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PEER REVIEW HISTORY
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are provided with free text boxes to elaborate on their assessment. These free text comments are
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ARTICLE DETAILS
TITLE (PROVISIONAL)
AUTHORS
Factors Affecting Japanese Retirees’ Healthcare Service Utilisation
in Malaysia – A Qualitative Study
Kohno, Ayako; NIk Farid, Nik Daliana; Musa, Ghazali; Abdul Aziz,
Norlaili; Nakayama, Takeo; Dahlui, Maznah
VERSION 1 - REVIEW
REVIEWER
REVIEW RETURNED
GENERAL COMMENTS
Boon-How Chew
Department of Family Medicine
Faculty of Medicine and Health Sciences
Universiti Putra Malaysia, 43400 UPM Serdang,
Selangor Darul Ehsan, Malaysia
09-Dec-2015
Overall, the reported experience and expectation of health services
by the Japanese retirees were no surprise.
Standard of written English could be better.
Abstract
Line 24: it is better to state the theory mentioned here for clarity
Line 49 & 52: It would be clearer to mention what the specific
phenomenon that occurs in general health ailments experience.
Introduction
Generally well written. May be the AHUM needs more elaboration.
Methods
Page 4 line 43-44: unnecessary repetition ‘As mentioned earlier, this
study examines the healthcare service utilisation among Japanese
retirees in Malaysia…’
Table 2 on the definitions could be incorporated as the third column
in Table 1.
I wonder how many of the Japanese retirees who participated in the
study were husbands and wives. Couples would probably have the
same experience.
May be the discussion guide for the FGD could be made available
as a supplementary material linked to this report when published.
Page 7 line 20: unnecessary repetition.
Page 7 line 24-26: unnecessary repetition ‘As mentioned earlier, the
Andersen Healthcare Utilisation Model (AHUM) was adopted as a
theoretical framework.’
Results
Overall, I think there need to be more quotes from the retirees
themselves and other participants besides the often quoted
interpreters’ opinion. The presented quotes were rather few and not
supportive of all the mentioned codes.
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Page 8 Line 11: I think you referred to Table 2
Page 8 Line 20: I think you referred to Table 3
Page 8 Line 56: unclear phrase ‘… through their easier to
understand information communication…’
Page 9 Line 36: objective data, rather than subjective data?
Page 9: On Medical Symptoms, the quote is kind of inappropriate.
May be one or few from the retirees themselves are needed to
support the section preceding narration.
Page 10: The narration under the Health Insurance could be concise
and without repetition of its points.
Discussions and Conclusions
Page 12 line 36: punctuation error
Page 13 lines 24-27: quality of health services or the comparison
between that of Japan and Malaysia was not mentioned by
respondents in the results
Overall, the discussion could be more relevant to the results, which
might need to have more retirees' quotes.
It was not certain whether the data collection reached saturation of
themes.
REVIEWER
REVIEW RETURNED
GENERAL COMMENTS
Dr Vicente Rodriguez
Spanish National Research Council
21-Dec-2015
3. The study design is fine when the decision to run a qualitative
methods has been selected. Common choice in other international
studies on IRM is to combine quanti- and quali- approaches, but this
is not the case.
7. No statistic analysis is required. In spite of this, no further
information on how the qualitative analysis has been really
conducted: has been this carried out by a qualitative analysis
software? have been other qualitative results identified other than
verbatim, i.e. code frequencies, networks of factors,...?
8. IRM references on other outstanding areas are not properly
identified (only the two first, which are outdated), the same can be
said on qualitative data analysis. Probably number of references are
conditioned by the BMJOpen requirements. If this is true, please
don't draw attention to the last comment
11. Not all results are extensively discussed (only three of six), with
no reasons to do that
12. Although a limitation on quantitative method is discussed, no
solution is provided to solve it. Could it be feasible?
15. Written English should be improved, according to my opinion as
a non-English speaker, mainly the verbatim translation
The reviewer also provided a marked copy with additional
comments. Please contact the publisher for full details.
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VERSION 1 – AUTHOR RESPONSE
Response to Reviewer 1: Prof. Boon-How Chew, Department of Family Medicine, Faculty of Medicine
and Health Sciences, Universiti Putra Malaysia
Comments from the Reviewer:
Line 24 of Abstract: it is better to state the theory mentioned here for clarity.
Response:
Thank you for your comment. The following change (addition) is made to the text.
Three themes, health beliefs, medical symptoms and health insurance were identified which align with
the theory of Andersen Healthcare Utilisation Model.
Comments from the Reviewer:
Line 49 & 52 in The study’s limitation: It would be clearer to mention what the specific phenomenon
that occurs in general health ailments experience.
