Dementia Care Decisions, Caregiving Situations, and Formal Service Use in Korean Immigrant Families: A Qualitative Application of a Sociocultural Model

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Article “Dementia Care Decisions, Caregiving Situations, and Service Use in Korean Immigrant Families: A Qualitative Application of a Sociocultural Model” approaches very important topic, which is relevant to the Social Sciences. Article is very well-written and structured. There are only few minor issues that needs to be considered before publishing this manuscript.

(1)    Authors write that “Despite the fact that caregivers in immigrant families are more prone to caregiving stress due to various immigration and culture-related challenges, these caregivers have been understudied and underserved (Rote & Moon, 2018).” I understand that focus is on the culture, but I believe that some studies about rasism and structural challenges that migrants face should be also added in the introduction. This could provide good ground abput why this topic is important. Also results shows that there are some language-related challenges. Is there other studies that suggest similar results? Can this perspective also be hightlighted more in the beginning?

 

(2)    In the text authors writes that they focus on formal services, however in the heading only consept servises is used. This can confuse especially readers from other countries, if there is not clarification from the beginning what services are in focus. Is it possible to clarify it in heading?

 

(3)    Authors states that: ”Sources for recruitment included established community networks, referrals, and public advertisement” Can this be spesified? I am not saying to jeopardize anonymity of participants, but to elaborate what referrals and advertisement means in practise.

 

(4)    Most of the interviews were conducted in zoom. It would be good to elaborate about implementation interviews remotely. How was interview situation? privacy issues etc.

 

(5)    Results of the study are very interesting, but most of the analysis chapters ends with the quotes. I encourage authors to reflect weather this is a good way to implement analysis in all of the chapters, because if chapter ends with the quotes, reader have to do the analysis, bacause authors leaves quotes ”flowing” without analysin it. I hope authors looks closely especially at the Chapter 3.2. Also there is not enought in-depth analysis in the chapter 3.3.2.

 

I wish authors good luck in finalizing their manuscript and am looking forward to read the published article.

Comments on the Quality of English Language

Great

Author Response

Article “Dementia Care Decisions, Caregiving Situations, and Service Use in Korean Immigrant Families: A Qualitative Application of a Sociocultural Model” approaches very important topic, which is relevant to the Social Sciences. Article is very well-written and structured. There are only few minor issues that needs to be considered before publishing this manuscript.

• Authors write that “Despite the fact that caregivers in immigrant families are more prone to caregiving stress due to various immigration and culture-related challenges, these caregivers have been understudied and underserved (Rote & Moon, 2018).” I understand that focus is on the culture, but I believe that some studies about rasism and structural challenges that migrants face should be also added in the introduction. This could provide good ground abput why this topic is important. Also results shows that there are some language-related challenges. Is there other studies that suggest similar results? Can this perspective also be hightlighted more in the beginning?

Response: We have added the following statements.

Despite the fact that caregivers in immigrant families are more prone to caregiving stress due to various immigration and culture-related challenges (e.g., limited English proficiency, cultural barriers, racism, discrimination, health inequity), these caregivers have been understudied and underserved (Rote & Moon, 2018; Yellow Horse & Patterson, 2022).

• In the text authors writes that they focus on formal services, however in the heading only consept servises is used. This can confuse especially readers from other countries, if there is not clarification from the beginning what services are in focus. Is it possible to clarify it in heading?

Response: Throughout the manuscript, including the title and figure, we have consistently used the terminology of formal service use.

• Authors states that: ”Sources for recruitment included established community networks, referrals, and public advertisement” Can this be spesified? I am not saying to jeopardize anonymity of participants, but to elaborate what referrals and advertisement means in practise.

Response: We have added details on participant recruitment as below.

Sources for recruitment included established community networks, referrals, and public advertisement. One exemplary source was the Asian American Resource Database (AARD), which our research team had developed, listing health and social services available in Asian communities in the greater Los Angeles area. We established strong partnerships with key leaders and organizations in Korean communities identified in the AARD, and they were actively engaged in the recruitment and referral effort. It should also be noted that there were two participants who were referred by other participants.

