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. 2025 Jan 3;20(1):e0316757. doi: 10.1371/journal.pone.0316757

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

Yen-Nung Lin 1,2, Yosika Septi Mauludina 1, Beth E Fields 3, Tsan-Hon Liou 2,4, Yu Su 1, Han-Ting Tsai 2, Feng-Hang Chang 1,2,*
Editor: Chai-Eng Tan5
PMCID: PMC11698342  PMID: 39752547

Abstract

Background

Global populations are aging, and the numbers of stroke survivors is increasing. Consequently, the need for caregiver support has increased. Because of this and demographic and socioeconomic changes, foreign caregivers are increasingly in demand in many developed countries. Therefore, the perspectives of older adult care recipients regarding foreign caregivers warrants attention. This study explored the experiences of older stroke survivors receiving care from foreign caregivers in Taiwan, examining their expectations, needs, and challenges.

Methods

This study employed a descriptive qualitative approach, conducting in-depth interviews with 23 older stroke survivors (mean age, 73.4 years; women, 47.8%). Thematic analysis was applied to transcribed data, with reflective memos aiding in meaning derivation. Methodological rigor was ensured through member checking, triangulation, and auditing.

Results

Three major themes emerged: the motivations for hiring a foreign caregiver, expectations of stroke survivors toward foreign caregivers, and challenges related to employing foreign caregivers. Stroke survivors expected foreign caregivers to be obedient, embrace the local language and culture, and be proficient in caregiving and homemaking. Various challenges, including communication difficulties, cultural differences, skill gaps, and unfavorable attitudes and behaviors among caregivers, were noted.

Conclusions

Foreign caregivers are a major part of the long-term care workforce and play a crucial role in stroke rehabilitation in aging Asian societies. Older stroke survivors often hire foreign caregivers to alleviate caregiving burdens, and they typically expect foreign caregivers to conform to their needs. However, employing foreign caregivers can be frustrating and stressful. Government intervention and open dialogue is necessary to improve care quality and prevent recurring caregiving problems and conflicts.

Introduction

Stroke is a major contributor to disease burden in older adults [1]. This disabling disease imposes a direct financial burden on patients and also burdens health-care systems, social welfare systems, and labor markets [2, 3]. Family caregivers are essential for reducing this burden and assisting stroke survivors in returning to their homes and communities.

Family caregivers typically play a key role in stroke recovery [4]. In Asian cultures, caring for one’s older parents is typically regarded as a family responsibility [5]. Primary caregivers of stroke survivors often experience a considerable burden due to the complexity of care [6]. Caregiving has become increasingly challenging over time due to societal changes such as more older adults working and more women working outside the home [7, 8]. These and other factors, such as more women migrating for work, often lead families in developed countries such as Singapore, China, and Taiwan to hire live-in foreign caregivers [9].

Foreign caregivers are migrant workers and are mostly young women from nearby developing countries who are employed on a full-time basis to assist older adults and individuals requiring home care [10]. In high-income countries, the demand for home-based health care has increased, and foreign caregivers have increasingly been hired to meet this demand [11]. Since 1992, the Taiwanese government has allowed hiring of live-in foreign caregivers through a regulation aimed at addressing a shortage of local caregivers for families with disabled members [12]. Taiwan has a long-term care project that offers services such as adult daycare and home care by local workers [13]; however, many individuals still prefer to hire foreign caregivers. By 2019, approximately 28% of people with disabilities were cared for by live-in foreign caregivers [14]. In 2021, the numbers of foreign and local caregivers were 225,432 and 74,601, respectively [15]. This difference is likely because foreign caregivers can be employed at a lower cost. Foreign caregivers typically earn a monthly salary of NT$18,000 to NT$21,000 (approximately US$550 to US$650), whereas domestic caregivers receive significantly higher pay, ranging from NT$70,000 to NT$80,000 (approximately US$2,300 to US$2,500) per month. [16, 17].

Formal training for foreign caregivers is minimal, and most foreign caregivers are not required to have caregiving or medical qualifications prior to their arrival in Taiwan [18]. Concerns have been raised that foreign caregivers lack the ability to provide quality care, particularly care for individuals with complex health needs, because of their lack of formal training [19].

Most studies involving foreign caregivers have focused on the challenges faced by these workers (i.e., workload and wellbeing) [20, 21]. Few studies have examined how care recipients, especially those with long-term disabilities, view their experiences with foreign caregivers. A scoping review of international literature highlighted the lack of research in Asia on care recipients’ experiences with foreign caregivers [21]. Notably, few studies have explored how individuals with care needs and their families perceive foreign caregivers. Several qualitative studies have explored the complex relationships between foreign caregivers and recipients [21–23]; however, no studies have specifically focused on the needs and expectations of stroke survivors toward foreign caregivers. Given Taiwan’s aging society and the growing number of stroke survivors facing unique challenges [24], understanding their caregiving experiences is crucial. The present qualitative study described the experiences of older stroke survivors in Taiwan who employ foreign caregivers, focusing on their expectations, needs, and challenges. The findings will help improve care services, assist policymakers in identifying unmet needs, and enhance care quality, which can support caregivers and guide policy development for long-term care systems around the world.

