The Institutional Factors Affecting the Growth of Korean Migrant Care Market and Sustainability in Long-Term Care Quality
Round 1
Reviewer 1 Report
The paper underlines a perspective of the Korean migrant care market in terms of long-term care quality in South Korea. Two migrant workers groups are analysed: migrant care workers in home-based long term care versus nursing hospitals.
The paper is very interesting but quite difficult to follow. In addition, the overuse of acronyms might hinder the paper’s readability.
Abstract: The objectives of the paper, as well as the focus of this study (on Korean-Chinese MCW who have recently joined LTC workforce), need to be clearly mentioned
The introduction section could be improved to provide a scientific perspective adapted to the objectives of the paper (with more connection among the topic addressed, the context and the research objectives)
The authors need to explain why the two groups are compared
Section 3. Data collection is presented in a general manner, without required specifications. For example, which data were extracted from on-site documents?
For E.g., ‘interview guidelines which were extracted from the theories and institutions’ (line 194). Which type of theory and qualitative methodology support? The qualitative approach is contextually situated.
Line 200: seems to be redundant or outside the context.
A brief structure of the interview could be presented. Also, is it useful to explain why the interview participants range from 50-60 years?
Line 221, line 205-is it necessary to mention the authors who did the interviews each time? This information could be added at the end of the paper (authors contributions)
The content analysis of institutional texts and other data types must be performed in terms of reflexivity, self-reflection, interpretation and description.
What are the meanings and relationships of the informant’s statements? (to better describe the social world of the migrants).
One of the hindering factors of MCWs, such as qualification requirements or wage regulation policies, could be more analysed and comprehensively interpreted.
The paper needs to focus more on the relevant topics (the visa requirements, qualification requirements, wage regulation policies, and social security obligations) that might hinder the Korean market care.
The conclusion section needs to be extended to provide evidence for the issue addressed.
Author Response
Response to Reviewer 1 Comments
Point 1: The paper underlines a perspective of the Korean migrant care market in terms of long-term care quality in South Korea. Two migrant workers groups are analysed: migrant care workers in home-based long term care versus nursing hospitals.
The paper is very interesting but quite difficult to follow. In addition, the overuse of acronyms might hinder the paper’s readability.
Abstract: The objectives of the paper, as well as the focus of this study (on Korean-Chinese MCW who have recently joined LTC workforce), need to be clearly mentioned
The introduction section could be improved to provide a scientific perspective adapted to the objectives of the paper (with more connection among the topic addressed, the context and the research objectives) The authors need to explain why the two groups are compared.
Response 1: We greatly appreciate your constructive comments. Your comments have helped us develop this manuscript further. We added and revised the following explanation: First, in both the abstract (Line 14-18) and introduction (Line 69-70, 72-84), we clearly explained the analysis of the two groups in the background and purpose of the study to be consistent with the topic. Then, we also stated that it was related to the quality of long-term care services. Second, we changed all “abbreviations” except MCW and LTC to “full words” throughout pages 1-14.
Third, we added the rationale for comparing the characteristics of the two groups through their commonalities and differences on Line 72-84. We explained the research background (the reason for the recent emergence of MCWs in the LTC market) and the relevance of this research topic to the historical background and institutional factors:
1) Historical background: we explained the history of MCWs. The reason that foreign care workers were recently included in the long-term care sector is that the nursing hospitals in the migrant care market were first established in the 2000s when the immigration policy for Chinese compatriots was improved. In contrast, home-based long term care started when the long-term care insurance system was launched in 2008.
2) Institutional factors: Although the two groups have both performed the similar job of caring for the elderly, they exhibited differences in the care system. In particular, a comparative study is needed because the differences between the two groups across the three institutional systems (migration, care, and employment) lead to promotion and hindrance of foreign workforce. There are two differences here: i) Home-based long term care is in-home, but nursing hospitals are inpatient facilities. ii) Home-based long term care directly hires its manpower, whereas nursing hospitals outsource their care workers. This detailed explanation was added in lines 72 to 84.
Point 2: Section 3. Data collection is presented in a general manner, without required specifications. For example, which data were extracted from on-site documents? For E.g., ‘interview guidelines which were extracted from the theories and institutions’ (line 194). Which type of theory and qualitative methodology support? The qualitative approach is contextually situated.
Response 2: As you pointed out, the explanation of the data collection process in this manuscript was insufficient. To clarify, we conducted institutional sampling. The basis for institutional sampling originates in the institutional framework in Section 2. For example, we identified the need for worker eligibility criteria (i.e. visas, qualifications) to enter the care market as deriving from the combination of migration and the care system. Based on this, we constructed interview guidelines which were extracted from the theories and institutions. We then investigated (interviews and on-site documents) received) to understand the lived experiences of MCW. Additionally, in the combination of care and employment system, the necessity of an employment contract and pay stub was identified, and these documents were collected from institutions. Therefore, to explain in connection with the methodology, institutional sampling was performed through the theoretical and institutional framework derived in Section 2, and the coding of directed analysis was also based on this. (refer to Line 220-221, 231-234).
