The Health Behaviour of German Outpatient Caregivers in Relation to Their Working Conditions: A Qualitative Study

Round 1

Reviewer 1 Report

Dear Dr. Mojtahedzadeh and Dr. Mache,

Thanks for your manuscript to IJERPH. However, I think this article may go to the other daughter Journal under MDPI.

Here are my suggestions.

1, Could you summarize the health behavior observed in the current state of research (citation 37-58) in a table(Line 126)? Table 1 in the article below is a good example, please also list the sample size of those studies.

Jattamart, A., and A. Leelasantitham. "The influence of social media lifestyle interventions on health behavior: A study on patients with major depressive disorders and family caregivers." The Open Public Health Journal 12.1 (2019).

2, Could you show the number of caregivers enrolled from each city district on the map of Hamburg (Line 885)?

3, Could you add a paragraph about subjects before study design(Line 289)? The subjects part in the article below is an example.

Torres, Sussan J., Marita McCabe, and C. A. Nowson. "Depression, nutritional risk and eating behavior in older caregivers." The journal of nutrition, health & aging 14.6 (2010): 442-448.

4, In the limitation part(Line 913), could you mentioned more details about “ quantitative and mixed-methods studies” in each of the factors in the results part? Could you cite some articles that design like that? At less one article for each factor.  

Author Response

Reviewer 1

Thank you very much for your feedback, we appreciate it.

Here are my suggestions.

1, Could you summarize the health behavior observed in the current state of research (citation 37-58) in a table(Line 126)? Table 1 in the article below is a good example, please also list the sample size of those studies.

Jattamart, A., and A. Leelasantitham. "The influence of social media lifestyle interventions on health behavior: A study on patients with major depressive disorders and family caregivers." The Open Public Health Journal 12.1 (2019).

Thank you very much for your feedback. We have created a summary table and placed it behind the first paragraph of the Current State of Research, as you have suggested.

2, Could you show the number of caregivers enrolled from each city district on the map of Hamburg (Line 885)?

Thank you very much for your interest in outpatient caregivers interviewed. However, we would politely ask to refrain from producing such a table in order to best ensure the privacy of our interviewees.

3, Could you add a paragraph about subjects before study design(Line 289)? The subjects part in the article below is an example.

Torres, Sussan J., Marita McCabe, and C. A. Nowson. "Depression, nutritional risk and eating behavior in older caregivers." The journal of nutrition, health & aging 14.6 (2010): 442-448.

Thank you very much for your suggestion. However, we have already integrated a paragraph about the description of the participating outpatient caregivers in the Results section under "3.1. Sample Characteristics". In qualitative research, this is usual in the results section, rather than in the methodology. Therefore, a table follows in this section for a better overview.

4, In the limitation part(Line 913), could you mentioned more details about “ quantitative and mixed-methods studies” in each of the factors in the results part? Could you cite some articles that design like that? At less one article for each factor.  

As no studies on health behaviour of outpatient caregivers from Germany have been published so far, we were interested in emphasizing the future research interest with our implications for further research. Quantitative studies show a higher representativeness due to a supposedly larger study population. However, responses that are difficult to understand can be better complemented by qualitative research findings (Creswell/Plano-Clark 2007). Therefore, we have also proposed a mixed-methods study.

Creswell, J. W.; Plano Clark, V. L., Designing and Conducting Mixed Methods Research. SAGE: Thousand Oaks, CA, 2007.

Reviewer 2 Report

General comments

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

The paper “The Health Behaviour of German Outpatient Caregiver in Relation to their Working Conditions: a Qualitative Study“ aims at (1) examining “health behavioural patterns (nutrition, exercise, smoking, regeneration) of outpatient caregivers”, at (2) illuminating “their personal health-promoting behaviours” and (3) at identifying “potential work-related factors influencing their health behavior ways” (p. 1, line 34-37).

The authors have applied a cross-sectional survey approach by conducting fifteen problem-centered interviews with outpatient caregivers working in Northern Germany in terms of methodology. The interviews were conducted between January and April 2020 and analyzed after verbatim transcription using qualitative content analysis.

The manuscript is the result of a commendable effort regarding its contents, the applied methodology, the description of the results, and its writing style. It is easy to understand and reveals a fluent writing style. There are only minor errors concerning grammar and wording (at least from my non-English native speaker view). The team of the authors seems to dispose of the necessary and profound background knowledge in the field and thus has been best placed to shed light on the research areas as mentioned above and to acquire in-depth knowledge in the area of the working conditions and health behavior of German outpatient caregivers.