Methods

Design

This study employed a descriptive qualitative approach [25–27] to understand stroke survivors’ experiences in receiving care from foreign live-in caregivers. The study was reviewed and approved by the Institutional Review Board of the affiliated university and all participating research sites (approval number: N201907057). Informed consent was obtained from all participants before interviews were conducted, and participants were informed they had a right to withdraw from the study at any time. The Consolidated Criteria for Reporting Qualitative Research checklist [28] was used to evaluate this study’s methodological reporting quality (S1 File).

Study setting and recruitment

Participants were recruited from the rehabilitation outpatient clinics of three academic medical centers in greater Taipei, Taiwan. Taiwan’s National Health Insurance places no restrictions on the duration of outpatient rehabilitation services for stroke patients, allowing them to access these services for as long as needed. This policy enabled us to recruit patients at different stages of recovery. Patients with stroke were screened for study inclusion eligibility by staff at the rehabilitation clinics, and potentially eligible patients were introduced to the study researchers, who then met with the patients in person and explained the purpose of the study by using informational leaflets. Recruitment continued on a rolling basis until data saturation was reached [29].

Study participants

The criterion sampling approach [30] was adopted to identify potential participants. Patients were included if they had received a diagnosis of stroke, were aged ≥60 years, were enrolled in an outpatient rehabilitation program, had been receiving 24-hour home care from a live-in foreign caregiver for at least 6 months, could communicate in Mandarin, could engage in an interview for at least 60 min, and could understand and provide informed consent. Patients were excluded if they had severe aphasia (determined using the aphasia subscale of the National Institutes of Health Stroke Scale [31]) or a medical complication that might have prevented them from participating in interviews. Written informed consent was obtained from all participants between December 3, 2020, and October 20, 2021.

Positionality of the research team

The research team comprised individuals from diverse professional backgrounds. Each professional contributed unique expertise to the study. YL and TL, who were both male professors and attending physicians at a teaching hospital in Taiwan, have extensive experience in stroke rehabilitation. YM, a female Indonesian PhD student, specializes in geriatric physical therapy and qualitative research. BF, a female associate professor in an occupational therapy department in the United States, is an occupational therapist with expertise in caregiving, aging, and geriatric health. YS, a female research assistant from Taiwan, has a master’s degree in injury prevention and is trained in qualitative research. HT is a male occupational therapist at a teaching hospital in Taiwan. FC, the senior researcher, is a female professor in Taiwan with expertise in rehabilitation sciences. Both BF and FC have significant experience in qualitative research and led the study.

To minimize personal biases, YS and YM, who had no prior relationships with the participants, managed recruitment. YS conducted all interviews in Mandarin. FC, YM, and YS led data analysis, with regular team meetings held to reflect on how each researcher’s professional background might affect data interpretation. These discussions helped address the potential influence of personal assumptions, ensuring the integrity of the findings.

Procedure

Semistructured interviews were conducted to obtain in-depth insights from the participants. An interview guide comprising seven open-ended questions was developed and reviewed by an interdisciplinary expert panel, stroke survivors, and caregivers. The full interview guide is available in S1 Table. Three of the seven questions are as follows:

  1. What led you to decide to hire a foreign caregiver?

  2. What do you believe are the duties and responsibilities of foreign caregivers?

  3. What benefits or challenges have you experienced after employing a foreign caregiver?

Interviews were conducted between December 2020 and October 2021. The interviews were scheduled at times that were convenient for the participants and took place in quiet settings, either at academic medical centers or in the participants’ homes. Family caregivers were encouraged to accompany the participants and provide assistance as necessary to answer the questions. The presence of caregivers was solely for assistance purposes, and if any interference in the interview process was observed, the caregivers were asked to leave to minimize their influence on the interview.

Each participant was interviewed once, and each interview lasted 60–90 min. The interviews were audio-recorded and transcribed verbatim by the interviewer. One of the other researchers assessed the accuracy of the transcripts.

Participant demographic and clinical information was collected from medical charts and by using a questionnaire. Data were handled confidentially. Participant information was deidentified by using unique identification numbers that were stored separately from the study data on a secure, password-protected drive. Only the principal investigator and select research staff had access to the encrypted file linking identification numbers to participants. The Office of Human Research was responsible for monitoring and auditing the collected data to ensure compliance with ethical standards.

Data analysis

All data were stored, managed, and analyzed using NVivo 12 Pro (QSR International, Melbourne, Australia). Thematic analysis was performed to interpret the meaning of textual data [32]. Two researchers independently read, abstracted, and coded the transcripts immediately after each interview and then translated the coded data and quotes from Mandarin to English. Translation accuracy was verified by a third researcher. Data with similar meanings were grouped and synthesized into descriptive themes, which were reviewed by the entire research team [33]. For example, quotes that were coded as “obedient” and “respectful” were grouped under the subtheme “Being obedient and submissive.” Analysis continued until thematic saturation was reached, with co-coders agreeing that no new categories emerged [33, 34]. Translated coding results were reviewed and discussed until consensus was reached on the final interpretation of participants’ experiences [34, 35].

Between-methods triangulation [36] was used to enhance the credibility of the findings by cross-verifying data collected from different methods and sources. Interview data were compared with the interviewer’s observations and reflective memos. YS and YM recorded these comparisons during the interview process to better understand the meaning of the data. Additionally, we conducted member checking, where YS shared the analysis results with the participants in person or through phone calls to confirm the accuracy of the data interpretation [37].