Point 3: Line 200: seems to be redundant or outside the context. A brief structure of the interview could be presented. Also, is it useful to explain why the interview participants range from 50-60 years?
Response 3: We respect your point, and for clarity we made some changes.
1) We cited numbers [23-29, 31-33, 35-42] on the reference page in the manuscript. The contents of lines 200-201(original manuscript)– “Please refer to the references for the source of the online institutional texts.” – were deleted in the revised manuscript. Please refer to line (211) of the revised manuscript.
2) Some of the interview contents are presented in-text to help the reader's understanding. For example, “guidelines with questions such as ‘What are the institutional requirements for MCWs to care for the elderly in South Korea?’ and ‘Is there any difference between the system and real working as LTC workers?’ “
3) In regards to the ages of the participants, lines 239-243 offer a simple description of their sociodemographic characteristics. We did not sample a specific age target because this study recruited participants based on institutional sampling: targeting foreigners who work as elderly care workers. However, the participants’ age range (50s-60s) was only a result of the participants’ recruitment process. The interpretation of this cannot be generalized to a small number of participants. It is relevant, though, that aging of elderly care workers in Korea is often pointed out (OECD, 2021: 19). Thus, our understanding of the age of study participants was added to the lines 239-243: “We did not sample at a specific age because we did institutional sampling (home vs. nursing hospital) in the sampling. However, the average number of Korean caregivers working in Korea is in their late 50s, the highest among OECD countries.” on line 239-243.
Point 4: Line 221, line 205-is it necessary to mention the authors who did the interviews each time? This information could be added at the end of the paper (authors contributions).
Response 4: We agree with you completely. As you suggested, we deleted references to the authors (lines 192, 221, and 205 of original manuscript) and replaced them with an author contribution note on the last page (14) of this manuscript.
Point 5: The content analysis of institutional texts and other data types must be performed in terms of reflexivity, self-reflection, interpretation and description. What are the meanings and relationships of the informant’s statements? (to better describe the social world of the migrants).
Response 5: Although this study blends the deductive and inductive characteristics of directed content analysis, the rigor of the qualitative study was pursued by considering reflexivity, self-reflection, interpretation and description in the overall process.
Reflexivity and self-reflection were reconfirmed in the description and interpretation of the revised manuscript. We tried to illuminate and describe the participants' world view in greater detail. For example, participant MCW #7 said that H2 visa holders are institutionally able to work as LTC workers, but they could not work with this visa. The authors identified the phenomenon of decoupling from institutions as recognizing the difference between the institutional text and the real, lived experiences of MCWs. See lines 497-500. In addition, throughout our reflections, we realized that MCWs made sense of job qualifications and working conditions based on their co-workers’ occupational knowledge as opposed to laws or administrative rules. Such occupational knowledge was constituted outside the institutional system and was interpreted as the MCWs voice in the real world. On the other hand, we interpreted our study in light of the theoretical system (Section 2); however, when discrepancies such as decoupling occur, the suitability of the interpretation should be based on the data.
Point 6: One of the hindering factors of MCWs, such as qualification requirements or wage regulation policies, could be more analysed and comprehensively interpreted.
Response 6: As you pointed out, we further analyzed participants' statements about MCWs' qualifications and wage regulation policies. We regret to say that we did not fully understand the intended meaning behind “comprehensively interpreted?” If this means not omitting the statements and interpretations for each item of the research question, then we chose important statements in consideration of space constraints.
Point 7: The paper needs to focus more on the relevant topics (the visa requirements, qualification requirements, wage regulation policies, and social security obligations) that might hinder the Korean market care. The conclusion section needs to be extended to provide evidence for the issue addressed.
Response 7: We greatly appreciate your assistant. This is a very important point. We have revised the discussion and extended evidence for the issue in the conclusion on page 14.
Reviewer 2 Report
I regard it more as a research note rather than as such a significant contribution (line 557) as the authors think. It remains a bit unclear why it is offered only now for publication when the "qualitative interviews" (add an s in line 189 to interview) made did take place in 2020 already, could have been done with more interview partners, and lead to quite descriptive results, although these ones are certainly of interest.
Overall, in my opinion the methodological and also analytic descriptions used could be shortened quite a bit, since sometimes they appear a bit trivial (e.g. as it is obvious for such type of research - e.g. lines 188-190) and whether it is really of interest of the reader who of the authors was responsible for which part of the research in such a detail (lines 192 following (f) as well as lines 562f). It is perhaps not as important to repeat explaining the ways and findings of the analysis very broad and repeatedly after after line 459.