Response:
Thank you for your comment. Some descriptions for clarifications were added as below.
 The research does not focus on specific ailments such as hypertension or diabetes, but rather
centres on general health ailments experienced by Japanese retirees living in Malaysia.
 A qualitative study with recruited participants describes only a specific phenomenon; for a better
generalizability of the findings, a quantitative study is required which focus on such themes as health
beliefs, medical symptoms, and health insurance of retirees abroad.
Comments from the Reviewer:
Introduction
Generally well written. May be the AHUM needs more elaboration.
Response:
Thank you very much for your words of compliments and advice. The following sentence was added
in Introduction to elaborate further on AHUM.
To gain a structured understanding of the issue, we adopted the Andersen Healthcare Utilisation
Model (AHUM) as the research’s conceptual framework. There are three factors in the AHUM which
explain the individual’s healthcare services utilisation, and these are ‘predisposing’, ‘enabling’, and
‘need’. ‘Predisposing’ characteristics include variables such as age, gender, marital status and
educational level. ‘Enabling’ resources are what support or impede a patient’s access to healthcare.
While, ‘need’ is the perceived and evaluated needs of the patients.
Comments from the Reviewer:
Page 4 line 43-44 (in Methods, Study design): unnecessary repetition ‘As mentioned earlier, this study
examines the healthcare service utilisation among Japanese retirees in Malaysia…’
Response:
Thank you for your advice. The referred sentence as below was deleted entirely to avoid repetition.
As mentioned earlier, this study examines the healthcare service utilisation among Japanese retirees
in Malaysia, using directed content analysis method.(16)
Instead, the following new sentence was added.
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This qualitative study uses the directed content analysis method. (16)
Comments from the Reviewer:
Table 2 on the definitions could be incorporated as the third column in Table 1.
Response:
Thank you very much for your insightful comment. Following your advice, Table 1 and 2 were merged
together.
Comments from the Reviewer:
I wonder how many of the Japanese retirees who participated in the study were husbands and wives.
Couples would probably have the same experience.
Response:
Thank you for your very thoughtful advice. The following information about husband and wives
amongst the participants was added in the section on participants.
Out of thirty participants, sixteen retirees were husbands and wives.
Comments from the Reviewer:
May be the discussion guide for the FGD could be made available as a supplementary material linked
to this report when published.
Response:
Thank you for your advice. The discussion guide for the FGD and interview guide for IDI will be made
available as a supplementary materials linked to this manuscript, using Dryad. Please see attached
files for the discussion guide for the FGD and interview guide for the IDI.
Comments from the Reviewer:
Page 7 line 20: unnecessary repetition.
Response:
Thank you for your comment. The referred sentences as below were deleted entirely to avoid
repetition.
As earlier mentioned, we analysed the data using the directed content analysis method.(16, 17) The
method allows the data to be organised in a structured and systematic manner.
Comments from the Reviewer:
Page 7 line 24-26: unnecessary repetition ‘As mentioned earlier, the Andersen Healthcare Utilisation
Model (AHUM) was adopted as a theoretical framework.’
Response:
Thank you for your comment. The referred sentences were deleted entirely to avoid repetition.
As mentioned earlier, the Andersen Healthcare Utilisation Model (AHUM) was adopted as a
theoretical framework.(22) The analysis was based on three categories specified in the model.(22)
Instead, the following new sentence as below was added.
The analysis method employed the directed content analysis, guided by the three categories specified
in the AHUM. (25)
Comments from the Reviewer:
Overall, I think there need to be more quotes from the retirees themselves and other participants
besides the often quoted interpreters’ opinion. The presented quotes were rather few and not
Downloaded from http://bmjopen.bmj.com/ on June 16, 2017 - Published by group.bmj.com
supportive of all the mentioned codes.
Response:
Thank you for your thoughtful advice. We have added more quotes, especially from Japanese
retirees. Please see the revised manuscript for the Results section.
Comments from the Reviewer:
Page 8 Line 11: I think you referred to Table 2.
Response:
Thank you for your correction. Now that we have merged Tables 1 and 2, we are referring to Table 1
in the specific part of the manuscript where comment was made.
Comments from the Reviewer:
Page 8 Line 20: I think you referred to Table 3.
Response:
Thank you for your correction. Now that we have merged Tables 1 and 2, finally it is OK to refer here
as Table 2.
Comments from the Reviewer:
Page 8 Line 56: unclear phrase ‘… through their easier to understand information communication…’
Response:
Following unclear phrase was deleted.
"... through their easier to understand information communication, ..."
Comments from the Reviewer:
Page 9 Line 36: objective data, rather than subjective data?
