Title: Illuminating health aspects for immigrant Thai women in Swedish transnational marriages
Version: 5 Date: 30 Jul 2023
Reviewer's report:
Review of Revision2: BMC Women’s Health - ID 63a8ea18-92c9-4154-b4c6-33381d2c4b5d
Illuminating health aspects for immigrant Thai women in Swedish transnational marriages
Thank you again to the authors for continuing to improve your manuscript in response to
reviewers’ feedback. It is solid in many ways and there are still a few concerns that I’d like to
share with you.
Introduction, Theory, and Methodology Sections: Your expanded introduction provides the
reader with a better understanding of the context of Thai women’s marriage migration to
Sweden. I appreciate that you added a more detailed description of the NSM and your use of both
inductive and deductive processes in data analysis. I now have a better sense of how you worked
with the narratives. My suggestion is that you move up the “Theoretical influence” section to
follow your “Aim” section and before your “Methods” section. This will help you make a clear
connection between your theoretical lens and methodology, the critical incident technique.
Results: Where I continue to struggle is in your results section. Although I understand that
you counted the number of times that critical incidents of a specific nature appeared across
the women’s narratives, I continue to wonder about their distribution across the 40 participants
in your sample. It seems that a subset of women, for example, might talk a lot about their
marriage issues and another group might not share much. I recall in an earlier draft that you
wrote that about half of the women had no serious issues; reporting your results in this way may
be misleading.
Might it be possible to add a column to your Critical Health Incident table that indicates the
number of women who reported each of them in their narratives? For example, there were 66
mentions of emotional abuse. Did every woman report at least one incident? Did half of the
women report most of the incidents? As written, we do not know. Adding that information would
give us a sense of the preponderance of the particular health issue in this sample. Currently, you
report a total count across narratives for each incident, which may include multiple mentions by
any one participant. An alternative way to report your data is to report the number of narratives
in which women reported experiencing a specific incident. The former is not very meaningful
in terms of interpreting which incidents are most common across your sample, and to the lives
of Thai immigrant women in Sweden, and which are unique to a smaller subset of women.
Please know that I am not asking for a quantitative analysis but a more detail in your qualitative
reporting.
Finally, I am still not ‘hearing’ enough of the women’s voices! I read a lot of data interpretation
but note a lack of ‘evidence’ to back it up. For transparency, I highly encourage you to add
more quotes, especially when your incidents involve multiple dimensions. Further, please pay
attention the following related to your themes. A) Check to be sure that the titles of the incidents
in your table are the same as the titles in your narrative. Currently there are some mismatches.
Example: Table: Spiritual health actions; Text: Spiritual health dilemmas as actions. B) Follow
a similar format for reporting your themes. For example, first provide your interpretation of the
overall theme and the subthemes included. Then describe each subtheme with quotes, formatted
per the journal’s guidelines. Currently, some are in quotation marks and some are not. If you
use a summary paragraph, indicate that in some way. For example in your ‘human trafficking’
incident, the first quote is clearly relevant. However, the following paragraph does not seem
to fit. Is that supposed to be a summary paragraph for that overall theme of ‘Sociocultural
health’? If so, please use a lead-in sentence, subheading or other consistent writing convention
to avoid confusing the reader. C) Pay attention to main headings and subheadings, and follow
the journal’s formatting guidelines consistently.
Discussion: My sense is that your discussion section is a bit redundant with your results section.
If you take a step back and think about three or four salient points you would like the reader to
remember, focus on those and synthesize your findings into a few strong paragraphs. As written,
it repeats what we have just read in the previous section. This would also leave room for more
quotes in your results section, if you were worried about the length of the manuscript.
A few sentences in your discussion confused me. I am not sure what you mean by: “stressors
…… can also interrupt an individual’s systemic ability to create health and wellness”. Please
explain what you mean by an individual’s systemic ability.
I am also wondering about this idea: women need to “concentrate on earning money rather
than taking care of their own health; they maintained the marital relationship for economic and
security reasons rather than love, as marriage migration might have promised.” Only 6 women
indicated that they came to Sweden ‘because of love and the desire to build family’; 32 wanted
‘to have a better life’. That says to me that they were not primarily looking for love, but rather
economic and security. However, they may have been unrealistic about how difficult it would
be to achieve the ‘better life’ they had envisioned.
Have you considered the idea that Thai women may face racism or anti-immigrant sentiment in
Sweden? Your continued reference to women’s experiences of acculturative stress, even when
some had lived in Sweden for decades (range = 6-43 years; mean = 18 years), struck me as
rather odd. The immigration literature has increasingly recognized that migrants of color who
settle in dominant White societies are minioritzed upon arrival. This is a new experience for
them because most were of the majority race in their countries of origin. They face acculturative
stress as they adjust their new culture and minority stress from discrimination by the dominant
society, especially when they enter the workforce, as most of the women in your study did. This
is certainly something about which healthcare professional should be aware.
Finally, I noted that you removed the statement that communicated that half of the women in
your study had no problems. I believe it is important to handle this in a forthright manner.
At the beginning of the methodology section, you could explain this, perhaps that you will
focus exclusively on the negative experiences that women shared per your theoretical lens and
methodological choice. If that results in a reduction of your sample size, I think that is fine. I
am actually not quite sure what your initial comment about ‘half having no problems’ actually
meant. I just know that ignoring it and reporting only negative data is biased at best and unethical
at worst.
I hope you receive this feedback in the spirit intended, which is to be helpful. I continue to feel
your research is novel and is an important topic for the field.