Although several theoretical frameworks are mentioned in the Background section, like the transactional stress model according to Lazarus and Folkman (line 76, 67), the occupational psychological stress model (line 74), the demands-strain model according to Rohnert (line 75), the authors do not use these frameworks later on for their classification or for drawing research questions thereof. Thus, these mentioned theoretical frameworks included seem to serve as some kind of fig-leaf function in the present form of the manuscript. As the methodology they used is a qualitative approach, and the tool for analyzing the collected qualitative data is the qualitative content analysis, this does not constitute a severe problem in my view. Nevertheless, it is a little bit unclear, which of the categories in the results section were the deductive ones drawn out of literature and/or theoretical models and which ones were the inductive ones. The authors should clarify this.

The topic, in general, is exciting. Concerning an increased proportion of older adults in many populations worldwide causing an increased demand for outpatient caregivers, it seems to be an unexplored and important topic so far. Thus, the topic of the available manuscript at hand is up-to-date and, in my view, fascinating for the readership of the International Journal of Environmental Research and Public Health. The title sounds very promising but is, in my opinion, not suitable to meet the expectations raised (“in relation to”) because, in the Results section, health behavior and working conditions are not interrelated or correlated with each other. Maybe it would be a wise decision to rephrase the title in the following way: “The Health Behaviour of German Outpatient Caregivers against the Backdrop of their Working Conditions: A Qualitative Study.” This, however, is only a well-intended proposal, and the authors do not have to comply with my suggestion but should decide by themselves whether to withdraw the term “in relation to” from the title this is a good idea or not in their view.

Unfortunately, the exact wording of the interview guidelines was not supplied, and therefore the categorization of the material is not entirely comprehensible.

In my view, although I have read the manuscript with great interest, there are some – more or less minor - weaknesses that should be addressed regarding the paper, which have to be resolved before it can be considered for publication in the target journal. I would like to elaborate on the weaknesses of the present manuscript in detail as follows.

Please regard the following points as constructive criticism.

Specific comments

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

Major comments

-----------------------

1. In the beginning, I would propose to explain the term “outpatient caregivers” in detail and deliver some facts about the German health system and the organization of the professional group of “outpatient caregivers” and their daily work. There seem to be different kinds of outpatient caregivers, as can be seen in Table 2. There is a distinction in the denomination of “outpatient geriatric nurses,” “outpatient caregivers,” “nursing specialists for intensive care,” “outpatient home and family caregivers,” and “palliative care specialists,” as well as “health and care assistants in the outpatient care.” Thus, I would invite the authors to elaborate on the term “outpatient caregiver” first and deliver some basic information on this occupational group in Germany against the backdrop of the German health care system, which should also explained briefly.
2. The whole manuscript delivers a thorough and profound literature base with a total of 175 references. Nevertheless, I would point to the fact that many of the references are only available in German. Thus, a large proportion of the average readership of IJERPH might not have access to these references. In future manuscripts, the authors are cordially invited to reduce German-speaking literature and replace it with similar literature in English. However, this is not really a point of criticism bearing in mind that the present list of references consists of 175 references, which is impressive.
3. The Current State of Research (Chapter 1.2.) is well structured, and this is also true for all of the other parts of the manuscript except for the Background section (Chapter 1.1). The Background section should be better structured and should be made more concise. In the first paragraph, e.g., the increase of care-dependents in Germany is mentioned (line 56-59), the second paragraph deals with the particular stressful situation of German employees and theoretical frameworks coping with stress, the third paragraph again deals with the increasing number of outpatient caregiver organizations in Germany, followed by the description of health behavior. Thus, I do not see a golden thread in the whole Background section. The entire section has an open end without a clear statement mentioning the rationale for the topic or its importance, a clear research gap, or the present manuscript's core contribution under consideration. Thus, the authors should strengthen their golden thread in the Background section and underline the importance of the topic and maybe highlight the significance of mentioning the outbreak of the pandemic in-between, bearing in mind that the interviews were conducted between January and April 2020. The worldwide pandemic might have even worsened the working conditions of outpatient caregivers and strengthened the importance of focusing on their health behavior and working conditions. The outpatient caregivers could substitute and/or complement inpatient caregivers being even more over-challenged by the pandemic situation. Thus, from my perspective, the topic of the present manuscript has gained importance due to the COVID-19 situation.
4. The whole Section “Current State of Research” is a section dealing with inpatient caregivers and is only partially relevant for the present empirical study. Therefore, it should be stated much more clearly that literature has been scarce so far concerning outpatient caregivers, and this seems to be the core contribution of the present manuscript. However, it is not mentioned in this clarity. The authors should underline their core contribution and emphasize making it clear that there is almost no literature investigating the working conditions and health behavior of outpatient caregivers so far.
5. The whole Materials and Methods Section is well written and the result of a commendable effort. As I have mentioned already in the introduction, the only thing I wonder is what categories were deductive and which ones were inductive. Maybe a Table could shed light on this distinction? The authors should elaborate on this.
6. Although Table 1 shows the Interview topic list, I would find it interesting to deliver the exact interview guidelines in an appendix.
7. The Results section is also the result of a commendable effort, nicely written and well structured. Figure 1 is lacking by mistake (see line 696-697), and therefore should be added and included in the revised version of the manuscript.
8. In the Limitations section, the outbreak of the pandemic should be mentioned more in detail because the whole empirical part was conducted partially before and partially during the outbreak of the COVID-19 pandemic. Thus, it should be added as a limitation that some of the interviews were completed before the outbreak and some of them after the outbreak. This inconsistency in the framing conditions could jeopardize the comparability of the first and the later interviews. I do not think that the whole validity of the results has been jeopardized due to the outbreak of the pandemic in general. It should be included, however, at least as a limitation in the Limitations section.
9. Why did the authors replace the personal interviews by one-to-one telephone interviews and not by Zoom-meetings or MS Teams-meetings or other kinds of virtual meetings? The authors should justify their decision to conduct one-to-one telephone interviews instead of virtual meetings.

