Diversity and Integration: Exploring the Role of Religion in End-of-Life Care in Rural Gansu Province, China
Gavril Flora
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsThe basic aim of this paper demonstrates a high degree of originality: namely, to explore the intricate, very complex relationship between secular and sacral dimensions of hospice care from the double perspective of local community ethnic culture induced differentiation and multi-ethnic cultural integration. If this task successfully completed, it can potentially provide a significant contribution to the research field.
Certainly, there are already important strengths of the article in its present form which point to this desirable outcome: the paper offers a very well described and documented picture of the Chinese health care system, with particular regard to hospice practices, emphasising general characteristics as well as socially and culturally rooted differences. The author also demonstrates a profound knowledge of local ethno-cultural and ethno-religious community practices related to death and dying and successfully links them to the standard secular ways of application of the hospice care. The empirical part of the paper is based on a rich field-work material material, and presents highly relevant findings.
However, for the successful (and scientifically sound) completion of the assumed task there are some critical issues in the article in its present form, which need to be addressed:
1. In the title of the article I suggest replacing "commonality" with "integration", as the latter is expressing more precisely the general aim of the research as stated in the abstract: "this paper focuses on the presentation and significance of multi-ethnic cultural integration in the process of hospice care and mourning for the dead" (line 10-12).
2. Research question(s) need(s) to be formulated clearly in the introductory part of the article. In the current form of the text, the reader has to rely on the general formulations expressed in the abstract and may be can trace the scientific intents of the author from the content of the paper. However, we don't see clearly, what the researcher sought to find out when initiating this research and whether he/she obtained the answers to his/her questions.
3. The theoretical background of the paper needs to be considerably enhanced and linked to research questions. The literature referred so far concerns almost exclusively the local Chinese hospice care situation and religious practices. Since the author emphasised the differences between Chinese and Western Christian cultural tradition (line 59), tt would be important to insert references to relevant international literature, especially concerning Western hospice practices and the role of secular and religious dimensions within those practices. In this way, the article might benefit from a possible comparative perspective between this two radically different areas of culture and civilization.
4. To facilitate understanding, in the presentation part of the results (chapters II and III), it would be essential to insert after each local community case study 1-2 concluding paragraphs in order to summarise the most important findings of that case study, discussed from the perspective of the research questions.
5. Although "ethnic cultural integration" is a key term of the research which is referred to extensively in the theoretical part (lines 47-57, 88-94, 118-124), and again in Conclusions (502-519) the empirical research results are only discussing it briefly (357-369), mentioning only a few examples without detailed discussion. I think this part should be developed more (perhaps as distinct sub-chapter) , as integration of different cultural elements in hospice care appears to be fascinating (and very less known) research information, which is supposed to be at the core of this research.
6. A structural problem of the paper is that after Results and before Conclusions customary there should be Discussions. This is completely missing currently as a distinct unit, although part of the Conclusions can perhaps be renamed/relocated to this new section. The Discussions also offer opportunity to relate the findings to the specialist literature, to provide new insights and to propose possible new avenues of interpretation . These elements can significantly raise the scientific quality of the article and can make it an essential reference for future researchers in this field.
Author Response
1.The modified and rewritten parts of the text are marked in blue font.
2.Responding to First Reviewer：
First, we agree to change the title by replacing "commonality" with "integration". The new title reflects our agreement with the first reviewer’s first suggestion.
Second, we agree that the central research question of this article should be stated more clearly. And that question is about why there is a need for spiritual care in end of life care in general and in China particularly. Our revised abstract and introduction are in agreement with the first reviewer’s second suggestion.
Third, we agree that the paper’s background and theoretical discussions should situate our case studies in northwestern China in a comparative context by referring to international literature. The revised background and theoretical discussions draw the first reviewer’s third suggestion.
Four, each of the two case studies should be strengthened by a summary of reflections in response to our central research question. A summary for each case study is now included.
Five, we agree that the conclusion should place a focused emphasis on cultural integration in end of life care, namely addressing the question how Tibetan, Muslin, and Han beliefs about life and death merge and configure praxis. The conclusion is revised accordingly.
Six, we agree that we need to write a section called “discussions” so as to relate our findings and interpretations to the specialist literature. In this version of our writing, a section for discussion is added.
We greatly appreciate the professional and enthusiastic comments made by the reviewers. The authors will try the best to revise the paper.
Reviewer 2 Report
Comments and Suggestions for AuthorsThe article gives a nice insight into palliative care in a certain region in China. The chapter is ethnographically engaging, and I believe the addition of a Chinese case study to the academic field of palliative care is valuable. I especially liked the detailed description of the rituals (although I believe the “diversification” of ritual care does not come strongly enough to the fore yet). The text is overall also well written, with just a few minor mistakes here and there. I do advice the author to insert quotation marks where applicable, to indicate more clearly what research informants have said, and to rethink the writing of “in folk,” which is unclear.
