Unseen Strength: Dementia, the COVID-19 Pandemic, and the Resilient Hearts That Never Stopped Caring

Round 1

Reviewer 1 Report

General comment:

The study highlights the challenges faced by patients in residential care homes with dementia during COVID-19. The cultural and human values of the Chinese people seem to help reduce the abandonment of these patients. Although many patients no longer recognize their relatives, which causes some emotional distress, this has not prevented regular visits. The study highlights the need for staff in residential care homes to be more aware of the consequences of these patients' dementia problems and also alerts authorities to create policies that help mitigate these problems and their consequences.

Methodologically, It seemsadequate.

Results: The data analysis is done in: Mitigation or affliction Family expectations and hopes - Supporting in nutritional deficit - Supporting in physical deficit - Supporting in cognitive deficit From red flags to resilience and rebuilding stronger relational bonds - Supporting in emotional deficit - Resolving conflicts. This ends up making a very broad analysis of the problem under analysis.

Discussion: The discussion presents the comparison of the data obtained in this study with that of other authors. The authors refer to the limitations of the study. The authors should make a brief reference to the internal and external validity of the study.

The authors should make a brief reference to the internal and external validity of the study.

Author Response

Point 1: Does the introduction provide a comprehensive yet concise overview about the state of knowledge in the area of research? No

The epidemiologic situation of the COVID-19 pandemic in Hong Kong during the study period could be mentioned.

 

Response 1: Agree. We have carefully reviewed your comments and agree that the Introduction section can be improved. Our team has revised address the concerns raised in Line 23 and line 27 to provide a comprehensive information.

“A report from the Centre for Health Protection concerning the COVID-19 pandemic in Hong Kong indicated that between January 2020 and January 2023, a total of 12,266,467 individuals tested positive for the SARS-CoV-2 virus through nucleic acid assays, supplemented by 1,880,112 positive identifications from Rapid Antigen Tests [1]. [Line 23-27]

 

Reference 1. Centre for Health Protection. Situation of COVID-19 (23 January 2020 to 29 January 2023). Department of Health. 2023. https://www.chp.gov.hk/files/pdf/local_situation_covid19_en.pdf

 

Point 2: Are the results presented clearly and in sufficient detail, are the conclusions supported by the results and are they put into context within the existing literature? No

In order to appraise the results quickly, a table with the subthemes and their most highlighted phases could be indicated.

 

Response 2: Thank you for your feedback regarding the presentation of our results and the contextualization of our finding results. We revised the table with subthemes of this study in Table 3 [Line 198-199]

 

 

Point 3: A mention of the type of residential care homes for the dementia patients in the study could be useful.

 

Response 3: Thank you for your comment. Our team has revised address the concerns raised in Line 107 to 108 to provide a comprehensive information.

“Recruitment sites encompassed a diverse range of RCH, including non-profit, self-financing, and subvented institutions.” [Line 107 – 108]

 

Point 4: Could you describe the epidemiologic situation of the COVID-19 pandemic in Hong Kong during the study period to better understand the study?

 

Response 4: Thank you for your comment which has provided valuable insights for improving our manuscript. We have carefully reviewed your comments and agree that the Introduction section can be improved. Our team has revised address the concerns raised in Line 23 and line 27 to provide a comprehensive information.

“A report from the Centre for Health Protection concerning the COVID-19 pandemic in Hong Kong indicated that between January 2020 and January 2023, a total of 12,266,467 individuals tested positive for the SARS-CoV-2 virus through nucleic acid assays, supplemented by 1,880,112 positive identifications from Rapid Antigen Tests [1]. [Line 23-27]

 

Reference 1. Centre for Health Protection. Situation of COVID-19 (23 January 2020 to 29 January 2023). Department of Health. 2023. https://www.chp.gov.hk/files/pdf/local_situation_covid19_en.pdf

 

Point 5: The situation of the COVID-19 pandemic in residential care homes could be explained in great detail.