 

Minor comments

-----------------------

10. I have a question concerning reference no. 91. It is mentioned that women tend to participate in studies more often than men, in general, and refer to the book of Bortz/Döring (2006). This book deals with research methods and evaluations for human and social scientists. However, I do not find a hint to these gender differences about willingness to participate in studies throughout the entire book. I would be pleased if the authors could deliver the page number in their authors’ response to refer precisely to the gender differences concerning the willingness to participate in studies. I know this book very well, but I have not been aware of this claim so far and do not find it in the book although I have searched for it extensively.
11. Concerning the conclusions, I would find it fruitful to additionally think about how to solve the problem of not finding a parking space (line 647). Bearing in mind that some cities deliver free parking for e-cars for sustainability reasons, it should seriously be considered to think about offering free parking not only for physicians (as is the case and many cities) but also for outpatient caregivers who have a tight schedule and feel distressed caused by a lack of parking space. I think outpatient caregivers contribute to bear a heavy burden for the whole public healthcare system and should also be supported much more than communal decision-makers and politicians currently do it. This feasibility would go along with the claim for an availability of much more public toilets etc. Another suggestion would be to think of mediated health communication targeted at inpatient and outpatient caregivers to support their health behavior and coping distress mechanisms. Thoughts in this vein could be added in the Conclusions section as well. This, however, is only a well-intended proposal from my side. The authors should deliberate these suggestions by their own.

To sum up, I appreciate the present manuscript under consideration very much, and I think with a small amount of effort, it could be made publishable soon in IJERPH.

Good luck with your research!

Author Response

Reviewer 2

Thank you very much for your comprehensive feedback. We appreciate it very much.

Please regard the following points as constructive criticism.

Specific comments

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

Major comments

-----------------------

1. In the beginning, I would propose to explain the term “outpatient caregivers” in detail and deliver some facts about the German health system and the organization of the professional group of “outpatient caregivers” and their daily work. There seem to be different kinds of outpatient caregivers, as can be seen in Table 2. There is a distinction in the denomination of “outpatient geriatric nurses,” “outpatient caregivers,” “nursing specialists for intensive care,” “outpatient home and family caregivers,” and “palliative care specialists,” as well as “health and care assistants in the outpatient care.” Thus, I would invite the authors to elaborate on the term “outpatient caregiver” first and deliver some basic information on this occupational group in Germany against the backdrop of the German health care system, which should also explained briefly.

Thank you very much for your feedback. We have explained the work activities in the outpatient care and differentiated their professional qualifications in the first paragraph of “1.1. Background” with adding a new reference as well.

1. The whole manuscript delivers a thorough and profound literature base with a total of 175 references. Nevertheless, I would point to the fact that many of the references are only available in German. Thus, a large proportion of the average readership of IJERPH might not have access to these references. In future manuscripts, the authors are cordially invited to reduce German-speaking literature and replace it with similar literature in English. However, this is not really a point of criticism bearing in mind that the present list of references consists of 175 references, which is impressive.