Results

A total of 28 stroke survivors were invited to participate in the study. Of these, 23 completed the interviews, 3 withdrew due to scheduling conflicts, and 2 declined participation. Data saturation was reached after interviewing 20 participants, with 3 more interviews conducted to ensure no new themes emerged. Recruitment concluded after 23 participants were interviewed. The participant demographics are presented in Table 1. Overall, 47.8% of the participants were women, the average age was 73.4 years, the average time since stroke was 3.5 years, and the average Barthel Index score was 51.

Table 1. Demographic data.

Participant ID Age (years) Sex Education level Monthly household income (New Taiwan Dollar) Religion Primary caregiver Time since stroke (months) Barthel Index score (out of 100) Duration of foreign caregiver employment (months) Self-reported relationship with foreign caregivers
PS01 85 Female Junior high school 0–29,999 Buddhism Foreign caregiver 20 70 13 Very good
PS02 78 Female Elementary school 30,000–49,999 Buddhism Foreign caregiver 60 55 50 Not good
PS03 80 Female Elementary school 30,000–49,999 Buddhism Foreign caregiver 96 50 84 Very good
PS04 71 Male Graduate school 80,000–119,999 Buddhism Foreign caregiver and spouse 39 15 30 Very good
PS05 63 Male High school 0–29,999 Buddhism Foreign caregiver 4.5 60 12 Not good
PS06 88 Male College degree 50,000–79,999 No Foreign caregiver and children 6 95 18 Very good
PS07 61 Male College degree 0–29,999 Christian Foreign caregiver and spouse 15.5 50 9 Good
PS08 63 Male High school >120,000 Buddhism Foreign caregiver 12 55 12 Very good
PS09 81 Female Elementary school 0–29,999 Buddhism Foreign caregiver 33 70 26 Good
PS10 63 Male High school 30,000–49,999 Buddhism Foreign caregiver 40 85 30 Good
PS11 68 Female High school 30,000–49,999 Buddhism Foreign caregiver 13 50 8 Not good
PS12 68 Male College degree 50,000–79,999 Christian Foreign caregiver 50 75 30 Good
PS13 81 Male Junior high school 30,000–49,999 Buddhism Foreign caregiver 25 0 20 Good
PS14 84 Female Elementary school >120,000 No Foreign caregiver 25 35 24 Good
PS15 69 Male College degree 30,000–49,999 Christian Foreign caregiver and nurse 108 0 96 Good
PS16 78 Male High school 30,000–49,999 Buddhism Foreign caregiver 19 70 16 Good
PS17 70 Female Elementary school 0–29,999 Buddhism Foreign caregiver 120 35 24 Good
PS18 70 Male College degree 30,000–49,999 Christian Foreign caregiver 20 95 20 Very good
PS19 69 Female Elementary school 30,000–49,999 Buddhism Foreign caregiver 36 65 22 Very good
PS20 80 Female Elementary school 50,000–79,999 Buddhism Foreign caregiver and spouse 36 0 30 Good
PS21 69 Female High school 30,000–49,999 Buddhism Foreign caregiver 24 75 12 Okay or moderately good
PS22 84 Female Elementary school 50,000–79,999 Buddhism Foreign caregiver 160 20 70 Good
PS23 65 Male College degree 30,000–49,999 Buddhism Foreign caregiver 20 50 36 Very good
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We identified 3 major themes with 11 subthemes. Quotes supporting each theme are provided in the following sections.

Theme 1. Motivations for hiring a foreign caregiver

Several reasons were provided for hiring foreign caregivers. The reasons included needing supervision and physical assistance, lacking family caregiving support, and cost.

Need for supervision and physical assistance

Foreign caregivers were critical in helping the participants perform daily living activities. Caregivers also ensured the safety of the participants. One participant said, “I can’t walk without her. I need her to be with me at all times.” (PS01)

Another participant said, “After I had a second stroke, I decided I needed someone to stay with me to ensure my safety.” (PS13)

Lack of family caregiving support

The primary reason for hiring a foreign over a local caregiver was a lack of family caregiving support. Some participants lived alone, without family nearby. Some participants lived with family members who did not have time to take care of them. “I live alone. My husband has passed away. My son lives nearby, but he doesn’t have time to take care of me.” (PS12)

Some participants lived with family members who were available to provide care but unable or unwilling to be a primary caregiver.

“My family basically can’t do anything about caregiving. They are not very busy either. They just want to live their own lives. We discussed with hospital staff whether my family would be able to assist me, and the doctor advised me to hire a caregiver.” (PS21)

Financial limitations

Several participants explained that they hired foreign caregivers instead of local caregivers because of cost considerations. One participant said, “Local caregivers are too expensive. They cost NT$1,000 to NT$2,000 per hour.” (PS15)

Another participant said “The cost of hiring a foreign caregiver is around $NT26,000 per month. This is much cheaper than hiring a local caregiver, which costs around NT$75,000 per month.” (memos recorded by YS, March 2021)

Participants selected foreign caregivers over local caregivers because hiring a foreigner caregiver is half as expensive. “If we could hire a Taiwanese caregiver, that would be ideal because then we wouldn’t have to deal with language and culture barriers. But Taiwanese caregivers are just too expensive. My sons can’t afford it.” (PS27)

Theme 2. Expectations of participants toward foreign caregivers

The participants held various expectations for their foreign caregivers. The participants expected caregivers to be obedient and submissive, to learn Mandarin, to embrace Taiwanese culture, to master stroke care and homemaking, and to provide care for other family members.