 

Response 5: Agree. We have carefully reviewed your comments and agree that the Introduction section can be improved. Our team has revised address the concerns raised in Line 36 and line 42.

“The COVID-19 pandemic distressed Hong Kong’s RCH, creating a ‘perfect storm’ of

dependence. The 2022 Omicron wave was particularly fatal due to extremely low initial vaccination rates among the frail, older population living in crowded conditions [8]. This led to explosive outbreaks, with RCH accounting for roughly 60% of all COVID-19 deaths in Hong Kong in 2022. Understaffed and unequipped for quarantine, these institutes were overburdened. Prolonged visitors ban also caused severe social isolation and loneliness, compounding the crisis for vulnerable residents [8,9]. [Line 36-42]

 

Reference:

8. Leung, C. L. K.; Wei, W. I.; Li, K. K.; McNeil, E. B.; Tang, A.; Wong, S. Y. S.; Kwok, K. O. Revisiting vaccine hesitancy in residential care homes for the elderly for pandemic preparedness: A lesson from COVID-19. 2023, 11, 1700. DOI:10.3390/vaccines11111700
9. Cheung, P. H. H.; Chan, C. P.; Jin, D. Y. Lessons learned from the fifth wave of COVID-19 in Hong Kong in early 2022. Microbes & Infect. 2022, 11, 1072-1078. DOI:10.1080/22221751.2022.2060137

 

 

Point 6: What criteria were used to include the families of caregivers of patients with dementia in the study?

 

Response 6: Thank you for your comment. Our research team has revised the concern in Line 102 to Line 108.

“A convenience sampling strategy was employed to recruit participants. To be eligible for inclusion, individuals were required to be family caregivers, aged 18 years or older, re-siding in Hong Kong, and capable of communicating in Cantonese, Putonghua, or English. The primary inclusion criterion specified that the care recipient—the family member—must have a formal diagnosis of dementia and be a current resident in a Hong Kong RCH. Recruitment sites encompassed a diverse range of RCH, including non-profit, self-financing, and subvented institutions.” [Line 102-108]

 

Point 7:  How was the sample size of this study estimated?

 

Response 7: We thank you for this important query regarding the estimation of our sample size. As this is a qualitative descriptive study, the sample size was not determined by a priori power calculations, which are characteristic of quantitative research. Instead, we were guided by the principle of data saturation. This is a well-established standard in qualitative research where the sample size is considered adequate and complete when the data collection and analysis process ceases to generate new themes or significant insights. In our study, data collection and analysis were conducted concurrently. Our research team engaged in an iterative process of interviewing participants, transcribing the data, and performing thematic analysis. This dual process persisted until no new significant themes emerged from subsequent interviews. This point of saturation was identified following the engagement and analysis of data from the 25^th participant. At this junction, our analysis confirmed that the information being gathered was becoming repetitive and was reinforcing the existing thematic framework, rather than expanding it. Therefore, the final sample size of 25 participants was not an arbitrary number, but rather the result of a systematic, data-driven process to ensure the richness and comprehensiveness of the themes presented in Line 157 to Line 160.

 

Point 8: Explain the characteristics of the research team to comprehend the study.

 

Response 8: We would like to highlight the interdisciplinary composition of our research team, which we believe was a significant strength in conducting this study. Our team’s collective expertise ensured a comprehensive analysis of the data. Methodological oversight was provided by experts in qualitative research, who ensured the rigor of the study design and thematic analysis. A scholar specializing in the COVID-19 pandemic offered crucial context on the unique public health and social challenges during the study period. Furthermore, a team member with expertise in dementia and geriatric care provided the clinical lens necessary to interpret the specific health-related challenges reported by caregivers. This collaborative approach allowed us to produce findings that are not only methodologically sound but also contextually sensitive and clinically relevant.

 

Point 9: In order to appraise the results quickly, a table with the subthemes and their most highlighted phases could be indicated.

 

Response 9: Thank you for your advice. Our team has revised address the concerns the table with themes and subthemes of this study in Table 3. [Line 198].