So streamlining he article and taking out the unnecessary repetition could improve the article quite a lot: "less is more" in my opinion and would lead to potentially many more readers when the arguments/methodology are explained more concise compared to the current version of the academic article.
For final editing of the article it would make sense to ensure that tables are being printed on one page only rather than on two ones as in the case of table 1 in line 115. perhaps not so hard to grasp that an article of this length is necessary.
The quality of English is overall very high in my opinion (but I am not a native speaker, nevertheless I worked several year at a British University that I am quite familiar with the use of academic English).
Author Response
Response to Reviewer 2 Comments
Point 1: I regard it more as a research note rather than as such a significant contribution (line 557) as the authors think. It remains a bit unclear why it is offered only now for publication when the "qualitative interviews" (add an s in line 189 to interview) made did take place in 2020 already, could have been done with more interview partners, and lead to quite descriptive results, although these ones are certainly of interest.
Response 1: We agree with you completely.
1) Following your suggestions, we changed the phrase “a significant contribution” to “We believe that our study filled the gap to the existing~” on line 592.
2) In stead of adding an s in line 189 (original manuscript line, refer to line 203 in the revised manuscript) to interview, we deleted repeated sentence by reviewers’ comments.
3) At the time of the interviews, South Korea's COVID-19 policy prohibited contact with persons traveling to and from China. Our researchers had to report any contact with such travelers. Due to this situation, we had to stop the interview. Therefore, the researchers judged that the sufficiency of the collected interviews was met to some extent. We searched institutional data and conducted additional telephone and e-mail interviews with Korean employers.
Point 2: Overall, in my opinion the methodological and also analytic descriptions used could be shortened quite a bit, since sometimes they appear a bit trivial (e.g. as it is obvious for such type of research - e.g. lines 188-190) and whether it is really of interest of the reader who of the authors was responsible for which part of the research in such a detail (lines 192 following (f) as well as lines 562f). It is perhaps not as important to repeat explaining the ways and findings of the analysis very broad and repeatedly after after line 459. So streamlining he article and taking out the unnecessary repetition could improve the article quite a lot: "less is more" in my opinion and would lead to potentially many more readers when the arguments/methodology are explained more concise compared to the current version of the academic article.
Response 2: We greatly appreciate your comments. This is a very important point. 1) Based on your comments, we shortened our methodology and analytical descriptions to improve understanding and readability. Specifically, lines 188-190(original manuscript) of the methodology were deleted, the authorship was deleted, and line authors’ responsibility was replaced with author contribution note. Finally, in the discussion on line 459(original manuscript), phrases not needed to explain the analysis method and results have been deleted.
2) The repeated portions were deleted and an emphasis on logical flow was attended to. We also endeavored to present a concise conclusion.
Point 3: For final editing of the article it would make sense to ensure that tables are being printed on one page only rather than on two ones as in the case of table 1 in line 115. perhaps not so hard to grasp that an article of this length is necessary.
The quality of English is overall very high in my opinion (but I am not a native speaker, nevertheless I worked several year at a British University that I am quite familiar with the use of academic English)..
Response 3: The table has been formatted to fit on one page in the entire manuscript.
Reviewer 3 Report
Brief summary The aim of the (empirical) article is to analyse the factors that hinder and promote employment of migrant care workers in nursing hospitals versus home-based long-term care. Contributions to the literature are clearly stated and sustained by appropriate previous literature, thus the article distinctly identifies how it closes the gaps (lines 68-74) in the literature. The article seems very relevant and supported by a solid methodological design, which is carefully described.
Broad comments The article fits the scope of the journal, although the meaning of sustainability is not sufficiently clarified.
Specific comments
1) English review is required in some lines (e.g., line 14-5; line 32-3; lines 61-2; …).
2) The authors should clarify what the term “sustainability” means in the context of their research.
- In the title “The Institutional Factors Affecting the Growth of Korean Migrant Care Market and sustainability in Long-term care Quality” and in lines 23-4 “our findings suggest that the growth of migration care market and sustainability in LTC quality depend on the policy directions of the Korean long-term care insurance (LTCI).”, it seems like the authors are referring to the “sustainability of LTC quality”
- However, in lines 529-30 “The core of these issues is LTC quality (care workforce’s expertise), cost efficiency, and sustainability”, it seems like quality and sustainability are different aspects.
- I suggest that the authors clarify the concept of sustainability within the research context.
- Moreover, I also suggest making the sentences consistent: Line 32 “The core of these issues is the lack of care workers, cost efficiency, and sustainability.” And in lines 529-30 “The core of these issues is LTC quality (care workforce’s expertise), cost efficiency, and sustainability”
3) I recommend that the authors explain the choice to include the “labour cost” issues in the “care system/job skills” dimension, rather than in the “employment system/work-place conditions” (which seems more obvious).