• Most of the interviews were conducted in zoom. It would be good to elaborate about implementation interviews remotely. How was interview situation? privacy issues etc.

Response: The following statements have been added.

In compliance with the research activity restriction imposed due to COVID-19, all interviews were conducted remotely. Fifteen of the interviews took place online via Zoom; one interview was conducted via phone with an 82-year-old female who was not a user of computers and the Internet. We ensured that participants were in a setting that could ensure their privacy.

• Results of the study are very interesting, but most of the analysis chapters ends with the quotes. I encourage authors to reflect weather this is a good way to implement analysis in all of the chapters, because if chapter ends with the quotes, reader have to do the analysis, bacause authors leaves quotes ”flowing” without analysin it. I hope authors looks closely especially at the Chapter 3.2. Also there is not enought in-depth analysis in the chapter 3.3.2.

Response: We have rewritten the results section to add more elaborations of the results and make better flows. Please see the highlighted parts in the revision.  

I wish authors good luck in finalizing their manuscript and am looking forward to read the published article.

Reviewer 2 Report

Comments and Suggestions for Authors

Dear authors,

Thank you for the interesting paper, this work can certainly make a relevant contribution to knowledge in this field, but some revisions are necessary. 

p.2: Previous qualitative studies with Korean American dementia caregivers have demonstrated 76 varying experiences of and attitudes toward caregiving (e.g., Casado et al., 2015; Kim et 77 al., 2019; Y. Lee & Choi, 2013). Expanding their scope, in the present study we apply Roberto et al.’s (2022) model of culture and place in exploring dementia care decisions, caregiving situations, and service use.

-) Can you please elaborate on previous studies and their findings and explain which research gaps are addressed by this study and to what extent is this study positioned as complementary to existing study results?

Methods:

-) Due to this sensitive topic: zoom and telephone interviews are not the appropriate approach. Was this due to Covid-19? Please elaborate on limitations, explain the methodological approach etc.

Attitude towards formal care:

-) No culturally determined expectations of taking on the role of caregiver?

Findings

-) The findings are interesting, but very briefly described. Please elaborate.

Discussion & Findings

Above all, when reading through the discussion, it is not always clear on which findings you draw your conclusions. I therefore recommend a more detailed elaboration/description of the findings from the interviews and also a description that makes the causalities of different factors better and more comprehensible. I would also recommend adding an additional chapter (conclusions) and using this to establish a more elaborated link to the Conceptual Model of Care Decisions, Caregiving Situations, and Service Use of Dementia Caregivers in Immigrant Families in accordance with the research approach presented by you. Cultural aspects in particular are given far too little attention in the explanations, but represent an essential dimension of your research question. The presentation of the complexity of dementia caregiving in diverse groups of caregivers, taking their culture and place into account, is not sufficiently elaborated; it almost seems to be a simplification of this complex topic through the very brief description and presentation of the findings and conclusions.

The interplay between the dimensions of dementia care decisions - caregiving situations - service use is only dealt with briefly and the possible influence of other factors that may have been mentioned in the interviews (but even if not, at least their existence should be addressed) is not mentioned. Nor is there sufficient explanation of what the three dimensions mentioned encompass (i.e. in the form of a definition of each dimension so that it is clear exactly what is meant).

 

 

 

 

Author Response

Dear authors,

Thank you for the interesting paper, this work can certainly make a relevant contribution to knowledge in this field, but some revisions are necessary. 

p.2: Previous qualitative studies with Korean American dementia caregivers have demonstrated 76 varying experiences of and attitudes toward caregiving (e.g., Casado et al., 2015; Kim et 77 al., 2019; Y. Lee & Choi, 2013). Expanding their scope, in the present study we apply Roberto et al.’s (2022) model of culture and place in exploring dementia care decisions, caregiving situations, and service use.

-) Can you please elaborate on previous studies and their findings and explain which research gaps are addressed by this study and to what extent is this study positioned as complementary to existing study results?