 

Point 10: The experience of family caregivers with respect to staff and restriction measures during the pandemic period could be more explicit.

 

Response 10: Thank you for your advice. Our team has revised address the concerns raised in Point 10, providing clearer and more detailed narrative with respect to staff and restriction measures during the pandemic period.

“… Separated by COVID restrictions, I longed to see my grandma. My pain was eased by profound respect for the heroic RCH staff who became our family’s protective shield.” [Line 343-345]

 

Point 11: Considering the high incidence of COVID-19, a question could be raised:

Did they suffer from the disease themselves?

 

Response 11: Thank you for your advice. We have carefully reviewed your comments and agree that the interview guide question can be improved.

“5. Did they suffer from the disease themselves?” [Line 126-127]

 

Point 12: A limitation of the study is that there are few details about the family caregivers in the COVID-19 pandemic

 

Response 12: Thank you for your advice. We have carefully reviewed your comments and agree that the Limitations section can be improved. Our team has revised address the concerns raised in Point 12, providing clearer and more detailed information about our study’s limitations.

“This study has several limitations that warrant consideration. A primary limitation is the sampling fame, which did not proportionally represent all four types of RCH in Hong Kong. This may restrict the generalizability of the findings. Furthermore, data were collected during the acute crisis of the COVID-19 pandemic, a context that likely influenced care-giver responses. The necessary shift to remote data collection may have also impacted data quality. The remote nature of interviews via telephone and videoconference can disrupt rapport-building and limit the observation of non-verbal cues, potentially affecting the depth of participant responses. Future studies could mitigate these effects by intentionally building rapport at the outset of interviews and utilizing video to capture visual cues. While some research suggests remote and in-person methods can yield comparable data, ensuring participants have adequate technology and a private space is crucial. These context-specific findings highlight the need for future research using more comprehensive sampling and data collection strategies.” [Line 503-515]

 

Author Response File: Author Response.pdf

Reviewer 2 Report

The manuscript studies family caregivers visiting family members with dementia in residential care homes in Hong Kong during the COVID-19 pandemic. The issue of this manuscript is important considering a public health perspective. In order to improve the manuscript, some suggestions could be considered. See detailed comments.

 

1. A mention of the type of residential care homes for the dementia patients in the study could be useful.
2. Could you describe the epidemiologic situation of the COVID-19 pandemic in Hong Kong during the study period to better understand the study?
3. The situation of the COVID-19 pandemic in residential care homes could be explained in great detail.
4. What criteria were used to include the families of caregivers of patients with dementia in the study?
5. How was the sample size of this study estimated?
6. Explain the characteristics of the research team to comprehend the study.
7. In order to appraise the results quickly, a table with the subthemes and their most highlighted phases could be indicated.
8. The experience of family caregivers with respect to staff and restriction measures during the pandemic period could be more explicit.
9. Considering the high incidence of COVID-19, a question could be raised:

Did they suffer from the disease themselves?

10. A limitation of the study is that there are few details about the family caregivers in the COVID-19 pandemic.

 

Author Response

Point 1: The English could be improved to more clearly express the research.

 

Response 1: Thank you for your comment. To enhance the quality of this manuscript, I plan to apply for MDPI’s author services, specifically their language editing, to ensure the content is expressed with greater clarity.

 

Point 2: Although Table 2 presents sociodemographic data, it lacks a more detailed analysis of differences in experiences based on variables such as gender, age, or frequency of visits. It is recommended that the authors discuss how these variables may have influenced caregivers’ motivations and resilience.

 

Response 2: Thank you for your feedback regarding the sociodemographic data, we have meticulously ensured that the detailed analysis of differences in experienced based on variables in Table 2. [Line 195-197].

 

Point 3: The limitations section is concise and clear. However, the remote nature of data collection (via telephone and videoconference) may have affected the quality of communication and the depth of participants’ responses. It would be beneficial to expand on this point by discussing the potential impact of remote interviews on data quality and strategies to mitigate these effects in future studies.