4) Table 3 seems relevant but is not very clear. Are there are no hindering factors in nursing hospitals? Additionally, this table should be presented in the Discussion section (it is referred in line 463) rather than between lines 288 and 289.
5) I also recommend improving the conclusions in relation to the research questions presented in lines 85-9, specially how the key aspects of LTC quality, cost efficiency, and sustainability differ between nursing hospitals vs home-based LTC.
Author Response
Response to Reviewer 3 Comments
Point 1: Brief summary The aim of the (empirical) article is to analyse the factors that hinder and promote employment of migrant care workers in nursing hospitals versus home-based long-term care. Contributions to the literature are clearly stated and sustained by appropriate previous literature, thus the article distinctly identifies how it closes the gaps (lines 68-74) in the literature. The article seems very relevant and supported by a solid methodological design, which is carefully described.
Broad comments The article fits the scope of the journal, although the meaning of sustainability is not sufficiently clarified.
Response 1: We greatly appreciate your constructive comments. Your comments have helped us develop this manuscript further. We tried to improve our discussion of sustainability on line 553-557, 563-565.
Point 2: 1) English review is required in some lines (e.g., line 14-5; line 32-3; lines 61-2; …).
Response 2: Response 2: In consideration of the reviewers' comments, we requested an English proofreading service for this part and modified it.
1) lines 14-18: “This study underlines a perspective of the Korean migrant care market in terms of long-term care quality in South Korea. Thus, the study explored the institutional factors that restrict and promote the migrant care workers (MCWs). Two migrant workers groups were analysed: migrant care workers in home-based long-term care versus nursing hospitals.”
2) line 33-35; “Most developed countries are responding to these issues through a variety of policies.”
3) line 63-66; Korean-Chinese MCWs generally have fewer qualifications than their Korean national counterparts [10, 16, 17]; as a result, the debate on the sufficiency of MCWs' geriatric knowledge and communication skills is ongoing [3, 10].
Point 3: The authors should clarify what the term “sustainability” means in the context of their research. In the title “The Institutional Factors Affecting the Growth of Korean Migrant Care Market and sustainability in Long-term care Quality” and in lines 23-4 “our findings suggest that the growth of migration care market and sustainability in LTC quality depend on the policy directions of the Korean long-term care insurance (LTCI).”, it seems like the authors are referring to the “sustainability of LTC quality”
However, in lines 529-30 “The core of these issues is LTC quality (care workforce’s expertise), cost efficiency, and sustainability”, it seems like quality and sustainability are different aspects.
I suggest that the authors clarify the concept of sustainability within the research context.
Moreover, I also suggest making the sentences consistent: Line 32 “The core of these issues is the lack of care workers, cost efficiency, and sustainability.” And in lines 529-30 “The core of these issues is LTC quality (care workforce’s expertise), cost efficiency, and sustainability”.
Response 3: We really appreciate your comments. Our research has progressed further thanks to your comments.
1) The issue of inconsistency on the meaning of sustainability: We added and modified lines 553-557, 563-565. Our concept of sustainability, in a macro context, defines that hiring a local care worker can be costly, but it can make the LTC quality more sustainable.
2) In term of the core of the issues, this is a very important point but the authors miss it. So we modofied as follows: Based on this study’s results, the reason is that improving the service quality (guaranteeing professionalism) from the user's (the elderly) view can be rather cost-effective. We addressed again that ensuring professionalism can ultimately be cost-effective modified on lines 553-557, 563-565..
Point 4: I recommend that the authors explain the choice to include the “labour cost” issues in the “care system/job skills” dimension, rather than in the “employment system/work-place conditions” (which seems more obvious).
Response 4: This is a good point that shows us why the government needs to be intervened. The government's intentional intervention in the care labor market is required to maintain our sustainability. This includes strengthening the qualification and education system, and paying the government a part of the education cost. In order to ensure long-term care quality, the government may need to invest in the system and bear the appropriate labor costs.
Point 5: Table 3 seems relevant but is not very clear. Are there are no hindering factors in nursing hospitals? Additionally, this table should be presented in the Discussion section (it is referred in line 463) rather than between lines 288 and 289.
Response 5: This study revealed that facilitation factors were generally found in nursing hospitals, and there were no interfering factors. In addition, we moved table 3 to the discussion section on line 485.
Point 6: 5) I also recommend improving the conclusions in relation to the research questions presented in lines 85-9, specially how the key aspects of LTC quality, cost efficiency, and sustainability differ between nursing hospitals vs home-based LTC.
Response 6: We added our answers to the two research questions based on Table 3 in the conclusion on line 582-591.
Round 2
Reviewer 1 Report
The authors explained or/ and made necessary changes according to the suggestions. Now paper improved in clarity and warrants to be published.