In spite of the many positive points of the article, I do believe it can be strengthened, in light of the following:
Theoretical framework: The article engages with the field of palliative care. While I appreciate a Chinese reflection on this, and the use of Chinese sources to support this framework, the paper will definitely be strengthened with a theoretical exploration of palliative care (and the palliative care revolution) in general. I advise the author to explore this theoretical side further. How does relevant literature and research done on palliative care align with your experiences and how do your insights challenge existing scholarship in the field? And what is unique (or not) about palliative care in China (e.g., the overemphasis on medication, it seems). This can help ground the article in a larger academic discourse, and will make more clear the significance of the article. This also aligns with the comment made in line 73 on the “norms of hospice care from the West” – what are these?
Methodology: While it is mentioned a survey was conducted, not much additional information is given. When was the survey conducted, with how and which kind of participants, and what where the methodological and ethical considerations behind the survey? I advise the author to insert a strong methodological paragraph.
Contextualisation: At times, I felt important contextualisation was missing, as well as relevant information to fully appreciate the value of the article. Maybe the author can provide additional contextual information which situates the research in larger social, cultural or historical frameworks, and can indicate how the care described relates to broader social trends, historical events, and/or cultural dynamic. My questions on contextualization relate amongst others to the following: 1) Why a focus on the rural? What is the relevance about that, in the context of China? 2) When, how and why did official palliative care arrive in China? 3) Please give more information on medical professionals in hospice care in China. Is this something you need to be ordained for? And who provides the hospice care training, to whom, since when, and why? 4) What exactly does the author believe does and does not fit under “palliative care”? Is the guidance given by religious clergy at the end of life also palliative care, and is it seen/acknowledged as such in China? And what about traditional Tibetan medicine? How does this relate to a potential official discourse on palliative care?
Conclusion: I believe the conclusion should be entirely rewritten, as the conclusion as it is does not seem to fit the article. I hope in the conclusion the author can more clearly state what the significance of the study has been, what the main outcomes have been, and how it relates to larger scholarship on end of life/palliative care.
Comments on the Quality of English Language
The text is overall also well written, with just a few minor mistakes here and there. I do advice the author to insert quotation marks where applicable, to indicate more clearly what research informants have said, and to rethink the writing of “in folk,” which is unclear.
Author Response
1.The modified and rewritten parts of the text are marked in blue font.
2.Responding to Second Reviewer：
First, we agree that a number of quotation marks should be used to indicate more clearly what research informants have said. We’ve done so by using quotes where they are most needed.
Second, we agree that we need to relate our case studies to existing scholarship in the field of palliative care and ground our paper in broader academic discourse by making it clearly why our study is significant. We’ve done so by answering, instance, why research on spiritual care in end of life care in rural China is important for China and for other countries broadly speaking. We’ve also tried to address our study’s relevance to China’s official discourse of palliative care. In a nutshell, China’s official discourse of palliative care avoids spiritual care.
Third, we agree that the conclusion should be entirely rewritten to emphasize the significance of our study by relating our research findings a larger picture. We’ve written a new conclusion.
We greatly appreciate the professional and enthusiastic comments made by the reviewers. The authors will try the best to revise the paper.
Round 2
Reviewer 1 Report
Comments and Suggestions for AuthorsAs the result of the changes implemented, the article has improved significantly enough to warrant publication. However, I still have two suggestions to make. First, in his response the Author mentions that a Discussion section is now included. Indeed, starting from line 536 to line 662, the newly introduced text serves for this purpose, but this text is inadequately included in section III.(III) 3. "A Taoist Mantra Ceremony". I suggest therefore to include a new section title (section IV.) starting from line 536, entitled Discussion. In this way, Conclusion will become section V.
My second observation is concerning the list of references. There are only seven references included in the final list of references at the end of the article, all the other references are included only in the footnotes. The Author does not explain the reasons for this. I suggest to include in the final list all references mentioned in the article in alphabetical order, arranged according to the family names of the referenced authors.
Author Response
Please see the attachment.
Author Response File: 
Author Response.pdf
Reviewer 2 Report
Comments and Suggestions for AuthorsDear authors,
I have gone through the revised version. I appreciate the changes that have been made. While I think the paper could have been even more strenghtened theoretically speaking (i.e., engagement with scholarly debate on palliative care) I believe the article is fine enough for publication.
Comments on the Quality of English LanguageSome small errors here and there
Author Response
Please see the attachment.
Author Response File: Author Response.pdf