Being obedient and submissive

Most participants expected their caregivers to be obedient and submissive. Stroke survivors and their families tend to see themselves as masters with an ownership claim on their foreign caregivers. They expect caregivers to “listen to the master” and complete all assigned tasks, including providing care, performing household chores, and handling personal and family responsibilities. This expectation stems from the fact that the caregivers are paid and employed to work for them 24 hours a day. “She must do everything we tell her to do. That’s her job, plain and simple.” (PS01)

“I’m the one paying, so she better listens to me, right? Otherwise, what’s the point of having her here?” (PS06)

Learning mandarin and embracing taiwanese culture

Nearly all participants expected their foreign caregivers to speak their language (Mandarin or Taiwanese) and adapt to Taiwanese culture. Several participants contended that effective communication with their foreign caregivers is only possible if they speak Chinese or Taiwanese. “If she doesn’t understand Chinese, how can she know what I’m saying?” (PS03)

The participants also expected their caregivers to embrace Taiwanese culture, the Taiwanese diet, Taiwanese religious practices, and Taiwanese societal rules. The participants believed their interactions with their caregivers would be smoother if the caregivers integrated into Taiwanese culture.

“She’s in Taiwan now, so she should just go with the flow and adapt to Taiwanese customs, like saying ‘please,’ ‘thank you,’ and ‘excuse me.’ That’s how we Taiwanese talk.” (PS06)

Mastering stroke care and homemaking

All of the participants believed that foreign caregivers should have caregiving experience and be capable of caring for stroke survivors. The participants with functional limitations expected their caregivers to assist them with transferring, eating, showering, toileting, and dressing.

“My caregiver should be at least capable of helping me get in and out of bed, shifting my position, and changing my diaper.” (PS17)

The participants and their families believed that caregivers should do housecleaning, do household chores, do laundry, run errands, and prepare meals. “When she’s not busy taking care of me, she should be cleaning the house, cooking, taking out the trash—stuff like that. After all, we paid her to work for us 24 hours a day. She should not be sitting there doing nothing.” (PS02).

“Sometimes we ask her to buy fruits and vegetables or to go to the supermarket to buy milk.” (PS22)

Providing care for other family members

Foreign caregivers are expected to care for other family members in addition to their primary care recipient. For example, caregivers may be expected to babysit children, take care of other older family members, and cook for the entire family. The participants considered these additional tasks to be part of the caregiver’s job. One participant said, “If she doesn’t do it, then no one will.” Another participant said, “I expect her to cook dinner for our whole family, so when everyone gets home from work, we can all eat together.” (PS21).

Another participant said, “I also need her to help bathe my son. He’s 8 years old.” (PS05)

Theme 3. Challenges related to employing a foreign caregiver

Several participants provided examples of the challenges they encountered when engaging with their foreign caregivers. The challenges were related to communication difficulties, cultural differences, caregiving skill deficiencies, and problematic attitudes and behaviors. These challenges caused substantial frustration and distress for the participants.

Communication difficulties

Several participants were unable to easily communicate with their caregivers, and communication difficulties often led to misunderstandings. One participant said, “I talk to her; she doesn’t understand a word. I ask her to hold my hand, and she still doesn’t get it—it’s like talking to a brick wall! It just makes me so angry!” (PS02). Because of these communication challenges, participants often felt that their caregivers struggled to perform certain tasks effectively, such as running errands or following medical instructions. These difficulties significantly impeded the caregiving process.

Cultural differences

Many participants did not initially expect that cultural differences would be a concern. However, many reported dietary and religious differences that they had noted. For example, most Indonesian people do not eat pork, which is popular in Taiwan, and most Indonesian people are Muslim, whereas most Taiwanese people are Buddhist or Taoist. Various differences in behaviors, habits, and customs between the participants and their caregivers resulted in conflict. “Due to cultural differences, their gestures and actions can be more pronounced and a bit rough. Although there’s no ill intent, it can sometimes be startling.” (PS25).

“She is Muslim and does not eat pork. This causes a bit of trouble for us. When we cook together, we have to avoid pork. This is a bit of a hassle.” (PS26).

“She prays several times a day, every day. She refuses to help while praying. For example, she won’t help with things like clearing phlegm or changing diapers while she is praying.” (PS27)

Because of these differences, the participants experienced considerable frustration during the caregiving process and were required to continually adjust their thoughts and behaviors and changed their deeply ingrained beliefs.

Caregiving skill deficiencies

Many participants were disappointed with their foreign caregivers because of their lack of knowledge and skills in caring for stroke survivors. This disappointment is often heightened for first-time foreign caregivers who have no experience caring for older adults with disabilities and likely have not received training. “My caregiver didn’t have any experience with taking care of patients or older people before she came to our house.” (PS04)

“My caregiver had zero caregiving training. She even caused me to fall over when she first arrived.” (PS07)

Some participants complained that their caregivers lacked household skills, citing poor cooking, ineffective cleaning, or an inability to maintain a tidy environment. “She is completely inept at housework, and cooking is out of the question. The things she cooks are inedible.” (PS24)

Concerns with foreign caregivers’ attitudes and behaviors

Nearly all participants were disappointed with their foreign caregivers’ attitudes and behaviors, citing issues such as a lack of obedience, a lack of focus, a lack of productivity, and even engagement in unethical conduct.