 

Response 3: Thank you for your comment. We have carefully reviewed your comments and agree that the Limitations section can be improved. Our team has revised address the concerns raised in Line 503 to Line 515.

“This study has several limitations that warrant consideration. A primary limitation is the sampling fame, which did not proportionally represent all four types of RCH in Hong Kong. This may restrict the generalizability of the findings. Furthermore, data were collected during the acute crisis of the COVID-19 pandemic, a context that likely influenced care-giver responses. The necessary shift to remote data collection may have also impacted data quality. The remote nature of interviews via telephone and videoconference can disrupt rapport-building and limit the observation of non-verbal cues, potentially affecting the depth of participant responses. Future studies could mitigate these effects by intentionally building rapport at the outset of interviews and utilizing video to capture visual cues. While some research suggests remote and in-person methods can yield comparable data, ensuring participants have adequate technology and a private space is crucial. These context-specific findings highlight the need for future research using more comprehensive sampling and data collection strategies.” [Line 503-515]

 

Point 4: While the article effectively contextualizes cultural dimensions, the discussion could be strengthened by further exploring how care institutions can adopt culturally sensitive practices and better support family caregivers, particularly in future public health crises. It is suggested that this discussion include examples of good practices or international public policies that could be adapted to the Chinese context.

 

Response 4: Thank you for your comment which has provided valuable insights for improving the discussion section of our manuscript.

“International public polices, such as Germany’s provision of paid leave for family caregivers and the World Health Organization’s goal for 75% of countries to offer carer support and training, provide adaptable models [62-66]. A multi-component societal intervention is urgently required to enhance psychological well-being for both Chinese family [67,68]. For Chinese context, this could mean integrating psychoeducation with culturally adapted practices like mindfulness and peer support groups, an approach that has proven effective in Hong Kong for reducing caregiver distress [69,70]. Good practices like person-centered care, which focuses on an individual’s life story and preferences, can be aligned with cultural values such as filial piety [67-71]. This study elucidates the motivations of Chinese family caregivers visiting relatives in RCH, disclosing how their perspectives foster positive attitudes and resilience. It also highlights the need for further studies into the emerging needs of those with dementia following public health crises like the COVID-19 pandemic.”  [Line 488-500]

 

Point 5: There are some linguistic inconsistencies and minor grammatical issues throughout the text, particularly in the use of prepositions and verb tenses, likely stemming from translation. A final language review by a native speaker or a specialist in academic English is recommended.

 

Response 5: Agree. To enhance the quality of this manuscript, I plan to apply for MDPI’s author services, specifically their language editing, to ensure the content is expressed with greater clarity.

Author Response File: Author Response.pdf

Reviewer 3 Report

The manuscript makes a valuable contribution to the scientific literature by exploring the resilience of family caregivers of people with dementia during the COVID-19 pandemic, with a specific focus on Chinese culture. The qualitative approach is appropriate for the study's objectives and was conducted with methodological rigor.
The topic is innovative, particularly in highlighting cultural aspects such as filial piety, which are often overlooked in Western studies. The presentation of the findings is strong, supported by rich excerpts from participants’ narratives, and the discussion is well grounded in the international literature.

Some aspects could be improved to enhance the methodological robustness of the manuscript:
- Although Table 2 presents sociodemographic data, it lacks a more detailed analysis of differences in experiences based on variables such as gender, age, or frequency of visits. It is recommended that the authors discuss how these variables may have influenced caregivers’ motivations and resilience.
- The limitations section is concise and clear. However, the remote nature of data collection (via telephone and videoconference) may have affected the quality of communication and the depth of participants’ responses. It would be beneficial to expand on this point by discussing the potential impact of remote interviews on data quality and strategies to mitigate these effects in future studies.
- While the article effectively contextualizes cultural dimensions, the discussion could be strengthened by further exploring how care institutions can adopt culturally sensitive practices and better support family caregivers, particularly in future public health crises. It is suggested that this discussion include examples of good practices or international public policies that could be adapted to the Chinese context.
- There are some linguistic inconsistencies and minor grammatical issues throughout the text, particularly in the use of prepositions and verb tenses, likely stemming from translation. A final language review by a native speaker or a specialist in academic English is recommended.