Thank you for your feedback. We will keep your suggestion in mind for future publications.

1. The Current State of Research (Chapter 1.2.) is well structured, and this is also true for all of the other parts of the manuscript except for the Background section (Chapter 1.1). The Background section should be better structured and should be made more concise. In the first paragraph, e.g., the increase of care-dependents in Germany is mentioned (line 56-59), the second paragraph deals with the particular stressful situation of German employees and theoretical frameworks coping with stress, the third paragraph again deals with the increasing number of outpatient caregiver organizations in Germany, followed by the description of health behavior. Thus, I do not see a golden thread in the whole Background section. The entire section has an open end without a clear statement mentioning the rationale for the topic or its importance, a clear research gap, or the present manuscript's core contribution under consideration. Thus, the authors should strengthen their golden thread in the Background section and underline the importance of the topic and maybe highlight the significance of mentioning the outbreak of the pandemic in-between, bearing in mind that the interviews were conducted between January and April 2020. The worldwide pandemic might have even worsened the working conditions of outpatient caregivers and strengthened the importance of focusing on their health behavior and working conditions. The outpatient caregivers could substitute and/or complement inpatient caregivers being even more over-challenged by the pandemic situation. Thus, from my perspective, the topic of the present manuscript has gained importance due to the COVID-19 situation.

Thank you very much for your comprehensive feedback on our background section. We have made some changes and hope that the structure is now improved for understanding.

We take your point about the COVID-19 pandemic very well. The study project was designed before the outbreak of the pandemic. In order not to change the study content, we deliberately did not include the pandemic. Other study results, on the health behaviour of outpatient caregivers in relation to the pandemic, are in the publication process in cooperation with other project partners.

1. The whole Section “Current State of Research” is a section dealing with inpatient caregivers and is only partially relevant for the present empirical study. Therefore, it should be stated much more clearly that literature has been scarce so far concerning outpatient caregivers, and this seems to be the core contribution of the present manuscript. However, it is not mentioned in this clarity. The authors should underline their core contribution and emphasize making it clear that there is almost no literature investigating the working conditions and health behavior of outpatient caregivers so far.

Thank you very much. In the paragraph “Because of different settings regarding inpatient and outpatient care, transferability of knowledge might be possible to a certain extent [28, 86], as there seem to be similar demands and resources in the outpatient care [cf. 87].” we indicate that the occupational demands of inpatient and outpatient care in Germany appear to be similar and are based on scientific findings. The fact that there are no studies from the outpatient care setting in Germany reinforces the research gap and the resulting research interest. After that we already emphasize that there are no studies yet by writing “there is hardly anything known about German outpatient caregivers’ health behaviour [28] (…) In consequence of the different workplace settings and the associated framework conditions which could influence inpatient and outpatient caregivers’ health behaviour, study results from inpatient care are only transferable to a limited extent. (…) Ultimately, yet there are no studies analysing specifically German outpatient caregivers’ health behaviour, simultaneously focusing on eating behaviour, physical activity, smoking behaviour, and rest and regeneration behaviour [28] and which factors might have an inhibiting or promoting effect in this context.” In our opinion therefore that seemed to sufficient to highlight that there are no studies focusing on outpatient caregivers’ health behaviour so far. In addition, we have created a new Table 1, which is intended to summarise the “1.2. Current State of Research”. It is also clear from this that the majority of studies deal with the inpatient care setting.

1. The whole Materials and Methods Section is well written and the result of a commendable effort. As I have mentioned already in the introduction, the only thing I wonder is what categories were deductive and which ones were inductive. Maybe a Table could shed light on this distinction? The authors should elaborate on this.

Thank you for your interest in our code system. We have presented this in Appendix B under Table B1 with the differentiation of deductive/inductive categories and referred to it in the text under "2.4. Data Analysis".

1. Although Table 1 shows the Interview topic list, I would find it interesting to deliver the exact interview guidelines in an appendix.

Thank you very much for this proposal. We have gratefully accepted your suggestion and have prepared a corresponding Table A1 in Appendix A, which shows the complete interview guideline and referred to it in the text under “2.3. Interview Guideline”.

1. The Results section is also the result of a commendable effort, nicely written and well structured. Figure 1 is lacking by mistake (see line 696-697), and therefore should be added and included in the revised version of the manuscript.