One participant shared an example of a foreign caregiver who frequently refused her requests. The caregiver often refused to help the participant with dressing, toileting, and going on outings. The caregiver also complained that the participant was difficult to care for.

“She helped me pull up my pants, but it was crooked. I told her it felt uncomfortable. I told her the pants were not pulled all the way up. I asked her to help me pull them up properly, but she got mad and called me difficult.” (PS01)

Participants were distressed and disappointed because their foreign caregivers could not focus. The most common complaint among participants was that foreign caregivers were constantly on personal phone calls, from morning till night, even during work hours, disregarding their duties. This deeply bothered nearly all of the participants, who were with their foreign caregivers 24 hours a day. “She’s on the phone all the time, from morning till night. She talks on the phone even while helping me bathe, totally distracted. Pushing my wheelchair while chatting? Super dangerous. What if I bump into something?” (PS07)

“She’s on the phone all day, literally nonstop. Chatting with friends, chatting with family, never a moment without phone in hand. She’s totally unfocused on her tasks. And she talks so loudly on the phone, it’s so annoying!” (PS14)

“She’s always on the phone with her friends or family in Indonesia, talking in a language I don’t understand, and it’s so loud. I’m actually not a fan of loud noises, and hearing her talking all day drives me crazy. Trying to talk to her about it doesn’t work—she just keeps on talking all day. Sigh.” (PS18)

Some participants even reported that their caregivers engaged in unethical behavior. For example, some caregivers would ignore them, leave them alone, steal money, or run away. “She’s always on the phone, and once she drops me off at the rehab room, she disappears. Nurses have to help me find her. She’s here one moment, and gone the next, vanishing for half an hour.” (PS09) “I left my wallet on the table with NT$20,000 inside. I went into the room for just a moment, and when I came out, NT$10,000 was missing. Only the two of us were home. Who do you think took it?” (PS02)

“She got her salary, said she had to do something downstairs, and then never came back. She just ran off.” (PS12)

Additional sample quotes supporting the themes and subthemes are provided in S2 Table.

Discussion

As the world shifts toward becoming an aged society, many developed countries have introduced migrant workers into their long-term care systems to shift the burden of care from families to society [22, 38, 39]. Although the reasons for recruiting foreign caregivers to meet long-term care needs might be similar across these countries, care recipients’ experiences can vary considerably because of differences in societal backgrounds and cultural contexts. This study explored the perspectives and experiences of stroke survivors in Taiwan concerning foreign caregivers. In line with the global trend of foreign caregivers becoming a crucial part of the long-term care workforce in many developed countries because of their changing socioeconomic, cultural, and familial structures [40], our findings suggest that the primary reason stroke survivors hire caregivers for long-term care is because family members are unable to provide this care. Furthermore, the primary reason stroke survivors choose to hire foreign caregivers instead of local caregivers is that foreign caregivers are less expensive to hire. In Taiwan, individuals with disabilities or severe chronic illnesses may employ foreign live-in caregivers [41]. Stroke survivors, who are qualified to apply for foreign caregivers, are often advised by clinicians to seek such support to assist with daily living following hospital discharge. Hiring live-in foreign caregivers enables these older people to live at home with their family instead of at an institution [12]. This is also a primary reason foreign caregivers have become a notable source of formal long-term care labor in aging Asian societies [42].

The stroke survivors who participated in interviews in this study shared their expectations for their foreign caregivers. Caregivers were expected to be obedient, to embrace the local language and culture, to master caregiving and homemaking, and to care for other family members. Nearly all of the participants hired foreign caregivers to assist with household chores in addition to providing care. Foreign caregivers were expected to set aside their language, culture, and ideas and dedicate themselves entirely to the employer and the employer’s family, with a commitment to providing 24-hour services. This raises concerns about fairness and respect for the caregivers’ autonomy. The participants often overlooked their caregivers’ own cultural values, rights, and limitations. They developed a strong and unequal hierarchical dynamic that resembles a master–servant dynamic rather than a mutually respectful employer–employee relationship. Employers and agents in Asian societies often refer to foreign caregivers as maids, treating them as the property of their employees rather than as human beings with their own will and freedom. This belief is particularly prevalent in Sinitic cultures, in which a master is considered to have control over their maid’s body and personhood [42].

The reality of employing a foreign caregiver did not fully align with the expectations of stroke survivors and their families. Unexpected challenges—such as communication difficulties, cultural differences, caregiving skill deficiencies, and improper caregiver attitudes and behaviors—frequently left stroke survivors struggling to cope and sometimes caused considerable distress. These challenges reflect the fact that stroke survivors and foreign caregivers tend to have different expectations regarding the role that foreign caregivers should play. Stroke survivors believe that foreign caregivers should obey their employers; relinquish their original language, culture, and personal life; and know how to provide care and perform household duties. Research indicates that foreign caregivers do not wish to be treated as property or as servants. They believe that they should be provided with private time and space to connect with their family and friends and a reasonable amount of time off for rest and recuperation [20]. Differences in expectations can create tension between stroke survivors and foreign caregivers, potentially affecting quality of care and the health and wellbeing of both parties [42, 43]. Differences in perceptions between stroke survivors and foreign caregivers stem from a range of complex factors, including culture, social class, and institutional systems [42]. Government attention and active dialogue is necessary to identify solutions to the aforementioned problems to prevent deterioration of the relationships between stroke survivors and their caregivers.