Author Response

Point 1: The English could be improved to more clearly express the research.

 

Response 1: Thank you for your comment. To enhance the quality of this manuscript, I plan to apply for MDPI’s author services, specifically their language editing, to ensure the content is expressed with greater clarity.

 

Point 2: - Although Table 2 presents sociodemographic data, it lacks a more detailed analysis of differences in experiences based on variables such as gender, age, or frequency of visits. It is recommended that the authors discuss how these variables may have influenced caregivers’ motivations and resilience.

 

Response 2: Thank you for your feedback regarding the sociodemographic data, we have meticulously ensured that the detailed analysis of differences in experienced based on variables in Table 2. [Line 195-197].

 

Point 3: The limitations section is concise and clear. However, the remote nature of data collection (via telephone and videoconference) may have affected the quality of communication and the depth of participants’ responses. It would be beneficial to expand on this point by discussing the potential impact of remote interviews on data quality and strategies to mitigate these effects in future studies.

 

Response 3: Thank you for your comment. We have carefully reviewed your comments and agree that the Limitations section can be improved. Our team has revised address the concerns raised in Line 503 to Line 515.

“This study has several limitations that warrant consideration. A primary limitation is the sampling fame, which did not proportionally represent all four types of RCH in Hong Kong. This may restrict the generalizability of the findings. Furthermore, data were collected during the acute crisis of the COVID-19 pandemic, a context that likely influenced care-giver responses. The necessary shift to remote data collection may have also impacted data quality. The remote nature of interviews via telephone and videoconference can disrupt rapport-building and limit the observation of non-verbal cues, potentially affecting the depth of participant responses. Future studies could mitigate these effects by intentionally building rapport at the outset of interviews and utilizing video to capture visual cues. While some research suggests remote and in-person methods can yield comparable data, ensuring participants have adequate technology and a private space is crucial. These context-specific findings highlight the need for future research using more comprehensive sampling and data collection strategies.” [Line 503-515]

 

Point 4: While the article effectively contextualizes cultural dimensions, the discussion could be strengthened by further exploring how care institutions can adopt culturally sensitive practices and better support family caregivers, particularly in future public health crises. It is suggested that this discussion include examples of good practices or international public policies that could be adapted to the Chinese context.

 

Response 4: Thank you for your comment which has provided valuable insights for improving the discussion section of our manuscript.

“International public polices, such as Germany’s provision of paid leave for family caregivers and the World Health Organization’s goal for 75% of countries to offer carer support and training, provide adaptable models [62-66]. A multi-component societal intervention is urgently required to enhance psychological well-being for both Chinese family [67,68]. For Chinese context, this could mean integrating psychoeducation with culturally adapted practices like mindfulness and peer support groups, an approach that has proven effective in Hong Kong for reducing caregiver distress [69,70]. Good practices like person-centered care, which focuses on an individual’s life story and preferences, can be aligned with cultural values such as filial piety [67-71]. This study elucidates the motivations of Chinese family caregivers visiting relatives in RCH, disclosing how their perspectives foster positive attitudes and resilience. It also highlights the need for further studies into the emerging needs of those with dementia following public health crises like the COVID-19 pandemic.”  [Line 488-500]

 

Point 5: There are some linguistic inconsistencies and minor grammatical issues throughout the text, particularly in the use of prepositions and verb tenses, likely stemming from translation. A final language review by a native speaker or a specialist in academic English is recommended.

 

Response 5: Agree. To enhance the quality of this manuscript, I plan to apply for MDPI’s author services, specifically their language editing, to ensure the content is expressed with greater clarity.

Author Response File: Author Response.pdf