Thank you very much for your feedback. However, Figure 1 is shown to us in the version already submitted. We are adding it to you here and will contact the journal about this.

 

1. In the Limitations section, the outbreak of the pandemic should be mentioned more in detail because the whole empirical part was conducted partially before and partially during the outbreak of the COVID-19 pandemic. Thus, it should be added as a limitation that some of the interviews were completed before the outbreak and some of them after the outbreak. This inconsistency in the framing conditions could jeopardize the comparability of the first and the later interviews. I do not think that the whole validity of the results has been jeopardized due to the outbreak of the pandemic in general. It should be included, however, at least as a limitation in the Limitations section.

Thank you very much for pointing that out. We have added a proper paragraph in the limitations section.

1. Why did the authors replace the personal interviews by one-to-one telephone interviews and not by Zoom-meetings or MS Teams-meetings or other kinds of virtual meetings? The authors should justify their decision to conduct one-to-one telephone interviews instead of virtual meetings.

Thank you for enquiring. Indeed, we have suggested to all participants to conduct an interview via video. However, all of them preferred a telephone interview because it was less time-consuming for them. Nevertheless, we have added your suggestion in the limitations section, also noting the advantages of a video conversation.

 

Minor comments

-----------------------

1. I have a question concerning reference no. 91. It is mentioned that women tend to participate in studies more often than men, in general, and refer to the book of Bortz/Döring (2006). This book deals with research methods and evaluations for human and social scientists. However, I do not find a hint to these gender differences about willingness to participate in studies throughout the entire book. I would be pleased if the authors could deliver the page number in their authors’ response to refer precisely to the gender differences concerning the willingness to participate in studies. I know this book very well, but I have not been aware of this claim so far and do not find it in the book although I have searched for it extensively.

Thank you very much for the suggestion and the effort you put into it. We have updated the references and made the necessary link to nurses in the text.

 

Polit, D. F.; Beck, C. T., Is there gender bias in nursing research? Research in Nursing and Health 2008, 31, (5), 417-427.

 

Polit, D. F.; Beck, C. T., International gender bias in nursing research, 2005–2006: A quantitative content analysis. International Journal of Nursing Studies 2009, 46, (8), 1102-1110.

 

Polit, D. F.; Beck, C. T., Is there still gender bias in nursing research? An update. Research in Nursing and Health 2013, 36, (1), 75-83.

1. Concerning the conclusions, I would find it fruitful to additionally think about how to solve the problem of not finding a parking space (line 647). Bearing in mind that some cities deliver free parking for e-cars for sustainability reasons, it should seriously be considered to think about offering free parking not only for physicians (as is the case and many cities) but also for outpatient caregivers who have a tight schedule and feel distressed caused by a lack of parking space. I think outpatient caregivers contribute to bear a heavy burden for the whole public healthcare system and should also be supported much more than communal decision-makers and politicians currently do it. This feasibility would go along with the claim for an availability of much more public toilets etc. Another suggestion would be to think of mediated health communication targeted at inpatient and outpatient caregivers to support their health behavior and coping distress mechanisms. Thoughts in this vein could be added in the Conclusions section as well. This, however, is only a well-intended proposal from my side. The authors should deliberate these suggestions by their own.

Thank you very much for these valuable suggestions. We have added a paragraph regarding free parking zones in the practical implications for further practice.

To sum up, I appreciate the present manuscript under consideration very much, and I think with a small amount of effort, it could be made publishable soon in IJERPH.

Good luck with your research!

Thank you very much for your comprehensive feedback and suggestions. We hope that you agree with the updated version taking all points into account.

Round 2

Reviewer 1 Report

Dear Dr. Mojtahedzadeh and Dr. Mache,

 

Thank you for editing this manuscript again.

 

However, there is still one question to be answered.

 

1, This is question 3 I asked before. Could you write a paragraph about the criteria you used for enrolling the subjects for the study? This is not the “Sample Characteristics” in the results part. It is usually a flow chart in the method part. Please read the method-subjects part in the study below.

Torres, Sussan J., Marita McCabe, and C. A. Nowson. "Depression, nutritional risk and eating behavior in older caregivers." The journal of nutrition, health & aging 14.6 (2010): 442-448.

 

Thank you so much for your modification.

Author Response

Thank you very much for your feedback and please excuse the misunderstanding. We have looked at the publication by Torres et al. 2010 and added a corresponding paragraph with the heading "2.1. Subjects" under "2. Material and Methods".

We hope that you agree with the revision of our manuscript and look forward to your feedback.