Another concern that emerged from the findings of the current study is that many stroke survivors discovered that their foreign caregivers had not received formal training before starting work, leading to various problems, such as a lack of knowledge and skill in caring for the stroke survivors, communication difficulties, and unprofessional attitudes and behaviors. Foreign caregivers tend to receive little or no training before starting their caregiving jobs [12], and most foreign caregivers are not required to have caregiving or medical training before arriving in Taiwan, although some agencies provide brief training sessions to foreign caregivers upon their arrival in Taiwan [18]. This lack of formal training has raised concerns about quality of care, especially for patients with more complex health needs [19]. Many foreign caregivers are not adequately prepared to provide professional care or effectively communicate with their care recipients [12, 20]. Notably, among foreign caregivers interviewed in another study, the primary reason for choosing to work overseas as a caregiver was the minimal job training requirements [20]. Training is essential for safety. One participant in the current study recounted an incident in which his caregiver’s inexperience caused him to fall early in their working relationship. Some participants also reported feeling neglected or disrespected. Others did not receive adequate attention from their foreign caregivers. These problems require government attention and proactive intervention. Foreign caregivers must receive training before and during employment to effectively enhance care quality and prevent recurring caregiving problems and conflicts.

This study has several strengths. First, this study is the first qualitative exploration of the perspectives of stroke survivors in Taiwan regarding their experiences with foreign caregivers. The use of in-depth, face-to-face interviews allowed for the collection of rich, detailed data. The study’s methodological rigor, including its use of triangulation, member checking, and reflective memos, further enhanced the trustworthiness and credibility of the findings.

This study has several limitations. Our participants were older stroke survivors recruited from three medical centers in the greater Taipei area; the results may not be generalizable to individuals in other areas. Future studies should consider including participants from other regions to gain a broader understanding. Moreover, our participants were stroke survivors, and their cognitive functions and language abilities may have affected the quantity and quality of information they shared. Future studies could employ observational methods and questionnaire surveys to address these biases when collecting data from care recipients and their families.

Conclusions

In Taiwan, stroke survivors often hire foreign caregivers to alleviate the burden of caregiving on their family. However, stroke survivors tend to see foreign caregivers as servants and expect caregivers to conform to their needs. Communication difficulties, cultural differences, and unfavorable attitudes and behaviors among caregivers are concerns that cause stroke survivors frustration and distress, and stroke survivors often believe that foreign caregivers require more training. Government intervention is necessary to address these challenges and ensure foreign caregivers are able to perform their roles effectively. The government should provide training and support to foreign caregivers, bolster caregiving services, and foster more balanced and equitable relationships between caregivers and care recipients. Hiring families should have realistic expectations about the roles, capabilities, and limitations of foreign caregivers. A system of ongoing cultural competency training for both employers and caregivers could help minimize misunderstandings and foster mutual respect. Additionally, clear ethical guidelines could be established to protect the rights of foreign caregivers while ensuring that stroke survivors receive the quality care they need.

Supporting information

S1 File. Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.

(DOCX)

pone.0316757.s001.docx (21.2KB, docx)
S1 Table. Interview guide.

(DOCX)

pone.0316757.s002.docx (22.2KB, docx)
S2 Table. Sample quote.

(DOCX)

pone.0316757.s003.docx (18.8KB, docx)

Acknowledgments

We thank the staff members at the collaborating hospitals, that is, Taipei Medical University Hospital, Taipei Municipal Wanfang Hospital, and Shuang Ho Hospital. We extend particular thanks to the collaborating therapists, including Yen-Ting Liu, OTR/L (Taipei Municipal Wan Fang Hospital), and Jui-Chi Lin, OTR/L (Shuang Ho Hospital).

Data Availability

Data cannot be shared publicly because of the significant amount of personal and sensitive information contained in the interview transcripts. The informed consent form guaranteed the privacy and confidentiality of participants' interviews, as overseen by the Office of Human Research at Taipei Medical University. Data are available from the Office of Human Research at Taipei Medical University (contact via ohr@tmu.edu.tw) for researchers who meet the criteria for access to confidential data.

Funding Statement

This study was supported by Taipei Medical University – Wan Fang Hospital (grant numbers: 111-TMU-WFH-02 and 113TMU-WFH-05, PI: YL) and the Ministry of Science and Technology, Taiwan (grant numbers: MOST111-2628-B-038-015-MY3 and NSTC113-2326-B-038-002-MY3, PI: FC). The funder had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Decision Letter 0

Chai-Eng Tan

24 Sep 2024

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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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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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?

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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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Reviewer #1: Yes: Åsa Rejnö

Reviewer #2: Yes: Chai-Eng Tan

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PLoS One. 2025 Jan 3;20(1):e0316757. doi: 10.1371/journal.pone.0316757.r002

Author response to Decision Letter 0

4 Nov 2024

Response: We sincerely appreciate the valuable feedback provided by both reviewers, which has greatly improved the quality of our manuscript. We have carefully considered and addressed all of your suggestions and concerns in this revision, and we believe the changes have strengthened the clarity and rigor of our work. Please see our itemized responses to each comment below.

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.

1. 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.

