the burden related to it.

Author Response

We are grateful for the careful evaluation carried out and the favorable opinion issued. Regarding the comments, we respond below with an indication of the changes made:

(Reviewer 1)

Reviewer comment: Thank you for the opportunity to review this article. For the beginning - the term "elderly" is no longer in use in professional gerontological language. Also' paragraph must include more than 1-2 sentences.

Authors' response: The authors considered the observation. The term "elderly" was replaced in the full text as directed by the reviewer.

• Reviewer comment: It is not clear why the authors choose Brazil and Portugal - is it because convenience? their state of birth? other reasons? is there a clear basis for comparing those two countries and not others?

Authors' response: Thank you for your observation, the justification for sample selection was inserted between lines 126 to 127.  “The sample was defined by convenience, as a result of a graduate exchange (PhD sandwich) carried out by the first author”.

• Reviewer comment: The study uses the Theory of Social Representations. 1. The authors should explain this theory. 2. there is no mention of it or referring it in the discussion and conclusions.

Authors' response: The authors are grateful for the observation, and if the reviewer deems it appropriate, suggest including more information in lines 311 e 322

• Reviewer comment: Lines 56-57 - the authors tackle the limitations of family caregiving. What about benefits? there is a lot of literature dealing with it and although the findings show only negative things in caregiving (which is strange), it should be mentioned in the literature review.

Authors' response

Regarding this aspect, we understand the question, but at this moment the objective of the study is to analyze the difficulties perceived and reported by these caregivers in the function they perform. However, we appreciate the idea proposed by the reviewer, which could serve as a motto for the preparation of a future article.

• Reviewer comment: Lines 59-76 - those two paragraphs are not coherent. The reader can't understand whether the authors refer to caregiver or care reciever. The authors themselves get confused with it. Also, in line 73 - "home environment" - who's? the caregiver? care reciever?

Authors' response: We appreciate the observation, and if the reviewer considers it adjusted, we suggest including the information on lines:

• 58 -60: “Faced with the installed dependency and the imposed care demand, family members, who will become informal caregivers, seek to organize themselves in the best way to provide care, but there are two factors to be considered at this time.”
• 61: “The first concerns the previous preparation of caregivers for the development of the function and the second is related to the practical conditions of the same”.
• Reviewer comment:

The paragraph between lines 141-149: authors mention family caregivers and informal caregivers (lines 141-142). What is the difference? and if there is no difference? why using different terms? Also, what is inclusion criteria for informal caregivers?

Authors' response: Informal caregivers are those who do not receive formal remuneration for the exercise of their functions, most often being family members. This was one of the inclusion criteria for the study. However, we understand the reviewer's observation. The use of the term has been changed, standardizing it to “informal caregivers”.

Regarding the inclusion criteria, they are described between lines 144 and 148.

• Reviewer comment:

Theme 3.2: What does the authors refers to in "support network"? family? services? it is not the same and the benefits from both of them are different.

Authors' response: The authors understand the observation, and justify that in this data presentation, the formal health services and the family represent the support network revealed by the participants, safeguarding the particularities of each group. The differentiation and greater detail on the benefits of each network is presented later in the discussion, starting on line 367.

• Reviewer comment: To conclude: Authors should consider using the "Family Solidarity Theory" and "Conflict Model" to try and explain why people are giving care to aged family members even with all the burden related to it.

Authors' response: We appreciate the suggestion proposed by the reviewer, which will certainly serve as a starting point for future research.

Reviewer 2 Report

REVIEW:

First of all, I would like to congratulate the authors for discussing a subject that is often undervalued in the health sector, namely the study of the conditions of carers of the elderly.

I believe that the study shows a very correct vision of the subject and therefore deserves to be considered for publication in the journal.I add the following comments:

Novelty: The study is sufficiently original to be considered for publication in the journal.

Scope: The topic fits the scope of the journal, taking into account that it is an analysis of a possible area of action in the health sciences.

Relevance: The data are adequately interpreted, and are sufficiently scientifically sound to be relevant. I would ask for a more rigorous description of the method as well as the procedure used. Special emphasis should be placed on a more detailed description of the variables under study, as well as the description of the statistical analysis performed. The "methods" section could be improved.

Quality: The article is adequately written, well structured and supported by similar studies that raise issues to be worked on in this project. The results section is optimal and very clear in its exposition.

Scientific soundness: The study presents the necessary scientific soundness to extract highly significant and valid results for the scientific community. 

Readership interest: We think that the scientific robustness is sufficient to attract a significant number of readers from the scientific community.

Overall merit: I think the study could have sufficient scientific strength to be considered for publication. We encourage researchers to pursue the topic further and to increase knowledge on this important topic in the health sciences in future studies.

Level of English: I do not feel qualified to judge on English language and style.

More specific comments:

- The term "elderly" is no longer used, it should be changed.

- The origin of the sample should be clarified, as it is not clear exactly where the patients come from, neither in number nor in quantity.

- When referring to "home environment", what do they mean, caregiver, family? This needs to be clarified.

- The same applies to the concept of "home support network". I think that all these concepts need to be differentiated and explained well so that they do not create controversy for the reader.

- The discussion could be deepened, as it is a little thin and no major conclusions can be drawn from it.

Author Response

We thank you for the very encouraging evaluation that was carried out, and the favorable opinion issued. Regarding the comments, we replied below with the indication of the changes made:

• Reviewer comment:

Relevance: The data are adequately interpreted, and are sufficiently scientifically sound to be relevant. I would ask for a more rigorous description of the method as well as the procedure used. Special emphasis should be placed on a more detailed description of the variables under study, as well as the description of the statistical analysis performed. The "methods" section could be improved.

Authors' response: We understand the observations and more information about the method was inserted, however we emphasize that there was no intention on the part of the authors to carry out a statistical analysis in this study, which does not rule out the possibility of being addressed in a future work.

• Reviewer comment: - The term "elderly" is no longer used, it should be changed.

Authors' response: The authors considered the observation. The term "elderly" was replaced in the full text as directed by the reviewer.

• Reviewer comment: The origin of the sample should be clarified, as it is not clear exactly where the patients come from, neither in number nor in quantity.

Authors' response: We appreciate the observation, and if the reviewer considers it adjusted, we suggest including the information on line 146 - 156

• Reviewer comment: When referring to "home environment", what do they mean, caregiver, family? This needs to be clarified..

Authors' response: We appreciate the observation, and if the reviewer considers it adjusted, we suggest including the information on line 73.

• Reviewer comment: The same applies to the concept of "home support network". I think that all these concepts need to be differentiated and explained well so that they do not create controversy for the reader.

Resposta dos autores: Agradecemos a observação. Porém a apresentação dos conceitos com detalhamento de suas diferenças é inserida a partir da linha 367.

• Comentário do revisor: A discussão poderia ser aprofundada, pois é um pouco tênue e dela não se podem tirar grandes conclusões.

Resposta dos autores: Agradecemos a observação, e caso o revisor a considere adequada, sugerimos incluir as informações nas linhas: 321 – 332 e 468 – 475.