Response: We appreciate the Reviewer 2 for the constructive feedback. We have revised the text to clarify previous findings and the research gaps addressed by our study. We hope that this adjustment better contextualize our research within the existing literature and theoretical framework. Below is the revised version:

Building upon prior qualitative research with Korean American dementia caregivers that has demonstrated diverse experiences and attitudes toward caregiving shaped by cultural norms and family dynamics (e.g., Casado et al., 2015; Kim et al., 2019; Y. Lee & Choi, 2013), our study extends its focus through a qualitative application of Roberto et al.’s (2022) model of culture and place. By investigating dementia care decisions, caregiving situations, and service utilization among Korean American caregivers, our approach seeks to deepen understanding of how cultural and geographical contexts influence caregiving practices within this community, thereby advancing current knowledge on caregiving experiences among Korean Americans.

Methods:

-) Due to this sensitive topic: zoom and telephone interviews are not the appropriate approach. Was this due to Covid-19? Please elaborate on limitations, explain the methodological approach etc.

Response: We have added the following statements in the methods section. Also, the limitation associated with the online/phone interview has been noted.  

In compliance with the research activity restriction imposed due to COVID-19, all interviews were conducted remotely. Fifteen of the interviews took place online via Zoom; one interview was conducted via phone with an 82-year-old female who was not a user of computers and the Internet. We ensured that participants were in a setting that could ensure their privacy.

Finally, given the sensitive nature of dementia caregiving, it is strongly recommended conducting in-person interviews with caregivers.

Attitude towards formal care:

-) No culturally determined expectations of taking on the role of caregiver?

Response: The following statement has been added.

An emerging subtheme, however, was the recognition that sometimes formal care was necessary. Caregivers stated that placement might be inevitable when patients’ safety was jeopardized, when family caregivers were unavailable or overburdened, or when professional medical care was needed: “The good thing about nursing homes is that nurses and doctors are there to take care of emergency situations” (male, age 63). Another caregiver (age 60) said that having nursing homes as an option made her feel relieved: “Neither myself nor my mom likes the idea [nursing home placement], but the fact that I do have an option helps me breathe.” Nonetheless, she ended her remarks by indicating her preference for caregiving at home: “If my mom’s condition gets worse, I may let her stay there temporarily, but I’d like to keep her at home as long as possible.” The caregivers generally felt that while the home was the ideal place for the patient, sometimes formal care could help alleviate some of the burden.

Findings

-) The findings are interesting, but very briefly described. Please elaborate.

Response: We have more elaborations on the findings. Please see the highlighted parts in the revision.  

Discussion & Findings

Above all, when reading through the discussion, it is not always clear on which findings you draw your conclusions. I therefore recommend a more detailed elaboration/description of the findings from the interviews and also a description that makes the causalities of different factors better and more comprehensible. I would also recommend adding an additional chapter (conclusions) and using this to establish a more elaborated link to the Conceptual Model of Care Decisions, Caregiving Situations, and Service Use of Dementia Caregivers in Immigrant Families in accordance with the research approach presented by you. Cultural aspects in particular are given far too little attention in the explanations, but represent an essential dimension of your research question. The presentation of the complexity of dementia caregiving in diverse groups of caregivers, taking their culture and place into account, is not sufficiently elaborated; it almost seems to be a simplification of this complex topic through the very brief description and presentation of the findings and conclusions.

Response: We have restructured the discussion section and added subheadings. Please see the highlighted parts in the revision.  

The interplay between the dimensions of dementia care decisions - caregiving situations - service use is only dealt with briefly and the possible influence of other factors that may have been mentioned in the interviews (but even if not, at least their existence should be addressed) is not mentioned. Nor is there sufficient explanation of what the three dimensions mentioned encompass (i.e. in the form of a definition of each dimension so that it is clear exactly what is meant).

Response: We have restructured the discussion section to address the interplay among the major constructs. Figure 1 has also revised to improve our discussions on the interconnectedness.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The comments were taken on consideration and the text was edited accordingly. The paper is an interesting piece of work and can make a contribution to this specific field of research. I wish the authors all the best for the future.