Response: Thank you for pointing out this inconsistency. We have carefully revised the Results section in the abstract to ensure that the theme titles now accurately align with those used in the main text (see Page 3 / Line 47 – 51).

2. 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?

RESPONSE: We added the following background: “Since 1992, the Taiwanese government has introduced live-in foreign caregivers under the regulation titled “Temporary Measure to Address Shortages of Manpower for Providing Care for Households’ Disabled,” in response to the needs of families with disabled members, addressing the crisis of the local caregiver shortage [12]. Although Taiwan’s Ten-Years Long-Term Care Project (LTC) offers various home-based and community-based services, such as adult daycare and home care provided by Taiwanese care workers [13], many individuals with care needs still prefer to hire foreign caregivers. By 2019, approximately 28% of people with disabilities were cared for by live-in foreign caregivers [14]. In 2021, 225,432 foreign caregivers were employed by families to provide care services, compared to only 74,601 Taiwanese care workers [15]. This gap may be attributed to the advantage of live-in foreign caregivers, who offer 24-hour assistance at an affordable cost (USD 550 to 650, per month)[16, 17].”

(see Page 4 - 5, Line 79 – 90)

3. 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.

RESPONSE: Thank you for your comment. We have addressed this by removing the redundant reference and now only cite the appropriate scoping review: Salami B, Duggleby W, Rajani F. The perspective of employers/families and care recipients of migrant live-in caregivers: a scoping review. Health & Social Care in the Community. 2017;25(6):1667-78. (see Page 6, Line 99)

4. 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?

RESPONSE: We apologize for the confusion. The cited scoping review included a variety of international studies that explored the experiences of families and live-in caregivers; it was not limited to qualitative research. Our intention was to emphasize that the review identified a lack of research in Asia on care recipients' experiences with foreign caregivers, regardless of whether the studies were qualitative or quantitative (while this review did review many qualitative studies regarding the experiences of families and live-in caregivers). To clarify, we have revised this section as follows: “A scoping review of international literature on the experiences of families and live-in caregivers highlighted the lack of research conducted in Asia regarding care recipients' experiences with the care they receive from foreign caregivers [21]. In fact, there is limited literature exploring the perspectives of individuals with care needs and their families on hiring foreign caregivers. Among these studies, some qualitative investigations have shed light on the complex and interdependent relationships between foreign caregivers and their care recipients [21-23].”

(see Page 6, Line 99 – 105)

5. 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.

RESPONSE: Since Taiwan’s National Health Insurance (NHI) covers all citizens, the out-of-pocket costs for rehabilitation services are minimal. As a result, patients face little financial burden when continuing outpatient rehabilitation after being discharged from the hospital. Additionally, many hospitals do not impose limits on the duration of outpatient rehabilitation programs, even if providers determine that the program is no longer beneficial for the patient [4]. To avoid confusion, we added the following description in the Study Setting and Recruitment: “Under Taiwan’s National Health Insurance (NHI) system, there are no restrictions on the use of outpatient rehabilitation services for stroke patients, allowing us to recruit patients at various stages of recovery.” (see Page7, Lines 130 – 133)

6. 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.

RESPONSE: Thank you for this suggestion. We added more information about the interview guide as following: “This guide included seven major open-ended questions, which were reviewed by an interdisciplinary expert panel, as well as stroke survivors, and caregivers. The full interview guide is available in S2 Table, with examples of key questions provided below…” (see Page 9 – 10, Lines 173 – 176)

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

RESPONSE: We apologize for the error. We revised this sentence to “Family caregivers were encouraged…” (see Page 10, Lines 185)

8. 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”.

RESPONSE: Thank you for your feedback. Based on a thorough literature review, the nature of our results, and the reviewer's suggestions, we have revised the study's design from a phenomenological approach to a descriptive qualitative approach. (see Page 7, Line 119)

9. 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?

RESPONSE: We added the ethical information in the Methods section: “Informed consent was obtained from all participants before the interviews, and they were informed of their right to withdraw from the study at any time.” (see Page 7, Lines 122 - 124); “Data was handled confidentially, with all participant information de-identified using unique identification numbers. These identifiers were stored separately from the study data on a secure, password-protected drive. Only the principal investigator and select research staff had access to the encrypted file linking identification numbers to subject identities. The Office of Human Research was responsible for monitoring and auditing the collected data to ensure compliance with ethical standards.” (see Page 11, Lines 195 – 201); and “To minimize personal biases and influence, several steps were taken. YS and YM, who had no prior relationships or power dynamics with any participants, managed participant recruitment to ensure a diverse sample. Additionally, YS conducted all interviews in Mandarin, maintaining neutrality throughout the data collection process.” (see Page 9, Line 162 – 165).

10. 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.

RESPONSE: We apologize for the confusion. Since family caregivers only provided assistance to the participants (e.g., repeating their words when their pronunciation was difficult to understand), they were not considered participants in this study. We addressed this in the Methods section as follows: “Family caregivers were encouraged to accompany participants and provide needed assistance, especially for those with mild aphasia that could affect their communication. Their presence was solely for assistance purposes, and if any interference in the interview process was observed, the family caregivers were asked to leave to minimize their influence on the interview.” (see Page 10, Lines 185 – 189) To avoid confusion, we also removed the caregiver’s quote from the results section.

11. 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.

RESPONSE: We revised the subtheme “Severity and complexity” to “Need for supervision and physical assistance.” (see Page 19, Line 239)

12. 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.