Response:
We have rechecked the transcript of Japanese language, and it actually means “detailed data” in
Japanese, so we have replaced the word "subjective data" with "detailed data".
Comments from the Reviewer:
Page 9: On Medical Symptoms, the quote is kind of inappropriate. May be one or few from the
retirees themselves are needed to support the section preceding narration.
Response:
Thank you for your thoughtful advice. We have added more quotes, especially from Japanese
retirees. Please see the revised manuscript for the Results section, on Medical Symptoms.
Comments from the Reviewer:
Page 10: The narration under the Health Insurance could be concise and without repetition of its
points.
Response:
Thank you for your comment. The narration under the Health Insurance was made simpler without
repetitions. Also, one more quote was added to improve on clarity.
Comments from the Reviewer:
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Page 12 line 36 (in Discussions and Conclusions): punctuation error
Response:
Thank you for your comment. Part of the sentence was deleted and modified.
From the standpoint of the destination country, this phenomenon is a missed opportunity for the
healthcare industry.
Comments from the Reviewer:
It was not certain whether the data collection reached saturation of themes.
Response:
Saturation of themes was reached but was not mentioned in the previous version of the manuscript.
Thank you for your comment. The following explanation as below was added.
Data saturation from FGDs and IDIs were was reached after conducting five FGDs and seven IDIs. At
that stage no new themes emerged even by having additional data (24).
Response to Reviewer 2: Dr. Vicente Rodriguez, Spanish National Research Council
Comments from the Reviewer:
3. The study design is fine when the decision to run a qualitative methods has been selected.
Common choice in other international studies on IRM is to combine quanti- and quali- approaches,
but this is not the case.
Response:
Thank you very much for your insightful comment. We have added below sentence as limitation of
this study.
 A qualitative study with recruited participants describes only a specific phenomenon; for a better
generalizability of the findings, a quantitative study which gained a representative sample of Japanese
retirees in Malaysia is required to objectively measure the perceptions of crucial themes such as
health beliefs, medical symptoms, and health insurance of retirees abroad.
Comments from the Reviewer:
7. No statistic analysis is required. In spite of this, no further information on how the qualitative
analysis has been really conducted: has been this carried out by a qualitative analysis software? have
been other qualitative results identified other than verbatim, i.e. code frequencies, networks of
factors,...?
Response:
Thank you for your comment. In data analysis, NVivo software version 10 was used. We have added
below sentence in the Data analysis section. (Below sentence is what was added.)
We managed the data using QSR NVivo 10 software.
Comments from the Reviewer:
8. IRM references on other outstanding areas are not properly identified (only the two first, which are
outdated), the same can be said on qualitative data analysis. Probably number of references are
conditioned by the BMJOpen requirements. If this is true, please don't draw attention to the last
comment
Response:
Thank you for your comment. In the introduction section, we added three more references, and
regarding the reference on qualitative data analysis, I added three more references. Please see the
attached modified manuscript for details.
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Comments from the Reviewer:
11. Not all results are extensively discussed (only three of six), with no reasons to do that.
Response:
Thank you for your comment. Due to the recommended limitation of words (4,000 words) written in
the journal manuscript submission guideline for BMJ Open, we had decided to focused on only three
themes based on frequency of theme commented as the percentage of participants mentioning about
the specific theme.
Comments from the Reviewer:
12. Although a limitation on quantitative method is discussed, no solution is provided to solve it. Could
it be feasible?
Response:
Thank you for your comment. We had added sentence regarding need for future research as below.
A quantitative study can further measure and quantify factors which affect healthcare utilisation
among Japanese retirees in Malaysia, the results often allow generalisation of the findings. In the
future, we plan to carry out quantitative research to quantify and to verify the issues that we found in
this study.
Comments from the Reviewer:
15. Written English should be improved, according to my opinion as a non-English speaker, mainly
the verbatim translation.
Thank you for your comment. This manuscript was already checked by native English proofreader
from British Council in Kuala Lumpur, Malaysia. In order to respond to your concern, we had gone
through another English proofreading check the manuscript for the second time. We would like to
inform you that the verbatim translation of the quoted comments from the study participants are now
modified for the improvement of readability.
Downloaded from http://bmjopen.bmj.com/ on June 16, 2017 - Published by group.bmj.com
Factors affecting Japanese retirees'
healthcare service utilisation in Malaysia: a
qualitative study
Ayako Kohno, Nik Daliana Nik Farid, Ghazali Musa, Norlaili Abdul Aziz,
Takeo Nakayama and Maznah Dahlui
BMJ Open 2016 6:
doi: 10.1136/bmjopen-2015-010668
Updated information and services can be found at:
http://bmjopen.bmj.com/content/6/3/e010668
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References
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