RESPONSE: Thank you for the suggestion. We revised Theme 2 to “The expectations of participants toward foreign caregivers.” (see Page 20, Line 268)

13. 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.

RESPONSE: We apologize for any confusion caused by the original headings. We have revised the theme name to 'The challenges of employing a foreign caregiver' and changed the subtheme from 'Language barriers' to 'Communication difficulties.” (see Page 24, Line 326)

14. Discussion has a section dedicated to that. Examples that needs to be removed from the results are for example line 225.

RESPONSE: Thank you for the suggestion. We removed the redundant descriptions.

15. 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.

RESPONSE: We removed the word “Unexpectedly” and made sure no other valuing word in the results section. (see Result section)

16. 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.

RESPONSE: Thank You.

17. 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.

RESPONSE: We have added the strengths of the study (see Page 32, Lines 477 – 485). Additionally, we have removed the limitation regarding individuals with negative experiences possibly declining to participate in the study, as per your suggestion (see Page 32, Line 486 – 493).

18. Conclusion

Supported by the results.

RESPONSE: Thank You.

19. 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.

RESPONSE: We have corrected the errors. (See Pages 35 – 36, Ref. [25] and [42])

20. 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:

1. 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

RESPONSE: Thank you for this critical suggestion. We revised the study design as a descriptive qualitative approach. (see Page 7, Line 119),

2. 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 care

Attachment

Submitted filename: Response to Reviewers 2024.10.17.docx

pone.0316757.s004.docx (42KB, docx)

Decision Letter 1

Chai-Eng Tan

12 Nov 2024

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. 

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

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PLOS ONE

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Reviewers' comments:

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Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

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Reviewer #2: Yes

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Reviewer #1: (No Response)

Reviewer #2: N/A

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Reviewer #1: (No Response)

Reviewer #2: Yes

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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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Reviewer #1: Yes: Åsa Rejnö

Reviewer #2: Yes: Chai-Eng Tan

**********

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PLoS One. 2025 Jan 3;20(1):e0316757. doi: 10.1371/journal.pone.0316757.r004

Author response to Decision Letter 1

10 Dec 2024

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.

Response: Thank you for the critical feedback. We have revised this sentence to “Family caregivers are essential for reducing this burden and assisting stroke survivors in returning to their homes and communities.” (See page 5, lines 73-75)

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

Response: We have revised this sentence accordingly. (See page 9, lines 145-146)

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.

Response: We have removed the Joanna Briggs Institute Critical Appraisal Checklist and only kept the COREQ checklist. (See page 9, lines 151-152)

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?

Response: We described how we approached the potential participants at pages 9-10, lines 161-166): “Patients with stroke were screened for study inclusion eligibility by staff at the rehabilitation clinics, and potentially eligible patients were introduced to the study researchers, who then met with the patients in person and explained the purpose of the study by using informational leaflets.”

We also described the place where we conducted the interviews at page 13, lines 221-223: The interviews were scheduled at times that were convenient for the participants and took place in quiet settings, either at academic medical centers or in the participants’ homes.

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

Response: We have replaced "Chinese" with "Mandarin" accordingly. (See page 10, line 174)

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.

Response: We have separated the quotes from different participants into separate paragraphs. (See the Results section pages 22-33)

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.

Response: We revised this paragraph and highlighted the issue of patient safety as following: “Training is essential for safety. One participant in the current study recounted an incident in which his caregiver’s inexperience caused him to fall early in their working relationship. Some participants also reported feeling neglected or disrespected. Others did not receive adequate attention from their foreign caregivers.” (See page 30, lines 440-444)

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.

Response: Thank you for pointing out this issue. We have thoroughly reviewed all references and ensured their accuracy and consistency with the required formatting style. Additionally, for website references, we have included the date of access as recommended.

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

Response: Thank you for your suggestion. We have sent the manuscript for professional proofreading, and the necessary edits have been made to ensure clarity and accuracy.

Attachment

Submitted filename: Response to Reviewers.docx

pone.0316757.s005.docx (21.1KB, docx)

Decision Letter 2

Chai-Eng Tan

16 Dec 2024

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.

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Chai-Eng Tan

Academic Editor

PLOS ONE

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Reviewers' comments:

Acceptance letter

Chai-Eng Tan

22 Dec 2024

PONE-D-24-31334R2

PLOS ONE

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PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 File. Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.

    (DOCX)

    pone.0316757.s001.docx (21.2KB, docx)
    S1 Table. Interview guide.

    (DOCX)

    pone.0316757.s002.docx (22.2KB, docx)
    S2 Table. Sample quote.

    (DOCX)

    pone.0316757.s003.docx (18.8KB, docx)
    Attachment

    Submitted filename: Response to Reviewers 2024.10.17.docx

    pone.0316757.s004.docx (42KB, docx)
    Attachment

    Submitted filename: Response to Reviewers.docx

    pone.0316757.s005.docx (21.1KB, docx)

    Data Availability Statement

    Data cannot be shared publicly because of the significant amount of personal and sensitive information contained in the interview transcripts. The informed consent form guaranteed the privacy and confidentiality of participants' interviews, as overseen by the Office of Human Research at Taipei Medical University. Data are available from the Office of Human Research at Taipei Medical University (contact via ohr@tmu.edu.tw) for researchers who meet the criteria for access to confidential data.

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